Senior Synthesis Final?

A client receiving parenteral nutrition (PN) complains of a headache. The nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distension, and crackles bilaterally. The nurse determines that the client is experiencing which complication of PN therapy? a. sepsis b. Air embolism c. Hypervolemia d. Hyperglycemia

c. Hypervolemia

The nurse auscultates prolonged expiration with expiratory wheezing and diminished breath sounds while assessing the client. What does the nurse suspect? a. Tuberculosis b. Pneumonia c. Croup d. Asthma

d. Asthma

A client is admitted to the neurological unit from the emergency department with a diagnosis of cervical (c4) spinal cord injury. Which data should the nurse collect first when admitting the client to the nursing unit? a. Listen to breath sounds b. Check peripheral pulses c. Check for muscle flaccidity d. Determine extremity muscle strength

a. Listen to breath sounds

A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia? a. Lying recumbent following meals b. Consuming small, frequent, bland meals c. Raising the head of the bed on 6-inch blocks d. Taking H2-receptor antagonist medication

a. Lying recumbent following meals

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? a. bilateral wheezing b. Inspiratory crackles c. Intercostal retractions d. Increased respiratory rate

d. Increased respiratory rate

The father of an 18-month-old with no previous illness, who has been admitted to a surgery center for repair of an inguinal hernia, tells the nurse that his child is having trouble breathing. The father does not think the child choked. After telling the clerk to call the rapid response team, the nurse should do which of the following? Place in order from first to last! a. Notify the surgeon b. Assess the effectiveness of the abdominal thrusts c. Start an Intravenous Infusion d. Perform abdominal thrust maneuver e. Listen for breath sounds

1. e. Listen for breath sounds 2. d. Perform abdominal thrust maneuver 3. b. Assess the effectiveness of the abdominal thrusts 4. c. Start an Intravenous Infusion 5. a. Notify the surgeon

An unconscious client with multiple injuries arrives in the emergency department. Which nursing intervention receives the highest priority? a. Establishing an airway b. Replacing blood loss c. Stopping bleeding from open wounds d. Assessing for cervical fracture

a. Establishing an airway

When assessing for Attention Deficit Hyperactivity Disorder in children, the nurse recalls that symptoms of ADHD include: Select all that apply. a. Impulsive behavior b. Facial grimaces or tics c. Need for immediate gratification d. Extremely short attention span e. Repetitive bizarre behavior

a. Impulsive behavior c. Need for immediate gratification d. Extremely short attention span

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? a. It can develop into ventricular fibrillation at any time b. It is almost impossible to convert to a normal rhythm c. It is uncomfortable for the client, giving a sense of impending doom. d. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.

a. It can develop into ventricular fibrillation at any time

Which of the following statements by a female client indicates that instruction in ways to prevent urinary tract infection (UTI) was understood? a. I should limit intake of water so I won't need to urinate so often b. I should drink 8 to 10 glasses of fluid per day c. I should only wear nylon underpants d. I should void every 6 hours while I am awake

b. I should drink 8 to 10 glasses of fluid per day

The client who has been taking venlafaxine (Effexor) 25 mg po three times a day for the past 2 days states, "This medication isn't doing me any good. I'm still do depressed." Which of the following responses by the nurse is most appropriate? a. Perhaps we'll need to increase your dose b. Let's wait a few days and see how you feel c. It takes about 2 to 4 weeks to receive the full effects d. It's too soon to tell if your medication will help you.

c. It takes about 2 to 4 weeks to receive the full effects

A client receiving chemotherapy has an extremely low white blood cell count an is immediately placed on neutropenic precautions that include a low-bacteria diet. Which food items is the client allowed to consume? Select all that apply a. Raw Celery b. Fresh Apple c. Italian Bread d. Tossed Salad e. Baked Chicken f. Well-cooked cheeseburger

c. Italian Bread e. Baked Chicken f. Well-cooked cheeseburger

Zafirlukast (Accolate) is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication? a. Platelet count b. Neutrophil count c. Liver function tests d. Complete blood count

c. Liver function tests

A nurse has been told that a client's anxiety is at the panic level. The nurse would assess the client for which of the following? a. Dizziness, palpitations, nausea b. Feelings of "butterflies" in the stomach c. Feelings of fatigue and inability to remain awake d. Obsessive thoughts and compulsive behavior

