2✅✅

Explain that the client may be placed in five positions. Rationale: Frequently, the client is placed in five positions (head down, prone, right and left lateral, and sitting upright) to aid in drainage of each of the five lobes of the lungs (D). Postural drainage should be performed before meals to prevent nausea, vomiting and aspiration(A). The client should breath slow and exhale through pursed lips to help keep airway open so that secretions can be drained while assuming the various positions. C is not required

101. When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use? a- Perform the drainage immediately after meals b- Instruct the client to breath shallow and fast c- Obtain arterial blood gases (ABG's) prior to procedure d- Explain that the client may be placed in five positions

Inability to close the affected eye, raise brow, or smile. Rationale: Because the motor function controlling eye closure, brow movement and smiling are all carried on the 7th cranial (facial) nerve, the combination of symptoms directly relating to an impairment of all branches of the facial nerve indicate that Bell's palsy has occurred.

102. A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke? a- Slow onset of facial drooping associated with headache b- Inability to close the affected eye, raise brow, or smile c- A flat nasolabial fold on the right resulting in facial asymmetry. d- Drooling is present on right side of the mouth, but not on the left.

Confusion and papilledema. Rationale: papilledema is always an indicator of increased ICP, and confusion is usually the first sign of increased ICP. Other options do not necessarily reflect increased ICP.

105. A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse include the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased? a- Increased Glasgow coma scale score. b- Nuchal rigidity and papilledema. c- Confusion and papilledema d- Periorbital ecchymosis.

Provide the man and his mother with a copy of the Patient's Bill of Rights.

197. A man expresses concern to the nurse about the care his mother is receiving while hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take? a- Provide the man and his mother with a copy of the Patient's Bill of Rights b- Explain that the hospital adheres to all national accreditation standards c- Advise the man to discuss his concerns with his mother's healthcare provider d- Determine if he would like to review the hospital's manual of approved polices.

Keeps the irrigating container less than 18 inches above the stoma. Rationale: Keeping the irrigating container less than 18 inches above the stoma permits the solution to flow slowly with little excessive peristalsis does not cause immediate release of stool.

103. The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching? a- Turns to left the side to instill the irrigating solution into the stoma b- Keeps the irrigating container less than 18 inches above the stoma c- Instills 1,200 ml of irrigating solution to stimulate bowel evacuation d- Inserts irrigating catheter deeper into stoma when cramping occurs

Avoid grapefruits and its juice. Rationale: Grapefruit increase the effect of dronedarone thereby increasing the possibility of serious side effects. A does not cause a serious effect. C may potentiate lethal arrhythmias and should be avoided. D does not directly affect those taking dronedarone.

104. The nurse should teach the client to observe which precaution while taking dronedarone? a- Stay out of direct sunlight b- Avoid grapefruits and its juice c- Reduce the use of herbal supplements d- Minimize sodium intake.

Confirm the necessity for continued use of the CVC. Rationale: Increase the length of use increase the risk for infection. The CVC care bundle includes the review of the need for continued use of the CVC. Effective hand hygiene and standard precautions should be maintained but protective environment precautions are not needed. B is not needed if continuous IV fluid are infused, ad may introduce contaminants. Use of a transparent dressing allows the site to be visualized for any signs of infection but changing the dressing daily increases the risk for infection ©

106. The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection? a- Remind staff to follow protective environment precautions b- Gently flush the catheter lumen with sterile saline solution c- Cleanse the site and change the transparent dressing. d- Confirm the necessity for continued use of the CVC.

Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI). Rationale: FBS grater that 126 mg/dL or 7.0 mmol/L (SI) glucose (normal FBS range 70-110 mg/dL or 3.9 to 6.1 mmol/L (SI)) on at least two occasions is most diagnostic for DM. Classic symptoms of polyphagia, polydipsia, and polyuria may not be present in type....

107. During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)? a- An increased thirst with frequent urination b- Blood glucose range during past two weeks was 110 to 125 mg/dl or 6.1 to 7.0 mmol/L(SI) c- Two-hour postprandial glucose tolerance test (GTT) is 160 mg/dL or 8.9 mmol/L (SI) d- Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).

