VATI Comprehensive A

178. A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit. Which of the following clients is appropriate to assign to the float nurse? A. A 10-year-old client who has pneumonia and is receiving respiratory treatments B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect tomorrow D. A 14-year-old client who is scheduled for discharge today following placement of a Herrington rod

A 10-year-old client who has pneumonia and is receiving respiratory treatments

47. A nurse on a medical unit has just received change-of-shift report. Which of the following clients should the nurse assess first? A. A 68 year old client who had a myocardial infarction 2 days ago and reports chest pain on a scale of 0 to 10 B. A 48 year old client who has AIDS, pneumocystic pneumonia, and a temperature of 38.3 C (101F) C. A 60 year old client who has COPD, is receiving 2 L/min O2 via a nasal cannula, and has an oxygen saturation of 89% D. A 26 year old female client who has pelvic inflammatory disease and is unable to void

A 68 year old client who had a myocardial infarction 2 days ago and reports chest pain as a 4 on a scale of 0 to 10

152. An emergency department nurse triages a group of school children injured in a school bus crash. Which of the following children should the nurse have the provider evaluate first? A. A child who has a forehead wound that is bleeding copiously B. A child who has a compound fracture of the femur and is crying in pain C. A child who reports diplopia and nausea and was unconscious at the scene but is now awake D. A child who has several missing permanent teeth and a swollen, ecchymotic upper lip

A child who has a forehead wound that is bleeding copiously

167. A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel? A. A client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry B. A client who had a myocardial infarction 3 days ago and reports chest pain C. A client who had a stroke 2 days ago and needs help toileting D. A client who has awoken following a bronchoscopy and requests a drink

A client who had a stroke 2 days ago and needs help toileting

27. A nurse at the family planning clinic triages several client over the phone. Which of the following clients should the nurse instruct to come to the clinic? A. A client who uses a diaphragm for contraception and has lost 30 lb in the past 6 months dieting B. A client who had an intrauterine device inserted yesterday and has cramping and bleeding C. A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding D. A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday

A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday

39. A nurse is caring for a client who is postoperative following a bowel surgery and has an NG tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube might not be functioning properly? A. Wall suction set to 60 mmHg B. Drainage fluid is greenish-yellow C. Aspirate pH of 3 D. Abdominal rigidity

Abdominal rigidity

164. A nurse is caring for a client following a possible exposure to anthrax. Which of the following actions should the nurse take? A. Administer an antitoxin B. Quarantine the client C. Monitor the client for a productive cough D. Begin prophylactic treatment with ciprofloxacin

Administer an antitoxin

166. A nurse is providing teaching to the guardian of a school-age child who has a new prescription for ferrous sulfate capsules PO. Which of the following instructions should the nurse include in the teaching? A. Add the contents of the capsules to food B. Dissolve the capsules in a glass of chocolate milk C. Administer the medication with a glass of orange juice D. Administer the medication at bedtime

Administer the medication with a glass of orange juice

18. A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the following actions should the nurse identify as an indication that the newly licensed nurse understands wound irrigation? A. Cleanses the wound with povidone-iodine with cotton balls B. Administers PO analgesia 20 min prior to irrigation C. Warms the irrigation solution in the microwave oven prior to application D. Irrigates the wound from the top to the bottom

Administers PO analgesia 20 minutes prior to irrigation

16. A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is A. Asymmetric, with variegated coloring B. Scaly and red C. Brown, with a wart-like texture D. Firm and rubbery

Asymmetric, with variegated coloring

48. A nurse is assessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following food can indicate that the client has an allergy to latex? A. Peanuts B. Shellfish C. Avocados D. Eggs

Avocados

23. A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse should identify that which of the following findings indicates fluid overload? A. Diminished bowel sounds B. Bradycardia C. Hypotension D. Bounding pulses