a. Dizziness, palpitations, nausea

The registered nurse has finished reviewing the 0700 shift report on a telemetry unit. Which of the following clients would be the most appropriate for the RN to assign to the LPN? a. A 4-day postoperative CABg client with an infection in the sterna surgical incision requiring dressing changes and irrigation. b. A client who will be arriving at 0715 on the unit from the ED for observation to rule out myocardial infarction. c. A client who has had successful valve replacement therapy and will be discharged this morning. d. A client who is scheduled for a percutaneous transluminal coronary angioplasty (PTCA) at 1000

a. A 4-day postoperative CABg client with an infection in the sterna surgical incision requiring dressing changes and irrigation.

The nurse is preparing the client assignment for the day and needs to assign clients to a licensed practical nurse (LPN) and a (UAP). Which clients should the nurse assign to the LPN because of client needs that cannot be met by the UAP? Select all that apply a. A client is requiring frequent suctioning b. A client is requiring a dressing change to the foot c. A client requiring range-of-motion exercises twice daily d. A client requiring reinforcement of teaching about a diabetic diet e. A client on bed rest requiring vital sign measurement every 4 hours f. A client requiring collection of a urine specimen for urinalysis testing

a. A client is requiring frequent suctioning b. A client is requiring a dressing change to the foot d. A client requiring reinforcement of teaching about a diabetic diet

A client developed cardiogenic shock after a severe myocardial infarction and has developed acute renal failure. The client's family asks the nurse why the client has developed acute renal failure. The nurse should base the response on the knowledge that there was: a. A decrease in the blood flow through the kidneys b. An obstruction of urine flow from the kidneys c. A blood clot formed in the kidneys d. Structural damage to the kidney resulting in acute tubular necrosis

a. A decrease in the blood flow through the kidneys

The nurse manager is providing an educational session to the nursing staff in a skilled nursing facility on the guidelines for the safe use of physical restraints. Which are safe guidelines? Select all that apply a. A health care provider's prescription is required b. Restraints should be secured with a quick-release tie c. Restraints are secured to side rails so that they can be easily removed as necessary d. Restraints are used when other measures have failed to prevent self-injury or injury to others e. Restraints can be used as a usual part of treatment plans, as indicated by the client's condition or symptoms f. The use of restraints can be prescribed PRN (as needed) as long as the nurse performs a thorough assessment before applying them

a. A health care provider's prescription is required b. Restraints should be secured with a quick-release tie d. Restraints are used when other measures have failed to prevent self-injury or injury to others

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

a. Allow the newborn infant to signal a need

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. a. Communicate expected behaviors to the client b. Ensure the client that they know they are not in charge of the nursing unit. c. Assist the client in identifying ways of setting limits on personal behaviors d. Follow through about the consequences of behavior in a nonpunitive manner. e. Enforce rules by informing the client that they will not be allowed to attend therapy groups. f. Have the client state the consequences for behaving in ways that are viewed as unacceptable.

a. Communicate expected behaviors to the client c. Assist the client in identifying ways of setting limits on personal behaviors d. Follow through about the consequences of behavior in a nonpunitive manner. f. Have the client state the consequences for behaving in ways that are viewed as unacceptable.

The nurse on a mental health nursing unit is caring for a patient diagnosed with bipolar depression who is exhibiting mania and manipulative behavior. Select all the appropriate nursing interventions for this patient. a. Communicate expected behaviors to the client b. Enforce rules and inform the client that he/she will not be allowed to attend therapy groups. c. Ensure that the client knows that he/she is not in charge of the nursing unit. d. Be clear with the client regarding the consequences of exceeding limits set regarding behavior. e. Assist the client in testing out appropriate behaviors for obtaining needs.

a. Communicate expected behaviors to the client d. Be clear with the client regarding the consequences of exceeding limits set regarding behavior. e. Assist the client in testing out appropriate behaviors for obtaining needs.