Determine if she can ask for support from family, friend, or the baby's father. Rationale: Emotional support of significant family and friends can help a new mother cope with anxiety about transitioning to parenthood. The nurse should ask the client who is available to support her.

108. A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. What action should the nurse take? a- Provide reassurance to the client that these feeling are normal after delivery b- Discuss delaying the client's discharge from the hospital for another 24 hrs. c- Determine if she can ask for support from family, friend, or the baby's father. d- Explain the differences between postpartum blues and postpartum depression.

Stop the normal saline infusion. Rationale: If the IV has infiltrated or become dislodges, the fluid is infusing into surrounding tissue and not into the vein. Stopping the infusion C is the priority action. Establishing another IV site is necessary for fluid resuscitation after the infiltrated infusion is discontinuing the IV (D) is necessary due to the pain, and a large gauge needle is preferable.

109. A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first? a- Establish the second IV site b- Asses the IV for blood return c- Stop the normal saline infusion. d- Discontinue the 24-gauge IV

Ensure proper alignment of the leg in traction. Rationale: A fractured hip results in external rotation and shortening of the affected extremity. With the application of Buck's skin traction proper alignment ensures the transaction S pull is exerted to align the fracture hip with the distal leg, immobilize the fractured bone, and minimize muscle spasms and surrounding tissue injury related to the fracture. A should be implement but improper pull of traction can increase pain and soft tissue damage. B and C should be implemented but the greatest risk is improper alignment of the traction.

110. An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client's plan care? a- Evaluate her response to narcotic analgesia b- Asses the skin under the traction moleskin c- Place a pillow under the involved lower left leg d- Ensure proper alignment of the leg in traction.

Document the ongoing wound healing.

111. An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding? a- Immediately apply a pressure dressing b- Document the ongoing wound healing. c- Irrigate the wound with sterile saline d- Obtain a capillary INR, measurement

Anxiety.

112. At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client? a- Knowledge deficit b- Anxiety c- Anticipatory grieving d- Pain (acute)

Elevate the presenting part off the cord.

113. The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately? a- Administer oxygen by face mask at 6L/mint b- Transport the client for a cesarean delivery c- Elevate the presenting part off the cord. d- Place the client to a knee-chest position.

Reassess readiness for SNF transfer.

114. A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what recommendation should the nurse give the healthcare provider? a- Reassess readiness for SNF transfer. b- Obtain specimens for culture analysis c- Confer with family about home care plans d- Arrange physical therapy for strengthening.

Recognize signs and symptoms of hypoglycemia. Report persist polyuria to the healthcare provider. Take Glucophage with the morning and evening meal.

115. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.) a- Take an additional dose for signs of hyperglycemia b- Recognize signs and symptoms of hypoglycemia. c- Report persist polyuria to the healthcare provider. d- Use sliding scale insulin for finger stick glucose elevation. e- Take Glucophage with the morning and evening meal.

Contains a list with definitions of unfamiliar terms. Uses common words with few Syllables. Uses pictures to help illustrate complex ideas. Rationale: During the aging process older clients often experience sensory or cognitive changes, such as decreased visual or hearing acuity, slower thought or reasoning processes, and shorter attention span. Materials for this age group should include at least of terms, such as a medical terminology that incline may not know and use common words that expresses information clearly and simply. Simple, attractive pictures help hold the learner's attention. The reading level of material should be at the 4th to 5th grade level. Materials should be printed using large font (18-point or higher), not the standard 12-point font.

116. The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? Select all that apply a- Written at a twelfth-grade reading level b- Contains a list with definitions of unfamiliar terms c- Uses common words with few Syllables d- Printed using a 12-point type font e- Uses pictures to help illustrate complex ideas

Left Fourth Intercostal Space.

117. During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client's point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location)

Notify the healthcare provider of the client's change in mental status. Include q2 hour's reorientation in the client's plan of care.

118. An older male adult resident of long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.) a- Recommend a 24-hour caregiver on discharge to the long-term facility. b- Notify the healthcare provider of the client's change in mental status. c- Include q2 hour's reorientation in the client's plan of care. d- Request immediate evaluation by Rapid Response Team e- Apply soft wrist restraints so that the operative site is protected.

