prePping!!!

An elderly client reports shortness of breath with activity for the past 2 weeks. The nurse reviews the admission laboratory results and identifies which value as the most likely cause of the client's symptoms? 1. Brain natriuretic peptide 70 pg/mL (70 pmol/L) 2. Hematocrit 21% (0.21) 3. Leukocytes 3,500/mm3 (3.5 x 109/L) 4. Platelets 105,000/mm3 (105 x 109/L)

Hematocrit 21% (0.21)

An 8-month-old infant is scheduled for balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding could possibly delay the procedure and should be reported? 1. Auscultation of a loud heart murmur 2. Infant has been npo for 4 hours 3. Infant has polycythemia 4. Infant has severe diaper rash

Infant has severe diaper rash

The nurse inserts a small-bore nasogastric (NG) tube and prepares to initiate enteral feedings for a hospitalized client with laryngeal cancer. Which action should the nurse take first? 1. Crush and administer medications 2. Dilute enteral formula as prescribed 3. Flush the tube with 30 mL of water 4. Verify tube placement with an x-ray

Verify tube placement with an x-ray

A 14-year-old is scheduled for surgery to treat scoliosis. The child will be hospitalized for about a week and then discharged home to recuperate for 3-4 weeks before returning to school. What is the best activity the nurse can recommend to promote age-specific growth and development during this time? 1. Attending selected after-school events and social activities 2. Keeping up with schoolwork 3. Reading teen magazines 4. Visits from friends

Visits from friends

A client with latent tuberculosis has been taking oral isoniazid (INH) 300 mg daily for 2 months. The client tells the nurse that for the past week she has had numbness, a burning sensation, and tingling in her hands and feet. Additional intake of which of the following would most likely have prevented this? 1. Folic acid 2. Vitamin B6 3. Vitamin B12 4. Vitamin D

Vitamin B6

A newborn client is seen in the emergency department for vomiting. Which assessment finding indicates a possible emergency? 1. Frequent vomiting since birth 2. Tiny blood streaks in the vomit 3. Vomit that is green 4. Vomiting through the nose

Vomit that is green

What is the best activity for a school-aged child hospitalized for vaso-occlusive sickle cell crisis? 1. Finger painting 2. Playing a game of Chinese checkers in the activity room 3. Playing video games 4. Watching a favorite movie

Watching a favorite movie

The nurse is caring for a child admitted with measles. Which of the following interventions should the nurse anticipate for this client? Select all that apply. 1. Advising measles vaccination for susceptible family members 2. Applying calamine lotion to reduce itching 3. Placing a tracheostomy tray at the bedside 4. Placing the client in a negative-pressure isolation room 5. Using an N95 respirator mask during client contact

advising measles vaccination for susceptible family members placing the client in a negative- pressure isolation room using an N95 respirator mask during client contact

The nurse is administering a pink pill to a hospitalized medical-surgical client. The alert, oriented client says, "This is a pill I haven't seen before." What follow-up action should the nurse take next? 1. Check the health care provider's prescription in the medical record 2. Explain that the health care provider has prescribed the medication 3. Look up the medication in the pharmacology reference 4. Teach the client about the purpose of the medication

check the health care provider's prescription in the medical record

Which tasks are appropriate for the nurse in a long-term care unit to delegate to unlicensed assistive personnel? Select all that apply. 1. Assign lunch times to other unlicensed assistive personnel on the unit 2. Assist a client with bathing and changing an ostomy appliance 3. Collect vital signs on a client newly arrived on the unit 4. Pick up a prescribed oral antibiotic from the pharmacy 5. Record intake and output for a client with chronic neurogenic bladder

collect vital signs on a client newly arrived on the unit pick up a prescribed oral antibiotic from the pharmacy record intake and output for a client with chronic neurogenic bladder

Which appearance of a stoma immediately after colostomy requires that the practical nurse contact the supervising registered nurse immediately? 1. Brick red with slight moisture 2. Dusky with moderate edema 3. Pink with slight oozing of blood 4. Rosy with no stool produced

dusky with moderate edema

A client was medicated 2 hours ago with IV morphine 2 mg to relieve moderate abdominal pain after an appendectomy. The client becomes lethargic but arouses easily to verbal and tactile stimuli and is oriented to time, place, and person. The pulse oximeter reading has dropped from 99% to 89% on room air. Which oxygen delivery device is the most appropriate for the nurse to apply? 1. nasal cannula 2. non-rebreather mask 3. simple face mask 4. Venturi mask

nasal cannula

It is 0700 and the nurse is caring for an 84-year-old client with dementia and a fractured hip. The client has been disoriented to time, place, and person since admission. The client moans frequently and grimaces when moving. He is prescribed morphine IV every 2 hours as needed for pain and was last medicated at 0530. He is scheduled for surgery at 1000 to repair the hip fracture, but the consent has not yet been signed. The client's spouse and child are to arrive at 0900. Which intervention should the nurse carry out first? 1. Administer pain medication 2. Call the health care provider to meet with the family to obtain informed consent 3. Complete the preoperative checklist 4. Perform the morning assessment

perform the morning assessment

The spouse brings a client to an extremely busy emergency department due to erratic behavior and expressions of despair. When the triage registered nurse asks if the client feels suicidal now, the client shrugs the shoulders. Based on these findings, the practical nurse expects to be assigned which nursing responsibility? 1. Ask the client to make a verbal contract to not harm self 2. Document that the client is not currently suicidal 3. Place the client in an inside hallway with one-on-one observation 4. Return the client to the waiting room with the spouse

place the client in an inside hallway with one-on-one observation

The nurse is working with a client admitted with delirium and reduced level of consciousness due to pneumonia and respiratory failure. The nurse anticipates that the client may need to be intubated soon. The client is not able to make decisions. Who will make decisions for the client? 1. The client's sibling 2. The client's spouse 3. The health care provider (HCP) 4. The health care proxy

the health care proxy

The nurse is caring for a client with diabetes who is being discharged with a prescription for glyburide. Which statement by the client indicates a need for further instruction? 1. "I should avoid alcohol intake with this new medication." 2. "I should call my primary health care provider if my morning blood glucose is below 60 mg/dL (3.3 mmol/L)." 3. "I should read the labels on all foods I eat, including those that say 'sugarless'." 4. "This medication will help me lose weight."

"This medication will help me lose weight."

The nurse is attending an end-of-year school family picnic. Which situation needs an immediate intervention? 1. A 2-year-old eating a hot dog unsupervised 2. A 3-year-old playing alone in a wading pool 3. A 4-year-old tossing a beach ball 4. A 5-year-old climbing on monkey bars

A 2-year-old eating a hot dog unsupervised

The clinic nurse is collecting data on a pregnant client in the first trimester. Which finding is most concerning and warrants priority intervention? 1. Client has not been taking prenatal vitamins 2. Client is taking lisinopril to control hypertension 3. Client reports a whitish vaginal discharge 4. Client reports mild cramping pain in the lower abdomen

Client is taking lisinopril to control hypertension

A behavioral health clinic nurse assesses a 23-year-old client who started taking paroxetine 3 weeks ago. Which statement made by the client is most important for the nurse to investigate? 1. "I don't have much of an appetite since starting this medication." 2. "I have a lot more energy, but I'm feeling just as depressed." 3. "I have been feeling dizzy when I walk around at home." 4. "I have experienced frequent headaches lately."

"I have a lot more energy, but I'm feeling just as depressed."

A client with fibromyalgia refuses to take the prescribed drug duloxetine. When the nurse asks, why, the client responds, "Because I'm not depressed!" What is the nurse's most appropriate response? 1. "Depression is common with fibromyalgia, but a low dose of this drug can prevent it." 2. "It can relieve your chronic pain and help you sleep better at night." 3. "It helps to relieve the adverse effects of your other prescribed drugs." 4. "You have the right to refuse. I will notify your health care provider (HCP)."

"It can relieve your chronic pain nd help you sleep better at night."

A home health nurse is managing care for an adolescent client with cystic fibrosis. Which of the following potential complications should the nurse consider when developing a nursing care plan? Select all that apply. 1. Chronic hypoxemia 2. Diabetes insipidus 3. Frequent respiratory infections 4. Obesity 5. Vitamin deficiencies

1. chronic hypoxemia 3. frequent respiratory infections 5. vitamin deficiencies

Which statements involve acceptable use of an abbreviation, symbol, or dose designation in documentation? Select all that apply. 1. "2 cm × 3 cm × 1 cm stage II decubitus noted on left shin." 2. "4.0 u SSRI administered to cover capillary glucose of 160 mg/dL." 3. "Dose of .5 mg hydromorphone administered and the client feels 'better.'" 4. "Maalox 5 mL PO administered pc as requested for c/o heartburn." 5. "Spouse voiced understanding of home urinary catheterization QID."

1. "2 cm × 3 cm × 1 cm stage II decubitus noted on left shin." 4. "Maalox 5 mL PO administered pc as requested for c/o heartburn." 5. "Spouse voiced understanding of home urinary catheterization QID."

A client with suspected foot osteomyelitis is scheduled for an MRI. Which client findings should the nurse report before the test? Select all that apply. 1. Cardiac pacemaker 2. Colostomy 3. Retained metal foreign body in eye 4. Total hip replacement 5. Transdermal testosterone patch

1. Cardiac pacemaker 3. Retained metal foreign body in eye 4. Total hip replacement

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply. 1. Dimming the lights at night 2. Leaving the television on for diversion at night 3. Opening the window blinds/shades in the morning 4. Scheduling interventions and activities during the day when possible 5. Turning off equipment alarms in the client's room at night

1. dimming the lights at night 3. opening the windows and blinds/ shades in the morning 4. scheduling interventions and activities in the day when possible

Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply. 1. Exercise programs 2. Good room lighting 3. Handrails in stairwell 4. Smooth-soled shoes 5. Staff hourly rounds

1. excerise programs 2. good room lighting 3. handrails in stairwell 5. staff hourly rounds

The practical nurse is collaborating with the registered nurse to develop a plan of care for a 16-year-old client with bulimia nervosa. Which interventions would be included in the plan of care? Select all that apply. 1. Allow client to remain on current laxatives 2. Assess client for electrolyte imbalances 3. Be alert to hidden or discarded food wrappers 4. Do not allow client to keep a food diary during hospitalization 5. Monitor client for 60-90 minutes after each meal in a central area

2. Assess client for electrolyte imbalances 3. Be alert to hidden or discarded food wrappers 5. Monitor client for 60-90 minutes after each meal in a central area

The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis). Which of the following lifestyle changes should the nurse recommend? Select all that apply. 1. Avoid intake of dairy products 2. Consume a low-fat diet 3. Drink large amounts of fluids with meals 4. Eat several small meals a day 5. Lie down on the left side after meals

2. Consume a low-fat diet 4. Eat several small meals a day

A recently widowed client becomes tearful at a routine clinic visit and states, "I just can't get over my spouse's death." Which of the following responses by the nurse are appropriate? Select all that apply. 1. "A friend of mine passed away recently. I know how hard losses can be." 2. "I see that you're upset. I will step out while you process these feelings." 3. "It may take a while, but coming to terms with loss gets easier with time." 4. "This is a difficult time. Tell me about how you have been coping." 5. "What are your thoughts about attending a grief support group?"

4. "This is a diffucult time. Tell me about how you have been coping." 5. "What are your thoughts about attending a grief support group?"

The clinic nurse is caring for a 3-year-old client. Which task, if not observed or reported by the parents as accomplished, will cause the nurse concern? 1. Catches a ball at least 50% of the time 2. Copies a square with a pencil or crayon 3. Eats with a spoon 4. Hops on one foot

Eats with a spoon

The nurse is reinforcing discharge instructions to the parent of a child with Kawasaki disease. The nurse informs the parent that the presence of which symptom should be immediately reported to the health care provider? 1. Fever 2. Irritability 3. Joint pain 4. Skin peeling

fever

The nurse is assessing a client's peripheral pulses. The nurse palpates the top portion of the client's foot. The right pulse is easily palpable, and the left pulse is diminished but still palpable. How should the nurse document these findings? 1. Bilateral dorsalis pedis (DP) pulses palpable. Right DP 2+, left DP 1+. 2. Bilateral DP pulses palpable. Right DP 3+, left DP 2+. 3. Bilateral popliteal pulses palpable. Right foot > left foot. 4. Bilateral posterior tibial (PT) pulses palpable. Right PT 2+, left PT 1+.

Bilateral dorsalis pedis (DP) pulses palpable. Right DP 2+, left DP 1+.

A client with schizophrenia is started on clozapine. Which periodic measurements take priority in this client? 1. Complete blood count and absolute neutrophil count 2. ECG and blood pressure 3. Fasting blood glucose and fasting lipid panel 4. Height, weight, and waist circumference

Complete blood count and absolute neutrophil count

Four clients arrive in the urgent care clinic. Which does the nurse anticipate to be the priority for intervention? 1. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing 2. Child with an abscess on the buttock that is red, swollen, and warm to the touch 3. Child with immune thrombocytopenia who fell off a bike and reports shoulder pain 4. Child with low-grade fever, barking cough, and runny nose who has mild retractions

Child who is confused and irritable and whose parent claims 2 glyburide pills are missing

A woman who had a cesarean delivery 5 hours ago now appears anxious and reports shortness of breath. The practical nurse should assess for which priority problem before notifying the registered nurse? 1. Calf warmth and redness 2. Elevated temperature 3. Elevated white blood cell count 4. Incisional discomfort

Calf warmth and redness

The nurse is performing rounding on clients in restraints. Which situation would require immediate intervention by the nurse? 1. Client in a belt restraint in the semi-Fowler position 2. Client in mitten restraints in the side-lying position 3. Client in soft wrist restraints in the supine position 4. Client in vest restraint in the high-Fowler position

Client in soft wrist restraints in the supine position

The nurse observes a nursing student performing chest compressions on an adult client. Which technique indicates that the student understands how to provide high-quality chest compressions during cardiopulmonary resuscitation? 1. Compressing the chest to a depth of at least 2 in (5 cm) 2. Pausing after each set of 15 compressions to allow for 2 rescue breaths 3. Placing the heel of the hand on the upper half of the client's sternum 4. Providing compressions at a rate of at least 80-100/min

Compressing the chest to a depth of at least 2 in (5 cm)

A 12-year-old with moderate intellectual disability and an intelligent quotient of 45 is hospitalized. What will the nurse recommend as the best recreational activity for this child? 1. Child's favorite stuffed animal 2. Connect-the-dots puzzle book 3. Putting together a 300-piece jigsaw puzzle 4. Writing in a journal about the hospital stay

Connect-the-dots puzzle book

A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV. What is the nurse's priority action? 1. Assess the condition of the IV site 2. Check 2 client identifiers before administering medications 3. Consult a medication guide for compatibility 4. Wash hands prior to administering medications

Consult a medication guide for compatibility

A nurse in a pediatric clinic is collecting data on a 30-month-old child. Which finding requires further evaluation? 1. Bladder and bowel control achieved 2. Current weight is 6 times greater than birth weight 3. Head circumference increased by 1 in (2.5 cm) in the past year 4. Resting heart rate is 120 beats per minute

Current weight is 6 times greater than birth weight

The nurse is collecting data on the psychosocial development of a 2-year-old. What is the priority finding that should be reported to the supervising registered nurse? 1. Does not talk or respond when spoken or read to 2. Likes to imitate others by playing house and talking on the telephone 3. Refuses to go to sleep without a particular stuffed animal and a bedtime story 4. Says "no" to everything and has temper tantrums

Does not talk or respond when spoken or read to

A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker "force feed" the client. What is the priority nursing action? 1. Explain to the family that this is a normal physiological response to dying 2. Explore the family's thoughts and concerns about the client's refusal of food 3. Recommend a feeding tube 4. Tell the family that "force feeding" the client could cause the client to choke on the food

Explore the family's thoughts and concerns about the client's refusal of food

A nurse is changing a sterile dressing for a client with an infected wound. While doing so, unlicensed assistive personnel report that a second client is requesting pain medication. What is the nurse's most appropriate action? 1. Ask unlicensed assistive personnel (UAP) to take the second client's vital signs and report back immediately 2. Direct UAP to ask the second client to rate the pain on a 0-10 scale and report back immediately 3. Have UAP tell the second client that the nurse will be there soon and complete the sterile dressing change 4. Interrupt the dressing change to medicate the second client

Have UAP tell the second client that the nurse will be there soon and complete the sterile dressing change.