A registered nurse (RN) asks a license practical nurse (LPN) to change the colostomy bag on a client. The LPN tells the RN that although attendance at the hospital in-service was completed regarding this procedure, the LPN has never performed a colostomy bag change on a client. Which is the most appropriate action by the RN to implement? a. Perform the procedure with the LPN b. Request that the LPN observe another LPN perform the procedure c. Ask the LPN to review the materials from the in-service before performing the procedure d. Instruct the LPN to review the procedure in the hospital manual and take the written procedure into the client's room for reference

a. Perform the procedure with the LPN

The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on these observation, what is the nurse's immediate priority of care? a. Provide safety for the client and other clients on the unit b. Provide the clients on the unit with a sense of comfort and safety c. Assist the staff in caring for the client in a controlled environment d. Offer the client a less stimulating area to calm down in and gain control.

a. Provide safety for the client and other clients on the unit

The nurse is reading the history and physical examination of an older client admitted to the hospital. Which findings documented in the history should require the nurse to implement an accident prevention protocol? Select all that apply> a. Range of motion is limited b. Peripheral vision is decreased c. Transmission of hot impulses is delayed d. The client denies complaints of nocturia e. High - frequency hearing tones are perceptible f. Voluntary and autonomic reflexes are slowed

a. Range of motion is limited b. Peripheral vision is decreased c. Transmission of hot impulses is delayed f. Voluntary and autonomic reflexes are slowed

A 59 yr old female is diagnosed with a left vertebral artery CVA. She has unsteady gait, dysphagia, and dysarthria. What is the priority nursing diagnosis for this patient? a. Risk for aspiration b. Low self-esteem c. Impaired verbal communication d. Impaired physical mobility

a. Risk for aspiration

The nurse is assigned to care for a client with complete right-sided hemiparesis. Which characteristics are associated with this condition? Select all that apply. a. The client is aphasic b. The client has weakness in the face and tongue c. The client has weakness on the right side of the body d. The client has complete bilateral paralysis of the arms and legs. e. The client has lost the ability to move the right arm but is able to walk independently f. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

a. The client is aphasic b. The client has weakness in the face and tongue c. The client has weakness on the right side of the body

The nurse manager is developing an educational session for nursing staff on the components of informed consent. Which information should the nurse manager include in the session? Select all that apply a. The client needs to be informed of the prognosis if the test, procedure, or treatment is refused. b. The client cannot refuse a test, procedure, or treatment once the test, procedure or treatment is started. c. The name(s) of the persons performing the test or procedure or providing treatment should be documented on the informed consent form. d. A description of the complications and risks of the test, procedure, or treatment, as well as anticipated pain or discomfort, needs to be explained to the client. e. The nurse is responsible for obtaining the client's signature on an informed consent form even if the client has questions about the test, procedure, or treatment to be performed.

a. The client needs to be informed of the prognosis if the test, procedure, or treatment is refused. c. The name(s) of the persons performing the test or procedure or providing treatment should be documented on the informed consent form. d. A description of the complications and risks of the test, procedure, or treatment, as well as anticipated pain or discomfort, needs to be explained to the client.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? a. Twitching b. Hypoactive bowel sounds c. Negative Trousseau's sign d. Hypoactive deep tendon reflexes

a. Twitching

The nurse's assignment consists of four patients. After receiving report, which order should the nurse plan for initial assessments of the patients? Place the patients in order of priority for assessment. a. _____ A 35 year old with suspected tuberculosis who is on respiratory isolation precautions. b. _____ A 60 year old client with chest tubes who is 2 days postoperative following a thoracotomy for lung cancer and is requesting pain medication. c. _____ An 85 year old client with bacterial pneumonia, temperature of 102.2 F, and shortness of breath. d. _____ A 56 year old with emphysema who is due for a scheduled bronchodilator at 0900 & is on 1L of oxygen per nasal cannula.

a. __4___ A 35 year old with suspected tuberculosis who is on respiratory isolation precautions. b. ___2__ A 60 year old client with chest tubes who is 2 days postoperative following a thoracotomy for lung cancer and is requesting pain medication. c. __1___ An 85 year old client with bacterial pneumonia, temperature of 102.2 F, and shortness of breath. d. __3___ A 56 year old with emphysema who is due for a scheduled bronchodilator at 0900 & is on 1L of oxygen per nasal cannula.