Assess the surroundings for noise and distractions.

119. An older male comes to the clinic with a family member. When the nurse attempts to take the client's health history, he does not respond to questions in a clear manner. What action should the nurse implement first? a- Ask the family member to answer the questions. b- Provide a printed health care assessment form c- Assess the surroundings for noise and distractions. d- Defer the health history until the client is less anxious.

Large amounts of fluid and electrolyte replacement. Rationale: This client, whose output is significantly high will need fluids and electrolyte replacement. The diuretic stage of ARF begins when the client has greater than 500 ml of urine in 24 hrs. A is associated with the oliguric and anuric stage of ARF. B and D should not occur until the client's BUN and electrolytes indicate a significant improvement that will allow for such changes.

120. The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need? a- Treatment for acute uremic symptoms within 24 hours b- Change to a regular diet c- Large amounts of fluid and electrolyte replacement. d- Unrestricted sodium intake

Minimize the amount of stimuli in the room.

121. Which intervention should the nurse include in the plan of care for a child with tetanus? a- Open window shades to provide natural light b- Reposition side to side every hour. c- Minimize the number of stimuli in the room. d- Encourage coughing and deep breathing

Remove cigarettes for the client's room.

122. Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement? a- Assign a sitter for constant observation b- Screen future visitors for contraband c- Document suicide monitoring frequently d- Remove cigarettes for the client's room.

A client must be willing to accept palliative care, not curative care. The healthcare provider must project that the client has 6 months or less to live.

123. A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (SATA) a- All family must agree about the need for hospice care. b- Hospice services are covered under Medicare Part B. c- A client must be willing to accept palliative care, not curative care. d- The healthcare provider must project that the client has 6 months or less to live. e- All medications except pain treatment will be stopped during hospice care.n should the nurse provide? (Select all that apply.)

Avoid use of nonsteroidal ant-inflammatory drugs (NSAID). Rationale: Dabigatran, a directed reversible thrombin inhibitor, is prescribe to reduce the risk of stroke in client with atrial fibrillation. The risk of bleeding and GI event can be significant and the concomitant use of NSAID and other anticoagulants should be avoided.

124. A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan? a- Keep an antidote available in the event of hemorrhage b- Continue obtaining scheduled laboratory bleeding test c- Eliminate spinach and other green vegetable in the diet. d- Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).

A mother with an infected episiotomy.

125. A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse? a- A client who is leaking clear fluid b- A mother who just delivered a 9 pounds boy c- A mother with an infected episiotomy. d- A client at 28- weeks' gestation in pre-term labor.

Digoxin. Rationale: This infant is demonstrating early signs of heart failure due to an increase right ventricular workload caused by a left to right shunt through the VSD, son an inotropic, such as digoxin should be administered first to improve the efficiency of myocardial contractility. Next a high ceiling diuretic to reduce fluid volume and workload of the heart. If hypokalemia occurs as result of potassium-wasting diuretic, should be given to reduce the risk of digoxin toxicity.

126. An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first? a- Spironolactone b- Potassium c- Ampicillin sodium parental d- Digoxin.

Supervise a newly hired graduate nurse during an admission assessment.

127. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN? a- Supervise a newly hired graduate nurse during an admission assessment. b- Transport a client who is receiving IV fluids to the radiology department. c- Administer PRN oral analgesics to a client with a history of chronic pain d- Complete ongoing focused assessments of a client with wrist restrain.

Ask the client what he is thinking about at his time.

128. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take? a- Remind the client that a rescue inhaler might save his life b- Leave the client alone so that he can grieve his illness c- Ask the client what he is thinking about at his time. d- Gently touch the client then continue with teaching.

Administer PRN nebulizer treatment. Obtain 12 lead electrocardiogram. Monitor continuous oxygen saturation.

129. After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.) a- Apply oxygen via nasal cannula b- Administer PRN nebulizer treatment. c- Obtain 12 lead electrocardiogram. d- Monitor continuous oxygen saturation. e- Give PRN dose of regular insulin

Administer a prescribed analgesia for pain.

130. The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take? a- Administer a prescribed analgesia for pain. b- Increase IV infusion rate for rehydration c- Provide additional blankets to increase body temperature d- Feed one ounce of formula to correct hypoglycemia.

