Question Trainer 2

The client diagnosed with Addison's disease comes to the health clinic. When assessing the client's skin, the nurse expects to make which observation? 1. Darker skin that is more pigmented 2. Skin that is ruddy & oily 3. Skin that is puffy & scaly 4. Skin that is pale & dry

1. Darker skin that is more pigmented

The nurse evaluates the desired client response to diuretic therapy. Which action is the most reliable client measure for the nurse to use? 1. Obtain daily weights 2. Obtain urinalysis 3. Monitor Na & K levels 4. Measure intake

1. Obtain daily weights

The nurse enters a client's room wearing a gown, mask & gloves. The chosen PPE is appropriate for which diagnosis? 1. RSV 2. Kawasaki disease 3. Lyme disease 4. Herpes simplex

1. RSV

The nurse cares for the homebound client with a urinary catheter. The client's spouse states the catheter is obstructed. Which observation by the nurse confirms this suspicion? 1. The nurse notes that the bladder is distended. 2. The client reports a constant urge to void. 3. The nurse notes that the urine is concentrated. 4. The client reports a burning sensation.

1. The nurse notes that the bladder is distended.

The health care provider prescribes lithium carbonate 300 mg PO QID for the adult client. The nurse in the outpatient clinic instructs the client about the medication. The nurse encourages the client to maintain an adequate intake of which substance? 1. Sodium 2. Protein 3. Potassium 4. Iron

1. Sodium Alkali metal salt acts like sodium ions in the body, so excretion depends on normal sodium levels. If sodium levels are low, lithium won't be excreted.

The nurse plans care for a 20-year-old client. Which psychosocial stage does the nurse identify as the priority to consider? 1. Identity vs identity diffusion 2. Intimacy vs isolation 3. Integrity vs despair 4. Industry vs inferiority

2. Intimacy vs isolation

The nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows which change in the pattern of urinary elimination occurs normally with aging? 1. Decreased frequency 2. Nocturia 3. Incontinence 4. Hematuria

2. Nocturia

The nurse cares for the client newly diagnosed with hypoparathyroidism. Which nursing action has the highest priority for this client? 1. Develop a teaching plan 2. Plan measures to deal with cardiac dysrhythmias 3. Take measures to prevent a respiratory infection 4. Assess laboratory results

2. Plan measures to deal with cardiac dysrhythmias Hypocalcemia is the hallmark of hypoparathyroidism. which can cause dysrhythmias.

The 4-year-old child is admitted with drooling & an inflamed epiglottis. The nurse identifies which symptom as indicative of an increase in respiratory distress? 1. Bradycardia 2. Tachypnea 3. General pallor 4. Irritability

2. Tachypnea

A client has an NG tube connected to intermittent low suction. At 0700, the nurse documents 235 mL of greenish drainage in the suction container, left from the previous shift. At 1500, there is 445 mL of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the tube with 30 mL of normal saline. Which is the actual amount of drainage from the NG tube for 0700 to 1500? 1. 150 mL 2. 210 mL 3. 295 mL 4. 385 mL

1. 150 mL

The client develops a low intestinal obstruction. The nurse anticipates which findings? (Select all that apply.) 1. Nausea 2. Vomiting 3. Explosive diarrhea 4. Tarry stool 5. Abdominal distension 6. Rectal bleeding

1. Nausea 2. Vomiting 5. Abdominal distension

The client has a newly inserted peritoneal dialysis catheter. The student nurse changes the dressing under the supervision of the RN. In which order does the student correctly perform the steps of the procedure? 1. Clean the insertion site using a circular motion from the insertion site outward. 2. Apply two sterile precut 4x4s to the catheter insertion site. 3. Remove old dressing using clean gloves. 4. Securely tape the edges of the sterile dressing with paper tape 5. Open package containing providone-iodine cotton swabs.

1. Remove old dressing using clean gloves. 2. Open package containing providone-iodine cotton swabs. 3. Clean the insertion site using a circular motion from the insertion site outward. 4. Apply two sterile precut 4x4s to the catheter insertion site. 5. Securely tape the edges of the sterile dressing with paper tape.

