CDM passpoint 2

A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction? a) "Weigh yourself daily and report a gain of 2 lb (0.91 kg) in 1 day." b) "Maintain bed rest." c) "Eat a high-sodium diet." d) "Limit yourself to smoking only 2 cigarettes per day."

A

A nurse is admitting a client to the palliative unit and discussing advanced directives. Which of the following statements made by the client leads the nurse to believe the client requires clarification around advanced directives? a) "This will stop my daughter-in-law from putting me in a home." b) "This will allow me to identify who my power of attorney will be." c) "It is good to do this now before I am unable to make the decisions." d) "I can let my family know what treatment I want in the future."

A

Choice Multiple question - Select all answer choices that apply. A postoperative client has an abdominal incision. While getting out of bed, the client reports feeling a "pulling" sensation in the abdominal wound. The nurse assesses the client's wound and finds that it has separated and that the abdominal organs are protruding. Which nursing interventions are most appropriate at this time? Select all that apply. a) Cover the wound with sterile gauze. b) Notify the client's primary physician. c) Cover the wound with saline-soaked sterile guaze. d) Push the organs back into the abdomen. e) Order an abdominal binder from the supply department. f) Give the client a dose of antibiotics.

A, B

Choice Multiple question - Select all answer choices that apply. The home health nurse is caring for a client receiving chemotherapy. The client reports anorexia and has a weight loss of 15 pounds (6.8 kilograms) over 6 weeks. Which client teaching would be helpful? Select all that apply. a) Eat small portions of each food group b) Obtain calorie dense foods for snack c) Have family prepare and deliver favorite meals d) Eat slowly and in a relaxed atmosphere e) Cook a hot meal for lunch and dinner f) Eat large meals when hungry

A, B, C, D

Choice Multiple question - Select all answer choices that apply. A nurse is caring for a client with history of heart failure and presenting with symptoms indicating a pulmonary embolism. The nurse documents admission findings of sudden shortness of breath, chest pain, and immobility. Which nursing diagnoses are admission priorities? Select all that apply. a) Risk for decreased cardiac output related to failure of the left ventricle. b) Social isolation related to hospitalization. c) Ineffective breathing pattern related to hypoxia. d) Disturbed sleep pattern related to restlessness in the night. e) Anxiety related to breathlessness. f) Activity intolerance related to inadequate oxygenation.

A, E, F, C

A nurse assesses a client who is in cardiogenic shock. Which statement by the nurse best indicates an understanding of cardiogenic shock? a) "A decrease in cardiac output and evidence of inadequate circulating blood volume and movement of plasma into interstitial spaces" b) "A decrease of cardiac output and evidence of tissue hypoxia in the presence of adequate intravascular volume" c) "It is due to severe hypersensitivity reaction resulting in massive systemic vasodilation." d) "Generally caused by decreased blood volume"

B

During a facility disaster drill, an "injured client" presents to the emergency department with complaints of dry mouth, inability to focus his vision, and double vision. A nurse notes that the client has an unsteady gait and appears to be very weak. The client states, "My arms and legs feel like they just can't move." A nurse suspects the client may be a victim of bioterrorism with: a) herpes. b) botulism. c) anthrax. d) Ebola.

B

In addition to teaching regarding medications, what would the nurse include to reinforce health promotion and illness prevention for a client with acquired immunodeficiency syndrome (AIDS)? a) Measures to be taken to prevent transmission, need for isolation precautions at home, and avoidance of infection b) Measures to prevent transmission, maintaining optimal nutrition, and exercise c) Importance of taking the medications, coping with the side effects, and introducing supplementation with megavitamin doses d) Importance of safe sex practices, discussion of choices of medications, and hospice care

B

The nurse is caring for a 7-year-old child who has just returned from the postoperative unit after surgery. The child is playing in bed with toys. The child's parents are smiling and state, "Isn't it great that our child does not have any pain?" What is the best response by the nurse? a) "A child who resumes usual play is not experiencing pain." b) "Some children distract themselves with play while in pain." c) "Children don't experience as much pain after surgery as adults." d) "The child's activity level is the best indicator of pain."