Use sunblock or protective clothing when outdoors.

131. A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child?

Notify the food services department of the allergy. Enter the allergy information in the client's record. Add egg allergy to the client's allergy arm band.

132. Two days after admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy. Which actions should the nurse implement? (Select all that apply) a- Notify the food services department of the allergy. b- Enter the allergy information in the client's record. c- Document the statement in the nurse's notes d- Note the allergy on the diet intake flow sheet e- Add egg allergy to the client's allergy arm band.

Perform bilateral chest auscultation.

133. The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement? a- Perform bilateral chest auscultation. b- Resume compression for 2 minutes c- Administer a dose of epinephrine d- Program the monitor for cardioversion.

Encouraging liberal fluid intake.

134. After administering an antipyretic medication. Which intervention should the nurse implement?

Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider.

135. A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment? a- Explain the need for using lead shields for 2 to 3 weeks after the treatment b- Describe the signs of goiter because this is a common side effect of radioactive iodine c- Explain that relief of the signs/symptoms of hyperthyroidism will occur immediately d- Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider

Determine client's pulse, blood pressure, and respirations.

136. After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first? a- Assess the client's dressing for bleeding b- Determine client's pulse, blood pressure, and respirations c- Administer a PRN dose of IV Morphine d- Check the client's orientation to time and place.

Take postoperative vital signs for a client who has an epidual following knee arthroplasty. Collect a sputum specimen for a client with a fever of unknown origin. Ambulate a client who had a femoral-popliteal bypass graft yesterday.

137. The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply) a- Change a saturated surgical dressing for a client who had an abdominal hysterectomy. b- Take postoperative vital signs for a client who has an epidural following knee arthroplasty c- Start a blood transfusion for client who had a below-the knee amputation. d- Collect a sputum specimen for a client with a fever of unknown origin e- Ambulate a client who had a femoral-popliteal bypass graft yesterday

Raise the head of the bed to a Fowler's position and support his arms with a pillow.

138. A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement? a- Reposition the client in a side-lying position and support his abdomen with pillows. b- Elevate the client's feet on a pillow while keeping the head of the bed elevated. c- Raise the head of the bed to a Fowler's position and support his arms with a pillow d- Place the client in a shock position and monitor his vital signs at frequent intervals.

Administer the analgesic as requested. Rationale: Chronic pain may be difficult to describe but should be treated with analgesics as indicated.

139. A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next?

Crutches with 4 point gait.

140. A client with a chronic health problem has difficulty ambulating short distance due to generalized weakness, but is able to bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client? a- A quad cane b- Crutches with 2-point gait. c- Crutches with 3-point gait. d- Crutches with 4-point gait.

Observe aspiration site.

142. A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? a- Assess body temperature b- Monitor skin elasticity c- Observe aspiration site. d- Measure urinary output

Reinforce the importance of annual papanicolaou (Pap) smears.

143. An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement? a- Tell the client that the vaccine for HPV is not indicated b- Inform the client that warts do not return following cryotherapy c- Recommended the use of latex condoms to prevent HPV transmission. d- Reinforce the importance of annual papanicolaou (Pap) smears.

Establish a structured routine for the client to follow.

144. A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first? a- Assess the client's ability to communicate with the other staff members b- Arrange a meeting with the family to discuss the client's situation c- Administer the client's antidepressant medication as prescribed. d- Establish a structured routine for the client to follow.

Ventricular arrhythmias. Rationale: adrenal crisis, a potential complication of bilateral adrenalectomy, results in the loss of mineralocorticoids and sodium excretions that is characterized by hyponatremia, hyperkalemia, dehydration, and hypotension. Ventricular arrhythmias are life threatening and required immediate intervention to correct critical potassium levels.

145. A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? a- Decrease urinary output b- Low blood glucose level c- Profound weight gain d- Ventricular arrhythmias.

Instruct the mother to change the child's diaper more often.

146. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? a- Instruct the mother to change the child's diaper more often. b- Encourage the mother to apply lotion with each diaper charge c- Tell the mother to cleanse with soap and water at each diaper change d- Ask the mother to decrease the infant's intake of fruits for 24 hours.