During a neurologic assessment, the nurse identifies the client has a dilated right pupil. The nurse understands this suggests a problem with which cranial nerve? a. cranial nerve III b. cranial nerve II c. cranial nerve VIII d. cranial nerve VII

a. cranial nerve III

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? a. pH 7.25, Pco2 50 mmHg b. pH 7.35, Pco2 40 mmHg c. pH 7.50, Pco2 52 mmHg d. pH 7.52, Pco2 28 mmHg

a. pH 7.25, Pco2 50 mmHg

The registered nurse (RN) is creating a plan for the assignments for the day and is leading a team composed of a licensed practical nurse (LPN) and a (UAP). Based on licensure, which client is most appropriate to assign to the LPN? a. A client with dementia b. A 1 day postoperative mastectomy client c. A client who requires some assistance with bathing d. A client who requires some assistance with ambulation

b. A 1 day postoperative mastectomy client

During the change of shift on a neurological nursing unit, the nurse is given four patient assignments. The nurse is prioritizing which patient to see first. Place the following four patient sin the order the nurse should assess each. The first patient would be the first patient the nurse would assess, the fourth patient would be the last patient the nurse would assess. a. A 28 yr old female being treated for bacterial meningitis who has a headache and a temperature of 102.6 F. b. A 62 yr old male with amytrophic lateral sclerosis (ALS) who is experiencing new onset shortness of breath and has a respiratory rat eof 8 breaths per minute. c. A 78 yr old male who is 6 days post-CVA who passed a swallow study and is currently eating breakfast. d. A 45 yr old male patient being treated for cluster headaches with a headache at 7/10.

b. A 62 yr old male with amytrophic lateral sclerosis (ALS) who is experiencing new onset shortness of breath and has a respiratory rat eof 8 breaths per minute. a. A 28 yr old female being treated for bacterial meningitis who has a headache and a temperature of 102.6 F. d. A 45 yr old male patient being treated for cluster headaches with a headache at 7/10. c. A 78 yr old male who is 6 days post-CVA who passed a swallow study and is currently eating breakfast.

The nurse recognizes that hospitalized patients are at increased risk for urinary tract infections. Which of the following patients would the nurse monitor most closely for s/s of UTI? a. A 28 yr old female recovering from a cesarean section delivery, up with assistance, normal diet. b. A 78 yr old male with prostatitis, up with assistance, fluid restriction, heart healthy diet. c. A 49 yr old female with a femur fracture, bed rest, normal diet. d. A 56 yr old male with pulmonary edema and congestive heart failure, bathroom privileges only, fluid restriction, heart healthy diet.

b. A 78 yr old male with prostatitis, up with assistance, fluid restriction, heart healthy diet.

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the emergency department. The nurse should take which action? a. Prepare the triage rooms b. Activate the emergency response plan c. Obtain additional supplies from the central supply department d. Obtain additional nursing staff to assist in treating the casualties

b. Activate the emergency response plan

Aspirin is administered to the client experiencing a myocardial infarction (MI) because of it's: a. Antipyretic action b. Antithrombotic action c. Anti-inflammatory reaction d. Analgesic action

b. Antithrombotic action

The nurse is administering propranolol (Inderal) to a client for control of migraine headaches. The client's pulse rate is 56 bpm. What should the nurse do next? a. Contact the physician immediately b. Assess blood pressure c. Administer Oxygen d. Ask for a relative to contact

b. Assess blood pressure

The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what best instruction should the nurse provide to the staff? a. Increase socialization of the client with peers b. Avoid laughing or whispering in front of the client c. Begin to educate the client about social supports in the community d. Have the client sign a release of information to appropriate parties for assessment purposes

b. Avoid laughing or whispering in front of the client

When assessing the client with meningitis, the nurse looks for which of the following as a frequent first sign of increased intracranial pressure? a. A rising systolic blood pressure b. Change in mood or attention level c. Irregular respiratory rate and depth d. A bounding radial pulse

b. Change in mood or attention level

The nurse should implement which measures to prevent an electrical shock when using electrical equipment? Select all that apply a. Use a two-prong outlet b. Check the electrical cord for fraying c. Keep the electrical cord away from the sink d. Place the excess electrical cord under a small carpet e. Grasp the electrical cord when unplugging the equipment f. Disconnect the electrical cord from the wall socket when cleaning the equipment

b. Check the electrical cord for fraying c. Keep the electrical cord away from the sink f. Disconnect the electrical cord from the wall socket when cleaning the equipment