A nurse finds a client unresponsive and is unable to palpate a pulse. Resuscitation is initiated and continued by the rapid response team. The nurse then finds a do not resuscitate (DNR) prescription in the client's chart. What is the appropriate action by the nurse? 1. Complete resuscitation as life support measures have already been started 2. Continue resuscitation until DNR status is verified with health care provider 3. Immediately have the rapid response team stop resuscitation measures 4. Verify with a family member if life-saving measures should be continued

Immediately have the rapid response team stop resuscitation measures.

The nurse is caring for a client with cirrhosis who has hepatic encephalopathy. The client is prescribed lactulose. Which assessment by the nurse will most likely indicate that the medication has achieved the desired therapeutic effect? 1. Higher potassium level 2. Improved mental status 3. Looser stool consistency 4. Reduced abdominal distension

Improved mental status

The nurse is planning a client care conference with the parents of a 3-year-old with newly diagnosed type 1 diabetes mellitus. What is the priority outcome for the caregivers? 1. Demonstrating adequate coping skills 2. Knowing how to keep blood sugars stable 3. Understanding how to perform meal planning 4. Understanding the need for periodic follow-up visits

Knowing how to keep blood sugars stable

A client recovering at home following a left total knee replacement 7 days ago is using a cane to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for reinforcement of teaching? 1. Faces forward when going up and down the stairs 2. Holds the cane with the right hand 3. Leads with left leg, follows next with cane, and finally right leg when going up the stairs 4. Places full weight on left leg when going down the stairs

Leads with left leg, follows next with cane, and finally right leg when going up the stairs

An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis. The client becomes angry with one of the unlicensed assistive personnel (UAP) who is trying to help the client bathe. Later, the UAP expresses frustration with the client to the nurse. Which statement would be the most appropriate response? 1. "I'll talk with the client to see why the client is angry." 2. "It sounds like you shouldn't work with this client, so I will reassign you." 3. "Let's go together to ask about the client's concerns." 4. "Why don't you go talk with the client about why the client is angry?"

Let's go together to ask about the client's concerns."

A nurse is preparing for a medical relief trip to West Africa and is concerned about a disruption in circadian rhythm from traveling across several time zones. Which herbal supplement might help synchronize the body to environmental time? 1. Evening primrose 2. Ginseng 3. Melatonin 4. St. John's wort

Melatonin

A nurse is caring for a 2-year-old with a new diagnosis of strabismus. Which intervention should the nurse anticipate? 1. Eye drops in the abnormal eye 2. Measurement of intraocular pressure (IOP) 3. Patching the stronger eye 4. Correction with laser surgery

Patching the stronger eye

The unlicensed assistive personnel notifies the charge nurse that the client is reporting feeling short of breath. What should the charge nurse do first? 1. Activate a rapid response team 2. Ask the unlicensed assistive personnel to take vital signs and report back 3. Direct the client's primary nurse to examine the client 4. Personally go and auscultate the client's lungs

Personally go and auscultate the client's lungs

The nurse has unlicensed assistive personnel (UAP) caring for a client with an acute attack of Meniere disease. Which action by the UAP will require follow-up by the nurse? 1. Assist the client in ambulating to the bathroom 2. Dim the room lights 3. Place the bed in low position with all side rails up 4. Turn off the television

Place the bed in low position with all side rails up

The emergency department nurse is caring for a client who requires gastric lavage for a drug overdose. Which action would be appropriate? 1. Lavage through a small-bore nasogastric tube 2. Place client in Trendelenburg position during lavage 3. Prepare intubation and suction supplies at the bedside 4. Wait an hour after gastric decompression to initiate lavage

Prepare intubation and suction supplies at the bedside

During the client interview for a developmentally normal 18-month-old, the parent expresses concern about the small amount of food the child consumes. What is the nurse's priority intervention? 1. Check the child for parasitic infections 2. Consult a pediatric nutritionist for suspected eating disorder 3. Notify the health care provider 4. Reinforce teaching about the toddler's nutritional needs

Reinforce teaching about the toddler's nutritional needs.

An elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization. The next day, the client becomes agitated and says to the nurse, "I've got to get back home to my things. I have so much to do." Which is the most likely interpretation of this client's behavior? 1. The client has been admitted to the facility without the client's consent 2. The client is becoming delirious and should be assessed for infection 3. The client is concerned that someone might steal possessions 4. The client wants to take care of business before imminent death

The client wants to take care of business before imminent death

A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action? 1. Document a description of the injury 2. Question the mother about where the infant sleeps 3. Report the injury per facility protocol 4. Separate the mother from the infant

Report the injury per facility protocol

A nurse is measuring the uterine fundal height of a client who is at 36 weeks gestation in supine position. The client suddenly reports dizziness and the nurse observes pallor and damp, cool skin. What should the nurse do first? 1. Auscultate for heart and lung sounds 2. Determine fetal heart rate and pattern 3. Notify the supervising registered nurse 4. Reposition client into a lateral position

Reposition client into a lateral position

The nurse reinforces teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug? 1. Need for an eye examination 2. Need for sunblock 3. Risk for infection 4. Risk for kidney injury

Risk for infection

In which position would the nurse place a client recovering from a right modified radical mastectomy who is admitted from the post-anesthesia unit? 1. High-Fowler's position with the affected side's arm resting on the bed 2. Semi-Fowler's position with the affected side's arm on several pillows 3. Supine with the affected side's arm on several pillows 4. Supine with the affected side's arm resting on the bed

Semi-Fowler's position with the affected side's arm on several pillows

While collecting data from pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first? 1. First-trimester client who reports frequent nausea and vomiting 2. Second-trimester client with dysuria and urinary frequency 3. Second-trimester client with obesity who reports decrease in fetal movement 4. Third-trimester client with right upper quadrant pain and nausea

Third-trimester client with right upper quadrant pain and nausea

An elderly client with end-stage renal disease who has refused dialysis is admitted to a long-term care facility for rehabilitation following hospitalization. The next day, the client becomes agitated and says to the nurse, "I've got to get back home to my things. I have so much to do." Which is the most likely interpretation of this client's behavior? 1. The client has been admitted to the facility without the client's consent 2. The client is becoming delirious and should be assessed for infection 3. The client is concerned that someone might steal possessions 4. The client wants to take care of business before imminent death

The client wants to take care of business before imminent death

A client with social anxiety disorder is receiving treatment at the local community mental health center. Which situation most likely caused the client to seek therapy? 1. The client and spouse are soon moving into a new neighborhood 2. The client's boss has asked the client to represent the company at an upcoming convention 3. The client's primary health care provider (HCP) of 30 years is retiring and the client will be seeing a new HCP 4. The client's son is getting married in a few months

The client's boss has asked the client to represent the company at an upcoming convention

The nurse is caring for a 5-year-old client who is dehydrated and malnourished, and suspects that the client may be neglected. Which information most strongly supports the nurse's suspicion of child neglect? 1. The parent cannot stay at the hospital due to potential job loss from absence 2. The parent is in the process of a divorce and will soon be a single parent 3. The parent is witnessed stealing food and drinks from the cafeteria 4. The parent leaves the client's younger sibling to care for the client's newborn sibling

The parent leaves the client's younger sibling to care for the client's newborn sibling.

The nurse cares for a group of clients in a medical surgical unit. The client with which diagnosis and condition requires the most immediate assistance by the nurse? 1. Post cholecystectomy, reporting incision pain of a 5 on a scale of 1-10 2. Post open reduction of the right femur, reporting nausea 3. Type 1 diabetes mellitus with a blood glucose of 55 mg/dL (3.1 mmol/L) 4. Type 2 diabetes mellitus with a blood glucose of 250 mg/dL (13.9 mmol/L)

Type 1 diabetes mellitus with a blood glucose of 55 mg/dL (3.1 mmol/L)

A nurse preceptor on a pediatric unit is reviewing interventions with a student nurse who will be caring for a toddler. What are appropriate activities to minimize the effect of hospitalization on a toddler? Select all that apply. 1. Integrate preferred snack foods in the day's routine 2. Explain the body changes that may occur 3. Plan quiet play prior to usual nap time 4. Post a daily schedule by the child's bed 5. Provide 1 or 2 options when choosing toys

integrate preferred snack foods in the day's routine plan quiet prior to usual nap time provide 1 to 2 options when choosing toys

Exhibit The nurse is monitoring a newborn with skin discoloration in the lumbar area. Which action by the nurse is appropriate? Click the exhibit button for additional information. (mongolian spot) 1. Check the infant's hemoglobin, hematocrit, and platelet levels 2. Measure and document the size and location of the markings 3. Notify the registered nurse of the markings immediately 4. Review the delivery record for evidence of a traumatic birth

measure and document the size and location of the markings

A client diagnosed with stable angina is being discharged home on the cholesterol-lowering drug rosuvastatin. The nurse should reinforce instructions for the client to report which side effect to the health care provider immediately? 1. Abdominal discomfort 2. Insomnia 3. Morning headache 4. Muscle aches or weakness

muscle aches or weakness

A 45-year-old client with atrial fibrillation has been prescribed diltiazem. Which client outcome would best indicate that the medication has had its intended effect? 1. Atrial fibrillation is converted to sinus rhythm 2. Blood pressure is 126/78 mm Hg 3. No signs or symptoms of stroke 4. Ventricular rate decreased from 158/min to 88/min

ventricular rate decreased from 158/min to 88/min

The nurse is drawing a blood specimen from the client's right basilic vein. The client cries out, retracts the arm, and reports feeling "pins and needles" in the right arm. Which action by the nurse is appropriate? 1. Obtain a smaller-gauge needle and reattempt at the same site 2. Partially withdraw and then reinsert the needle at a different angle 3. Provide reassurance and firmly stabilize the arm to complete the collection 4. Withdraw the needle and reattempt in a different site with new equipment

withdraw the needle and reattempt in a different site with new equipment

A client at 20 weeks gestation reports "running to the bathroom all the time," pain with urination, and foul-smelling urine. Which question is most important for the nurse to ask when assessing the client? 1. "Are you having any pain in your lower back or flank area?" 2. "Do you wipe from front to back after urinating?" 3. "Have you found that you urinate more frequently since becoming pregnant?" 4. "Have you had a urinary tract infection in the past?"

"Are you having any pain in your lower back or flank area?"

A client with asthma was recently prescribed fluticasone/salmeterol. After the client has received instructions about this medication, which statement would require further teaching by the nurse? 1. "After taking this medication, I will rinse my mouth with water." 2. "At the first sign of an asthma attack, I will take this medication." 3. "I have been smoking for 12 years, but I just quit a month ago." 4. "I received the pneumococcal vaccine about a month ago."

"At the first sign of an asthma attack, I will take this medication."

The nurse is preparing to administer a sodium polystyrene sulfonate retention enema. Which explanation by the nurse best describes the purpose of this type of enema? 1. "A contrast medium is administered rectally to visualize the colon via x-ray." 2. "Bedridden clients receive this enema to stimulate defecation and relieve constipation." 3. "This enema assists the large intestines in removing excess potassium from the body." 4. "This enema is administered before bowel surgery to decrease bacteria in the colon."

"Bedridden clients receive this enema to stimulate defecation and relieve constipation."

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch. What should be the nurse's initial action? 1. Abdominal thrusts 2. Back blows and chest thrusts 3. Blind sweep of the child's mouth 4. Call 911 for an ambulance

Abdominal thrusts

The nurse reinforces education with a client starting isotretinoin for acne. Which statement indicates the client needs further instruction? 1. "I should not donate blood while taking this medication." 2. "I will stop taking my tetracycline prior to taking this medication." 3. "I will take vitamin A supplements." 4. "I will use condoms and birth control pills."

"I will take vitamin A supplements

A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer. The client says to the nurse, "Is this disease going to kill me?" What is the best response by the nurse? 1. "Hearing this diagnosis must have been difficult for you. What are your thoughts?" 2. "We will do everything possible to prevent that from happening." 3. "Well, we're all going to die sometime." 4. "You should concentrate on getting better rather than thinking about death."

"Hearing this diagnosis must have been difficult for you. What are your thoughts?"

The school nurse is conducting an educational session for middle school teachers that is designed to heighten awareness of school bullying. The nurse recognizes that further instruction is needed when one of the teachers makes which comment? 1. "Bullying is a normal part of childhood growth and development." [91%] 2. "Children with physical disabilities are more vulnerable to bullying." [3%] 3. "Most children who are victims of a school bully do not tell an adult about it." [2%] 4. "The most common form of bullying is verbal aggression, such as insults and intimidation." [2%]

"Bullying is a normal part of childhood growth and development."

A nurse is reinforcing instructions regarding home management to a client newly diagnosed with severe psoriasis. Which client statement indicates that further teaching is needed? 1. "Exposure to sunlight will worsen my psoriasis." 2. "I should avoid drinking alcohol." 3. "I should avoid scratching the lesions." 4. "Stress can worsen psoriasis."

"Exposure to sunlight will worsen my psoriasis."

The nurse is reinforcing education to a prenatal client about the 1-hour glucose challenge test that will be performed at the next visit. Which client statement indicates a need for further education? 1. "Fasting is required before the 1-hour glucose challenge test." 2. "One blood sample is obtained at the end of the test." 3. "The test includes drinking a 50-g glucose solution." 4. "The test's purpose is to screen for gestational diabetes, not diagnose it."

"Fasting is required before the 1-hour glucose challenge test."

The nurse is caring for a college football player who recently sustained an accidental, forceful, helmet-to-helmet collision with another running football player. Which sign/symptom is most concerning and alerts the practical nurse to contact the registered nurse immediately? 1. Continually oozing epistaxis 2. "Hairnet" across vision 3. One episode of coffee-ground emesis 4. Temporal headache

"Hairnet" across vision

The practical nurse is assisting the registered nurse with completing a health history of a client with suspected rheumatic fever. Which question is most important to ask the client in order to establish a diagnosis? 1. "Do you typically take all of your antibiotics when they are prescribed?" [3%] 2. "Has anyone in your family had rheumatic fever?" [9%] 3. "Have you recently had a streptococcal throat infection?" [75%] 4. "What has your temperature been over the past several days?" [12%]

"Have you recently had a streptococcal throat infection?"

The nurse is reinforcing instructions to a client receiving oxybutynin for overactive bladder. Which client statement indicates that further teaching is required? 1. "I am looking forward to our summer vacation at the beach." 2. "I plan to eat more fruits and vegetables to prevent constipation." 3. "I should not drive until I know how this drug affects me." 4. "I will drink at least 6-8 glasses of water daily."

"I am looking forward to our summer vacation at the beach."

The nurse is reinforcing education to a client newly prescribed levetiracetam for seizures. Which statement made by the client indicates a need for further instruction? 1. "Drowsiness is a common side effect of this medication and will improve over time." 2. "I can begin driving again after I have been on this medication for a few weeks." 3. "I need to immediately report any new or increased anxiety when on this medication." 4. "I need to immediately report any new rash when on this medication."

"I can begin driving again after I have been on this medication for a few weeks."

The nurse is reinforcing teaching on nutritional therapy for a client with chronic kidney disease. Which statement indicates that further teaching is needed? 1. "Because I have chronic kidney disease, I should avoid canned soups and cold-cut sandwiches." 2. "I can use a salt substitute because I am required to restrict both sodium and potassium in my daily diet." 3. "I must avoid eating raw carrots and tomatoes on my salads because I take hemodialysis treatments." 4. "The popsicles I eat should be counted in my daily fluid intake because they become liquid at room temperature."

"I can use a salt substitute bc I am required to restrict both sodium and potassium in my daily diet."

The nurse is conducting a seminar for parents of adolescents about health issues common to this age group. Which parent's statement indicates that the adolescent may have bulimia nervosa? 1. "I found several empty boxes of laxatives in my child's wastebasket." 2. "I have noticed my child has started wearing bulky, oversized clothing." 3. "My child has lost 20 lb (9.1 kg) in the past 2 months." 4. "My child has stopped going to the gym."

"I found several empty boxes of laxatives in my child's wastebasket."

A client with obesity reports several failed attempts at weight loss. Which client statement best indicates that the client is ready and motivated for successful weight loss? 1. "I have signed up to be a dog walker when I normally would watch television." 2. "I understand that losing weight would improve my health and well-being." 3. "I want to lose 8 pounds (3.6 kg) so that my formal gown will fit in 4 weeks." 4. "My spouse and children are always encouraging me to eat healthier."

"I have signed up to be a dog walker when I normally would watch television."

The nurse reinforces teaching a client on prescribed dabigatran for chronic atrial fibrillation. Which statement by the client indicates a need for further teaching? 1. "I will call my health care provider if I notice red urine or blood in my stool." 2. "I will not stop taking dabigatran even if I get a stomachache." 3. "I will place capsules in my pill box so I will not forget to take a dose." 4. "I will swallow the capsule whole with a full glass of water."