Encourage the client to eat finger foods.

147. A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement? a- Allow client to choose foods from a menu b- Assign a staff member to feed the client c- Have meals brought to the client's room d- Encourage the client to eat finger foods.

Bowel patterns. Rationale: the client should be assessed for a change in bowel patterns to evaluate the effectiveness of this medication because Mesalamine is used to treat ulcerative colitis (a condition which causes swelling and sores in the lining of the colon [large intestine] and rectum) and also to maintain improvement of ulcerative colitis symptoms. Mesalamine is in a class of medications called anti-inflammatory agents. It works by stopping the body from producing a certain substance that may cause inflammation.

148. A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication? a- Pupillary response b- Oxygen saturation c- Peripheral pulses d- Bowel patterns

Contact the medical records department supervisor.

149. While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement? a- Place the records in a separate trash bag and tie the bag securely closed b- Point out the record to a worker in the medical records department c- Contact the medical records department supervisor. d- Immediately remove and shred the records.

Submit a referral for an evaluation by a physical therapist.

151. While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first? a- Inquire about an electric bed for the client's home use b- Submit a referral for an evaluation by a physical therapist. c- Explain the usual progression of osteoarthritis and HF d- Request social services to review the client's resources.

Palpate at the radial pulse site with the pads of two or three fingers.

152. A client has an intravenous fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement? a- Elevate the client's upper extremity before counting the pulse rate b- Auscultate directly below the IV site with a Doppler stethoscope c- Turn off the intravenous fluids that are infusing while counting the pulse. d- Palpate at the radial pulse site with the pads of two or three fingers.

Reposition the client with the head of the bed elevated. Rationale: Since children is sickle cell crisis often have shallow breathing due to acute chest syndrome, raising the head of the bed (A) will facilitate chest expansion by decreasing pressure of the diaphragm (B and C) are not be commended, nor should he UAP be corrected in front of the child. D is contraindicated because bed rest is warranted to conserve energy and promote oxygenation.

153. A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement? a- Reposition the client with the head of the bed elevated. b- Commend the UAP for implementing the proper position c- Tell the UAP that this position is harmful to the client d- Encourage the child to ambulate in the room

Ask the older brother how he felt during the incident.

154. A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take? a- Ask the older brother how he felt during the incident. b- Commend the older brother for his heroic actions c- Tell the older brother that he seems depressed d- Develop a water safety teaching plan for the family.

Hold oral intake until swallow evaluation is done.

155. After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement? a- Administer PRN medication b- Titrate the oxygen to keep saturation above 92% c- Hold oral intake until swallow evaluation is done. d- Elevate the head of his bed at least 45 degrees.

Interacts with a flat affect. Avoids eye contact. Has a disheveled appearance.

156. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply) a- Report feeling sad b- Interacts with a flat affect. c- Avoids eye contact. d- Has a disheveled appearance. e- Express suicidal thoughts.

Transfer the client to the surgical floor.

157. A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implement? a- The client should be kept in the recovery room b- Assess the client's respiratory status immediately c- Notify the client's surgeon immediately d- Transfer the client to the surgical floor.

Place personal religious artifacts on the body. Attach identifying name tags to the body. Follow cultural beliefs in preparing the body.

158. In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a- Place personal religious artifacts on the body. b- Confirm the client's wishes for tissue donation c- Observe consent for autopsy signature by family. d- Attach identifying name tags to the body. e- Follow cultural beliefs in preparing the body.

Be alert for possible cross-sensitivity to cephalosporin agents.

159. An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions? a- Be alert for possible cross-sensitivity to cephalosporin agents. b- Monitor peak ad trough levels whenever taking any antibiotic c- Watch daily urine output and weight gain while taking antibiotics d- Wear sun block and protective clothing to avoid exposure to sun.

The client's need for pain medication should be determined.