Bounding pulses

8. A nurse is teaching the parent of a school-age child who has scabies about the application of permethrin 5% cream. The nurse should include which of the following as a potential adverse effect of the medication? A. Burning B. Discoloration C. Photosensitivity D. Alopecia

Burning

151. A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in their diet during lactation? A. Vitamin D B. Iron C. Vitamin A D. Calcium

Calcium

14. A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement with 5 cm of dilation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse? A. Perform another internal exam B. Notify the client's provider C. Check the FHR D. Obtain a pH test of the fluid

Check the FHR

2. A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the following findings should cause the nurse to suspect a skull fracture? A. Clear fluid drainage from the nares B. Report of pain around the eyes C. Dried blood in the mouth D. Mandibular asymmetry

Clear fluid drainage from the nares

177. A nurse enters a client's room and finds the client lying on the floor in a puddle of water. Which of the following statements should the nurse document in an incident report? A. Client fell out of bed because an assistive personnel left the rails of the bed down B. Client's roommate thinks the client is confused and fell when getting out of bed C. Client appears to have slipped in water but reports no injuries D. Client found lying on the floor near the bedside table

Client found lying on the floor near the bedside table

11. A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching? A. A series of four hepatitis vaccines is recommended to prevent viral hepatitis B. Hepatitis B is transmitted by contaminated food C. Chronic hepatitis can lead to renal cell cancer D. Clients who have a history of viral hepatitis are unable to donate blood

Clients who have a history of viral hepatitis are unable to donate blood

20. A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the followings is the priority action? A. Notify the facility operator B. Close the fire doors on the unit C. Turn off oxygen sources D. Put out the fire with the appropriate extinguisher

Close the fire door on the unit

54. A charge nurse is evaluating the time management skills of a newly licensed nurse. Which of the following actions should the charge nurse identify as an effective time management skill? A. Delegates creation of a client's teaching plan to a licensed practical nurse B. Completes activities for one client before moving to the next client C. Focuses on activities rather than objectives D. Skips break times to catch up on charting

Completes activities for one client before moving to the next client

38. A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication A. Decreased reflexes B. Weight gain of 1.4 kg C. Increased urinary output D. Jugular vein distention

Decreased reflexes

17. A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take? A. Position the examination light toward the client's face B. Stand on the right side of the client when examining the left eye C. Dim the lights in the room prior to the examination D. Place the ophthalmoscope directly against the client's forehead

Dim the lights in the room prior to the examination

168. A nurse is caring for a client who is receiving continuous enteral feedings and reports diarrhea. Which of the following actions should the nurse take? A. Discard opened cans of formula after 24 hrs B. Replace the extension tubing every 48 hrs C. Irrigate the tubing every 12 hr with 50 mL of warm water D. Increase the infusion rate

Discard opened cans of formula after 24 hrs

62. A nurse is caring for a client who is requesting treatment for a gambling disorder. Which of the following medications should the nurse expect the provider to prescribe? A. Varenicline B. Disulfiram C. Sertraline D. Clonidine

Disulfiram

41. A client who is having suicidal thoughts tells the nurse, "It just does not seem worth it. Why not end my misery?" Which of the following responses by the nurse is appropriate? A. Why do you think your like is not worth it anymore? B. You can trust me and tell me what you are thinking? C. I need to know what you mean by misery? D. Do you have to plan to end your life?

Do you have a plan to end your life?

10. A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first? A. Instill erythromycin ophthalmic ointment in the newborn's eyes B. Weigh the newborn C. Place identification bracelets on the newborn D. Dry the newborn

Dry the newborn

33. A nurse is providing teaching to a client who is at 8 week gestation and experiencing episodes of nausea and vomiting. Which of the following instructions should the nurse include? A. Brush teeth immediately after eating B. Lay down for 30 min after meals C. Drink 12 oz of water with each meal D. Eat a dry carbohydrate before getting out of bed