The nurse has completed an assessment of a client with a decreased cardiac output. which set of findings should receive the highest priority for intervention? a. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles b. Confusion, urine output 15ml over the last 2 hours, orthopnea c. SpO2 92% on 2L per nasal cannula, respirations 20, 1+ edema of lower extremities d. weight gain of 1kg in 3 days, BP 130/80, mild dyspnea with exercise

b. Confusion, urine output 15ml over the last 2 hours, orthopnea

The nurse is preparing to administer a medication to a client and notes that the dose prescribed is higher than the recommended dosage. The nurse calls the health care provider to clarify the prescription, and the health care provider instructs the nurse to administer the dose as prescribed. Which action should the nurse take? a. Call the pharmacy b. Contact the nursing supervisor c. Call the medical director on call d. Administer the dose as prescribed

b. Contact the nursing supervisor

The nurse is monitoring a client who is taking digoxin (Lanoxin) for adverse effects. Which findings are characteristic of digoxin toxicity? select all that apply. a. Tremors b. Diarrhea c. Photophobia d. Blurred vision e. Nausea and vomiting

b. Diarrhea c. Photophobia d. Blurred vision e. Nausea and vomiting

The nurse finds the client sitting on the floor, ensures the client's safety, completes an incident report, and notifies the health care provider of the incident. Which should the nurse implement next? a. staple the incident report in the client's medical record b. Document the client events and follow-up nursing actions c. Provide a copy of the incident report to the provider and family d. Document in the client's medical record that the nurse sent a copy of the report to management

b. Document the client events and follow-up nursing actions

During the assessment of a patient with pericarditis, the nurse would expect the patient to have what symptom? a. Splinter hemorrhages in nail beds b. Friction rub on auscultation & grating chest pain, aggravated by breathing c. Mild chest pain that radiate to left shoulder d. Pitting peripheral edema

b. Friction rub on auscultation & grating chest pain, aggravated by breathing

The community health nurse is providing a teaching session about terrorism to members of the community and is discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted by which route(s)? Select all that apply a. Bites from ticks or deer flies b. Inhalation of bacterial spores c. Through a cut or abrasion in the skin d. Direct contact with an infected individual e. Sexual contact with an infected individual f. Ingestion of contaminated undercooked meat

b. Inhalation of bacterial spores c. Through a cut or abrasion in the skin f. Ingestion of contaminated undercooked meat

A client arrives at the prenatal clinic for the first prenatal assessment. She tells the nurse that the first day of her last menstrual period (LMP) was August 19, 2015. Using Nagele's rule, the nurse determines the estimated date of delivery as which date? a. May 12, 2016 b. May 26, 2016 c. June 12, 2016 d. June 26, 2016

b. May 26, 2016

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

b. Metabolic alkalosis

A client has been diagnosed with disseminated varicella zoster (shingles). Which personal protective equipment (PPE) will you need to put on when preparing to assess the client? Select all that apply a. Surgical face mask b. N95 respirator c. Gown d. Gloves e. Goggles f. Shoe covers

b. N95 respirator c. Gown d. Gloves

The nurse is assigned to care for a hospitalized toddler. Which measure should the nurse plan to implement as the highest priority of care? a. Providing a consistent caregiver b. Protecting the toddler from injury c. Adapting the toddler to the hospital routine d. Allowing the toddler to participate in play and diversional activities

b. Protecting the toddler from injury

The nurse is ordered to administer dexamethasone to an unconscious, unresponsive 22 yr old female patient being treated for bacterial meningitis. The nurse recognizes the medication is indicated to: a. Improve patient oxygenation b. Reduce intracranial pressure c. Maintain circulating volume d. Prevent the development of a thrombus

b. Reduce intracranial pressure

The driving force of water intake is: a. ADH b. Thirst c. Decline in blood volume d. Decrease in plasma osmolarity

b. Thirst

The nurse manager is reviewing with the nursing staff the purposes for applying ankle restraints to a client. The nurse manager determines that further education is necessary when a nursing staff member states that which is an indication for the use of a restraint? a. Limit movement of a limb b. keep the client in bed at night c. Prevent the violent client from injuring self and others. d. Prevent the client from pulling out intravenous lines and catheters.