B

Thirty people are injured in a train derailment. Which client should be transported to the hospital first? a) a 20-year-old who is unresponsive and has a high injury to his spinal cord b) an 80-year-old who has a compound fracture of the arm c) a 25-year-old with a sucking chest wound d) a 10-year-old with a laceration on his leg

C

An admitting nurse on a rehabilitation unit notices that an elderly client with a fractured hip and severe hypothyroidism is dirty and disheveled and that his personal hygiene is very poor. As the nurse gathers admission data, she further notes that the client has few personal connections, is depressed, and doesn't seem to care about his appearance. How should the nurse improve the client's performance of self-care activities? a) Offer to take the client to the shower and help him fix his hair. b) Ask the physician to refer the client to social services for a full evaluation and follow-up. c) Provide complete hygienic care and make an appointment for the client to see the hospital barber. d) Provide initial and routine hygienic care, then evaluate the client daily as treatment progresses.

D

The nurse assigned to telephone triage returns a call from a parent whose teenager experienced a hard tackle last night. The parent reports, "He seemed dazed after it happened and the coach had him sit out the rest of the game, but he is fine now." What is the most appropriate instruction for the nurse to give? a) "Take him immediately to the emergency department." b) "Watch him closely and call us back if you see any changes." c) "If he seems fine now and had no other symptoms, it probably was not a concussion." d) "He cannot return to play until he has been evaluated by a health care provider."

D

The nurse auscultates the lungs of a client who has been diagnosed with a tumor in the lung and notes wheezing over one lung. The nurse should assess the client further for: a) the client's history of smoking. b) an indication of pleural effusion. c) the presence of exudate in the airways. d) obstruction of the airway.

D

The nurse is assisting with conscious sedation for a 6-year-old undergoing a bone marrow biopsy. The nurse's most important responsibility during the procedure is to: a) administer the topical anesthetic. b) record the procedure. c) keep the parents informed. d) monitor the patient.

D

The nurse is caring for a client with multiple organ failure who is in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? a) Heart and lungs b) Kidneys and liver c) Pancreas and heart d) Lungs and kidneys

D

Which nursing action is most appropriate when trying to defuse a client's impending violent behavior? a) Leaving the client alone until he can talk about his feelings b) Placing the client in seclusion c) Diverting attention by involving the client in a quiet activity d) Helping the client identify and express feelings of anxiety and anger

D

As a nurse begins the shift on the obstetrical unit, there are several new admissions. The client with which condition would be a candidate for induction? a) face presentation b) active herpes c) fetus with late decelerations d) preeclampsia

D

The nurse should assess the client with multiple sclerosis for which associated health problem? a) drug dependency b) thought disorders c) psychosomatic illnesses d) mood disorders

D

Which symptom of post traumatic stress disorder (PTSD) can be treated with hypnosis? a) Confabulation b) Addiction c) Hallucinations d) Dissociation

D

Choice Multiple question - Select all answer choices that apply. A nurse preparing to administer medications to a client admitted to a respiratory unit is using the computerized medication-dispensing system and finds that the password is not working. The nurse should do which of the following? Select all that apply. a) Secure the medication until the problem can be corrected. b) Ask computer support to reset the password. c) Since the client is having respiratory problems, the medications should be given manually. d) Override the machine and deliver the medications. e) Use another nurse's password to finish dispensing the medication.

A, B

A client with type 2 diabetes who requires insulin asks the nurse about having alcoholic beverages. Which is the best response by the nurse? a) "if you are going to drink, it is best to consume alcohol on an empty stomach." b) "You can have one or two drinks a day as long as you have something to eat with them." c) "Alcohol is detoxified in the liver, so it is not a good idea for you to drink anything with alcohol." d) "If you have a drink, the blood glucose value may be elevated at bedtime, and you should skip having a snack."

B

The nurse understands that assessment of blood pressure in clients receiving antipsychotic drugs is important. What is a reason for this assessment? a) Most antipsychotic drugs cause elevated blood pressure. b) It will indicate the need to institute antiparkinsonian drugs. c) This provides additional support for the client. d) Orthostatic hypotension is a common side effect.

D

Under which circumstance may a nurse communicate medical information without the client's consent? a) when prescribed by another health care provider (HCP) b) when certifying the client's absence from work c) when requested by the client's family d) wWhen treating the client with a sexually transmitted disease

D

The nurse is reading the results of a tuberculin skin test (see figure). The nurse should interpret the results as:

positive. Explanation: The tuberculin test is positive. The test should be interpreted 2 to 3 days after administering the purified protein derivative (PPD) by measuring the size of the firm, raised area (induration). Positive responses indicate that the client may have been exposed to the tuberculosis bacteria. A negative response is indicated by the absence of a firm, raised area, or an area that is less than 5 mm in diameter. Since the test is positive, it is not necessary to redo the test. The test is positive, not false

A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately: a) reintroduce the tube and attach it to water seal drainage. b) cover the opening with petroleum gauze. c) clean the wound with povidone-iodine and apply a gauze dressing. d) call a physician and obtain a chest tray.