The nurse prepares discharge teaching for parents of a newborn. Which information does the nurse provide regarding the PKU screening test? 1. The initial specimen should be collected at 24 hours or within a week after discharge. 2. The infant can have water but should not have formula for 6 hours before the test. 3. The test will need to be repeated at 6 weeks & at the 3-month check up. 4. Blood will be drawn at three 1-hour intervals; there is no specific preparation.

1. The initial specimen should be collect at 24 hours or within a week after discharge.

The home care nurse plans activities for the day. In which order does the nurse see the clients? 1. The older client who used all the diuretic medication & is expectorating pink-tinged mucus. 2. The client who is breastfeeding a 2-day-old infant born 5 days before the due date. 3. The client discharged yesterday after IV heparin therapy for a DVT. 4. The older client diagnosed with pneumonia & discharged from the hospital 3 days ago.

1. The older client who used all the diuretic medication & is expectorating pink-tinged mucus. 2. The client discharged yesterday after IV heparin therapy for a DVT. 3. The older client diagnosed with pneumonia & discharged from the hospital 3 days ago. 4. The client who is breastfeeding a 2-day-old infant born 5 days before the due date.

The UAP assists a client with anemia at lunch time. The UAP tells the RN that the client reports weakness. Which nursing response to the UAP is best? 1. "Listen to the client's breath sounds & report back to me." 2. "Set up the client's lunch tray." 3. "Obtain a diet history from the client." 4. "Instruct the client to balance rest & activity."

2. "Set up the client's lunch tray."

The nurse plans discharge teaching for the client after a lumbar laminectomy. Which muscle or muscles does the nurse instruct the client to exercise regularly? 1. Anal sphincter 2. Abdominal 3. Trapezius 4. Rectus femoris

2. Abdominal Adds support to the lumbar spine

The client was just placed in physical restraints. Which nursing intervention is most important for the client's care? 1. Prepare PRN dose of psychotropic medication. 2. Check that the restraints have been applied correctly. 3. Review hospital policy regarding duration of restraints. 4. Monitor the client's needs for hydration & nutrition while restrained.

2. Check that the restraints have been applied correctly.

The nurse cares for the client admitted with a diagnosis of closed head injury. Which symptoms indicate the client has developed diabetes insipidus? (Select all that apply.) 1. Glucosuria 2. Cracked lips 3. Weight gain of 5 lb 4. BP 160/100, pulse 56 5. Urinary output of 4 L/24 hours 6. Urine specific gravity of 1.004

2. Cracked lips 5. Urinary output of 4 L/24 hours 6. Urine specific gravity of 1.004

The client is admitted to the ER in acute respiratory distress. The client is very anxious, edematous & cyanotic. The client receives morphine sulfate. Which finding does the nurse recognize as the desired response to the medication? 1. Increase in pulse pressure 2. Decrease in anxiety 3. Depression of the SNS 4. Enhanced ventilation & decreased cyanosis

2. Decrease in anxiety

The nurse cares for the client during an acute manic episode. The nurse identifies which client behaviors as most characteristic of mania? (Select all that apply.) 1. Paranoia 2. Grandiose delusions 3. Somatic difficulties 4. Difficulty concentrating 5. Agitation 6. Distorted perceptions

2. Grandiose delusions 4. Difficulty concentrating 5. Agitation

The client is diagnosed with pneumonia secondary to chronic pulmonary disease. Which nursing goal is most appropriate? 1. Maintain & improve the quality of oxygenation. 2. Improve the status of ventilation. 3. Increase oxygenation of peripheral circulation. 4. Correct the bicarbonate deficit.