b. keep the client in bed at night

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? a. Call for help b. Extinguish the fire c. Activate the fire alarm d. Confine the fire by closing the room door

c. Activate the fire alarm

The nurse is working on a medical nursing unit during an external disaster is called to assist with care for clients coming into the emergency department. Using principles of triage, the nurse should initiate immediate care for a client with which injury? a. Fractured tibia b. Penetrating abdominal injury c. Bright red bleeding from a neck wound d. Open massive head injury, resulting in deep coma

c. Bright red bleeding from a neck wound

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? a. Hot, flushed feeling b. Sudden chills and fever c. Chest pain that occurs suddenly d. Dyspnea when deep breaths are taken

c. Chest pain that occurs suddenly

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 F orally. Which action should the nurse take? a. Begin the transfusion as prescribed b. Administer an antihistamine and begin the transfusion c. Delay hanging the blood and notify the Health Care Provider (HCP) d. administer two tablets of acetaminophen (Tylenol) and begin the transfusion

c. Delay hanging the blood and notify the Health Care Provider (HCP)

After receiving detailed information about a colonoscopy from the healthcare provider (HCP), the nurse asks the client to sign the informed consent form and discovers that the client cannot write. Which is the best intervention for the nurse to implement? a. Contact the provider to obtain informed consent b. Obtain a verbal informed consent from the client c. Have two nurses witness the client sign with an X d. Clarify information to the client with another nurse

c. Have two nurses witness the client sign with an X

A client diagnosed with bipolar disorder and experiencing acute mania states to the nurse, "Where Is my son? I love Lucy. Rain, rain go away. Dogs eat dirt". Another client approaches the nurse and says, "Man, is he ever nuts! He's driving me crazy with all his weird talk". Which response by the nurse to the second client most appropriate? a. I agree. He's a little hard to take sometimes. b. Just walk away and leave him alone. There is nothing else you can do. c. I realize his behavior bothers you, but he can't control it right now. d. I'll give him some medication so he won't bother you.

c. I realize his behavior bothers you, but he can't control it right now.

A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, " I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? a. Suggesting a reduction in the medication b. Allowing increased "in-room" activities c. Increasing the level of suicide precautions d. Allowing the client off-unit privileges as needed

c. Increasing the level of suicide precautions

The nurse has completed client teaching with the hemodialysis client about self monitoring between hemodialysis treatments. The nurse determines that the client best understands the information if the client states to record daily the: a. Amount of activity b. Pulse and respiratory rate c. Intake and output and weight d. Blood urea nitrogen and creatinine levels

c. Intake and output and weight

The nurse is caring for a 49 year old male patient diagnosed with unstable angina. The patient's telemetry monitor indicates the patient's rhythm has suddenly changed to the rhythm in the attached rhythm strip. Which of the following is the first action that the nurse should take? a. Administer intravenous amiodarone according to emergency protocol b. Obtain a defibrillator and defibrillate the client c. Quickly assess the client's level of consciousness, pulse, and respirations. d. Begin chest compressions and bag-valve ventilations

c. Quickly assess the client's level of consciousness, pulse, and respirations.

The nurse plans care for a client with COPD, understanding that the client is most likely to experience what type of acid-base imbalance? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

c. Respiratory acidosis

A nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of congestive heart failure (CHF). The nurse assesses the infant for which early sign of CHF? a. Cough b. Pallor c. Tachycardia d. Slow and shallow breathing

c. Tachycardia

As an initial step in treating a client with angina, the physician prescribes nitroglycerin 0.3 mg sublingually. The drug's principal therapeutic effects are produced by: a. Antispasmodic effects on the pericardium b. Increasing myocardial oxygen demand c. vasodilation of vasculature d. Improved conductivity in the myocardium

c. vasodilation of vasculature

The nurse observes that a client with potential for violence is agitated, pacing up and down the hallway, and is making aggressive and belligerent gestures at other clients. Which statement would be most appropriate to make to this client? a. You need to stop that behavior now b. You will need to be placed in seclusion c. you seem restless; tell me what is happening d. You will need to be restrained if you do not change your behavior.