B

A nurse is caring for a client at the local health care facility. Which of the following ensures that legislation related to client confidentiality is implemented at the facility? a) Present end-of-shift reports to the nurse coming on duty in the client's room. b) Put the client's health information up on a whiteboard to be seen by health care workers. c) Place in private areas light boxes for examining x-rays with the client's name. d) Ensure that the client's name is displayed on the first page of all faxed records.

C

A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse? a) A wound measuring 9 cm × 5 cm × 0.5 cm with granulation tissue b) A wound measuring 1 cm × 2 cm × 0.5 cm with a red, moist wound bed c) A wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance d) A wound measuring 2 cm × 2 cm × 0.5 cm with granulation tissue

C

A pregnant client is experiencing a thin, odorless, vaginal discharge. What should a nurse tell her to do to prevent vaginal infections? a) "Don't worry, nothing will happen to you." b) "You must not be washing thoroughly." c) "Try wearing a panty liner and discarding it after every urination." d) "When you notice the discharge, take a bath and come into the office."

C

After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer? a) Esophageal carcinoma b) Laryngeal carcinoma c) Pituitary carcinoma d) Colorectal carcinoma

C

For an 8-month-old infant, which toy promotes cognitive development? a) Climbing gym b) A play gym strung across the crib c) Jack-in-the-box d) Activity quilts

C

Immediately after nasogastric (NG) tube removal the nurse should: a) palpate for abdominal distention. b) auscultate for bowel sounds. c) provide the client with mouth care. d) provide orange sherbet.

C

Nursing care for a client after electroconvulsive therapy (ECT) should include: a) bed rest for the first 8 hours after a treatment. b) no special care. c) assessment of short-term memory loss. d) nothing by mouth for 24 hours after the treatment because of the anesthetic agent.

C

A nurse is assigned to four clients. Which client should the nurse see first? a) A client who had open reduction internal fixation (ORIF) receiving fondaparinux b) A client with a low white blood cell count receiving pegfilgastrim c) A client who is being prepared for a major surgery receiving clopidogrel d) A client with acquired immunodeficiency syndrome receiving emtricitabine

C

A 10-year-old client with rheumatic fever is on bed rest. Which diversional activity would be appropriate for the nurse to encourage? a) watching television with his roommate b) building a bird house c) keeping up with school work d) coloring picture books with the brother

c

The client diagnosed with osteoarthritis tells the nurse, "My friend takes steroid pills for her rheumatoid arthritis. Should I be taking steroids, too?" What should the nurse explain to the client? a) Rheumatoid arthritis and osteoarthritis are two similar diseases. b) A systemic effect is needed in osteoarthritis. c) Intra-articular corticosteroid injections are used to treat osteoarthritis. d) Oral corticosteroids can be used in osteoarthritis.

c

The nurse is developing long-term goals with a family that has a toddler with a developmental delay. Which of the following is a priority concern for the nurse to address with the family regarding the care of the child within the next several years? a) Adjusting to the child's physical limitations b) How to handle the strain of caregiving c) Preparing for school and learning difficulties d) Planning for ongoing diagnostic evaluations

c

Drag and Drop question - Click and drag the following steps to place them in the correct order. Question: The nurse is preparing to interpret an ECG rhythm strip. Place the following steps for ECG rhythm analysis from first to last, in chronological order. All options must be used. 1 Determine the rate and rhythm. 2 Analyze the P waves. 3 Measure the QRS duration. 4 Interpret the rhythm. 5 Measure the P-R interval.

1, 2, 5, 3, 4

The nurse is calculating intake and output for a client. Intake included 1750 ml of D5W, 500 ml of ceftriaxone, 8 oz of coffee, 4 oz of juice, and 800 ml of water. The client's output included 1560 ml of urine, and 45 ml of vomitus. What is the total intake for this client? Record your answer using a whole number.