2. Improve the status of ventilation.

A client on the outpatient oncology unit undergoes a routine chemotherapy transfusion. The client's current lab report is WBC 2,500/mm3, RBC 5.1/million3, total serum calcium 9.3 mg/dL. On the basis of the lab values, the nurse determines which is the priority client problem? 1. Difficulty tolerating activity 2. Increased potential for infection 3.Feeling anxious 4. Low fluid volume

2. Increased potential for infection. WBC less than 4,500.

The nurse recognizes which client symptoms as characteristic of a panic attack? (Select all that apply.) 1. Decreased blood pressure 2. Palpitations 3. Decreased perceptual field 4. Bradycardia 5. Diaphoresis 6. Fear of going crazy

2. Palpitations 3. Decreased perceptual field 5. Diaphoresis 6. Fear of going crazy

The nurse observes the student nurse auscultate the right middle lobe lung of a client. The nurse knows the student nurse is auscultating correctly if the stethoscope is placed in which position? 1. Posterior & anterior base of right side 2. Right anterior chest between the fourth & sixth intercostal spaces 3. Left of the sternum, midclavicular, at fifth intercostal space 4. Posterior chest wall, midaxillary, right side

2. Right anterior chest between the fourth & sixth intercostal spaces

The nurse develops a comprehensive care plan for the young client diagnosed with anorexia nervosa. The client is referred to assertiveness skill classes. This is an appropriate intervention because the client may exhibit which problem? 1. Aggressive behaviors & angry feelings 2. Self-identity & self-esteem issues 3. An intense focus on reality 4. Family boundary intrusions

2. Self-identity & self-esteem issues

The nurse cares for a client diagnosed with Meniere's syndrome. The nurse stands directly in front of the client when speaking. Which best describes the rationale for the nurse's position? 1. This enables the client to read the nurse's lips. 2. The client does not have to turn the head to see the nurse. 3. The nurse will have the client's undivided attention. 4. There is a decrease in client's peripheral visual field.

2. The client does not have to turn the head to see the nurse. Decreasing movement may decrease vertigo attacks.

The nurse assesses orientation to person, place & time for the elderly hospitalized client. Which principle does the nurse understand? 1. Short-term memory is more efficient than long-term memory. 2. The stress of an unfamiliar environment may cause confusion. 3. A decline in mental status is a normal part of aging. 4. Learning ability is reduced during hospitalization of the elderly client.

2. The stress of an unfamiliar environment may cause confusion.

The client is diagnosed with Cushing syndrome. Which assessment finding does the nurse recognize as pertinent to this diagnosis? 1. Low blood pressure & weight loss. 2. Thin extremities with easy bruising. 3. Decreased urinary output & decreased serum potassium. 4. Tachycardia with reports of night sweats.

2. Thin extremities with easy bruising. Clients with Cushings tend to lose muscle mass in their legs & have petechiae & bruising.

The nurse obtains a specimen from the client for sputum culture & sensitivity. Which instruction is best? 1. After pursed lip breathing, cough into a container. 2. Upon awakening, cough deeply & expectorate into a container. 3. Save all sputum for three days in a covered container. 4. After respiratory treatment, expectorate into a container.

2. Upon awakening, cough deeply & expectorate into a container.

The client diagnosed with metastatic lung cancer is admitted to the hospital. The client's prescriptions include DNR & morphine 2mg/h by continuous IV infusion. The client's BP is 86/50, respirations are 8 & the client is nonresponsive. Naloxone HCl 0.4 mg IV is ordered STAT. It is important for the nurse to consider which action? 1. The BP & respirations will need to increase before a second dose of naloxone can be given. 2. Naloxone should not be given to the client because of the DNR status. 3. A dose of naloxone may need to be repeated in 2 to 3 minutes. 4. Naloxone is effective in treating respiratory changes caused by opiates, barbiturates, & sedatives.

3. A dose of naloxone may need to be repeated in 2-3 minutes.

A client returns from surgery after a right mastectomy. An IV of 0.9% NS is infusing at 100 mL/hour into the lower portion of the left forearm. The IV infiltrates several hours later. The nurse supervises the student nurse preparing to insert a new peripheral IV catheter. The nurse intervenes in which situation? 1. A site is selected with soft, elastic veins. 2. A site is selected proximal to the site of infiltration on the left arm. 3. A site is selected close to the left wrist joint. 4. The skin is held taut prior to insertion of the catheter.

3. A site is selected close to the left wrist joint.

The client returns from surgery. There is a fine, reddened rash around the area where povidone iodine prep was applied prior to surgery. The priority nursing notation in the client's record includes which information? 1. Time & circumstances under which the rash was noted 2. Explanation given to the client & family of the reason for the rash 3. Documentation of rash & notification of the health care provider 4. The need for application of corticosteroid cream to decrease inflammation.