"I will place capsules in my pill box so I will not forget to take a dose."

The nurse is reinforcing discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective? 1. "I'm glad that I can continue taking my Ginkgo biloba." 2. "I will increase my intake of leafy green vegetables." 3. "I will start applying vitamin E to my chest incision after showering." 4. "I will shave with an electric razor from now on."

"I will shave with an electric razor from now on."

The nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations. The client says in a trembling voice, "There's a bad man standing over there in the corner of my room." What is the best response by the nurse? 1. "I know you are frightened, but I do not see a man in your room." 2. "I'll make the bad man go away." 3. "Let's go into the dayroom and play checkers." 4. "Your illness is making you hallucinate."

"I know you are frightened, but I do not see a man in your room."

The health care provider (HCP) prescribes paroxetine to a client with depression. What statement by the client indicates proper understanding of the medication? 1. "I can discontinue the medication if my symptoms improve." 2. "I need a healthy diet and regular exercise to combat weight gain." 3. "If I don't feel better in 1-2 weeks, then the medication is not working." 4. "This medication might increase my sexual performance."

"I need a healthy diet and regular exercise to combat weight gain."

During a routine office visit, the nurse documents the list of current medications of a client with a history of hypertension. Which statement by the client would cause the most concern? 1. "I periodically take docusate sodium for constipation." 2. "I regularly take ibuprofen for chronic low back pain." 3. "I take hydrochlorothiazide to prevent swelling around my ankles." 4. "I take omeprazole daily to prevent heartburn."

"I regularly take ibuprofen for chronic low back pain."

A nurse is discussing parallel play with the parent of a 2-year-old. Which statement by the parent indicates understanding of the discussion? 1. "I encourage working in a group to build towers with large blocks." 2. "I have a chalk board available to teach the alphabet and numbers." 3. "I set out a basket of various balls in the backyard when other children come to play." 4. "I try to organize games that involve a team approach."

"I set out a basket of various balls in the backyard when other children come to play."

The nurse is reinforcing teaching to a client, gravida 1 para 0, at 8 weeks gestation about expected weight gain during pregnancy. The client's prepregnancy BMI is 21 kg/m2. Which statement made by the client indicates an appropriate understanding about weight gain? 1. "I should gain 10 pounds during the first trimester." 2. "I should gain about 30 pounds during the entire pregnancy." 3. "I should gain no more than half a pound per week during the third trimester." 4. "If I gain no more than 20 pounds during pregnancy, it will be easier to lose weight postpartum."

"I should gain about 30 pounds during the entire pregnancy."

The nurse is reinforcing instructions to a client scheduled for cardiac pharmacologic nuclear stress testing. Which client statements indicate appropriate understanding? 1. "I can smoke 1 cigarette the day of the test so that I won't have withdrawal." 2. "I should eat a hearty breakfast the morning of the test to avoid nausea." 3. "I should stop drinking coffee 24 hours before the procedure." 4. "I should take my usual dose of insulin the day of the test."

"I should stop drinking coffee 24 hours before the procedure."

A 3-month-old child with developmental dysplasia of the hip (DDH) is being fitted for a Pavlik harness. Which statement made by the parent indicates a need for further instruction? 1. "I should leave the harness on during diaper changes." 2. "I will adjust the harness straps every 3-5 days." 3. "I will inspect the skin under the straps 2-3 times daily." 4. "The harness should keep my baby's legs bent and spread apart."

"I will adjust the harness straps every 3-5 days."

Which statement made by the client demonstrates a correct understanding of the home care of an ascending colostomy? 1. "I will avoid eating foods such as broccoli and cauliflower." 2. "I will empty the pouch when it is one-half full of stool." 3. "I will irrigate the colostomy to promote regular bowel movements." 4. "I will restrict my fluid intake to 2,000 milliliters of fluid a day."

"I will avoid eating foods such as broccoli and cauliflower."

A client, who has been hospitalized for 3 days with major depressive disorder, has stayed in the room and not gotten out of bed except for toileting. The nurse enters the room to remind the client that breakfast will be served in the dining room in 20 minutes. The client says, "I'm not hungry and I don't feel like doing anything." What is the best response by the nurse? 1. "I will help you get ready; then we can walk to the dining room together." 2. "I'll have breakfast brought to your room." 3. "It's okay. You can join us when you are ready." 4. "You'll feel better when you get up."

"I will help you get ready; then we can walk to the dining room together."

A nurse in a school health clinic is reinforcing teaching for the parent of a young client with pediculosis capitis. Which statement by the parent indicates understanding of the teaching? 1. "I will launder recently worn clothing, sheets, and towels in hot water." 2. "I will make sure all eating utensils are placed in the dishwasher." 3. "I will spray the house with insecticide to control this problem." 4. "I will throw away stuffed animals and toys that cannot be washed."

"I will launder recently worn clothing, sheets, and towels in hot water."

The nurse is caring for a 7-year-old client diagnosed with nephrotic syndrome who will be discharged soon. Which statement by the parent indicates the need for further teaching? 1. "I'll provide a healthy diet without added salt for my child." 2. "I'll organize playdates to keep my child's spirits up during relapses." 3. "I'll restrict my child's fluids if I notice swelling or rapid weight gain." 4. "I'll test for protein in my child's urine every day."

"I'll organize playdates to keep my child's spirits up during relapses."

A 45-year-old client is in a rehabilitation unit receiving long-term care for injuries sustained in a motor vehicle accident. The client's spouse used to stay home but started working to replace the client's lost income. The nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences. Which statement is the most appropriate first response by the nurse? 1. "How is your spouse's new job going?" 2. "I've noticed that you seem frustrated lately." 3. "It's normal to be angry when you can't work anymore." 4. "We have a support group that can help you adjust to rehab."

"I've noticed that you seem frustrated lately."

A couple is excited about finding out the sex of their baby during ultrasound at 14 weeks gestation. What is the nurse's best response? 1. "Basic structures of major organs are not yet formed." 2. "External genitalia are not usually visualized until 21-24 weeks." 3. "If the baby is in the right position, the genitalia may be visualized." 4. "Sex cannot be determined until fetal movement is felt."

"If the baby is in the right position, the genitalia may be visualized."

The clinic nurse is interviewing the parents of a 6-month-old client about the infant's diet. Which statement by the parents is most concerning? 1. "Because apples are healthy, we make apple pie and feed small, soft bites to our baby." 2. "If our baby refuses to finish foods, we continue to offer small bites, so food isn't wasted." 3. "Infant oatmeal sweetened with fresh honey is our baby's favorite breakfast." 4. "We found that the food in TV dinners can be easily pureed and is convenient."

"Infant oatmeal sweetened with fresh honey is our baby's favorite breakfast."

The clinic nurse is interviewing the parents of a 6-month-old client about the infant's diet. Which statement by the parents is most concerning? 1. "Because apples are healthy, we make apple pie and feed small, soft bites to our baby." 2. "If our baby refuses to finish foods, we continue to offer small bites, so food isn't wasted." 3. "Infant oatmeal sweetened with fresh honey is our baby's favorite breakfast." 4. "We found that the food in TV dinners can be easily pureed and is convenient."

"Infant oatmeal sweetened with fresh honey is our baby's favorite breakfast."

The nurse is reinforcing teaching about trazodone to an elderly client with depression. Which statement by the client indicates that additional teaching is needed? 1. "I will call the health care provider if I develop a prolonged erection." 2. "I will get up slowly, in stages, from supine to standing." 3. "I will take this medication at night to avoid daytime drowsiness." 4. "It is okay to drink 2 glasses of wine at night."

"It is okay to drink 2 glasses of wine at night."

A client with a diagnosis of antisocial personality disorder was given a 2-hour pass to leave the hospital. The client returned to the unit 15 minutes past curfew and did not sign in. The next day, this behavior is brought up in a group meeting. The client says, "It's all the nurse's fault. The nurse was right there and did not remind me to sign in." What is the best response by the nurse? 1. "I'm sorry. I should have reminded you to sign in." 2. "It is not my fault that you forgot to sign in." 3. "It is your responsibility to sign in when you return from a pass." 4. "You were late coming back from your pass. Is that why you did not sign in?"

"It is your responsibility to sign in when you return from a pass."

The nurse reinforces teaching for a client newly prescribed buspirone for generalized anxiety disorder. Which client statement indicates that teaching has been effective? 1. "Driving is not recommended until I stop taking this medication." 2. "If I experience a panic attack I should take an extra dose of medication." 3. "It will be 2-4 weeks before I feel the full effect of this medication." 4. "Withdrawal symptoms will occur if I abruptly stop taking this medication."

"It will be 2-4 weeks before I feel the full effect of this medication."

An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis. The client becomes angry with one of the unlicensed assistive personnel (UAP) who is trying to help the client bathe. Later, the UAP expresses frustration with the client to the nurse. Which statement would be the most appropriate response? 1. "I'll talk with the client to see why the client is angry." 2. "It sounds like you shouldn't work with this client, so I will reassign you." 3. "Let's go together to ask about the client's concerns." 4. "Why don't you go talk with the client about why the client is angry?"

"Let's go together to ask about the client's concerns."

The ambulatory care nurse is reassessing an unvaccinated 4-month-old infant for fever, irritability, and open-mouthed drooling. After the infant is successfully treated for epiglottitis, the parents ask how this could have been avoided. Which response by the nurse would be most appropriate? 1. "It's impossible to know for sure what could have caused this episode; please don't worry." 2. "Most cases of epiglottitis are preventable by standard childhood immunizations." 3. "There is nothing you could have done differently; the important thing is that your child is better." 4. "Why are you concerned? We are still waiting on the final report from the lab."

"Most cases of epiglottitis are preventable by standard childhood immunizations."

A nurse is providing care to a group of postpartum clients. Which client comment should prompt further investigation? 1. "I feel so exhausted that I started taking naps when the baby sleeps." 2. "I have trouble sleeping well at night because I worry that I won't hear the baby cry." 3. "My aunt has come over every day to care for the baby because the baby's cries bother me." 4. "My spouse thinks that I have been more emotional since I had the baby last week."

"My aunt has come over every day to care for the baby because the baby's cries bother me."

Which of the following statements made by the mother of a child recently diagnosed with celiac disease indicates a need for further teaching? 1. "I will need to read the labels of all processed foods." 2. "It is okay if my child eats rice, corn, and potatoes." 3. "My child can have small amounts of foods containing wheat as long as she remains symptom free." 4. "My child will need to be on a gluten-free diet for the rest of her life."

"My child can have small amounts of foods containing wheat as long as she remains symptom free."

The nurse reinforces education to the parent of a child who was diagnosed with attention-deficit hyperactivity disorder and received a prescription of methylphenidate. Which statement by the parent best demonstrates that teaching has been effective? 1. "An additive-free, low-sugar diet will reduce my child's symptoms." 2. "I can now manage my child's condition on my own." 3. "My child should take the last daily dose of methylphenidate before 6:00 PM." 4. "Once the medication is started, I will not have to monitor my child anymore."

"My child should take the last daily dose of methylphenidate before 6pm."

The nurse assists with a community teaching program for parents and caregivers of infants. Which statement by a participant indicates that teaching has been successful? 1. "After age 6 months, it is safe to use honey to sweeten my infant's formula." 2. "I should wait until my infant is 1 year old to introduce egg products." 3. "I will switch my 1-year-old to low-fat milk instead of commercial formula." 4. "My infant should be able to pick up small finger foods by age 10 months."

"My infant should be able to pick up small finger foods by age 10 months."

The parents of a 4-year-old tell the nurse that the child won't go to sleep at night due to fear of tigers living under the bed. Which response by the nurse is most helpful? 1. "Have you recently visited the zoo? Maybe the tigers looked scary." 2. "If you agree with your child, the fears could continue through this developmental stage." 3. "Night fears are common at this age. Look under the bed with your child." 4. "This is very unusual. Maybe the child saw something scary on TV."

"Night fears are common at this age. Look under the bed with your child."

The nurse is caring for a client with absence seizures. The unlicensed assistive personnel (UAP) asks if the client will "shake and jerk" when having a seizure. Which response from the nurse is the most helpful? 1. "No, absence seizures can look like daydreaming or staring off into space." 2. "No, you are wrong. Don't worry about that." 3. "Yes, so please let me know if you see the client do that." 4. "You don't have to monitor the client for seizures."

"No, absence seizures can look like daydreaming or staring off into space."

The nurse cares for a client who just had surgical excision and biopsy of a tumor. The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider. The client asks the nurse, "Am I going to die?" Which statement by the nurse is appropriate? 1. "I know how anxious you must be. Watching some television might help you relax." 2. "Tell me more about your thoughts and feelings regarding the situation." 3. "The biopsy result shows that you have cancer, but many cancers are treatable." 4. "Waiting for test results can be stressful. I am sorry I cannot tell you more."

"Tell me more about your thoughts and feelings regarding the situation."

The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom? 1. "I need for you to get rid of these bugs that are crawling under my skin." 2. "Hear that? She told me to kill my father." 3. "That song is a message sent to me in secret code." 4. "Those Martians are trying to poison me with the tap water."

"That song is a message sent to me in secret code."

The student nurse observes the respiratory therapist (RT) preparing to draw an arterial blood gas from the radial artery. The RT performs the Allen's test and the student asks why this test performed before the blood sample is drawn. Which statement made by the RT is most accurate? 1. "The Allen's test is done to determine if capillary refill is adequate." 2. "The Allen's test is done to determine if the radial pulse is palpable." 3. "The Allen's test is done to determine the patency of the ulnar artery." 4. "The Allen's test is done to determine the presence of a neurologic deficit."

"The Allen's test is done to determine the patency of the ulnar artery."

The clinic nurse is asked by the mother of a 15-month-old, "I am worried about my child's thumb sucking and its effects on tooth alignment. What should I do?" What is the nurse's best response? 1. "As long as your child's thumb sucking stops by age 2-3 years when all of the primary teeth have erupted, there is little concern." 2. "Because your child already has teeth, it is important to implement a plan to stop the thumb sucking as soon as possible." 3. "Newer research shows that thumb sucking has little effect on a child's teeth." 4. "The risk for misaligned teeth occurs when thumb sucking persists after eruption of permanent teeth."

"The risk for misaligned teeth occurs when thumb sucking persists after eruption of permanent teeth."

The nurse caring for a terminally ill client asks if the client has an advance directive. The client states, "I already have a power of attorney." What is the best response by the nurse? 1. "A power of attorney (POA) is good to have in place. It sounds like you are on the right track." 2. "Great. Your POA can start to make decisions for you when you are no longer able to do so." 3. "Many people find a lawyer at this stage of life. A lawyer can help you get your affairs in order." 4. "There are many types of POAs. Let's clarify if your POA can make health care decisions for you."

"There are many types of POAs. Let's clarify if your POA can make health care decisions for you."

The nurse is preparing to administer a sodium polystyrene sulfonate retention enema. Which explanation by the nurse best describes the purpose of this type of enema? 1. "A contrast medium is administered rectally to visualize the colon via x-ray." 2. "Bedridden clients receive this enema to stimulate defecation and relieve constipation." 3. "This enema assists the large intestines in removing excess potassium from the body." 4. "This enema is administered before bowel surgery to decrease bacteria in the colon."

"This enema assists the large intestines in removing excess potassium from the body."

A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse, "If I hadn't come home early from work, my spouse would be dead. I can't believe this is happening." What is the best response by the nurse? 1. "Do you have any relatives or close friends who can help you through this?" 2. "Has your spouse seemed depressed lately?" 3. "This has been very overwhelming for you. What are you feeling right now?" 4. "Well, you did find your spouse. You need to focus on helping your spouse get better."

"This has been very overwhelming for you. What are you feeling right now?"

A client with a history of obsessive-compulsive personality disorder (OCPD) is seeking treatment for a gastrointestinal disorder and is scheduled for a colonoscopy at 10:00 AM. Due to a computer glitch, the procedure is postponed to 3:00 PM. Which response would be characteristic of an individual with OCPD? 1. "How dare they change my appointment? I insist that the procedure be done at 10:00 AM." 2. "That's fine. I can come in whenever it is convenient for everyone." 3. "This is unacceptable. I had my whole day planned out." 4. "Why are they doing this to me?"

"This is unacceptable. I had my whole day planned out."

A 21-year-old client is being evaluated in the outpatient psychiatric clinic after starting isocarboxazid 2 weeks ago. Which of the client's statements needs to be addressed first? 1. "I am not sleeping well at night and would like a sleeping aid." 2. "I do not know how well I will do on this restricted diet." 3. "I have been having quite a bit of nausea and constipation." 4. "This medicine is not working; I am so tired of being depressed."