Eat a dry carbohydrate before getting out of bed

57. A nurse is assessing a client who has a long arm cast. For which of the following findings should the nurse monitor when assessing for acute compartment syndrome A. Edema B. Shortness of breath C. Petechiae D. Change in mental status

Edema

170. A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include? A. Educating the client how to cover nose and mouth with tissues when coughing B. Recommending the client may return to work after two negative sputum cultures C. Instructing the client that he is no longer contagious after 1 week of medication therapy D. Teaching the client's family to wear protective masks while with the client

Educating the client how to cover the nose and mouth with tissues when coughing

174. A nurse is caring for a client who is receiving total parental nutrition. For which of the following findings should the nurse monitor as a potential complication of TPN? A. Constipation B. Respiratory depression C. Hypotension D. Electrolyte imbalance

Electrolyte imbalance

173. A nurse is analyzing the laboratory data on a client who has dehydration. Which finding should the nurse anticipate in a client who has fluid volume deficit? A. Decreased serum osmolarity B. Decreased hematocrit C. Elevated blood urea nitrogen D. Lower urine specific gravity

Elevated blood urea nitrogen

150. A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections. Which of the following information should the nurse plan to include in the teaching about UTI prevention? A. Decrease intake of citrus foods and beverages B. Wear nylon underwear C. Empty the bladder before and after intercourse D. Increase the time between voiding

Empty the bladder before and after intercourse

69. A nurse is assessing a client who is postoperative following abdominal surgery. The client states, "I feel like my incision ripped open." The nurse notes dehiscence of the incision. Which of the following actions should the nurse take? A. Extend the client's legs above heart level B. Place the client in a low-Fowler's position C. Instruct the client to perform the Valsalva maneuver D. Apply a dry gauze dressing to the incision

Extend the client's legs above heart level

22. A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect? A. Hallucinations B. Agnosia C. Bradycardia D. Aphasia

Hallucinations

28. A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels? A. 3-hr oral glucose tolerance test B.. HbA1c C. Fasting blood glucose test D. Urinalysis for ketones

HbA1C

61. A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect? A. Head compression B. Fetal hypoxia C. Abruptio placentae D. Postmaturity

Head compression

40. A nurse is caring for a 7-year-old child who has severe dehydration. Which of the following findings should the nurse expect? A. Blood pressure 94/68 mmHg B. Urinary output 30 mL/hr C. Respiratory rate 24/min D. Heart rate 152/min

Heart rate 152/min

25. A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective? A. Heart rate greater than 60/min B. Pedal pulses 2+ C. Pacer spikes after the QRS complex D. Distended jugular veins

Heart rate greater than 60/min

51. A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable diagnosis to the CDC? A. Herpes simplex virus (HSV) type 1 B. Hepatitis A C. Human papillomavirus (HPV) D. Pediculosis capitis

Hepatitis A

55. A nurse is caring for a client who has a prescription for atorvastatin. Which of the following client conditions is a contraindication to this medication? A. Hepatitis C B. Crohn's disease C. Peptic ulcer disease D. Bronchitis

Hepatitis C

60. A nurse is planning to perform wound irrigation for a client who has an open secondary wound. When creating a sterile field, which of the following actions should the nurse take? A. Set up the sterile field 7.6 cm below waist level B. Hold the bottle of sterile solution with the palm over the label while pouring C. Place the sterile items within 1 cm of the edge of the sterile border D. Place the lid of a bottle of sterile solution within the sterile field

Hold the bottle of sterile solution with the palm over the label while pouring

24. A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing? A. INR 1.1 B. Hyperemesis C. HbA1c 5.6% D. Uncontrolled pain

Hyperemesis

A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which of the following findings should the nurse expect? A. Hyperreflexia B. Meiosis C. Euphoria D. Hypothermia

Hyperreflexia

50. A nurse is preparing to witness a client's signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surgeon? A. I wonder if the metal in my knee will show up in airport screenings B. The physical therapy has not been working, so I will need to have the surgery C. I look forward to being able to bend my knee again when I sit in a chair D. I am thankful there are no serious complications from this type of surgery

I am thankful there are no serious complications from this type of surgery

172. A nurse is providing teaching about car seat safety to the parent of a term newborn. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should place a rolled blanket along each side of my baby's head in the car seat." B. "I should place my baby's car seat rear-facing until 6 months of age." C. "I should put the car seat retainer clip at the level of my baby's belly button." D. "I should position my baby's car seat at a 90-degree angle in the car."