3. Documentation of rash & notification of the health care provider. Any suspected reactions should be reported to the health care provider.

A client has a modified radical mastectomy & axillary dissection. The nurse identifies which client concern as the basis for the priority nursing diagnosis immediately after the procedure? 1. Expresses concern about hearing the pathology report results. 2. An extensive surgical wound is covered with a large dressing. 3. Expresses a need for medication for severe pain. 4. A need for assistance to sit up & complete self-care.

3. Expresses a need for medication for severe pain.

The client at 16 weeks gestation has an amniocentesis. The client asks what will be learned from this procedure. The nurse responds that which condition can be detected? 1. Tetralogy of Fallot 2. Talipes equinovarus 3. Hemolytic disease of the newborn 4. Cleft lip & palate

3. Hemolytic disease of the newborn

The nurse evaluates the nutritional intake of an adolescent female client attending camp. The client receives three balanced meals per day & consumes 100% of each meal with an average nutritional intake per meal of 900 calories with 3 mg of iron. The adolescent menstruates monthly & is of average weight for height. Which best describes the adolescent's nutritional intake? 1. Low in calories & high in iron. 2. Low in calories & low in iron. 3. High in calories & low in iron. 4. High in calories & high in iron.

3. High in calories & low in iron. Needs 15 mg of iron each day

The client has a history of hypertension & angle-closure glaucoma. Which medication order does the nurse question? 1. Propanolol 80 mg PO QID 2. Verapamil 40 mg PO TID 3. Tetrahydrozoline 2 drops in each eye TID 4. Timolol 1 drop in each eye once daily

3. Tetrahydrozoline 2 drops in each eye TID Ophthalmic vasoconstrictor; contraindicated with glaucoma.

The nurse develops care plans for these four clients. The nurse plans to use a restraint for which client? 1. The infant with septicemia 2. The child after a tonsilectomy 3. The infant after a cleft lip repair 4. The child with meningitis

3. The infant after a cleft lip repair.

The nursing team consists of one RN, two LPNs, & three NAPs. The RN cares for which client? 1. The client with a chest tube who is ambulating in the hall. 2. The client with a colostomy requiring assistance with irrigation. 3. The client with a right-sided stroke requiring assistance with bathing. 4. The client declining medication to treat cancer of the colon.

4. The client declining medication to treat cancer of the colon. Requires assessment skills.

Promethazine HCl 25 mg IV push is ordered for the client. Prior to administering this medication, the nurse makes which assessment? 1. The color of the medication solution. 2. The client's pulse & temperature. 3. The time of the last analgesic dose the client received. 4. The patency of the client's vein.

4. The patency of the client's vein.

Which assessment information indicates to the nurse the client has hypocalcemia? 1. Constipation 2. Depressed reflexes 3. Decreased muscle strength 4. Positive Trousseau's sign

4. Positive Trousseau's sign Indicative of neuromuscular hyperreflexia associated with hypocalcemia

A Miller-Abbott tube is ordered for the client. The nurse knows this tube is inserted for which main reason? 1. Provides an avenue for nutrients to flow past an obstructed area. 2. Prevents fluid & gas accumulation in the stomach. 3. Administers medications that can be absorbed directly from the intestinal mucosa. 4. Removes fluid & gas from the small intestine.

4. Removes fluid & gas from the small intestine. Intestinal decompression often used for treatment of paralytic ileus.

A newborn is diagnosed with fetal alcohol spectrum disorder. The nurse knows which action is an important consideration for this newborn? 1. Prevent iron deficiency anemia 2. Decrease touch to prevent over stimulation 3. Provide feeding via gavage to decrease energy expenditure 4. Replace vitamins depleted as a result of poor maternal diet

4. Replace vitamins depleted as a result of poor maternal diet

The nurse reviews procedures with the health care team. The nurse intervenes if the RN staff member makes which statement? 1. "It is my responsibility to ensure the consent form has been signed & is attached to the client's record." 2. "It is within my scope of practice that I can witness the signature of the client before surgery is performed." 3. "It is my responsibility to explain the surgery & ask the client to sign the consent form." 4. "It is my responsibility to answer questions the client may have before surgery."