"This medicine is not working; I am so tired of being depressed."

The student nurse is preparing to perform a heel stick on a neonate to collect blood for diagnostic testing. Which statement by the student nurse indicates a need for further education? 1. "I can perform the stick on either the medial or lateral side of the outer aspect of the heel." 2. "Sucrose and a pacifier can help alleviate the infant's pain and stress during the puncture." 3. "The heel area should be warmed for 3-5 minutes prior to puncture." 4. "Venipuncture should be reserved only for failed heel sticks because it is more painful."

"Venipuncture should be reserved only for failed heel sticks because it is more painful."

The nurse is reinforcing discharge instructions for the parents of a 4-year-old with heart failure. Which statement by one of the parents indicates the need for further teaching related to digoxin administration? 1. "We will hold the dose if our child's heart rate is above 90/min." 2. "We will not give a second dose if our child vomits after the first dose." 3. "We will not mix the medication with other foods or liquids." 4. "We will report symptoms of nausea and vomiting to our health care provider."

"We will hold the dose if our child's heart rate is above 90/min."

The parent of a 15-month-old calls the nurse and says that the child developed a rash and mild fever after receiving a routine measles, mumps, rubella, and varicella (MMRV) vaccine in the pediatric clinic 5 days ago. What is the best response by the nurse? 1. "Apply over-the-counter hydrocortisone cream to the rash." 2. "Bring your child to the clinic this afternoon." 3. "This is a common reaction to the MMRV vaccine." 4. "What is your child's temperature right now?"

"What is your child's temperature right now?"

An African American client comes to the clinic for a follow-up visit 2 months after starting enalapril for hypertension. Which client statement should be reported to the health care provider immediately? 1. "Is there anything I can take for my dry, hacking cough?" 2. "My blood pressure this morning was 158/84 mm Hg." 3. "Sometimes I feel a little dizzy when I stand up." 4. "Will you look at my tongue? It feels thicker than normal."

"Will you look at my tongue? It feels thicker than normal."

The nurse is evaluating a client's understanding of postcircumcision care for a 24-hour-old newborn. Circumcision was performed using the clamp method. Which statement by the client demonstrates a need for further teaching? 1. "Bleeding should be no larger than the size of a quarter." 2. "I should cleanse the glans with warm water occasionally." 3. "I should expect at least 2 wet diapers in the next 24 hours." 4. "Yellow exudate on the glans penis indicates infection."

"Yellow exudate on the glans penis indicates infection."

A client recently diagnosed with schizophrenia is brought to the mental health clinic by the identical twin sibling for the first follow-up visit after hospitalization. The client's sibling says to the nurse, "I read that schizophrenia runs in families. I guess I'm doomed." Which is the best response by the nurse? 1. "At the moment, I would worry more about how your sibling is doing." 2. "The odds are about 50-50 that you will come down with the disease as well." 3. "Would you like to talk to a health care provider about this?" 4. "You are at risk for the disease. However, there are other factors that contribute to the development of schizophrenia."

"You are at risk for the disease. However, there are other factors that contribute to the development of schizophrenia."

An infant is experiencing respiratory depression immediately after a vaginal delivery using epidural analgesia with morphine. The health care provider prescribes 0.1 mg/kg naloxone IM to be given STAT once. The client weighs 3600 grams and naloxone 0.4 mg/mL is available. How many milliliters will the nurse administer? Record your answer using one decimal place.

0.25 mL

The nurse reviews prescriptions for assigned adult clients. Which prescription should the nurse question? 1. 0.45% sodium chloride (NaCl) solution prescribed for a client with syndrome of inappropriate antidiuretic hormone secretion who has a sodium level of 120 mEq/L (120 mmol/L) 2. 0.9% NaCl solution prescribed for a client with gastrointestinal bleeding who has a hemoglobin level of 8.9 g/dL (89 g/L) 3. 1,000 mL bolus of 0.9% NaCl solution prescribed for a client with septic shock who has a white blood cell count of 18,000/mm3 (18.0 × 109/L) 4. Lactated Ringer's solution prescribed for a male client with hypovolemic shock and a thermal burn who has a hematocrit level of 56% (0.56)

0.45% sodium chloride (NaCl) solution prescribed for a client with syndrome of inappropriate antidiureic hormone secretion who has a sodium level of 120mEq/L

A laboring client weighing 187 lb is 5 cm dilated and having contractions every 2-3 minutes. The client rates the pain at 7 out of 10. Nalbuphine hydrochloride 10 mg/70 kg IV push × 1 is prescribed by the health care provider. Nalbuphine hydrochloride 10 mg/1 mL is available. How many milliliters does the nurse administer? Record your answer using one decimal place.

0.8 mL

The nurse assists with data collection during a screening event at a gastroenterology clinic. Which of the following client statements include risk factors for esophageal cancer? Select all that apply. 1. "A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week." 2. "I am proud that I was able to lose 10 lb, but I'm still considered obese for my height." 3. "I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently." 4. "I have struggled with daily episodes of acid reflux for years, especially at nighttime." 5. "I snack on a lot of salted foods like popcorn and peanuts."

1. "A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week." 2. "I am proud that I was able to lose 10 lb, but I'm still considered obese for my height." 3. "I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently." 4. "I have struggled with daily episodes of acid reflux for years, especially at nighttime."

The nurse is reinforcing education to a group of clients that are pregnant or planning pregnancy. Which of the following client statements about alcohol use in pregnancy should concern the nurse? Select all that apply. 1. "As long as I don't binge drink, an occasional glass of wine is fine." 2. "I drank alcohol heavily before realizing I was pregnant, so there is no benefit to quitting now." 3. "If I drink alcohol, my baby may have withdrawal after birth but no permanent damage." 4. "It is important to stop drinking while I am trying to conceive." 5. "Third-trimester alcohol use is less harmful because the baby is fully developed."

1. "As long as I don't binge drink, an occasional glass of wine is fine." 2. "I drank alcohol heavily before realizing I was pregnant, so there is no benefit to quitting now." 3. "If I drink alcohol, my baby may have withdrawal after birth but no permanent damage." 5. "Third-trimester alcohol use is less harmful because the baby is fully developed."

The nurse is reinforcing home care education to a client newly diagnosed with von Willebrand disease. Which of the following client statements demonstrate correct understanding of the education? Select all that apply. 1. "I can use a humidifier to help prevent nosebleeds." 2. "I need to avoid contact sports such as soccer or hockey." 3. "I should use a soft-bristled toothbrush and electric razor." 4. "I will call my health care provider if I soak a menstrual pad in an hour." 5. "I will take naproxen to decrease pain and inflammation if I am injured."

1. "I can use a humidifier to help prevent nosebleeds." 2. "I need to avoid contact sports such as soccer or hockey." 3. "I should use a soft-bristled toothbrush and electric razor." 4. "I will call my health care provider if I soak a menstrual pad in an hour."

The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply. 1. "I should rinse my mouth with water before collecting the sputum." 2. "I will be careful not to touch the inside of the specimen cup or lid." 3. "I will inhale deeply a few times and then cough forcefully." 4. "It is best to collect the sputum mid-day when my secretions are loose." 5. "It is helpful if I am sitting upright when I collect the sputum."

1. "I should rinse my mouth with water before collecting the sputum." 2. "I will be careful not to touch the inside of the specimen cup or lid." 3. "I will inhale deeply a few times and then cough forcefully." 5. "It is helpful if I am sitting upright when I collect the sputum."

The nurse reinforces teaching for the parents of a child with impetigo. Which of the following statements by a parent indicates correct understanding of teaching? Select all that apply. 1. "I should wash my hands before and after touching the infected area." 2. "I will clean the infected area with alcohol before applying the antibiotic ointment." 3. "I will separate my child's towels from other laundry and wash them with hot water." 4. "My child's fingernails should be kept short and well-filed." 5. "The infection could easily spread to other children who come in contact with my child."

1. "I should wash my hands before and after touching the infected area." 3. "I will seperate mu child's towles from other laundry and wash them with hot water." 4. "My child's fingernails should be kept short and well- filed." 5. "The infection could easily spread to other children who come in contact with my child."

The parent of a 3-month-old with tetralogy of Fallot calls the clinic nurse with concerns about the child. Which of the following statements indicate that the infant may be experiencing heart failure? Select all that apply. 1. "My baby gained 0.5 lb over the weekend." 2. "My baby had two extra feedings today." 3. "My baby has not had a wet diaper in 6 hours." 4. "My baby's eyes look swollen and puffy." 5. "My baby's fingers and toes feel ice cold."

1. "My baby gained 0.5 lb over the weekend." 3. "My baby has not had a wet diaper in 6 hours." 4. "My baby's eyes look swollen and puffy." 5. "My baby's fingers and toes feel ice cold."

A nurse is reinforcing education given to the parents of a child diagnosed with chronic allergic rhinitis that is triggered by household and environmental allergens. Which statements by the parents indicate that the teaching has been effective? Select all that apply. 1. "My wife plans to wipe down our child's furniture with a damp rag every other day." 2. "Our child needs plastic covers for the mattress and pillow." 3. "We must give away the family dog." 4. "We will keep the windows open during warm weather to air out the house." 5. "We will replace the carpet with hardwood floors throughout the house."

1. "My wife plans to wipe down our child's furniture with a damp rag every other day." 2. "Our child needs plastic covers for the mattress and pillow." 5. "We will replace the carpet with hardwood floors throughout the house."

The clinic nurse has contributed to the teaching plan for the following 6 clients. The nurse reinforces the teaching by instructing which client to avoid the Valsalva maneuver when defecating? Select all that apply. 1. 22-year-old man with a head injury sustained during a college football game 2. 30-year-old woman recently hospitalized for reconstructive augmentation mammoplasty 3. 56-year-old man 2 weeks post myocardial infarction 4. 68-year-old woman recently diagnosed with pancreatic cancer 5. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis 6. 82-year-old woman 1 week post cataract surgery

1. 22-year-old man with a head injury sustained during a college football game 3. 56-year-old man 2 weeks post myocardial infarction 5. 74-year-old man with portal hypertension related to alcohol-induced cirrhosis 6. 82-year-old woman 1 week post cataract surgery

The nurse is reinforcing education on child abuse and neglect to a certified home health aide. The nurse will include which statements in identifying the characteristics of the typical perpetrator of child abuse? Select all that apply. 1. Abusers often have a history of growing up in an environment of domestic violence 2. Abusers often have a history of substance abuse 3. Child abusers always present as being agitated or out of control 4. Men are much more likely to abuse children than are women 5. Most child abusers have a diagnosed mental illness 6. Teenage parents are particularly vulnerable to abusing their children

1. Abusers often have a history of growing up in an environment of domestic violence 2. Abusers often have a history of substance abuse 6. Teenage parents are particularly vulnerable to abusing their children

The home health nurse is providing long-term care to several clients. Which are examples of inappropriately crossing professional boundaries? Select all that apply. 1. Accepting a birthday gift of a gold bracelet from a client 2. Making a visit to the hospital after a client has surgery 3. Offering to pray together if a client so wishes 4. Sending a sympathy card to family after a client dies 5. Soliciting a wealthy client to invest in a company 6. Staying after work hours and drinking wine with a client

1. Accepting a birthday gift of a gold bracelet from a client 5. Soliciting a wealthy client to invest in a company 6. Staying after work hours and drinking wine with a client

The nurse assists with a staff education conference about appropriate nonpharmacological pain-management interventions for newborns and infants. Which of the following strategies should be included in the presentation? Select all that apply. 1. Administer an oral sucrose solution to a newborn during a circumcision procedure 2. Apply a cold pack to a newborn's heel 30 minutes before performing a heel stick 3. Assist the parent to hold a newborn skin-to-skin during an immunization injection 4. Offer a pacifier to an infant while performing venipuncture 5. Swaddle an infant while leaving one arm unwrapped during an IV dressing change

1. Administer an oral sucrose solution to a newborn during a circumcision procedure 3. Assist the parent to hold a newborn skin-to-skin during an immunization injection 4. Offer a pacifier to an infant while performing venipuncture 5. Swaddle an infant while leaving one arm unwrapped during an IV dressing change

The hospice nurse is providing end-of-life care to a client who is experiencing anorexia and cachexia. Which interventions are appropriate? Select all that apply. 1. Allow the client to refuse food if not feeling hungry 2. Ask if the client is experiencing any pain or nausea 3. Involve the client in meal planning and food selection 4. Plan for loved ones to share mealtimes with the client 5. Provide oral care before and after meals to alleviate dry mouth

1. Allow the client to refuse food if not feeling hungry 2. Ask if the client is experiencing any pain or nausea 3. Involve the client in meal planning and food selection 4. Plan for loved ones to share mealtimes with the client 5. Provide oral care before and after meals to alleviate dry mouth

Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply. 1. Amenorrhea 2. Fluid and electrolyte imbalances 3. Heat intolerance 4. Presence of lanugo 5. Refusal to exercise 6. Weight loss of 25% below normal weight

1. Amenorrhea 2. Fluid and electrolyte imbalances 4. Presence of lanugo 6. Weight loss of 25% below normal weight

The nurse is planning education for clients in group prenatal care who are entering the second trimester of pregnancy. Which of the following are appropriate for the nurse to include in second-trimester teaching? Select all that apply. 1. Anticipate light fetal movements around 16-20 weeks gestation 2. Expect to have an abdominal ultrasound for fetal anatomy evaluation 3. Gain about 1 lb (0.5 kg) per week if pre-pregnancy BMI was normal 4. Increase consumption of iron-rich foods like meat and dried fruit 5. Plan for gestational diabetes screening near the end of the second trimester

1. Anticipate light fetal movements around 16-20 weeks gestation 2. Expect to have an abdominal ultrasound for fetal anatomy evaluation 3. Gain about 1 lb (0.5 kg) per week if pre-pregnancy BMI was normal 4. Increase consumption of iron-rich foods like meat and dried fruit 5. Plan for gestational diabetes screening near the end of the second trimester

After a recent outbreak of varicella in an elementary school, the practical nurse is assisting with the development of an informative letter to parents. Which of the following instructions are appropriate to include? Select all that apply. 1. Apply calamine lotion to soothe lesions 2. Clip your child's fingernails short 3. Ensure that your child's vaccinations are up to date 4. Keep your child home until lesions have crusted 5. Place mittens on your child's hands when sleeping

1. Apply calamine lotion to soothe lesions 2. Clip your child's fingernails short 3. Ensure that your child's vaccinations are up to date 4. Keep your child home until lesions have crusted 5. Place mittens on your child's hands when sleeping

The inpatient hospice nurse is caring for a Muslim client newly admitted with terminal cancer. Which of the following interventions would the nurse anticipate for this client? Select all that apply. 1. Arrange for health care workers of the same sex to provide care for the client 2. Coordinate with the registered dietician to provide halal meals 3. Reposition the immobile client to face the city of Mecca during daily prayer times 4. Restrict the number of visitors from the family to preserve the client's privacy 5. Upon death, provide the family with supplies for postmortem care

1. Arrange for health care workers of the same sex to provide care for the client 2. Coordinate with the registered dietician to provide halal meals 3. Reposition the immobile client to face the city of Mecca during daily prayer times 5. Upon death, provide the family with supplies for postmortem care

While caring for a client in skeletal traction, which tasks can the nurse assign to experienced unlicensed assistive personnel to help prevent immobility hazards? Select all that apply. 1. Assist with active and passive range of motion exercises 2. Change bed linens while logrolling the client from side to side 3. Check the color and temperature of the affected extremity 4. Reapply pneumatic compression device after bathing the client 5. Remind the client to use the incentive spirometer

1. Assist with active and passive range of motion exercises 4. Reapply pneumatic compression device after bathing the client 5. Remind the client to use the incentive spirometer

A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply. 1. Blood pressure 82/64 mm Hg 2. Crackles on auscultation 3. Distended jugular veins 4. Pulse 120/min 5. Shoulder pain

1. BP 82/64 4. HR 120 5. shoulder pain

The nurse admits a client to the unit who reports taking high doses of aspirin to ease the pain of chronic headaches. The nurse should monitor for which adverse effects? Select all that apply. 1. Black tarry stools 2. Bradycardia 3. Bruising 4. Hypertension 5. Ringing in the ears

1. Black tarry stools 3. Bruising 5. Ringing in the ears

The nurse is reviewing the records of an adolescent client. Which findings suggest that the client may need referral for depression screening? Select all that apply. 1. Client has had school disciplinary issues due to absenteeism and angry outbursts 2. Client has lost approximately 8 lb (3.64 kg) over the last 3 weeks without trying 3. Client is often found sleeping during class or activities 4. Client quit sports despite receiving previous athletic awards and trophies 5. Client voices concern about appearance related to facial acne