3410

A 10-year-old child diagnosed with acute glomerulonephritis is admitted to the pediatric unit. The nurse should ensure that which action is a part of the child's care? a) Taking vital signs every 4 hours and obtaining daily weight b) Checking every urine specimen for protein and specific gravity c) Obtaining a blood sample for electrolyte analysis every morning d) Ensuring that the child has accurate intake and output and eats a high-protein diet

A

A client in labor has an episiotomy. The nurse understands that the client is at risk for which complication? a) Prolonged dyspareunia b) Hormonal fluctuations postpartum c) Uterine disfiguement d) Blood loss

A

A client with a diagnosis of major depression and a history of several suicide attempts tells a nurse, "I have no reason to live. Nobody cares about me." Which response by the nurse is most therapeutic? a) "How long have you been feeling like this?" b) "You have everything to live for." c) "Do you really think you should kill yourself?" d) "Depression commonly causes people to feel like this."

A

A multiparous client tells the nurse that she is using medroxyprogesterone for contraception. The nurse should instruct the client to increase her intake of which nutrient? a) calcium b) folic acid c) vitamin C d) magnesium

A

A nurse is leading group therapy with psychiatric clients. During the working phase of the group, what should the nurse do? a) Encourage group cohesiveness. b) Encourage a discussion of feelings of loss regarding the group's termination. c) Offer advice to help resolve conflicts. d) Explain the purposes and goals of the group.

A

A nurse is preparing for the discharge of a client who has been hospitalized for schizophrenia. The client's husband expresses concern over whether his wife will continue to take her daily ordered medication. The nurse should inform him that: a) his wife can be given a long-acting medication that is administered every 1 to 4 weeks. b) his wife knows she must take her medication as ordered to avoid future hospitalizations. c) he can easily mix the medication in his wife's food if she stops taking it. d) his concern is valid, but his wife is an adult and has the right to make her own decisions.

A

A nurse is teaching a client about tricyclic antidepressants. The nurse determines that teaching has been effective when the client states: a) "Improvement in my mood will take up to 28 days." b) "I need to call the prescriber if I get a sore throat." c) "I should avoid all milk and dairy products." d) "This drug causes weight loss so I need to eat properly."

A

A nurse is teaching an elderly client about developing good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required? a) "I need to use laxatives regularly to prevent constipation." b) "I will eat raw, green-leafy vegetables, unpeeled fruit, and whole grain bread." c) "I should try to drink twice as much water as I am now." d) "I will take my dog for a walk every day."

A

A postpartum client has a temperature of 99.8° F (37.7.° C) during the first 24 hours after birth. Which nursing intervention is appropriate? a) Encourage more fluid intake. b) Check for signs of puerperal infection. c) Check the client's breasts for red, swollen areas. d) Assess lochia for foul odor.

A

An 86-year-old client with dementia is being discharged after treatment for a hip fracture. In reviewing the notes, the nurse identifies that the sole care-giver at home is an adult daughter with a moderate intellectual disability. Which is the most important action the nurse should ensure is in place before discharging the client home? a) An immediate home visit is arranged with the visiting nurse service and the social worker. b) Social work support has been established for the caregiver. c) Physical therapy service has been coordinated in the home. d) The insurance company is aware of the need for increased services.

A

Before the neonate's discharge, the mother tells the nurse that she is worried that her 5-year-old daughter will be jealous of the new baby when they get home. After explaining ways to deal with sibling rivalry, the nurse determines that the mother understands the instructions when she says she will do which action? a) Allow the 5-year-old undivided attention several times a day. b) Let the 5-year-old feed the baby at least once every day. c) Divide her time equally between the baby and the daughter. d) Tell the daughter that the baby is just like one of her dolls.

A

The nurse has provided health teaching about physiologic changes that can be expected during the postpartum period to a postpartum client who is bottle-feeding her neonate. Which client statement indicates that this teaching has been effective? a) "My menstrual flow should resume in approximately 6 to 10 weeks." b) "It's normal for me to have reddish lochia until my 6-week checkup." c) "Any varicosities I had during pregnancy will disappear within 2 weeks." d) "I can expect to have heart palpitations for several weeks."

A

The nurse is assessing a 6-month-old and notices no pincer grasp on either hand. The mother asks the nurse if this is abnormal. The nurse correctly responds that: a) The six month old does not normally have a pincer grasp yet. b) The physician will be in to check the child and the mother can ask the physician. c) The infant may be at risk for developmental disabilities. d) The physician will need to ask questions about the infant's siblings and their development.