I should place my baby's car seat rear-facing until 6 months of age

161. A nurse is providing teaching to a client who has osteoporosis and a new prescription for alendronate. Which of the following statements by the client indicates an understanding of the teaching? A. "I will take this medication within 15 minutes of eating." B. "I will take this medication at bedtime." C. "I will take this medication with 8 ounces of water." D. "I will increase my caffeine intake while taking this medication."

I will take this medication with 8 ounces of water

165. A nurse in an inpatient mental health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first? A. Explain to the client the consequences of refusal B. Identify the reason for the client's refusal C. Document the client's refusal in the medical record D. Inform the provider of the client's refusal

Identify the reason for the client's refusal

68. A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following? A. Treat mild to moderate depression B. Enhance the immune system C. Prevent and treat prostate enlargement D. Improve joint functioning

Improve joint functioning

43. At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? A. Constipation B. Indigestion C. Swollen ankles D. Urinary frequency

Indigestion

1. A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action? A. Inform the client of available community resources B. Assist the client in finding child care options C. Agree upon short-term goals for the client D. Ask the client about their understanding of the diagnosis

Inform the client of available community resources

56. A nurse delegates tasks to a licensed practical nurse and an assistive personnel. When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN? A. Insert an indwelling catheter if the client has not voided in 3 hr B. Obtain the abdominal girth now and every 4 hr C. Assess and document the level of consciousness every hour D. Measure the amount of gastric drainage every 2 hr

Insert an indwelling catheter if the client has not voided in 3 hr

163. A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take? A. Prohibit visitors for the first 24 hrs B. Keep a 3 foot distance from the radiation implant C. Maintain the client on bed rest for 72 hr D. Require the client wear a dosimeter badge

Keep a 3 foot distance from the radiation implant

19. A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of consciousness. Which of the following interventions should the nurse include in the plan of care? A. Perform active range-of-motion exercises B. Maintain the head at a midline position C. Suction the airway frequently D. Perform neurological checks every 4 hrs

Maintain the head at a midline position

13. A nurse is assessing an adult male who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories? A. Healthy weight B. Malnutrition C. Overweight D. Obesity

Malnutrition

171. A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all new employees to screen for the presence of tuberculosis? A. Sputum culture B. Chest x-ray C. QuantiFERON-TB Gold blood analysis D. Mantoux test

Mantoux test

15. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? A. Encourage the client to gain 2.3 kg per week B. Weigh the client once per week throughout hospitalization C. Monitor the client for 1 hr after meals D. Allow the client to choose meal times

Monitor the client for 1 hr after meals

160. A nurse is assessing a client who has a fentanyl patch in place for chronic pain. Which of the following findings should the nurse report to the provider? A. No bowel movement for 3 days B. Report of dry mouth C. Respiratory rate 14/min D. Potassium level 4.8 mEq/L

No bowel movement for 3 days

156. A nurse is admitting a client to the medical-surgical unit. Which of the following actions should the nurse take first? A. Place the client's valuables in the facility's safe B. Observe the client's level of mobility C. Administer prescribed medications D. Electronically enter the prescriptions from the provider

Observe the client's level of mobility

44. A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to intervene? A. Encourages the client to use the incentive spirometer B. Elevates the head of the client's bed C. Offers oral fluids to the client D. Checks the client's pulse oximetry

Offers oral fluids to the client

158. A nurse is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output? A. Oliguria B. Constricted pupils C. Shivering D. Bradypnea