1. Client has had school disciplinary issues due to absenteeism and angry outbursts 2. Client has lost approximately 8 lb (3.64 kg) over the last 3 weeks without trying 3. Client is often found sleeping during class or activities 4. Client quit sports despite receiving previous athletic awards and trophies

In which scenarios should the nurse hold the prescribed medication and question its administration? Select all that apply. 1. Client on IV heparin and the platelet count is 50,000/mm3 (50 x 109/L) 2. Client on newly prescribed lisinopril and is at 8 weeks gestation 3. Client on nitroglycerin patch for heart failure and blood pressure is 84/56 mm Hg 4. Client on phenytoin for epilepsy and the nurse notes gingival hyperplasia 5. Client on warfarin and prothrombin time/International Normalized Ratio is 1.5 times control value

1. Client on IV heparin and the platelet count is 50,000/mm3 (50 x 109/L) 2. Client on newly prescribed lisinopril and is at 8 weeks gestation 3. Client on nitroglycerin patch for heart failure and blood pressure is 84/56 mm Hg

The nurse is conducting intake interviews at the clinic. Which client situations would require the nurse to intervene? Select all that apply. 1. Client with iron deficiency anemia takes iron supplements with milk 2. Client takes levothyroxine early in the morning on an empty stomach 3. Client taking phenazopyridine for urine infection states that the urine has turned orange 4. Client taking metronidazole mentions going to a wine-tasting party tonight 5. Client with closed-angle glaucoma takes over-the-counter diphenhydramine for a cold

1. Client with iron deficiency anemia takes iron supplements with milk 4. Client taking metronidazole mentions going to a wine-tasting party tonight 5. Client with closed-angle glaucoma takes over-the-counter diphenhydramine for a cold

The nurse prepares a community education program about health promotion strategies for postmenopausal women. Which of the following teaching points are appropriate to include? Select all that apply. 1. Consider seeing a dietitian for help with healthy weight maintenance 2. Consult with a health care provider for cholesterol monitoring 3. Engage in a daily weight-bearing exercise regimen 4. Prioritize consumption of green, leafy vegetables and dairy products 5. Seek support to cope with any emotional symptoms

1. Consider seeing a dietitian for help with healthy weight maintenance 2. Consult with a health care provider for cholesterol monitoring 3. Engage in a daily weight-bearing exercise regimen 4. Prioritize consumption of green, leafy vegetables and dairy products 5. Seek support to cope with any emotional symptoms

Which are appropriate examples of cost-effective care? Select all that apply. 1. Considering the inside of the sterile glove wrapper as a small sterile field 2. Donning clean, rather than sterile, gloves to remove a client's dressing 3. Returning opened, unused supplies from a client's room to the central supply room 4. Reusing a tourniquet for multiple clients unless it is visibly soiled 5. Using remaining sterile saline in a bottle opened 48 hours ago before discarding

1. Considering the inside of the sterile glove wrapper as a small sterile field 2. Donning clean, rather than sterile, gloves to remove a client's dressing

A nurse is caring for a 1-month-old client who is being evaluated for congenital hypothyroidism. The nurse should recognize which of the following as clinical manifestations of hypothyroidism in infants? Select all that apply. 1. Difficult to awaken 2. Dry skin 3. Frequent, loose stools 4. Hoarse cry 5. Tachycardia

1. Difficult to awaken 2. Dry skin 4. Hoarse cry

A practical nurse is collaborating with a registered nurse educator to develop materials for a hospital-wide campaign about zero tolerance for lateral violence and bullying among staff. Which actions should staff members be encouraged to perform if they experience workplace violence? Select all that apply. 1. Document the interactions with the bully 2. Ignore the bully's comments, remarks, and allegations 3. Observe interactions between the bully and other colleagues 4. Report the violent incidents to the hospital administrator 5. Tell the bully you will not tolerate the unprofessional behavior

1. Document the interactions with the bully 3. Observe interactions between the bully and other colleagues 5. Tell the bully you will not tolerate the unprofessional behavior

The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesions. Which of the following actions are appropriate to include in the plan of care? Select all that apply. 1. Don gown, gloves, and N95 respirator when entering the client's room 2. Ensure that pregnant staff members are not assigned to care for this client 3. Place single-use, disposable thermometer and stethoscope in the room 4. Place the client in a private room with negative air pressure 5. Request discontinuation of isolation precautions once all lesions are dry and crusted

1. Don gown, gloves, and N95 respirator when entering the client's room. 2.Ensure that pregnant staff members are not assigned to care for this client. 3. Place single-use, disposable thermometer and stethoscope in the room. 4. Place the client in a private room with negative air pressure. 5. Request discontinuation of isolation precautions once all lesions are dry and crusted.

A nurse is caring for a school-age client with fever, somnolence, and a skin rash from suspected meningococcal meningitis. Which of the following interventions should the nurse plan to implement for this client? Select all that apply. 1. Elevate head of bed at 30 degrees 2. Implement seizure precautions 3. Keep a mask on the client at all times 4. Minimize environmental stimuli 5. Place client in a room with negative-pressure air flow

1. Elevate head of bed at 30 degrees 2. Implement seizure precautions 4. Minimize environmental stimuli

The nurse on a pediatric unit is caring for a preschooler who exhibits separation anxiety when the parents go to work. Which interventions should the nurse implement? Select all that apply. 1. Encourage the parents to leave the child's favorite stuffed animal 2. Establish a daily schedule similar to the child's home routine 3. Give the child time to calm down alone when visibly upset 4. Provide frequent opportunities for play and activity 5. Remove visual reminders of the parents from the room

1. Encourage the parents to leave the child's favorite stuffed animal 2. Establish a daily schedule similar to the child's home routine 4. Provide frequent opportunities for play and activity

The nurse assessing a client notices pearly white plaque-like lesions on the mouth mucosa. The nurse understands that which client is at highest risk for oral candidiasis? 1. A client with asthma who uses an albuterol nebulizer once a day 2. A client receiving intravenous broad-spectrum antibiotics daily 3. A teenage client with braces who drinks several sugary drinks daily 4. An elderly client with poor oral hygiene and inadequate nutrition

A client recieving intravenous broad-spectrum antibotics daily.

The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing actions should be implemented immediately? Select all that apply. 1. Guide the client to the floor and gently cradle the head 2. Insert a tongue blade to prevent client from swallowing the tongue 3. Move objects that may cause injury away from the client 4. Physically restrain the client to prevent injury 5. Place the client in left lateral position 6. Remain with the client, observe, and record the seizure activity

1. Guide the client to the floor and gently cradle the head 3. Move objects that may cause injury away from the client 5. Place the client in left lateral position 6. Remain with the client, observe, and record the seizure activity

The most recent laboratory results for a 12-month-old who is HIV-positive show a CD4 lymphocyte count of 500/mm3 and a CD4 lymphocyte percentage of 10%. The nurse anticipates administering which immunizations? Select all that apply. 1. Haemophilus influenzae type b (Hib) 2. Hepatitis A (Hep A) 3. Measles, mumps, rubella (MMR) 4. Pneumococcal conjugate vaccine (PCV) 5. Varicella

1. Haemophilus influenzae type b (Hib) 2. Hepatitis A (Hep A) 4. Pneumococcal conjugate vaccine (PCV)

The practical nurse is assisting the registered nurse to create a care plan for a 3-year-old client admitted with a pertussis infection. Which of the following interventions should be included? Select all that apply. 1. Institute droplet precautions 2. Monitor for signs of airway obstruction 3. Offer small sips of fluid frequently 4. Place client in a negative-pressure isolation room 5. Request a prescription for cough suppressants

1. Institute droplet precautions 2. Monitor for signs of airway obstruction 3. Offer small sips of fluid frequently

The health care provider has just prescribed tetracycline for an adolescent with acne vulgaris. The client takes oral contraceptive pills. The nurse should reinforce teaching about which topics? Select all that apply. 1. Not taking tetracycline with dairy products 2. Taking tetracycline at bedtime 3. Taking tetracycline with food 4. Using additional contraceptive techniques 5. Using sunblock

1. Not taking tetracycline with dairy products 4. Using additional contraceptive techniques 5. Using sunblock

A home health nurse is supervising a home health aide who is changing the dressing for a client with a chronic heel wound. Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply. 1. Open a sterile container of 4 x 4's using the outermost corner to peel back the cover 2. Pull glove off over the soiled dressing to encase it before disposal 3. Save unused sterile 4 x 4's by taping original package shut for the next dressing change 4. Wash hands prior to putting on gloves and after removing them 5. Wrap soiled dressing in paper towels before disposing of it in the trash can

1. Open a sterile container of 4 x 4's using the outermost corner to peel back the cover 2. Pull glove off over the soiled dressing to encase it before disposal 4. Wash hands prior to putting on gloves and after removing them

The nurse is caring for a child who has had a tonsillectomy. Which of the following are appropriate nursing interventions? Select all that apply. 1. Anticipate ear pain and give acetaminophen as needed 2. Educate parents to expect the child to develop bad breath postoperatively 3. Encourage the child to drink cold liquids through a straw 4. Notify the health care provider about frequent, increased swallowing 5. Use an oral suction device regularly to remove secretions from the back of the throat

1. anticipate ear pain and give acetaminophen as needed 2. educate parents to expect the child to develop bad breath postoperatively 4. notify the health care provider about frequent, increased swallowing

The nurse is caring for a client with moderate asthma exacerbation. Which of the following assigned tasks are within the practical nurse's scope of practice? Select all that apply. 1. Administering albuterol metered-dose inhaler and evaluating client response 2. Checking oxygen saturation with the pulse oximeter 3. Monitoring for shortness of breath and labored breathing 4. Teaching client how to use a newly prescribed peak expiratory flow meter 5. Writing the plan of care based on the client's peak flow results

1. amdinistering albuterol metered-dose inhaler and evaluating client response 2. chencking oxygen saturation with the pulse oximeter 3. monitoring for SOB and labored breathing

A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply. 1. Amphetamine use 2. Cigarette smoking 3. Cold exposure 4. Deep sleep 5. Sexual intercourse

1. amphetamine use 2. cigarette smoking 3. cold exposure 5. sexual intercourse

While caring for a client in skeletal traction, which tasks can the nurse assign to experienced unlicensed assistive personnel to help prevent immobility hazards? Select all that apply. 1. Assist with active and passive range of motion exercises 2. Change bed linens while logrolling the client from side to side 3. Check the color and temperature of the affected extremity 4. Reapply pneumatic compression device after bathing the client 5. Remind the client to use the incentive spirometer

1. assist with active and passive range of motion exercises 4. reapply pneumatic compression device after bathing the client 5. remind the client to use the incentive spirometer

The nurse is reinforcing discharge teaching for the parents of a 1-year-old with a newly diagnosed cow's milk allergy. Which nutrients normally provided by milk should be obtained from other sources? Select all that apply. 1. Calcium 2. Fiber 3. Iron 4. Vitamin D 5. Vitamin K

1. calcium 4. Vitamin D

The nurse is reviewing lifestyle and nutritional strategies to help reduce symptoms in a client with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? Select all that apply. 1. Choose foods that are low in fat 2. Do not consume any foods containing dairy 3. Eat three large meals a day and minimize snacking 4. Limit or eliminate the use of alcohol and tobacco 5. Try to avoid caffeine, chocolate, and peppermint

1. choose foods that are low in fat 4. limit or eliminate the use of alcohol and tobacco 5. try to avoid caffeine, chocolate, and peppermint

A client with chronic bronchitis tells the home health nurse of being exhausted all day due to coughing all night and being unable to sleep. The client can feel thick mucus in the chest and throat. Which teaching can the nurse reinforce to help the client mobilize secretions and improve sleep? Select all that apply. 1. Increase fluids to at least 8 glasses (2-3 L) of water a day 2. Sleep with a cool mist humidifier 3. Take prescribed guaifenesin cough medicine before bedtime 4. Use abdominal breathing and the huff cough technique at bedtime 5. Use pursed-lip breathing during the night

1. increase fluids to at least 8 glasses (2-3L) of water a day 2. sleep with a cool mist humidifier 3. take prescribed guaifenesin cough medicine before bedtime 4. use abdominal breathing and the huff cough technique at bedtime

A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? Select all that apply. 1. Keep dedicated equipment for client 2. Perform hand hygiene before exiting the room 3. Place a "No Visitors" sign on the client's door 4. Wear a face mask when in the room 5. Wear an isolation gown when providing direct care

1. keep dedicated equipment for client 2. perform hand hygiene before exiting the room 5. wear an isolation gown when providing direct care

The nurse is caring for 4 clients. Which client should the nurse see first? 1. 2 days post abdominal aortic aneurysm repair with weak pedal pulses and mottled skin on the legs 2. 2 days post coronary bypass graft surgery with a white blood cell count of 18,000/mm3 (18.0 × 109/L) 3. Chronic heart failure with peripheral edema and shortness of breath on exertion 4. Pneumothorax with a chest tube to negative suction and subcutaneous emphysema

2 days post abdominal aortic aneurysm repair with weak pedal pulses and mottled skin on the legs

The nurse is reinforcing teaching about constipation prevention to a client. Which of the following client statements indicate appropriate understanding of the teaching? Select all that apply. 1. "Drinking more caffeinated drinks such as tea and soda helps to stimulate the bowel." 2. "Having a routine for bowel movements is important, but I should not wait if I feel the urge." 3. "I can use an over-the-counter laxative every other day if needed." 4. "I should try to eat more fruits and vegetables every day." 5. "Increasing my daily exercise level may help keep my bowel movements regular."

2. "Having a routine for bowel movements is important, but I should not wait if I feel the urge." 4. "I should try to eat more fruits and vegetables every day." 5. "Increasing my daily exercise level may help keep my bowel movements regular."

An 80-year-old client is prescribed codeine for a severe cough. The home health nurse is reinforcing instructions on how to prevent the common adverse effects associated with codeine. Which client statements indicate an understanding of how to prevent them? Select all that apply. 1. "I'll be sure to apply sunscreen if I go outside." 2. "I'll drink at least 8 glasses of water a day." 3. "I'll drink decaffeinated coffee so I can sleep at night." 4. "I'll sit on the side of my bed for a few minutes before getting up." 5. "I'll take my medicine with food." .

2. "I'll drink at least 8 glasses of water a day." 4. "I'll sit on the side of my bed for a few minutes before getting up." 5. "'ll take my medicine with food."