A

The nurse is assigned to care for a client with an ocular prosthesis who is having surgery under a local anesthetic. Prior to surgery, the nurse should: a) leave the prosthesis in place. b) maintain surgical asepsis when caring for the prosthesis. c) instruct the client to cleanse the prosthesis daily. d) cleanse the ocular prosthesis with full-strength hydrogen peroxide.

A

The nurse is caring for a primipara during the first hour after a vaginal birth of a viable neonate under epidural anesthesia and intravenous fluids. While assessing the client, the nurse observes that the client has a heart rate of 65 bpm, temperature of 99.9° F (37.7° C), fundus firm at one finger breath above the midline, and a slow trickle of dark red vaginal bleeding on the perineal pad. The client's legs are still numb. The nurse should: a) massage the fundus and contact the client's primary care provider immediately. b) iscontinue the client's intravenous fluids if the client is drinking fluids. c) notify the anesthesiologist who performed the lumbar epidural anesthesia. d) continue to monitor the client's temperature on an hourly basis.

A

The nurse is caring for an adolescent with the above skin disorder. Which client statement indicates a need for further teaching? a) "My breakouts are exacerbated by eating fatty foods." b) "I use topical retinoids as prescribed at night on my skin." c) "I wash my face with soap and water every morning and night." d) "Stress and hormones worsen my breakouts."

A

The right hand of a client with multiple sclerosis trembles severely whenever she attempts a voluntary action. She spills her coffee twice at lunch and cannot get her dress fastened securely. Which is the best legal documentation in nurses' notes of the chart for this client assessment? a) "Slight shaking of right hand increases to severe tremor when client tries to button her clothes or drink from a cup." b) "Needs assistance with dressing and eating due to severe trembling and clumsiness." c) "Has an intention tremor of the right hand." d) "Right-hand tremor worsens with purposeful acts."

A

When explaining hospice care to a client, the nurse should tell the client: a) "Clients and their families are the focus of care." b) "All hospice clients will die at home." c) "The client's health care provider coordinates all the care." d) "Hospice care uses a team approach to direct hospice activity."

A

Which foods should the nurse encourage the mother to offer to her child with iron-deficiency anemia? a) potato, peas, and chicken b) rice cereal, whole milk, and yellow vegetables c) macaroni, cheese, and ham d) pudding, green vegetables, and rice

A

Which goal would be appropriate for a client with viral hepatitis? The client will: a) verbalize the importance of reporting bleeding gums or bloody stools. b) demonstrate a decrease in fluid retention related to ascites. c) restrict activity to within the home to prevent disease transmission. d) limit use of alcohol to two to three drinks per week.

A

Which of the following questions should the nurse ask a 47-year-old client to assist in establishing a nursing diagnosis of deficient knowledge? a) "When was your last mammogram?" b) "When was your last prostate examination?" c) "When was your last colonoscopy?" d) "When was your last smallpox vaccination?"

A

client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. What should the nurse do next? a) Apply a sterile, moist dressing. b) Assess heart rate and blood pressure. c) Notify the health care provider. d) Measure the length of the protrusion.

A

nurse completes the initial assessment of a full-term newborn and finds that the infant has increased vernix covering the newborn's body. Which of the following would be a priority action for the nurse? a) Assess the mother's due date in the medical record. b) Assess the infant for hypoglycemia. c) Assess for infant's vital signs. d) Assess for meconium aspiration.

A

Choice Multiple question - Select all answer choices that apply. The nurse is developing interventions to prevent a client with an eating disorder from developing refeeding syndrome. Which interventions are appropriate? Select all that apply. a) Administer fluid replacement as prescribed b) Monitor serum electrolytes c) Monitor the client's vital signs frequently d) Refeed the client over a period of three days e) Monitor the client three times a week in an outpatient clinic.

A, B, C

Choice Multiple question - Select all answer choices that apply. When developing a nutritional plan for a child who needs to increase protein intake, the nurse should suggest which foods? Select all that apply. a) cooked dry beans b) whole wheat bread c) apple d) yogurt e) peanut butter

A, D, E

Choice Multiple question - Select all answer choices that apply. A nurse, assigned to a client with emphysema, is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply. a) Teach diaphragmatic, pursed-lip breathing. b) Maintain the client in a supine position as much as possible. c) Reduce fluid intake to less than 850 ml per shift. d) Administer low-flow oxygen as needed. e) Encourage alternating client activity with rest periods. f) Teach the use of postural drainage and chest physiotherapy.