160. A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement? a- The impending signs of death should be documented b- The client's need for pain medication should be determined. c- The nurse manager should be updated on the client's status The client's status should be conveyed to the chaplain

Monitor abdominal girth. Report serum albumin and globulin levels. Note signs of swelling and edema. Rational: monitoring for increasing abdominal girth and generalized tissue edema and swelling are focused assessments that provide data about the progression of disease related complications. In advanced cirrhosis, liver function failure results in low serum albumin and serum protein levels, which caused third spacing that results in generalized fluid retention and ascites. Other options are not indicated in end stage liver disease.

161. A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.) a- Monitor abdominal girth. b- Increase oral fluid intake to 1500 ml daily. c- Report serum albumin and globulin levels. d- Provide diet low in phosphorous. e- Note signs of swelling and edema.

Report weight gain of 2 pounds (0.9kg) in 24 hours

162. During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge? a- Keep a daily weight record b- Obtain weight at the same time every day c- Limit intake of dietary salt. Report weight gain of 2 pounds (0.9kg) in 24 hours

Aural migraine headaches. Rationale: A client with a history of migraine headache requires further assessment to determine if medications from 5-HT1 receptor agonist (Triptans), such as sumatriptan, are currently be taken. Triptans and SSRI combination could potentially cause the fatal drug-drug interaction serotonin syndrome. SSRI are specific for treatment of A and B, although erectile dysfunction is a side effect of SSRI's.

163. Which problem, noted in the client's history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)? a- Bulimia nervosa b- Obsessive compulsive disorder c- Aural migraine headaches. d- Erectile dysfunction.

Identify a command center where activities are coordinated.

164. When implementing a disaster intervention plan, which intervention should the nurse implement first? a- Initiate the discharge of stable clients from hospital units b- Identify a command center where activities are coordinated c- Assess community safety needs impacted by the disaster d- Instruct all essential off-duty personnel to report to the facility.

Fever and dysuria.

165. The nurse is evaluating a client's symptoms, and formulates the nursing diagnosis, "high risk for injury due to possible urinary tract infection." Which symptoms indicate the need for this diagnosis? a- Hematuria and proteinuria b- Azotemia and anorexia c- Fever and dysuria. d- Straining on urination and nocturia

Maintain both lower extremities elevated on pillows.

166. A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement? a- Maintain both lower extremities elevated on pillows. b- Remove the contracting antiembolic stocking c- Administer diuretics in the morning hours d- Restrict PO fluid intake to 500 ml per shift

Teach family proper range of motion exercises.

167. A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care? a- Elevate lower extremities while out of bed b- Teach family proper range of motion exercises. c- Maintain proper body alignment when in bed d- Encourage diaphragmatic breathing exercises.

Postmenopausal women need an intake of at least 1,500 mg of calcium daily.

168. The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention? a- Family history is more important than calcium intake in determining the occurrence of osteoporosis b- Calcium should be taken once a day, preferable at the same time of day c- Smoking cessation is more important than calcium intake in preventing osteoporosis. d- Postmenopausal women need an intake of at least 1,500 mg of calcium daily.

Color characteristics of each stool.

169. When evaluating a client's rectal bleeding, which findings should the nurse document? a- Number of blood clots expelled with each stool. b- Unique odor noted with GI bleeding c- Evidence of internal hemorrhoids. d- Color characteristics of each stool.

High pitched or fine crackles.

170. The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound? a- High pitched or fine crackles. b- Rhonchi c- High pitched wheeze d- Stridor

Explain the reason for using only non-narcotics.

171. An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement? a- Request that the CT scan be done immediately b- Review the client's history for use of illicit drugs c- Assess client's pupils for their reaction to light. d- Explain the reason for using only non-narcotics.

Weigh the client and report any weight gain. Report any client complaint of pain or discomfort. Note and report the client's food and liquid intake during meals and snacks.

172. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) a- Evaluate the client for sleep disturbances b- Weigh the client and report any weight gain. c- Report any client complaint of pain or discomfort. d- Assess the client for weakness and fatigue e- Note and report the client's food and liquid intake during meals and snacks.

Medicate as needed for pain and anxiety.

173. Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client's plan of care? a- Allow the family to visit whenever they wish b- Medicate as needed for pain and anxiety. c- Allow client to participate in care provided d- Maintain quiet, low lighting environment

Decrease prevalence of glaucoma in the population.