3. "It is my responsibility to explain the surgery & ask the client to sign the consent form."

The nurse cares for the client the first day postoperative after a transurethral prostatectomy. The client has a continuous bladder irrigation. The client's spouse asks why the client has the CBI. Which response by the nurse is best? 1. "The CBI prevents bladder spasms & infection." 2. "The CBI dilutes the urine to prevent infection." 3. "The CBI enables urine to keep flowing." 4. "The CBI delivers medication to the bladder."

3. "The CBI enables urine to keep flowing." Prevents formation of blood clots.

During a prenatal visit, the client states, "I have been very nauseated during my first trimester & I don't understand the reason." Which response by the nurse is best? 1. "You are nauseated because of the fatigue you are feeling." 2. The nausea is due to an increase in the basal metabolic rate." 3. "The nausea is caused by an elevation in the hormones." 4. "If you eat different kinds of foods, you won't be nauseated."

3. "The nausea is caused by an elevation in the hormones."

A client receives parenteral nutrition for several weeks. If the PN is abruptly discontinued, the nurse expects the client to exhibit which signs & symptoms? 1. Tinnitus, vertigo, blurred vision 2. Fever, malaise, anorexia 3. Diaphoresis, confusion, tachycardia 4. Hyperpnea, flushed face, diarrhea

3. Diaphoresis, confusion, tachycardia Insulin levels remain high while glucose levels decline, resulting in hypoglycemia.

The client is admitted with a tentative diagnosis of late stage AIDS dementia complex. The nursing assessment is most likely to reveal which finding? 1. Hyperactive deep tendon reflexes 2. Peripheral neuropathy affecting the hands 3. Disorientation to person, place & time 4. Impaired concentration & memory loss

3. Disorientation to person, place & time

The nurse cares for the client with a radium implant. During the removal of the implant, it is most important for the nurse to take which action? 1. Clean the radium implant carefully with a disinfectant using long forceps. 2. Handle the radium carefully using forceps & rubber latex gloves. 3. Document the date & time of removal together with the total time of implant treatment. 4. Double-bag the radium implant before the person from radiology removes it from the room.

3. Document the date & time of removal together with the total time of implant treatment.

The parent tells the nurse about having had difficulty forming relationships. The parent is worried the 7-year-old child will have the same problem. Which statement by the nurse is best? 1. "Children develop trust from birth to 18 months of age." 2. "Children develop trust from 18 months to three years of age." 3. "Children develop trust from three to six years of age." 4. "Children develop trust from six to twelve years of age."

1. "Children develop trust from birth to 18 months of age."

The nurse prepares a client for an IVP scheduled in 2 hours. The nurse contacts the health care provider if the client makes which statement? 1. "I take metformin for type 2 diabetes." 2. "I completed the bowel prep last evening." 3. "I ate a light meal last evening." 4. "I had an IVP 3 years ago."

1. "I take metformin for type 2 diabetes." Metformin should be D/C'd 48 hours prior.

The nurse cares for the client receiving haloperidol. The nurse anticipates which adverse effects? 1. Blood dyscrasia & extrapyramidal symptoms 2. Hearing loss & unsteady gait 3. Nystagmus & vertical gaze palsy 4. Alteration in level of consciousness & increased confusion

1. Blood dyscrasia & extrapyramidal symptoms

The nurse plans care for the client diagnosed with paranoid schizophrenia. The nurse knows that questioning the client about the client's false ideas will elicit which response? 1. Cause the client to defend the idea. 2. Help the client clarify thoughts. 3. Facilitate better communication. 4. Lead to a breakdown of the defense.

1. Cause the client to defend the idea.

The client is diagnosed with an adjustment disorder with depressed mood. The client has the greatest chance of success in activities that require psychic & physical energy if the nurse schedules activities at which time? 1. During the morning hours 2. During the middle of the day 3. During the afternoon hours 4. During the evening hours

1. During the morning hours A client with reactive depression has the highest level of physical & psychic energy in the morning.