c. you seem restless; tell me what is happening

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer? a. Bradycardia b. Numbness in the legs c. Nausea and vomiting d. A rigid, boardlike abdomen

d. A rigid, boardlike abdomen

The nurse is caring for a 76 year old male patient who is hospitalized for the treatment of a DVT. 30 minutes prior, the patient complained of a new onset headache with no other symptoms. Pain medication was administered as ordered and the nurse is reassessing the patient. Upon entering the room, the nurse finds the patient responsive but aphasic with a new onset left facial droop and paralysis of the left upper and lower extremity. Based on the history and current assessment, what would the nurse suspect is occurring? a. Hemmorrhagic CVA b. Subdural hematoma c. Meningitis d. Ischemic CVA

d. Ischemic CVA

A client on the psychiatric unit with the diagnosis of anorexia nervosa has an elaborate, prolonged meal ritual that lasts almost 2 hours. The ritual includes cutting food into minute pieces, smearing mustard over everything, and moving the food around and around on the plate. Using behavioral therapy concepts, the most therapeutic nursing response to this prolonged process would be: a. A clear explanation of why ritualistic behaviors are not allowed on the unit. b. Arranging for a favorite activity after meals to decrease the ritual time. c. Allowing the client to continue the ritual to encourage food intake and gain weight. d. Limiting the meal time to 30 minutes and basing privileges on weight gain.

d. Limiting the meal time to 30 minutes and basing privileges on weight gain.

the nurse has just administered the first dose of omalizumab (Xolair) to a client. Which statement by the client would alert the nurse that the client may be experiencing a life threatening effect? a. I have a severe headache b. My feet are quite swollen c. I am nauseated and may vomit d. My lips and tongue are swollen

d. My lips and tongue are swollen

The nurse determines that a client with a stroke (brain attack) is experiencing difficulty with fine motor coordination when performing activities of daily living. The nurse should suggest that the client be referred to which member of the health care team? a. Physical therapist b. Speech Pathologist c. Recreational Therapist d. Occupational Therapist

d. Occupational Therapist

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention if noted in the plan indicates the need for revision of the plan? a. Wearing gloves when emptying the client's bedpan b. Keeping all linens in the room until the implant is removed c. Wearing a lead apron when providing direct care to the patient d. Placing the client in a semiprivate room at the end of the hallway

d. Placing the client in a semiprivate room at the end of the hallway

The nursing student is preparing a client who will have spinal anesthesia for surgery. The nurse in charge asks the nursing student to identify which highest priority preoperative data to report to the nurse on the next shift who will care for the client postoperatively? a. Pulse rate of 78 beats/min b. Voided 300 ml preoperatively c. Blood pressure of 126/78 mm Hg d. Presence of weakness in the left lower extremity

d. Presence of weakness in the left lower extremity

The nurse is reviewing laboratory results and notes that a client's sodium serum level is 150 meq/L. The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which food item does the nurse instruct the client to avoid? a. Peas b. Nuts c. Cauliflower d. Processed oat cereals

d. Processed oat cereals

A delivery room nurse is preparing a client for a cesarean delivery. Which position will promote maximum uteroplacental perfusion during this surgery? a. Prone position b. Semi-Fowler's position c. Trendelenburg's position d. Supine position with a wedge under the right hip

d. Supine position with a wedge under the right hip

The nurse is observing a nursing student auscultating the breath sounds of a client. The nurse should intervene if the nursing student performs which action? a. Used diaphragm of the stethoscope b. Placed the stethoscope directly on the client's skin c. Asked the client to breathe slowly and deeply through the mouth d. asked the client to lie flat while listening anteriorly

d. asked the client to lie flat while listening anteriorly

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. which position should the nurse instruct the client to assume? a. Sitting up in bed b. side-lying in bed c. sitting in a recliner chair d. sitting on the side of the bed and leaning on an overbed table

d. sitting on the side of the bed and leaning on an overbed table

when assessing a patient's pulmonic valve, where should the nurse place the stethoscope? Refer to the picture below. e. Yellow dot f. Blue dot g. Green dot h. Red dot

f. Blue dot