174. An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries? a- Decrease morbidity in the elderly population b- Decrease prevalence of glaucoma in the population. c- Increase mortality in the elderly population d- Increased incidence of glaucoma in the population.

Convey to the client that birth is imminent.

175. The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first? a- Convey to the client that birth is imminent. b- Prepare the client for spinal anesthesia c- Empty the client's bladder using a straight catheter d- Prepare the coach to accompany the client to delivery

Remind the client to keep his appointments to have his cholesterol level checked.

176. To evaluate the effectiveness of male client's new prescription for ezetimibe, which action should the clinic nurse implement? a- Remind the client to keep his appointments to have his cholesterol level checked. b- Teach the client to weigh himself weekly and keep a log of the measurements c- Assess the elasticity of the client's skin at the next scheduled clinic appointment d- Encourage the client to keep a diary of his food intake until his next visit to the clinic.

Fall prevention measures.

177. Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include? a- Application of joint splints b- Effective body mechanisms c- Fall prevention measures. d- Low fat, high protein diet.

Shock.

178. A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as " Risk of injury" What term best expresses the "related to" portion of nursing diagnosis? a- Infection b- Increase intracranial pressure c- Shock d- Head Injury.

Identify pills in the bag.

179. An older male client with history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first? a- Obtain a medical history b- Record pain evaluation c- Assess blood glucose d- Identify pills in the bag.

New onset of purple skin lesions. Rationale: During the convalescence period of hepatitis A, the client major complain is malaise and fatigability. Purple skin lesions may be indicative of the liver's impaired ability to produce clothing elements and should be reported to the healthcare provider (C) for further analysis. Urine may become dark when excess bilirubin is excreted by the kidney, which is expected even when the client is not jaundice during the acute phase hepatitis (A). Myalgia and arthralgia (B) are intermittent complains with ongoing malaise, fatigue and weakness (D) during convalescence of hepatitis A.

180. A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider? a- Dark yellow-brown colored urine b- Nonspecific muscle and joint pain c- New onset of purple skin lesions. d- Weakness when getting up to walk.

Ensure that no dependent loops are present in the tubing.

181. In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement? a- Increase the rate of the continuous bladder irrigation b- Manually irrigate the catheter with sterile normal saline c- Clam the catheter above the drainage. d- Ensure that no dependent loops are present in the tubing.

Yogurt and/or buttermilk. Rationale: A should be encouraging to help maintain intestinal flora and decrease diarrhea, which is a common side effect of antibiotic therapy, particularly cephradine. B and C are contraindicated because they can increase bowel elimination, thereby exacerbating diarrhea as a side effect.

182. The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat? a- Yogurt and/or buttermilk. b- Avocados and cheese c- Green leafy vegetables d- Fresh fruits

A young male with schizophrenia who said voices is telling him to kill his psychiatric. Rationale: The RN should deal with the client with command hallucinations and these can be very dangerous if the client's acts on the commands, especially if the command is a homicidal in nature. Other client present low safety risk.

183. The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN? a- An adult female who has been depress for the past several months and denies suicidal ideations. b- A middle-age male who is in depressive phase on bipolar disease and is receiving Lithium. c- A young male with schizophrenia who said voices is telling him to kill his psychiatric. d- An elderly male who tell the staff and other client that he is superman and he can fly.

Maternal pulse rate of 162 beats per min.

184. A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug? a- Maternal blood pressure of 90/60 b- Fetal heart rate of 170 beats per minute for 15 mints c- Maternal pulse rate of 162 beats per min d- Serum potassium of 2.3 mg/dl

Anxiety related to fear of suffocation.

185. In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client's appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis? a- Impaired gas exchange related to narrowing of small airways b- Death anxiety related to concern about prognosis c- Anxiety related to fear of suffocation. d- Ineffective coping related to knowledge deficit about COPD

Provide daily care of tong insertion sites using saline and antibiotic ointment.

186. A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's a plan of care? a- Provide daily care of tong insertion sites using saline and antibiotic ointment b- Modify the client's diet to prevent constipation c- Encourage active range of motion q2 to 4 hours. d- Instruct the client to report any symptoms of upper extremity paresthesia.

Determine the client's vital sign.