A client receives a blood transfusion & experiences a hemolytic reaction. The nurse anticipates which assessment findings? (Select all that apply.) 1. Hypotension 2. Low back pain 3. Wet breath sounds 4. Fever 5. Urticaria 6. Severe shortness of breath

1. Hypotension 2. Low back pain 4. Fever

The nurse provides care for a client diagnosed with a recurrent UTI. The client is given a prescription for ciproflaxin. The nurse instructs the client to limit intake of which fluid? 1. Milk 2. Sugar free cranberry juice 3. Water 4. Bottled water

1. Milk Avoid dairy products while on ciproflaxin

The health care provider prescribes estrogen 0.625 mg daily for the 43-year-old woman. The nurse identifies which symptom as a common initial adverse effect of this medication? 1. Nausea 2. Visual disturbances 3. Tinnitus 4. Ataxia

1. Nausea

The health care provider orders chlorpromazine to control the alcoholic client's restlessness, agitation & irritability following surgery. The nurse checks the order with the health care provider because of which rationale? 1. The nurse believes the client's symptoms reflect alcohol withdrawl. 2. The nurse does not know if the client is allergic to this medication. 3. The nurse knows the client is not psychotic. 4. The nurse routinely checks on the health care provider's orders.

1. The nurse believes the client's symptoms reflect alcohol withdrawal.

The 7-year-old child is having some difficulty adjusting to the parents' impending divorce. The health care provider suggests play therapy. The nurse identifies which reason this is effective for this age group? 1. Young children have difficulty verbalizing emotions. 2. Children hesitate to confide in anyone but their parents. 3. Play is an enjoyable form of therapy for children. 4. Play therapy is helpful in preventing regression.

1. Young children have difficulty verbalizing emotions.

An adolescent client is scheduled for a below-knee amputation following a motorcycle accident. The nurse includes which information in the preoperative teaching? 1. Explain that the client will walk with a prosthesis soon after surgery. 2. Encourage the client to share feelings & fears about the surgery. 3. Instruct the client that only the legal guardian can sign the informed consent. 4. Evaluate how the client plans to complete schoolwork during hospitalization.

2. Encourage that client to share feelings & fears about the surgery.

The nurse assesses a client diagnosed with a spinal cord injury. Which finding suggests the complication of autonomic dysreflexia? (Select all that apply.) 1. Urinary bladder spasm pain 2. Severe pounding headache 3. Profuse sweating 4. Dysrhythmias 5. Severe hypotension 6. Nasal congestion

2. Severe pounding headache 3. Profuse sweating 6. Nasal congestion

The nurse prepares the client for an MRI. Which client statement indicates the teaching is successful? 1. "The dye used in the test will turn my urine green for about 24 hours." 2. "I will be put to sleep for this procedure. I will return to my room in two hours." 3. "This procedure will take about 60 minutes to complete. There will be no pain." 4. "The wires that will be attached to my head & chest will cause me some pain."

3. "This procedure will take about 60 minutes to complete. There will be no pain."

The client comes to the clinic to have a HBA1C performed. Which client statement indicates to the nurse an understanding of the procedure? 1. "This test is performed by using a first voided urine specimen." 2. "This test needs to be performed in the morning before I eat breakfast." 3. "This test indicates how well my blood sugar has been controlled the past 2-3 months." 4. "I must follow my diet carefully for several days before the test."

3. "This test indicates how well my blood sugar has been controlled the past 2-3 months."

The geriatric residents of a long term care facility participate in a reminiscing group. The nurse identifies which goal as the primary goal of this type of group activity? 1. Provides psychosocial educational opportunities for stress & coping. 2. Provides an avenue for physical exercise. 3. Provides an environment for social interaction & companionship. 4. Reorients & provides a reality test for confused clients.

3. Provides an environment for social interaction & companionship.

The adult client receives dexamethasone for chronic lymphocytic leukemia. It is most important for the nurse to report which finding to the health care provider? 1. PT of 12 seconds & Hgb of 15 g/dL. 2. BUN of 18 mg/dL & creatinine of 1 mg/dL. 3. Serum K of 3.4 mEg/L & serum Ca of 7.8 mg/dL. 4. AST of 18 U/L & ALT of 12 U/L.