A, D, E, F

Choice Multiple question - Select all answer choices that apply. Which suggestions should the nurse include when teaching the parents of a child who has viral tonsillitis? Select all that apply. a) Gargle with warm salt water. b) Administer aspirin for fever control. c) Offer cough medicine every 4 hours. d) Supply a regular diet. e) Offer lots of fluids. f) Give acetaminophen for sore throat.

A, E, F

A 10-month-old child is found choking and becomes unconscious. What is the nurse's priority intervention after opening the child's airway? a) Attempt a blind finger sweep b) Look inside the child's mouth for a foreign object c) Attempt rescue breathing d) Give five back blows and five chest thrusts

B

A child is receiving amoxicillin for otitis media. Which action should the nurse recommend the mother do when the child develops diarrhea? a) Withhold food and fluids for 2 hours. b) Offer yogurt several times a day. c) Restrict the intake of pizza. d) Begin clear fluids.

B

A client has been compliant with her prescribed antipsychotic medication regimen for a number of years. With the addition of an antibiotic, the client reports distressing new symptoms. What is the most appropriate intervention by the nurse? a) Direct the client immediately to the health care provider b) Assess the client's symptoms and reinforce medication teaching c) Have a community nurse administer the medication d) Arrange for the client to be hospitalized

B

A client in the final stages of terminal cancer tells his nurse: "I wish I could just be allowed to die. I'm tired of fighting this illness. I have lived a good life. I continue my chemotherapy and radiation treatments only because my family wants me to." What is the nurse's best response? a) "I know you are tired of fighting this illness, but death will come in due time." b) "Would you like to meet with your family and your physician about this matter?" c) "Would you like to talk with your minister about the significance of death?" d) "Would you like to talk with a psychologist about your thoughts and feelings?"

B

A client with a bleeding peptic ulcer is admitted to an acute care facility. As part of therapy, the physician orders cimetidine I.V. Infusing this medication too rapidly may cause: a) hallucinations. b) hypotension. c) tetany. d) bronchospasms.

B

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to: a) use a condom catheter instead of an invasive one. b) increase the frequency of the catheterizations. c) insert an indwelling urinary catheter. d) place the client on fluid restrictions.

B

A client with amyotrophic lateral sclerosis (ALS) is admitted with weight loss and malnutrition. He can swallow without difficulty. While caring for the client, the nurse discovers that his weight loss is related to his refusal to eat. The client states to the nurse that he would rather die than remain alive with this disease. How should the nurse intervene? a) Report this finding to the client's family, and suggest they talk with the physician about having a feeding tube placed. b) Explore the client's feelings about dealing with ALS using open-ended questions. c) Ask the physician to consult a psychiatrist because the client is exhibiting suicidal behavior. d) Support the client's decision because he has a fatal disease.

B

A client with schizophrenia, who has a history of being placed in seclusion for physically assaulting other clients, is showing signs of increased agitation. The nurse observes that he's scraping his face and eyes with his fingernails and injuring himself. All nursing attempts to reduce this behavior have failed. What should the nurse do next? a) Call security to restrain the client and put him in seclusion for the safety of the unit. b) Apply physical restraints to protect the client, then contact the physician for orders. c) Contact the physician and apply physical restraints as instructed by the physician. d) Place the client in seclusion and contact the physician for further orders.

B

A mother and grandmother bring a 2-month-old infant to the clinic for a routine checkup. As the nurse weighs the infant, the grandmother asks, "Shouldn't the baby start eating solid food? My kids started on cereal when they were 2 weeks old." Which response by the nurse would be appropriate? a) "The baby is gaining weight and doing well. There is no need for solid food yet." b) "Babies can't digest solid food properly until they're 3 or 4 months old." c) "Things have changed a lot since your children were born." d) "Introducing solid food early leads to eating disorders later in life."

B

A new nurse tells a charge nurse that she isn't comfortable assessing a fetus from the fetal monitor strip. How should the charge nurse respond? a) "I'll reassign you to a client without a monitor." b) "I'll go with you to interpret this strip, and then we'll look at several others." c) "Don't worry about it. The last shift stated that the strips were normal." d) "The physician will be back soon. He'll make an assessment."