Oliguria

179. A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions? A. Hepatotoxicity B. Ototoxicity C. Hypercalcemia D. Hypertension

Ototoxicity

52. A nurse is giving change of shift report about a client who is 36 hr postoperative to another nurse. Which of the following should the nurse include? A. Daily bath given at 1000 B. Vomited a large amount of emesis immediately after surgery C. Flushed IV with 0.9% sodium chloride D. Pain relieved by position change

Pain relieved by position change

30. A nurse is planning care for a client who has a gambling disorder. Which of the following instructions should the nurse provide to the client? A. Participate in a 12-step program B. Plan to take clozapine for the next 6 months C. Use systematic desensitization to decrease gambling behaviors D. Learn to use projection to adapt to stressful experiences

Participate in a 12-step program

176. A nurse in the labor and delivery unit is reviewing medications for a group of clients. Which of the following medications places the fetus at risk for teratogenic effects? A. Levothyroxine for hypothyroidism B. Phenytoin for seizure disorder C. Magnesium oxide for constipation D. Ferrous sulfate for chronic anemia

Phenytoin for seizure disorder

157. A nurse in a newborn nursery is performing assessments on four neonates that are all less than 24 hr old. The nurse should plan to notify the provider of which of the following findings? A. Head circumference 1 cm greater than chest B. Positive Babinski reflex on bilateral feet C. Passage of meconium stool D. Pinna below the outer canthus of the eye

Pinna below the outer canthus of the eye

49. A nurse is planning discharge teaching for a client who is scheduled to receive intravenous infusions at home. Which of the following instructions should the nurse plan to include? A. Plug the infusion pump in an outlet next to the bathroom B. Pull the cord when unplugging the infusion pump C. Clean the infusion pump when it is turned on D. Place the infusion pump cord against the baseboards

Place the infusion pump cord against the baseboards

32. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? A. Clothe the newborn in light cotton B. Check the newborn's temperature every 8 hrs. C. Administer 120 mL of water between feedings D. Place the newborn 45 cm from the light source

Place the newborn 45 cm from the light source

63. A charge nurse overhears two assistive personnel in the unit lobby discussing the HIV status of a client. Which of the following response is the priority for the nurse to make? A. Do you understand HIPAA regulations? B. This discussion is only appropriate in a private area C. Please stop this discussion D. Did you know you can be liable if you breach confidentiality?

Please stop this discussion

5. A nurse plans to ambulate a client on the third day after cardiac surgery. Which of the following interventions should the nurse take so that the client will best tolerate ambulation? A. Provide the client with a water B. Premedicate the client with the prescribed analgesic C. Obtain the client's vital signs and oximetry prior to ambulation D. Reinforce the client's surgical dressing

Premedicate the client with the prescribed analgesic

9. A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the following actions should the nurse take? A. Rupture the amniotic sac B. Medicate the client for pain C. Prepare the client for a cesarean section D. Perform a vaginal exam

Prepare the client for a cesarean section

3. A nurse in an urgent care clinic is collecting admission history from a client who is at 16 weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical findings are associated with this infection? A. Profuse milky white discharge B. Frequency and dysuria C. Low-grade fever D. Hematuria

Profuse milky white discharge

153. A nurse is caring for a client who has been taking propranolol. Which of the following findings indicates a need to withhold the medication? A. Blood pressure 156/90 mm Hg B. Pulse 54/min C. Potassium 5.2 mEq/L D. Sodium 130 mEq/L

Pulse 54/min

6. A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment? A. Portable suction B. Cervical collar C. Hemodialyzer D. Pulse oximeter

Pulse oximeter

64. A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following actions should the nurse include in the plan of care? A. Remind the client to place the cane on the unaffected side B. Adjust the length of the cane to equal the distance from the client's iliac crest to the floor C. Remove the rubber tip from the cane to enhance ambulation D. Place the cane safely in the closet during naps and at bedtime

Remind the client to place the cane on the unaffected side

149. A nurse is teaching a client who has a new prescription for digoxin. Which of the following statements should the nurse include in the teaching? A. "Notify your provider if you experience muscle weakness." B. "Reports a weight gain of one-half pound per day." C. "Expect this medication to increase your blood pressure." D. "You will need to take a diuretic while taking this medication."