187. A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first? a- Administer prescribed pain medication b- Assess surgical site c- Determine the client's vital sign. d- Apply warmed blankets

No wheezing upon auscultation of the chest.

188. A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider? a- An apical pulse of 120 beats per minute b- Extreme agitation with staff and family c- Client report being anxious d- No wheezing upon auscultation of the chest.

During acute illness.

189. The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation? a- Prior to exercising b- Immediately after meals c- Before going to bed d- During acute illness.

Tell all their assigned clients to stay in their rooms.

190. A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs? a- Go to the emergency department and complete assigned tasks b- Shut all doors to client rooms on the unit in case a fire erupts c- Offer to assist the ICY with ventilator-dependent clients d- Tell all their assigned clients to stay in their rooms.

Murmur.

191. The nurse is auscultating is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.) a- Murmur b- s1 s2 c- pericardial friction rub d- s1 s2 s3

Administer the medication via the oral route as prescribed.

192. The healthcare provider changes a client's medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement? a- Continue to administer the medication via the IV route b- Give half the prescribed oral dose until the provider is consulted. c- Administer the medication via the oral route as prescribed. d- Consult with the pharmacist regarding the error in prescription.

Simethicone (Mylicon). Rationale: Simethicone is an antiflatulent that is used to increase the client's ability to expel flatus (B), which relieves the clients discomfort (A and D) are analgesic used to manage pain but do not alleviate the causes of the pain (C) is an antiemetic used to treat nauseas and does not relive excess flatus.

193. A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup" the client's abdomen is distended. Which prescribed PRN medication should the nurse administer? a- Hydrocodone/Acetaminophen (Lortab) b- Simethicone (Mylicon) c- Promethazine (Phenergan) d- Nalbupine (Nubain)

Vitamin supplements for high-risk pregnant women. Rational: Primary prevention activities focus on health promotions and disease preventions, so vitamin for high-risk pregnant women provide adequate vitamin and mineral for fetal developmental.

194. The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal? a- Case management and screening for clients with HIV. b- Regional relocation center for earthquake victims c- Vitamin supplements for high-risk pregnant women. d- Lead screening for children in low-income housing.

Review the client's use of over the counter (OTC) medications. Rationale: Sodium is used in several types of OTC medications. Including antacids, which the client may be using to treat his GERD. Further evaluation is need it to determine the need for hospitalization (A) A food journal (B) may help over, but dietary modifications are needed now since edema is present. (C) May relieve dependent edema, but not treat the underlying etiology.

195. When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement? a- Arrange to transport the client to the hospital b- Instruct the client to keep a food journal, including portions size. c- Review the client's use of over the counter (OTC) medications. d- Reinforce the importance of keeping the feet elevated.

Multiple organ dysfunction syndrome (MODS). Rational: MODS are a progressive dysfunction of two or more major organs that requires medical intervention to maintain homeostasis. This client has evidence of several organ systems that require intervention, such as blood pressure, hemoglobin, WBC, and respiratory rate. DIC may develop as a result of MODS. The other options are not correct.

196. An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition? a- Multiple organ dysfunction syndrome (MODS) b- Disseminated intravascular coagulation (DIC) c- Chronic obstructive disease. d- Acquired immunodeficiency syndrome (AIDS)

Initiate seizure precautions. Rationale: Withdrawal of CNS depressants, such as Xanax, results in rebound over-excitation of the CNS. Since the client exhibiting tremors, the nurse should anticipate seizure activity and protect the client.

198. A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action? a- Administer naloxone (Narcan) per PNR protocol b- Initiate seizure precautions c- Obtain a serum drug screen d- Instruct the family about withdrawal symptoms.

Jaundice.

199. The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose? a- Jaundice b- Nausea c- Fever d- Fatigue

Confirm the desired effect of the medication has been achieved. Rationale: Trazodone o Desyrel, an atypical antidepressant, is prescribed for client with AD to improve mood and sleep.

200. A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? a- Explain that it may take several weeks for the medication to be effective b- Confirm the desired effect of the medication has been achieved. c- Notify the health care provider than a change may be needed. d- Evaluate when and how the medication is being administered to the client.