B

A nurse and a nursing student drive to the home of a client with postpartum depression and discover the client and her baby completely naked in the backyard. The client is unable to communicate in an effective manner. What is the nurse's most appropriate response to resolve this situation? a) Contact the client's husband to come home from work and immediately take her to the emergency department. b) Contact the nursing supervisor to clarify the appropriate actions in this acute mental health situation. c) Ask the nursing student to stay with the client while the nurse performs the last home visit in the community. d) Contact the client's physician and the baby's pediatrician.

B

A nurse assesses spirituality to gain an understanding of what in relation to the client's life? a) Sense of meaning and purpose b) Possible coping mechanisms c) Meaning of afterlife d) Common practices shared with a group

B

A nurse assessing a client with catatonia notes a lack of responsiveness and ridged posturing. What is the best nursing intervention? a) Assist the client to a more comfortable position b) Administer 2 mg lorazepam intramuscular injection (IM) c) Assess the client's blood glucose level d) Infuse .9 normal saline (NS) 100 mL/hr

B

A severe winter storm has prevented most staff members from getting to work on a busy medical-surgical unit. One registered nurse, two licensed practical nurses, and three nursing assistants have been able to get to work. A nurse-manager must decide which nursing care delivery system (model) (NCDS) should be implemented for the best possible client care during this staffing crisis. The nurse-manager directs the staff to implement which NCDS (NCDM)? a) Team nursing b) Functional nursing c) Case management d) Primary nursing

B

At the admission interview, the father of a 4-year-old boy with attention deficit hyperactivity disorder (ADHD) says to the nurse, "I know that my wife or I must have caused this disease." What is the nurse's best response? a) "Many parents feel this way, but I doubt there is anything that you did that caused ADHD to develop in your child." b) "ADHD is more common within families, but there is no evidence that problems with parenting cause this disorder." c) "Let us not focus on the cause but rather on what needs to be done to help your son get better. I know that you and your wife are very interested in helping him to improve his behavior." d) "What do you think you might have done that could have led to causing this disorder to develop in your son?"

B

The nurse evaluates the effectiveness of the client's postoperative plan of care. Which outcome is expected for a client with an ileal conduit? a) The client demonstrates how to catheterize the stoma. b) The client will empty the drainage pouch frequently throughout the day. c) The client verbalizes the understanding that physical activity must be curtailed. d) The client will place an aspirin in the drainage pouch to help control odor.

B

The nurse is assigned to care for 4 mothers and their term newborns. Which mother and newborn couplet requires the nurse's attention first? a) Mother: fundus firm 2 cm below umbilicus, minimal lochia rubra. Infant: color is pink on room air, respirations 67 breaths/minute; bilateral crackles on auscultation. b) Mother: fundus firm 3 cm above umbilicus and to the right, moderate rubra lochia. Infant: color pink when active, currently dusky while quiet, respirations 70 breaths/minute. c) Mother: fundus firm at umbilicus, small amount lochia rubra. Infant: pale pink, quiet alert; respiration 65 breaths/minute; periodic breathing noted. d) Mother: fundus firm 1 cm above umbilicus, small amount lochia rubra. Infant: color pink with acrocyanosis, respirations 68 breaths/minute and intermittent expiratory grunting.

B

The nurse is caring for a G2, T1, P0, A0, L1 client at term. The client is completely effaced, dilated to 2 cm, with contractions every 3 minutes lasting 45 seconds. The client is asking for an epidural to make her more comfortable. Indicate the appropriate response by the nurse. a) "We cannot give epidurals until you are 5 to 6 cm dilated. There is IV medication available if you would like it now." b) "It is too early in labor for the epidural, but you can have IV medication to keep you comfortable until you have dilated 1 to 2 cm more." c) "You cannot have an epidural until your membranes have ruptured." d) "Your contraction pattern is slow at this point and will need to accelerate before you can have your epidural."

B

The nurse is performing a nutrition assessment of a client from the Middle East. What may the nurse expect as a traditional breakfast consumed by a client from the Middle East? a) Food made from corn. b) Cheese and olives. c) Fruits and bread. d) Cereal or eggs.