Report a weight gain of one-half pound per day

66. A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take? A. Report the incident to Adult Protective Services B. Interview the client with his adult child present C. Tell the client he must answer every assessment question D. Advise the client to consult a social worker

Report the incident to Adult Protective Services

46. A nurse in a mental health facility is interviewing a newly admitted client. Which of the following actions should the nurse take when conducting the interview? A. Insist the client use direct eye contact during the inerview B. Seat the client at least 3.7m from the nurse C. Position the client's chair between the nurse's chair and the door D. Lean in slightly when speaking to the client

Seat the client at least 3.7m from the nurse

59. A nurse is caring for a client who is at high risk for developing diabetes insipidus following a severe head injury. Which assessment finding indicates to the nurse that the client is developing DI? A. Urine specific gravity of 1.028 B. Urine output of 250 mL/hr C. Serum sodium of 155 mEq/L D. Blood glucose of 198 mg/dL

Serum sodium of 115 mEq/L

35. A nurse is planning care for a client who has schizophrenia and is having difficulty expressing their feelings. Which of the following referrals should the nurse make? A. Art therapist B. Speech-language pathologist C. Social worker D. Recreational therapist

Social worker

67. A home health nurse is assessing a client who reports a headache and appears confused and drowsy. The client has a kerosene space heater in use. Which of the following actions should the nurse take first? A. Take the client outdoors B. Wrap blankets around the client C. Loosen the client's clothing D. Open the client's windows

Take the client outdoors

31. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take? A. Encourage the client to ambulate in the hallway 1 hr before bedtime B. Tell the client to avoid drinking fluids 1 hr before bedtime C. Schedule routine care tasks during hours when the client is awake D. Advise the client to leave the television in the room on when trying to fall asleep

Tell the client to avoid drinking fluids 1 hr before bedtime

175. A nurse is performing high-frequency chest compressions using a mechanical chest compression device for a child who has cystic fibrosis. Which of the following findings indicates the treatment has been effective? A. The child develops a dry, hacking cough B. The child has increased nasal secretions C. The child has increased sputum production D. The child develops diminished breath sounds

The child has increased sputum production

162. A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration? A. The client tucks his chin while swallowing food B. The client sits upright in bed during meals C. The client pockets food on one side of his mouth D. The client has a cough reflex

The client pockets food on one side of his mouth

42. A nurse is caring for a client who has schizophrenia. Which of the following findings is the nurse's priority? A. The client asks other clients on the unit for help with bathing and getting dressed B. The client refuses to take prescribed oral risperidone C. The client reports hearing voices D. The client's thoughts jump rapidly from one idea to the next when speaking

The client reports hearing voices

45. A nurse is reviewing the medical history of a client who is taking a garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement? A. The client is taking an antidepressant B. The client has a history of a seizure disorder C. The client takes aspirin daily D. The client has a history of rheumatoid arthritis

The client takes aspirin daily

21. A nurse is talking with an adult child of a client who was involuntarily admitted to an inpatient mental health facility. Which of the following statements should the nurse make? A. The provider will notify your patient's employer about admission to the facility B. Your parent will have to take the medication that the doctor prescribes C. Your parent might have electroconvulsive therapy without providing consent D. The provider can prescribe restraints if your parent tries to harm others

The provider can prescribe restraints if your parent tries to harm others

4. A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique? A. This technique prevents injury to the sciatic nerve B. This technique decreases the risk of subcutaneous infiltration C. This technique allows a larger amount of medication to be injected D. This technique increases the absorption rate of the drug