Which actions would the nurse expect to be included in the care plan for a client hospitalized for bipolar disorder, acute manic episode? Select all that apply. 1. Ask the client to plan an outing for the unit 2. Assign the client to a private room 3. Choose clothing for the client 4. Include the client in group therapy sessions 5. Schedule the client for physical activity with a staff member 6. Seat the client with other clients in the dining room for meals

2. Assign the client to a private room 3. Choose clothing for the client 5. Schedule the client for physical activity with a staff member

The nurse cares for a hospitalized client with malnutrition related to anorexia nervosa. Which of the following actions are appropriate in the care of this client? Select all that apply. 1. Allow the client to continue to exercise per usual routine 2. Assist the client in reflecting on triggers of disordered eating 3. Document the client's daily intake of calories and protein 4. Remain with the client for the duration of each meal 5. Weigh the client each morning prior to any oral intake

2. Assist the client in reflecting on triggers of disordered eating 3. Document the client's daily intake of calories and protein 4. Remain with the client for the duration of each meal 5. Weigh the client each morning prior to any oral intake

A nurse is performing an assessment of a 12-month-old child. Which of the following findings would the nurse expect? Select all that apply. 1. Approaches strangers with ease 2. Birth weight is tripled 3. Can skip and hop on one foot 4. Fully developed pincer grasp 5. Sits from a standing position

2. Birth weight is tripled 4. Fully developed pincer grasp 5. Sits from a standing position

The nurse is reinforcing discharge teaching with a client who has been prescribed warfarin for chronic atrial fibrillation. The client should avoid excess or inconsistent intake of which foods? Select all that apply. 1. Bananas 2. Broccoli 3. Grapefruit juice 4. Red meat 5. Spinach

2. Broccoli 3. Grapefruit juice 5. Spinach

A client with an asthma exacerbation has been using her albuterol rescue inhaler 10-12 times a day because she cannot take a full breath. What possible side effects of albuterol does the nurse anticipate the client will report? Select all that apply. 1. Constipation 2. Difficulty sleeping 3. Hives with pruritus 4. Palpitations 5. Tremor

2. Difficulty sleeping 4. Palpitations 5. Tremor

The nurse is collecting data on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply. 1. Bright red bleeding from anus 2. Distended abdomen 3. Has not passed stool (meconium) 4. Nonbilious vomiting 5. Refuses to feed

2. Distended abdomen 3. Has not passed stool (meconium) 5. Refuses to feed

A client at 34 weeks gestation has constipation. The client has been taking 325 mg ferrous sulfate tid for anemia since the last appointment 4 weeks ago. Which instructions should the nurse reinforce for this client? Select all that apply. 1. Decrease total daily dairy intake 2. Increase intake of fruits and vegetables 3. Moderate-intensity regular exercise 4. One laxative twice daily for a week 5. Two cups of hot coffee each morning

2. Increase intake of fruits and vegetables 3. Moderate-intensity regular exercise

The nurse is caring for a confused client in soft wrist restraints. Which tasks can the nurse safely assign to unlicensed assistive personnel? Select all that apply. 1. Assess circulation and sensation of the extremities 2. Perform range of motion exercises 3. Reapply the restraints after toileting 4. Report changes in skin integrity 5. Turn and reposition the client in bed

2. Perform range of motion exercises 3. Reapply the restraints after toileting 4. Report changes in skin integrity 5. Turn and reposition the client in bed

The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? Select all that apply. 1. One artery and one vein in the umbilical cord 2. Plantar creases up the entire sole 3. Skin on the nose blanches to a yellowish hue 4. Toes fan outward when the lateral sole surface is stroked 5. White pearl-like cysts on gum margins

2. Plantar creases up the entire sole 4. Toes fan outward when the lateral sole surface is stroked 5. White pearl-like cysts on gum margins

A client is being discharged after having a coronary artery bypass grafting x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply. 1. Report any itching, tingling, or numbness around your incisions 2. Report any redness, swelling, warmth, or drainage from your incisions 3. Soak incisions in the tub once a week, then clean with hydrogen peroxide and apply lotion 4. Wash incisions daily with soap and water in the shower and gently pat them dry 5. Wear an elastic compression hose on your legs and elevate them while sitting

2. Report any redness, swelling, warmth, or drainage from your incisions 4. Wash incisions daily with soap and water in the shower and gently pat them dry 5. Wear an elastic compression hose on your legs and elevate them while sitting

The emergency department nurse cares for a client whose college roommate reports recent changes in the client's behavior. Which behaviors and clinical data meet the criteria for involuntary admission to the mental health unit? Select all that apply. 1. Client has been sleeping on the floor in the den rather than the bed 2. Client has refused food and water for 4 days and has poor skin turgor 3. Client repeatedly mumbles, "I must kill them before they get me" 4. Marijuana was found in the client's personal belongings 5. The health care provider makes a diagnosis of schizophrenia

2. client has refused food and water for 4 days and has poor skin turgor 3. client repeatedly mumbles, "I must kill them before rthey get me"

Which components are used in determining the standards of professional nursing practice? Select all that apply. 1. Care given with good intention to the best of one's ability 2. Clinical practice statements of professional organizations 3. Health care institution's policies and procedures 4. Nurse Practice Act of the state or province/territory 5. Nurse's usual custom and practice

2. clinical practice statements of professional organizations 3. healthcare institutions policies and procedures 4. Nurse Practice Act of the state or province/ territory

Which herbal supplements pose an increased risk for bleeding in surgical clients and should be discontinued prior to major surgery? Select all that apply. 1. Black cohosh 2. Garlic 3. Ginger 4. Ginkgo biloba 5. Hawthorn

2. garlic 3. ginger 4. ginko biloba

TThe nurse is caring for a client with newly prescribed hearing aids. Which of the following actions by the client indicate proper use and care of hearing aids? Select all that apply. 1. Keeps hearing aids clean by rinsing them with water 2. Lowers television volume when talking with nurse 3. Places hearing aids on food tray when not in use 4. Turns volume completely down prior to insertion of aid into the ear 5. Verifies that battery compartment is closed before insertion

2. lowers tv when talkin got the nurse 4. turns volume completely down prior to insertion into ear 5. verifies that battery compartment is closed before insertion

The nurse is obligated to make a report for which situations? Select all that apply. 1. Report to a client's employer that the client had a car crash while intoxicated 2. Report to the authorities of a death by suicide on the unit 3. Report to the client's spouse that the client has a reportable sexually transmitted disease 4. Report to the hotline that an elderly client has suspicious bruising but denies caregiver abuse 5. Report to the supervisor that a health care provider has the smell of alcohol on the breath

2. report to the authorities of a death by suicide on the unit 4. report to the hotline that an elderly client has suspicious bruising but denies caregiver abuse 5. report to the supervisor that a healthcare provider has the smell of alcohol on the breath

The clinic nurse is caring for several clients during well-child visits. The nurse should recognize which client as being the most at risk for anemia? 1. 1-month-old infant born at term gestation who exclusively breastfeeds 2. 2-month-old infant born at preterm gestation who exclusively receives iron-fortified formula 3. 3-month-old infant born at preterm gestation who is exclusively bottle-fed with breastmilk 4. 6-month-old infant born at term gestation who breastfeeds and eats iron-fortified infant cereal

3-mnth old infant born at preterm gestation who is exclusively bottle-fed with breastmilk.

The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client. Which statements made by the parents demonstrate correct understanding? Select all that apply. 1. "I can mix the medication in a bowl of my child's favorite cereal." 2. "I should give another dose if my child vomits after taking the medication." 3. "I should measure liquid medications using an oral syringe." 4. "I will encourage my child to help me as I prepare the medication." 5. "I will place my child in time-out if the medication is refused."

3. "I should measure liquid medications using an oral syringe." 4. "I will encourage my child to help me as I prepare the medication."

Which findings reflect vital signs that are concerning and require further nursing monitoring and intervention? Select all that apply. 1. After albuterol administration, 5-year-old client has a pulse of 120/min and reports tremor 2. After hydromorphone 1 mg IV push, blood pressure decreases from 130/80 mm Hg to 110/70 mm Hg 3. Blood pressure is 90/60 mm Hg, and the nurse is preparing to administer prescribed nifedipine 4. Blood pressure was 120/80 mm Hg and pulse was 80/min before blood transfusion; current values are 90/70 mm Hg and 100/min, respectively 5. Fetal heart rate monitored during labor decreases from 140/min to 100/min following a contraction

3. Blood pressure is 90/60 mm Hg, and the nurse is preparing to administer prescribed nifedipine 4. Blood pressure was 120/80 mm Hg and pulse was 80/min before blood transfusion; current values are 90/70 mm Hg and 100/min, respectively 5. Fetal heart rate monitored during labor decreases from 140/min to 100/min following a contraction

When monitoring an infant with a left-to-right-sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply. 1. Clubbing of fingertips 2. Cyanosis when crying 3. Diaphoresis during feedings 4. Heart murmur 5. Poor weight gain

3. Diaphoresis during feedings 4. Heart murmur 5. Poor weight gain

The nurse is interviewing a non-English-speaking client. Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency? Select all that apply. 1. Address the interpreter directly 2. Ask the client's adult child to translate 3. Hold a pre-conference with the interpreter 4. Identify any gender or age preferences 5. Speak in short sentences

3. Hold a pre-conference with the interpreter 4. Identify any gender or age preferences 5. Speak in short sentences

The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply. 1. Age of 50 2. Diagnosis of ovarian cancer 3. Lying pulse 80/min, standing pulse 110/min 4. Osteoarthritis of knees 5. Takes carbidopa/levodopa 6. Uses a cane to ambulate

3. Lying pulse 80/min, standing pulse 110/min 4. Osteoarthritis of knees 5. Takes carbidopa/levodopa 6. Uses a cane to ambulate

The nurse is caring for an adolescent client who just had placement of an external fixation device for long-term stabilization of a fractured tibia. Which interventions should the nurse expect to implement when caring for this client? Select all that apply. 1. Check the pins every 4 hours and turn the bolt clockwise to tighten loose pins 2. Maintain client on bed rest until the device is removed 3. Notify the registered nurse immediately of pin site drainage or increased pain 4. Perform neurovascular checks every 2-4 hours for 24 hours 5. Perform sterile pin care per institutional policy

3. Notify the registered nurse immediately of pin site drainage or increased pain 4. Perform neurovascular checks every 2-4 hours for 24 hours 5. Perform sterile pin care per institutional policy

The licensed practical nurse is working with a registered nurse to care for a client who has just returned to the cardiac unit after having a percutaneous coronary intervention. Which actions assigned by the registered nurse should the practical nurse question as outside of the practical nurse's scope of practice? Select all that apply. 1. Administering oral pain medication if client reports low back pain 2. Checking for bleeding at the catheter insertion site every 15 minutes 3. Performing post-procedure vital sign measurements 4. Reinforcing instructions to keep the involved extremity straight 5. Reviewing ECG for dysrhythmias

3. Performing post-procedure vital sign measurements 5. Reviewing ECG for dysrhythmias

The nurse is caring for a client with Clostridium difficile colitis. Which of the following infection control measures by the nurse are appropriate? Select all that apply. 1. Applies sterile gloves before performing client care 2. Ensures surgical masks are worn by staff in the client's room 3. Requests that the client be assigned to a single-client room 4. Uses alcohol-based sanitizers for hand hygiene 5. Wears a single-use, disposable gown during client care

3. Requests that the client be assigned to a single-client room 5. Wears a single-use, disposable gown during client care

The nurse is caring for a client with active pulmonary tuberculosis. Which elements of infectious disease precautions are mandatory for the nurse when providing routine care? Select all that apply. 1. Gown 2. Goggles or face shield 3. Hand washing 4. N95 particulate respirator 5. Surgical mask

3. hand washing 4. N95 particulate respirator

The nurse evaluating a 52-year-old diabetic male client's therapeutic response to rosuvastatin would notice changes in which laboratory values? Select all that apply. 1. Alanine aminotransferase from 20 U/L (0.33 µkat/L) to 80 U/L (1.34 µkat/L) 2. High-density lipoprotein cholesterol from 48 mg/dL (1.24 mmol/L) to 30 mg/dL (0.78 mmol/L) 3. Low-density lipoprotein cholesterol from 176 mg/dL (4.61 mol/L) to 98 mg/dL (2.54 mmol/L) 4. Total cholesterol from 250 mg/dL (6.47 mmol/L) to 180 mg/dL (4.66 mmol/L) 5. Triglycerides from 180 mg/dL (2.03 mmol/L) to 149 mg/dL (1.68 mmol/L)

3. low-density lipoprotein cholesterol from 176 mg/dL to 98 mg/dL 4. total cholesterol from 250 mg/dL to 180 mg/dL 5. triglycerides from 180 mg/dL to 149 mg/dL

The orthopedic health care provider instructs a client with a fractured right femur, who has been non-weight bearing for the past 5 weeks, to progress to full-weight bearing on the right leg. Which advanced crutch gait that most closely resembles normal walking should the nurse reinforce when teaching the client? 1. 2-point gait 2. 3-point gait 3. 4-point gait 4. 5-point gait

4-point gait

The nurse is preparing to administer an antibiotic to a child with pneumonia. The prescription reads: 7.5 mg/kg every 24 hours divided into 2 doses, PO in liquid form. The client weighs 78 lb. The pharmacy has supplied the drug in 125 mg/5 mL. How many milliliters (mL) should the client receive for each dose? Record your answer using one decimal place.

5.3 mL

The nurse in the pediatric clinic is planning to reinforce postoperative teaching to parents. The nurse should talk with the parent of which child first? 1. 2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear 2. 4-year-old post adenotonsillectomy who is now reporting ear pain 3. 6-year-old with strep throat who needs a note to return to school 24 hours after starting antibiotics 4. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice tomorrow

7- year old 5 days post tonsillectomy who wants to return to soccer practicw tomorrow

The nurse in the pediatric clinic is planning to reinforce postoperative teaching to parents. The nurse should talk with the parent of which child first? 1. 2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear 2. 4-year-old post adenotonsillectomy who is now reporting ear pain 3. 6-year-old with strep throat who needs a note to return to school 24 hours after starting antibiotics 4. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice tomorrow

7-year-old 5 days post tonsillectomy who wants to return to soccer practice tomorrow

The occupational health nurse administers an intradermal tuberculin skin test (TST) to a health care worker (HCW). The site must be assessed for a reaction afterward. The nurse instructs the HCW to return in how many hours? 1. 12 hours 2. 24 hours 3. 36 hours 4. 72 hours

72 hours

The office nurse receives 4 telephone messages from clients. Which client does the nurse anticipate as the priority for treatment? 1. 20-year-old college student who reports a ringlike, red bull's-eye-shaped, itchy leg rash after hiking in the woods 2 days ago 2. 65-year-old female with pneumonia taking antibiotics who reports white, curdlike vaginal discharge and itching 3. 78-year-old prescribed warfarin who reports increasing headaches and gait disturbance after falling a month ago 4. 86-year-old with gout who is prescribed colchicine and reports diarrhea and not feeling well

78-year-old prescribed warfarin who reports increasing headaches and gait disturbance after falling a month ago

A nurse is monitoring several clients in the medical-surgical unit. The nurse identifies which client as being at greatest risk for the development of delirium? 1. 32-year-old client with gastroenteritis 2. 55-year-old client with coronary artery disease, 4 days post coronary bypass surgery 3. 60-year-old client with type II diabetes, 2 months post bilateral above-knee amputations 4. 80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis

80-year-old client with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis

The post-anesthesia care unit nurse is caring for 4 clients during the immediate postoperative period. Which client would be the priority for the nurse to see first? 1. A client post cholecystectomy reporting increased nausea 2. A client post myomectomy with mild oozing of blood from the surgical site 3. A client post spinal surgery requesting additional pain medication 4. A client post transurethral resection of the prostate with reddish-pink drainage

A client post cholecystectomy reporting increased nausea

The post-anesthesia care unit nurse is caring for 4 clients during the immediate postoperative period. Which client would be the priority for the nurse to see first? 1. A client post cholecystectomy reporting increased nausea 2. A client post myomectomy with mild oozing of blood from the surgical site 3. A client post spinal surgery requesting additional pain medication 4. A client post transurethral resection of the prostate with reddish-pink drainage

A client post cholecystectomy reporting increased nausea

A nurse receives report on a group of clients. Which client should the nurse assess first? 1. A preschool-age child with a harsh cough, expiratory wheezes, and mild intercostal retractions 2. A toddler playing with small toys who appears in distress, has circumoral cyanosis, and cannot speak 3. A toddler with a barking cough, infrequent inspiratory stridor, and oxygen saturation of 94% on room air 4. An infant with an axillary temperature of 100.1 F (37.8 C) who is tugging at the left ear

A toddler playing with small toys who appears in distress, has circumoral cyanosis, and cannot speak

The practical nurse is collecting data on a client with acute diverticulitis. Which finding will the nurse report immediately to the registered nurse? 1. Abdominal pain has progressed to the left upper quadrant 2. Hemoglobin is 11.2 g/dL (112 g/L) 3. Lying on side with knees drawn up to abdomen and trunk flexed 4. White blood cell count is 12,000/mm3 (12 × 109/L)

Abdominal pain has progressed to the left upper quadrant

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch. What should be the nurse's initial action? 1. Abdominal thrusts 2. Back blows and chest thrusts 3. Blind sweep of the child's mouth 4. Call 911 for an ambulance

Abdominal thrusts

The nurse is caring for a client with hyperosmolar hyperglycemic state. The nurse understands which characteristic is most consistent with HHS? 1. Abdominal pain 2. Altered level of consciousness 3. History of type 1 diabetes 4. Kussmaul respirations

Altered level of consciousness

The clinic nurse cares for a 4-year-old who has been diagnosed with a pinworm infection. Which client symptom supports this diagnosis? 1. Anal itching that is worse at night 2. Intestinal bleeding with anemia 3. Poor appetite with weight loss 4. Red, scaly, blistered rings on skin

Anal itching that is worse at night

A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the client's back pain during early labor? 1. Applying counterpressure to the client's sacrum during contractions 2. Encouraging the client to remain in bed during early labor 3. Positioning the client on the left side with pillows for support 4. Requesting that the nurse anesthetist administer epidural anesthesia

Applying counterpressure to the client's sacrum during contractions

The nurse is assisting with care of a client with blunt head injury admitted for observation, including hourly neurologic checks. At 1:00 AM, the client reports a headache; the neurologic check is normal, and the nurse administers acetaminophen prn. At 2:00 AM, the client appears to be sleeping. What action does the nurse anticipate taking? 1. Arouse the client and ask what the current month is 2. Awaken the client and check for paresthesia 3. Document "relief apparently obtained" and recheck at 3:00 AM 4. Let the client sleep but verify respiratory rate

Arouse the client and ask what the current month is

The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time? 1. Ask the interpreter to explain the discussion 2. Confirm the client's consent with the interpreter, using gestures 3. Have the interpreter witness the signature 4. Indicate that the interpreter was used when witnessing the client's signature

Ask the interpreter to explain the discussion

The 11:00 AM routine fingerstick (glucose monitoring) test for a client was assigned to the unlicensed assistive personnel by the nurse. At 11:15 AM, the client tells the nurse that no one checked the blood level. The nurse should take what action first? 1. Ask the unlicensed assistive personnel (UAP) about the situation 2. Inform the nurse manager 3. Perform the test 4. Review the fingerstick procedure with the UAP

Ask the unlicensed assistive personnel (UAP) about the situation

The practical nurse is assisting the registered nurse during admission of a client with heart failure-related fluid overload. Which action should be completed first? 1. Administer oxygen 2. Assess the client's breath sounds 3. Initiate cardiac monitoring 4. Insert a peripheral IV catheter

Assess the client's breath sounds

A 15-year-old parent brings a 4-month-old infant for a well-baby checkup. The parent tells the nurse that the baby cries all the time; the parent has tried everything to keep the infant quiet but nothing works. What is the priority nursing action? 1. Advise the parent to give a pacifier whenever the infant cries 2. Ask the parent to describe what is done to "keep the baby quiet" 3. Assess the infant's pattern and frequency of crying 4. Explore the parent's support system

Assess the infant's pattern and frequency of crying

The postoperative client on hydromorphone becomes hypoxic, and naloxone is administered per protocol. What is most important for the nurse to consider in the follow-up care of this client? 1. Client's respiratory status 60 minutes later 2. Documenting the client's hypoxic event 3. Obtaining an order for a different analgesic 4. Potential for drug-drug interaction now

Client's respiratory status 60 minutes later.