3. Serum K of 3.4 mEq/L & serum Ca of 7.8 mg/dL.

A continent adult client undergoes admission to the hospital with a diagnosis of hepatitis A. Which precautions does the nurse include in the client's overall care during hospitalization? 1. Contact precautions 2. Airborne precautions 3. Standard precautions 4. Droplet precautions

3. Standard precautions Because client is continent.

The health care provider diagnoses Graves' disease for the client. The nurse expects the client to exhibit which symptom? 1. Lethargy in the early morning 2. Sensitivity to cold 3. Weight loss of 10 lb in 3 weeks 4. Reduced deep tendon reflexes

3. Weight loss of 10 lb in 3 weeks Increased metabolic rate

The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which is the best response by the nurse? 1. 11 months 2. 14 months 3. 17 months 4. 20 months

4. 20 months

The client is diagnosed with myasthenia gravis. It is most important for the nurse to consider which action? 1. Prevent accidents from falls as a result of vertigo. 2. Maintain fluid & electrolyte balance. 3. Control situations that could increase intracranial pressure & cerebral edema. 4. Assess muscle groups toward the end of the day.

4. Assess muscle groups toward the end of the day.

Which is the best method for the nurse to use when evaluating the effectiveness of tracheal suctioning? 1. Notes subjective data, such as "My breathing is much improved now." 2. Notes objective findings, such as decreased respiratory rate & pulse. 3. Consults with the respiratory therapist to determine effectiveness. 4. Auscultates the chest for change or clearing of adventitious breath sounds.

4. Auscultates the chest for change or clearing of adventitious breath sounds.

The client is newly diagnosed with Buerger's disease. The clinic nurse obtains a health history. The nurse expects the client's history to include which symptoms? 1. Heart palpitations 2. Dizziness when walking 3. Blurred vision 4. Digital sensitivity to cold

4. Digital sensitivity to cold Vasculitis of blood vessels in upper & lower extremities

The nurse assesses the client immediately after an exploratory laparotomy. Which nursing observation indicates the complication of intestinal obstruction? 1. Protruding soft abdomen with frequent diarrhea 2. Distended abdomen with ascites 3. Minimal bowel sounds in all four quadrants 4. Distended abdomen with reports of pain

4. Distended abdomen with reports of pain.

A client is brought to the ER after being raped in the home by an intruder. The client asks the nurse to call the spouse to come to the ER. The nurse knows the most common reaction of a significant other to a rape victim is reflected in which behavior? 1. Supportive & helpful to the victim 2. Disconnected & apathetic toward the victim 3. Frustrated & feeling vulnerable, but denying the need for help 4. Emotionally distressed &/or needing assistance

4. Emotionally distressed &/or needing assistance

A client is diagnosed with a gastric ulcer. The nurse anticipates the client will experience pain at which time? 1. Two to three hours after a meal. 2. During the night. 3. Prior to the ingestion of food. 4. One-half to 1 hour after a meal.

4. One-half to 1 hour after a meal.

The client reports a severe headache, nausea & photophobia. The health care provider prescribes a CBC and a lumbar puncture. A diagnosis of bacterial meningitis is made. Which laboratory result does the nurse expect? 1. CSF cloudy, Hgb 13g/dL, HCT 38%, WBC 18,000 2. CSF with RBCs present, Hgb 10g/dL, HCT 37%, WBC 8,000 3. CSF cloudy, Hgb 12 g/dL, HCT 37%, WBC 7,000 4. CSF clear, Hgb 15 g/dL, HCT 40%, WBC 14,000

1. CSF cloudy, Hgb 13g/dL, HCT 38%, WBC 18,000

The client with type 1 diabetes asks the nurse why the health care provider prescribed short-acting insulin instead of intermediate-acting insulin. Which response by the nurse is best? 1. "More injections are required with intermediate-acting insulin than with short-acting insulin." 2. Hypoglycemia & hyperglycemia are more common with intermediate-acting insulin." 3. Development of eye & kidney damage is less likely with short-acting insulin." 4. "Blood glucose levels can be controlled more accurately with short-acting insulin."

4. "Blood glucose levels can be controlled more accurately with short-acting insulin."