This technique decreases the risk of subcutaneous infiltration

180. A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect? A. Generalized edema B. Elevated urine specific gravity C. Thready pulse D. Increased hematocrit

Thready pulse

159. A nurse is caring for a client who reports chest pain. Which of the following findings indicates myocardial damage? A. aPTT 80 seconds B. Troponin I 1.8 ng/mL C. Erythrocyte sedimentation rate 17 mm/hr D. Human B-type natriuretic peptide 88 pg/mL

Troponin I 1.8 ng/mL

154. A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following instructions should the nurse include? A. "Wear an underwire bra between feedings." B. "Cover your breasts immediately after feedings." C. "Apply cold compresses to your breasts before feedings." D. "Try to have your baby empty your breasts with each feeding."

Try to have your baby empty your breasts with each feeding

37. An occupational health nurse at a group of health care clinics is planning activities to prevent and control the spread of communicable disease. The nurse should identify that which of the following activities is a secondary level of prevention? A. Influenze immunizations B. Tuberculosis screenings C. Presentations about safer sex practices D. Evaluations of bloodborne pathogen policies

Tuberculosis screenings

29. A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client? A. Wear an N95 respirator B. Insert an indwelling urinary catheter to monitor urinary output C. Monitor the client's vital signs every 8 hr D. Use a dedicated stethoscope

Use a dedicated stethoscope

7. A nurse is admitting a client who has antisocial personality disorder. Which of the following client behaviors should the nurse identify as consistent with this disorder? A. Compulsive attention to details B. Avoids interacting with others C. Uses others for personal gain D. Socially awkward in group situations

Uses others for personal gain

65. A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care? A. Limit each of the client's visitors to 1 hr per day B. Remove dirty linens from the room after double bagging C. Wear a dosimeter film badge while in the client's room D. Ensure family members remain at least 1 m from the client

Wear a dosimeter film badge while in the client's room

155. A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following findings requires immediate intervention by the nurse? A. Blood glucose level of 120 mg/dL B. Serum sodium 138 mEq/L C. Oral temperature of 37.6C D. Weight increase of 2 kg in the past 24 hours

Weight increase of 2 kg in the past 24 hr

26. A nurse is caring for a client who is taking levothyroxine. Which of the following findings should indicate to the nurse that the medication is effective? A. Decreased blood pressure B. Weight loss C. Decreased inflammation D. Absence of seizures

Weight loss

169. A nurse is caring for an adolescent who is receiving treatment for heart failure. Based on the client's chart findings, which of the following actions should the nurse plan to take? A. Administer furosemide B. Withhold digoxin C. Withhold spironolactone D. Administer ferrous sulfate

Withhold digoxin

12. A nurse in a residential mental health facility is planning care for a new client who has obsessive compulsive disorder. Which of the following is appropriate for the nurse to include in the plan of care? A. Work with the client to create a flexible daily schedule B. Gradually decrease the time allowed for ritualistic behavior C. Offer solutions to assist in problem solving D. Teach the client to meditate about obsessive thoughts

Work with the client to create a flexible daily schedule

36. A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, "Why did you choose to talk to me out of this room full of kids?" Which of the following responses by the nurse is therapeutic? A. You looked like you would be the most likely to talk back with me B. Let's go see what activities are going on outside C. Why shouldn't I talk to you? You looked lonely D. You're curious why I am interested in you and not the others?

You're curious why I am interested in you and not the others

34. A nurse is teaching a client who is scheduled for placement of a peripherally inserted central catheter line. Which of the following information should the nurse include in the teaching? A. Your PICC line will allow long-term access for antibody therapy B. You should use a 5-milliliter barrel syringe to flush your PICC line at home C. Your PICC line must be placed in your nondominant arm D. You should immobilize the arm with the PICC line using a sling

Your PICC line will allow long-term access for antibiotic therapy