A student nurse performs morning rounds and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus who is in contact precautions. The nurse preceptor intervenes when the student performs which action? 1. Cleans the stethoscope with 2% chlorhexidine solution before removing it from the room 2. Removes the urine specimen cup from the room in a sealed, leak-proof bag 3. Scrubs the Foley catheter collection port with alcohol for 15 seconds before withdrawing a urine specimen 4. Uses an alcohol-based hand antiseptic after removing gloves

Cleans the stethoscope with 2% chlorhexidine solution before removing it from the room

The nurse has received report on the following clients. Which client should be seen first? 1. Client 4 hours postoperative colon resection who has a blood pressure of 90/74 mm Hg 2. Client receiving hospice care who has Cheyne-Stokes respiration with 20-second periods of apnea 3. Client with anemia and hemoglobin level of 7 g/dL (70 g/L) who has a pulse of 110/min after ambulation 4. Client with diabetic ketoacidosis who has rapid, deep respirations at a rate of 32/min

Client 4 hours postoperative colon resection who has a blood pressure of 90/74mm Hg

During an initial prenatal visit, the practical nurse is reviewing the history of a client at 10 weeks gestation. Which finding is a priority to report to the registered nurse? 1. Client cares for a pet dog and a few outdoor cats 2. Client has gained 4 lb (1.8 kg) during the pregnancy so far 3. Client reports a nonodorous, milky white vaginal discharge 4. Client swims in a pool for exercise three times per week

Client cares for a pet dog and a few outdoor cats

The nurse has just received report on 4 clients. Which reported information is the most concerning? 1. Client on a heparin drip with an activated partial thromboplastin time of 60 seconds 2. Client reporting back pain 1 hour following coronary angiography 3. Client with a head injury and a Glasgow Coma Scale score of 14 4. Client with incisional pain rated 6/10 on day 2 post coronary artery bypass graft

Client reporting back pain 1 hour following coronary angiography

The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge? 1. Client on chemotherapy who started antibiotics today for cellulitis of the leg 2. Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours 3. Client with diabetes who has nausea, abdominal pain, and vomiting 4. Client with ulcerative colitis and diarrhea who has developed fever and vomiting

Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours

The nurse is assisting with community health screening. Which client is the priority to refer for further evaluation? 1. Client who is an athlete with a heart rate of 50/min 2. Client with a blood pressure of 129/79 mm Hg 3. Client with a random blood glucose of 139 mg/dL 4. Client with shiny, hairless legs that are cool to the touch

Client with shiny, hairless legs that are cool to the touch

A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives shift report to the oncoming nurse and conveys that the client's current Glasgow Coma Scale score is a "10." Which other information is most important for the reporting nurse to include? 1. Client's blood pressure was 120/80 mm Hg and pulse was 82/min recently 2. Client's Glasgow Coma Scale score was "11" one hour ago 3. Client believes that the current surroundings are a racetrack 4. Client is allergic to penicillin and vancomycin

Client's Glasgow Coma Scale score was "11" one hour ago

A 15-year-old client with type 1 diabetes mellitus is admitted to the hospital with a blood glucose of 460 mg/dL (25.6 mmol/L). Based on this information, the nurse understands that which factor is contributing to this client's noncompliant behavior? 1. Client has limited understanding of the disease process 2. Client is depressed and wants to die 3. Client's psychosocial developmental stage 4. Lack of supervision by the client's caregivers

Client's psychosocial developmental stage

A nurse prepares to administer an intermittent enteral feeding via nasogastric tube to a client with a prescription for gastric residual checks before each feeding. The nurse obtains a gastric residual volume of 80 mL. Which action should the nurse perform next? 1. Collect gastric pH measurement 2. Delay feeding for at least 1 hour 3. Discard the gastric residual 4. Return residual and administer feeding

Collect gastric pH measurement

A client with schizophrenia is started on clozapine. Which periodic measurements take priority in this client? 1. Complete blood count and absolute neutrophil count 2. ECG and blood pressure 3. Fasting blood glucose and fasting lipid panel 4. Height, weight, and waist circumference

Complete blood count and absolute neutrophil count [

A client with type 1 diabetes is prescribed NPH insulin before breakfast and dinner. Although the client reports feeling well, the 6 AM blood glucose level has averaged 60 mg/dL (3.3 mmol/L) over the past week. Which action is appropriate for the nurse to recommend to the client? 1. Collect urine sample to check for urine ketones 2. Consume a snack of milk and cereal at bedtime 3. Increase carbohydrate intake at each meal 4. Take only the prebreakfast dose of NPH

Consume a snack of milk and cereal at bedtime

A client is receiving lithium carbonate 900 mg/day for a schizoaffective disorder. The laboratory notifies the nurse that the client's lithium level is 1.0 mEq/L (1.0 mmol/L). Based on this result, which prescription does the nurse anticipate receiving from the health care provider? 1. Continue at the current dosage 2. Decrease the dosage 3. Discontinue the medication 4. Increase the dosage

Continue at the current dosage

A client is receiving lithium carbonate 900 mg/day for a schizoaffective disorder. The laboratory notifies the nurse that the client's lithium level is 1.0 mEq/L (1.0 mmol/L). Based on this result, which prescription does the nurse anticipate receiving from the health care provider? 1. Continue at the current dosage 2. Decrease the dosage 3. Discontinue the medication 4. Increase the dosage

Continue at the current dosage

The nurse is obtaining a client's history during an initial prenatal visit. The client's last menstrual period was from March 1 to March 5. Unprotected intercourse occurred on March 15. Slight vaginal spotting was noted on March 23. The client's menstrual cycles are regular and 28 days long. Using the Nägele rule, what is the estimated date of birth? 1. December 8 2. December 12 3. December 22 4. December 30

December 8

A client admitted to the medical surgical unit was recently weaned from the mechanical ventilator and an IV infusion of lorazepam. The client has been alert and oriented for 24 hours but is now experiencing confusion. The practical nurse assists the registered nurse with the evaluation of new-onset confusion by assessing the client's sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy. The practical nurse suspects which condition in this client? 1. Amnesia 2. Delirium 3. Dementia 4. Psychosis

Delirium

The nurse is reviewing prescriptions for the assigned clients. Which prescription should the nurse question? 1. Allopurinol for a client who developed tumor lysis syndrome from chemotherapy for acute leukemia [12%] 2. Dicyclomine for a client with a history of irritable bowel syndrome who develops a postoperative paralytic ileus [9%] 3. IV morphine for a client after percutaneous nephrolithotripsy who reports the last bowel movement was 2 days ago [29%] 4. Levofloxacin for a client with a urinary tract infection who has a history of anaphylaxis to penicillin drugs [49%]

Dicyclomine for a client with a history of irritable bowel syndrome who deveolps a postoperative paralytic ileus

The health care provider prescribes phenazopyridine hydrochloride for a client with a urinary tract infection. What would the office nurse remind the client to expect while taking this medication? 1. Constipation 2. Difficulty sleeping 3. Discoloration of urine 4. Dry mouth

Discoloration of urine

A client with chronic heart failure developed an intractable cough and an incident of angioedema after starting enalapril. Which prescription does the nurse anticipate for this client? 1. Alprazolam 2. Dextromethorphan 3. Lisinopril 4. Valsartan

Valsartan

A nurse is planning to complete a physical examination of a toddler. Which approach is an appropriate intervention by the nurse? 1. Encourage the parent to be involved with the child 2. Engage in physical contact by removing the toddler's outer clothing first 3. Have medical equipment lying on a counter within view 4. Perform an examination in a head-to-toe order

Encourage the patient to be involved with the child

The practical nurse (PN) is assisting the registered nurse (RN) to care for a 6-hour-old term newborn of a mother with gestational diabetes. A bedside capillary blood glucose measurement reveals that the newborn's blood glucose level is 45 mg/dL (2.5 mmol/L). The newborn is asymptomatic. Which intervention should the PN anticipate implementing first? 1. Feed the newborn 2. Notify the health care provider 3. Place the newborn under a radiant warmer 4. Prepare to administer IV glucose

Feed the newborn

Which task would the practical nurse on a surgical unit assign to experienced unlicensed assistive personnel? 1. Assisting a client in ambulating to the bathroom for the first time following surgery 2. Explaining why incentive spirometer use is important to a client with postoperative pneumonia 3. Feeding a client with dementia who has a blood sugar level of 70 mg/dL (3.9 mmol/L) 4. Taking vital signs every 15 minutes on a client who was just transferred from the post-anesthesia recovery unit

Feeding a client with dementia who has a blood sugar level of 70 mg/dL (3.9 mmol/L)

The registered nurse is preparing to administer oxytocin to induce labor in a client. The practical nurse assists the registered nurse and recognizes that the oxytocin infusion can lead to which of the following conditions? 1. Decreased postpartum hemorrhage 2. Delayed milk production 3. Fetal distress and cesarean birth 4. High risk of placenta previa

Fetal distress and cesarean birth

The nurse is caring for an 11-year-old admitted for surgical treatment of a fractured femur who also has attention-deficit hyperactivity disorder, predominantly inattentive type. What is the priority nursing action? 1. Encourage the child to keep up with school work 2. Give the child a written schedule of daily activities 3. Limit the number of visitors 4. Reinforce verbal explanations of what to expect during hospitalization

Give the child a written schedule of daily activities

An elderly client reports shortness of breath with activity for the past 2 weeks. The nurse reviews the admission laboratory results and identifies which value as the most likely cause of the client's symptoms? 1. Brain natriuretic peptide 70 pg/mL (70 pmol/L) 2. Hematocrit 21% (0.21) 3. Leukocytes 3,500/mm3 (3.5 x 109/L) 4. Platelets 105,000/mm3 (105 x 109/L)

Hematocrit 21% (0.21)

A child with cystic fibrosis is to receive a dose of pancrelipase at 12:00 PM. The client states that he is not hungry and will eat his lunch in an hour. Which action is appropriate for the nurse to take? 1. Administer the prescribed pancrelipase 2. Hold the pancrelipase until the client eats 3. Notify the health care provider 4. Skip this dose of the pancrelipase

Hold the pancrelipase until the client eats

The licensed practical nurse (LPN) assigns the ambulation of a client to unlicensed assistive personnel (UAP). The LPN observes UAP placing the client's Foley bag on the IV pole at the level of the client's chest during client ambulation down the length of the hallway. What action should the LPN take initially? 1. Immediately lower the bag and speak privately to unlicensed assistive personnel (UAP) 2. Let UAP complete assigned tasks and speak to them at the end of the shift 3. Praise UAP for encouraging the client to walk the entire hallway 4. Speak with the nurse manager about the need for UAP inservice education

Immediately lower the bag and speak privately to unlicensed assistive personnel (UAP)

The practical nurse collaborates with the registered nurse to develop a care plan for a client diagnosed with anorexia nervosa who is being admitted after failure of outpatient treatment. Which client outcome is the priority? 1. Acknowledges poor interpersonal skills 2. Identifies new coping mechanisms 3. Increases caloric intake to gain weight 4. Verbalizes sources of conflict and anger

Increases caloric intake to gain weight

A nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus requiring insulin. The client has been prescribed prednisone. The nurse anticipates which need? 1. Close monitoring for hypotension 2. Gradually increasing the prednisone dose 3. Increasing the insulin dose 4. Monitoring and recording intake and output

Increasing the insulin dose

An 8-month-old infant is scheduled for balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding could possibly delay the procedure and should be reported? 1. Auscultation of a loud heart murmur 2. Infant has been npo for 4 hours 3. Infant has polycythemia 4. Infant has severe diaper rash

Infant has severe diaper rash

A client comes to the emergency department reporting alkaline drain cleaner splashed into the eye. The conjunctiva of the affected eye is erythematous, and the client reports a burning sensation. What action is appropriate at this time? 1. Administer PO analgesic medication 2. Cover the affected eye with an eye patch 3. Initiate continuous eye irrigation 4. Perform a Snellen vision test

Initiate continuous eye irrigation

The nurse is assisting in planning care for a client experiencing an acute attack of Ménière disease. Which action is a high priority to include in the plan of care? 1. Initiate fall precautions 2. Keep the emesis basin at bedside 3. Provide a quiet environment 4. Start IV fluids

Initiate fall precautions

A child with a high level of school absenteeism has been determined to have school phobia. The nurse should remind the child's parent/caregiver to take which action? 1. Allow the child to stay home when the child seems particularly anxious 2. Encourage the parent/caregiver to sit in the classroom with the child 3. Insist on school attendance immediately, starting with a few hours a day 4. Return the child to school when the cause of the school phobia has been identified

Insist on school attendance immediately, starting with a few hours a day

The school nurse is speaking with the parent of a fourth grade student about a bed bug that was found on the child's sweater. The parent confirms that their home is infested but that the issue is being resolved. Which is the best action by the nurse? 1. Instruct the parent to launder the child's clothing and store it in tightly sealed plastic bags 2. Instruct the teacher of the child's classroom to use an insecticide spray 3. Send letters home to all of the children's parents informing them about the finding 4. Send the child home and prohibit school attendance until the infestation has been resolved

Instruct the parent to launder the child's clothing and store it in tightly sealed plastic bags

A 2-month-old infant has been admitted to the hospital with suspected shaken baby syndrome (abusive head trauma). In reviewing the infant's chart, the nurse expects to encounter which of these clinical findings? 1. A reported history of recent trauma 2. Abdominal bruising 3. External signs of trauma 4. Irritability and vomiting

Irritability and vomiting

The nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors? 1. Fears abandonment, agreeable, needs constant reassurance 2. Likes to be the center of attention, exaggerated emotional expression, little tolerance for frustration 3. Seems uncomfortable around people, lack of close friends, indifferent to praise or criticism 4. Tries to intimidate others, manipulative, lacks empathy

Likes to be the center of attention, exaggerated emotional expression, little tolerance for frustration

The nurse prepares to administer morning medications to assigned clients. Which prescription should the nurse clarify with the health care provider? 1. Clopidogrel for client with history of stroke and platelet count of 154,000/mm3 (154 × 109/L) 2. Losartan for client with hypertension who is 8 weeks pregnant 3. Prednisone for client with herpes simplex lesions and Bell palsy 4. Tiotropium for client with pneumonia and chronic obstructive pulmonary disease

Losartan for client with hypertension who is 8 weeks pregnant

The nurse is caring for a hospitalized client diagnosed with thyrotoxicosis (thyroid storm). Which action is most appropriate to assign to unlicensed assistive personnel? 1. Call the family to give an update on new aspects of the client's condition 2. Lower the temperature in the room to make the environment cooler 3. Reinforce teaching about signs and symptoms of hyperthyroidism 4. Take vital signs and place a warming blanket on the client

Lower the temperature in the room to make the environment cooler

Exhibit The nurse is assisting with cardiopulmonary resuscitation of a client in cardiac arrest. The rhythm in the exhibit is displayed on the cardiac monitor. Which medication administration should the nurse anticipate? Click the exhibit button for additional information. (very Tachycardic) 1. Adenosine IV 2. Dopamine IV 3. Magnesium IV 4. Metoprolol IV

Magnesium IV

The nurse is assisting with cardiopulmonary resuscitation of a client in cardiac arrest. The rhythm in the exhibit is displayed on the cardiac monitor. Which medication administration should the nurse anticipate? Click the exhibit button for additional information. (tachycardic) 1. Adenosine IV 2. Dopamine IV 3. Magnesium IV 4. Metoprolol IV

Magnesium IV

On arrival in the postanesthesia care unit, the practical nurse assists the registered nurse in performing the initial assessment of a client who had surgery under general anesthesia. Which assessment finding is the most concerning? 1. Difficult to rouse 2. Muscle stiffness 3. Pinpoint pupils 4. Temperature of 96 F (35.6 C)

Muscle stiffness

The nurse is reinforcing education to a pregnant client who is HIV-positive. Which information is appropriate for the nurse to include? 1. Prescribed antiretroviral therapy should be continued during pregnancy 2. Tetanus-diphtheria-acellular pertussis vaccine should be avoided until after birth 3. The infant should be exclusively breastfed for 6 months to receive maternal antibodies 4. The infant will not require treatment for HIV after birth

Prescribed antiretroviral therapy should be continued during pregnancy

A student nurse has been assigned to provide care to a client with suicidal ideation who is receiving treatment in an outpatient setting. The student nurse develops a nursing care plan and reviews it with the nurse preceptor before meeting with the client. Which of the following proposed nursing actions in the care plan requires intervention by the nurse preceptor? 1. Assist the client in identifying the warning signs of a crisis 2. Have the client write a list of people to contact for help and distraction 3. Help the client develop ways of coping with suicidal thoughts 4. Persuade the client to sign a contract promising not to commit suicide

Persuade the client to sign a contract promising not to commit suicide

After a client with Alzheimer disease is found wandering in the middle of the street at 3:00 AM and returned by police, the nurse reinforces teaching to family members about measures to keep the client safe at home. What is the most important strategy for the nurse to include in the instruction? 1. Ensure that the client is never left alone 2. Notify neighbors of the client's tendency to wander 3. Place a chain lock on the door above or below the client's eye level 4. Place a safe return bracelet on the client's non-dominant hand

Place a chain lock on the door above or below the client's eye level

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time? 1. Continue CPR without using the automated external defibrillator (AED) until paramedics arrive 2. Place one AED pad on the chest and the other on the back 3. Place one AED pad on the upper right chest and the other on the lower left side 4. Place one AED pad on the upper right chest and dispose of the other

Place one AED pad on the chest and the other on the back

A 2-year-old at an outpatient clinic stops breathing and does not have a pulse. CPR is initiated. When the automated external defibrillator (AED) arrives, the nurse notes that it has only adult AED pads. What is the appropriate action at this time? 1. Continue CPR without using the automated external defibrillator (AED) until paramedics arrive 2. Place one AED pad on the chest and the other on the back 3. Place one AED pad on the upper right chest and the other on the lower left side 4. Place one AED pad on the upper right chest and dispose of the other

Place one AED pad on the chest and the other on the back.

A child with autism spectrum disorder is being admitted to a medical-surgical unit. Which is the most appropriate nursing action? 1. Placing the child in a private room away from the nurses' station 2. Placing the child in a private room near the playroom 3. Placing the child in a semi-private room near the nurses' station 4. Placing the child in a semi-private room with another child with autism spectrum disorder

Placing the child in a private room away from the nurses' station

A student nurse is caring for a client with iron deficiency anemia who is newly prescribed ferrous sulfate. Which action by the student nurse requires the supervising nurse to intervene? 1. Encourages the client to drink extra fluids while taking ferrous sulfate 2. Offers the client orange juice for administration of ferrous sulfate 3. Plans to administer ferrous sulfate one hour before breakfast 4. Prepares to administer a prescribed calcium supplement with ferrous sulfate

Prepares to administer a prescribed calcium supplement with ferrous sulfate

A client with schizophrenia has been hospitalized for a week and placed on an antipsychotic medication. The client tells the nurse of hearing multiple voices all day long arguing about whether the client is a good or bad person. The client says, "Everyone tells me that the voices are not real, but they are driving me crazy." What is the best action by the nurse? 1. Give the client a book to read 2. Provide earphones and a DVD player and have the client sing along with the music 3. Tell the client that the voices will go away when the medication starts to work 4. Tell the client to ignore the voices

Provide earphones and a DVD player and have the client sing along with the music

A client with schizophrenia has been hospitalized for a week and placed on an antipsychotic medication. The client tells the nurse of hearing multiple voices all day long arguing about whether the client is a good or bad person. The client says, "Everyone tells me that the voices are not real, but they are driving me crazy." What is the best action by the nurse? 1. Give the client a book to read 2. Provide earphones and a DVD player and have the client sing along with the music 3. Tell the client that the voices will go away when the medication starts to work 4. Tell the client to ignore the voices

Provide earphones and a DVD player and have the client sing along with the music

The nurse is caring for a bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client? 1. Consult with the wound care nurse specialist 2. Insert a rectal tube to contain the feces 3. Provide perianal skin care with barrier cream 4. Use incontinence briefs to protect the skin

Provide perianal skin care with barrier cream.

An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently? 1. Apical heart rate is 62/min 2. Blood sugar level is 240 mg/dL (13.3 mmol/L) 3. Client is taking 20 mg fluoxetine daily 4. Serum creatinine is 2.3 mg/dL (203 µmol/L)

Serum creatinine is 2.3 mg/dL (203 µmol/L)

The nurse is reinforcing teaching to parents about childhood nutrition and feeding practices. The nurse recognizes that which snack is best for a toddler? 1. ½ cup orange juice 2. Dry, sweetened cereal 3. Raw carrot sticks 4. Slice of cheese

Slice of cheese

The nurse is assisting with a vaginal birth at term gestation. Which newborn assessment finding is most important for the nurse to follow-up? 1. Edema of the scalp crossing the suture lines 2. Flat, bluish, discolored area on the buttocks 3. Small tuft of hair at the base of the spine 4. White, waxy substance in the axillae and labial folds

Small tuft of hair at the base of the spine

A 1-year-old child who goes to day care is recovering from an episode of otitis media. Which intervention is most important for the nurse to reinforce to the parents in order to prevent recurrence? 1. Exclusive breastfeeding 2. Not sending the child to day care 3. Preventing water from entering the ear 4. Smoking cessation by the parents

Smoking cessation by the parents

A client postpartum 3 days scheduled for discharge today was given education about diaper changes yesterday. The client says to the nurse, "I'm so glad you are here. I think my baby has a dirty diaper. I can't change it as well as you can. Will you change my baby's diaper for me?" What is the nurse's best response? 1. Reassure the mother that it takes time to learn how to care for a baby while quickly changing the diaper 2. Suggest that the mother change the diaper as the nurse watches 3. Tell the mother that it is time to take over changing the baby's diaper as she will have to do it once discharged 4. Tell the mother that the nurse will change the baby's diaper while she watches

Suggest that the mother change the diaper as the nurse watches

A client states, "I just don't know what to do about this situation with my parents," and the nurse replies, "I'm sure you will do the right thing." Which summary is true regarding the nurse's response? 1. The nurse has encouraged exploration of the client's situation 2. The nurse has shown interest in the client's concerns 3. The response conveys empathy toward the client and promotes self-confidence 4. The response devalues the client's feelings and gives false reassurance

The response devalues the client's feelings and gives false reassurance

While collecting data from pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first? 1. First-trimester client who reports frequent nausea and vomiting 2. Second-trimester client with dysuria and urinary frequency 3. Second-trimester client with obesity who reports decrease in fetal movement 4. Third-trimester client with right upper quadrant pain and nausea

Third-trimester client with right upper quadrant pain and nausea

The nurse in a clinic is caring for an 8-month-old with a new diagnosis of bronchiolitis due to respiratory syncytial virus (RSV). Which instructions can the nurse anticipate reviewing with the parent? 1. Administering a cough suppressant and antihistamine 2. Prophylactic treatment of family members 3. Temporary cessation of breastfeeding 4. Use of saline drops and a bulb syringe to suction nares

Use of saline drops and a bulb syringe to suction nares

A 24-year-old female client is prescribed isotretinoin for severe cystic acne. Which instruction is most important for the nurse to reinforce? 1. Apply lubricating eye drops when wearing contacts 2. Do not break, crush, or chew capsules 3. Use sunscreen routinely during therapy 4. Use two forms of contraception consistently

Use two forms of contraception consistently

Which assessment findings of an 18-month-old cause the nurse to be concerned about delayed development? 1. Cannot climb steps alone, pulls a toy, turns the pages of a book 2. Is bottlefed, can use a spoon, creeps down stairs 3. Throws a ball, is able to point to 2 or 3 body parts, cannot draw a picture 4. Uses 2 words, cannot hold a cup, can seat self in a small chair

Uses 2 words, cannot hold a cup, can seat self in a small chair

A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate? 1. Cervical lacerations 2. Inversion of the uterus 3. Uterine atony 4. Vaginal hematoma

Vaginal hematoma

A client with chronic heart failure developed an intractable cough and an incident of angioedema after starting enalapril. Which prescription does the nurse anticipate for this client? 1. Alprazolam 2. Dextromethorphan 3. Lisinopril 4. Valsartan

Valsartan

The nurse is preparing to administer the fourth dose of IV vancomycin to a client. Which set of laboratory values would alert the nurse to hold the vancomycin and notify the health care provider? 1. Vancomycin trough 10 mg/L (6.9 µmol/L), creatinine 1.1 mg/dL (97.2 µmol/L), BUN 6 mg/dL (2.1 mmol/L) 2. Vancomycin trough 14 mg/L (9.7 µmol/L), creatinine 1.2 mg/dL (106.1 µmol/L), BUN 10 mg/dL (3.6 mmol/L) 3. Vancomycin trough 18 mg/L (12.4 µmol/L), creatinine 0.6 mg/dL (53 µmol/L), BUN 18 mg/dL (6.4 mmol/L) 4. Vancomycin trough 23 mg/L (15.9 µmol/L), creatinine 1.5 mg/dL (132.6 µmol/L), BUN 24 mg/dL (8.6 mmol/L)

Vancomycin trough 23 mg/L (15.9 µmol/L), creatinine 1.5 mg/dL (132.6 µmol/L), BUN 24 mg/dL (8.6 mmol/L)

The nurse is assisting with the care of an adolescent diagnosed with type 1 diabetes. The client has hot, dry skin and a glucose level of 350 mg/dL (19.4 mmol/L). Arterial blood gases show a pH of 7.27. STAT serum chemistry labs have been ordered. Cardiac monitoring reveals a sinus rhythm with peaked T waves, and the client has minimal urine output. What does the nurse anticipate as the next priority action? 1. Administer IV regular insulin 2. Administer normal saline infusion 3. Obtain client's urine for urinalysis 4. Request a potassium infusion prescription

administer normal saline infusion

A nurse is talking with the parent of a 6-year-old regarding sleep and rest. Which information should be included? 1. Active play before bedtime promotes restful sleep 2. Bedtime hours should be established 3. Rest needs are related to the high rate of growth in this age group 4. Seven to 8 hours of sleep are required

bedtime hours should be established

The nurse assessing a 2-year-old should expect the child to be able to perform which actions? Select all that apply. 1. Build a tower with blocks 2. Draw a square 3. Hop on one foot 4. Say own name 5. Walk without help

build a tower with blocks say own name walk without help

A client has been admitted to the acute inpatient psychiatric unit with a diagnosis of major depressive disorder (unipolar depression). The nurse understands that this diagnosis was made because the client has been exhibiting at least 1 of which of the 2 key clinical findings daily for at least 2 weeks? 1. Daily sleep disturbance or significant weight loss 2. Decreased ability to think or low energy 3. Depressed mood or loss of interest or pleasure 4. Thoughts of worthlessness or recurrent thoughts of death

depressed mood or loss of interest or pleasure

The nurse is caring for a client with a history of headaches who has come to the clinic reporting a "bad migraine." The client was able to provide a full health history while waiting to be seen. Which finding is most concerning? 1. Blood pressure of 136/88 mm Hg 2. Flat affect and drowsiness 3. Nausea and poor appetite 4. Respiratory rate of 12/min

flat affect and drowsiness

The practical nurse is monitoring a client 12 hours after the prolonged vaginal delivery of a term infant. Which finding should be reported to the registered nurse? 1. Discomfort during fundal palpation 2. Foul-smelling lochia 3. Oral temperature 100.1 F (37.8 C) 4. White blood cell count 24,000/mm3 (24.0 x 109/L)

foul- smelling lochia

A child is brought to the school nurse after having a permanent tooth knocked out during gym class. Which action by the nurse is appropriate? 1. Gently rinse the tooth with sterile saline and reinsert it into the gingival cavity 2. Gently scrub the root of the tooth to remove any debris, and wrap it in sterile gauze 3. Place the tooth in water and transport the client to the nearest emergency department 4. Wrap the tooth in sterile gauze and advise the parent to arrange for a dental appointment

gently rinse the tooth with sterile saline and reinsert it into the gingival cavity

The nurse is caring for an infant with suspected meningitis and preparing to assist with a lumbar puncture. What is the appropriate nursing intervention? 1. Administer oxygen via nasal cannula for client comfort and safety 2. Clean area with povidone iodine in a circular motion moving outward 3. Hold the child with the head and knees tucked in and the back rounded out 4. Monitor and record vital signs every 15 minutes throughout the procedure

hold the child with the nead and knees tucked in and the back rounded out

The nurse should monitor for which potential complication in a client receiving IV vancomycin and gentamicin? 1. Blood in nasogastric tube drainage [3%] 2. Decrease in red blood cell count [9%] 3. Increase in serum creatinine level [46%] 4. Onset of muscle aches and cramping [41%]

increase in serum creatinine level

The school nurse is speaking with the parent of a fourth grade student about a bed bug that was found on the child's sweater. The parent confirms that their home is infested but that the issue is being resolved. Which is the best action by the nurse? 1. Instruct the parent to launder the child's clothing and store it in tightly sealed plastic bags 2. Instruct the teacher of the child's classroom to use an insecticide spray 3. Send letters home to all of the children's parents informing them about the finding 4. Send the child home and prohibit school attendance until the infestation has been resolved

nstruct the parent to launder the child's clothing and store it in tightly sealed plastic bags

The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote the client's comfort? Select all that apply. 1. Encourage adequate sodium intake 2. Place client in semi-Fowler position 3. Place client in Trendelenburg position 4. Provide alternating air pressure mattress 5. Use music to provide a distraction

place client in semi-fowler position provide alternating air pressure mattress use music to provide a distraction

A client with a chronic kidney disease has blood laboratory values as shown in the exhibit. The nurse administers sodium polystyrene sulfonate by mouth per the health care provider's prescription. The nurse evaluates that the therapy is effective when which value is noted on the follow-up results? Click on the exhibit button for additional information. 1. Calcium 7.4 mg/dL (1.85 mmol/L) 2. Creatinine 4.0 mg/dL (353 µmol/L) 3. Phosphorus 3.9 mg/dL (1.26 mmol/L) 4. Potassium 4.9 mEq/L (4.9 mmol/L)

potassium 4.9 clients with kidney disease are at risk for hyperkalemia

The nurse is caring for a bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client? 1. Consult with the wound care nurse specialist 2. Insert a rectal tube to contain the feces 3. Provide perianal skin care with barrier cream 4. Use incontinence briefs to protect the skin

provide perianal skin care with barrier cream

A 16-year-old walks in unaccompanied by a parent and approaches the clinic nurse. The adolescent asks to be tested for a sexually transmitted infection (STI). How should the clinic nurse respond? 1. Determine if the client wore protection 2. Inform that parental consent is required 3. Inform that the request is honored if the client has symptoms 4. Provide requested service

provide requested service

A nurse is discharging a client who is receiving lithium for treatment of a bipolar disorder. It is most important for the nurse to reinforce which instruction to the client? 1. Avoid a high-potassium diet 2. Exercise regularly and maintain a high-fiber diet 3. Maintain oral hygiene 4. Report excessive urination and increased thirst

report excessive urination and increased thirst