B

The nurse is planning the care of a client with schizophrenia. The nurse understands that the client will need the most extensive laboratory monitoring regiment if which medication is prescribed? a) haloperidol b) clozapine c) olanzapine d) risperidone

B

The nurse is teaching two unlicensed assistive personnel (UAP) who are new to the inpatient unit about caring for a client who is suicidal. The nurse determines that additional teaching is needed when which statement is made? a) "Documenting suicide checks is absolutely necessary." b) "I need to check the client precisely at 15-minute intervals." c) "Clients on one-to-one suicide precautions can never be left alone." d) "All clients using razors must be supervised by staff."

B

The nurse should teach the client who is receiving radiation therapy to: a) clean the skin daily with antibacterial soap. b) avoid shaving with straight-edge razors. c) apply moisturizing lotion before and after each treatment. d) keep the radiated area covered with a sterile gauze dressing.

B

To prevent the spread of infection in the home healthcare environment, the nurse should follow appropriate technique by: a) Donning a mask and gown before greeting the client's family members. b) Placing equipment back on a liner when setting it down in the client's home. c) Donning gloves prior to entering the client's home. d) Performing hand hygiene after reaching into the equipment bag for supplies.

B

When performing Leopold's maneuvers on a primigravid client, the nurse is palpating the uterus as shown. Which maneuver is the nurse performing? a) second maneuver b) third maneuver c) fourth maneuver d) first maneuver

B

When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information? a) The client should avoid contact with children diagnosed with rubella. b) Pregnancy should be avoided for 4 weeks after the immunization. c) The injection will provide immunity against the chickenpox. d) The vaccine prevents a future fetus from developing congenital anomalies.

B

Which finding in the client who has returned from having a subtotal thyroidectomy would require a nurse to take immediate action? a) Shallow respirations b) Facial muscle twitching c) Diminished deep tendon reflexes d) Shortened QT interval

B

Which group is at greatest risk for Raynaud's phenomenon? a) young men b) young women c) old men d) old women

B

Which is the best nursing response to make when a client asks why their blood glucose is higher on days when they sleep less? a) "Your body is producing cortisol for the extra energy you need when you sleep less." b) "Cortisol levels remain high when you sleep less, since cortisol is inhibited during sleep." c) "You are probably eating more when you sleep less. This is making your blood glucose higher than usual." d) "You are more active when you sleep less, so your blood glucose will be higher."

B

Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?" a) As-needed order b) Standing order c) Stat order d) One-time order

B

While attending a support group, the parents of a child with hemophilia become concerned because they heard stories about how many children with hemophilia have died from acquired immunodeficiency syndrome (AIDS). They ask the nurse how these children got the AIDS virus. The nurse bases the response on which as the most likely route of transmission of AIDS to these children? a) use of a contaminated needle to obtain a blood sample for type and crossmatching b) contamination of the factor VIII replacement received during bleeding episodes c) casual contact with a child testing positive for human immunodeficiency virus d) exposure in the waiting room to children with AIDS attending the same hematology clinic

B

Choice Multiple question - Select all answer choices that apply. When creating an educational program about safety, what information should the nurse include about sexual predators? Select all that apply. a) Child molesters gain the child's trust before making sexual advances so the child feels obligated to comply with sex. b) Child molesters pick children or teens over which they have some authority, making it easier for them to manipulate the child with special favors or attention. c) Child molesters often choose children whose parents must work long hours, making the extra attention initially welcomed by the child. d) Child molesters resort to molestation because they have bad childhoods, so understanding that can help them decrease their molesting. e) Child molesters maintain the secrecy of their actions by making threats if offering attention and favors fail or if the child is close to revealing the secret.

B, A, C, E

Choice Multiple question - Select all answer choices that apply. The neonate in the nurse's care has a pneumothorax. The nurse knows the signs of early decompensation and to observe carefully for changes in which assessments? Select all that apply. a) temperature b) blood pressure c) heart rate d) color e) urinary output

B, C, D

Choice Multiple question - Select all answer choices that apply. The nurse is caring for a client with a tracheotomy. When suctioning the client, which actions would be considered safe nursing practice? Select all that apply. a) Commence suctioning upon insertion of the catheter and continue for 5 seconds while withdrawing the catheter. b) Suction when needed to prevent secretions from accumulating. c) Suction every 4 hours when there are copious thick secretions. d) Oxygenate the client, then suction for 10 to 15 seconds while withdrawing the catheter. e) Insert the suction catheter as far as the client can tolerate and suction for 25 seconds.

B, D

Choice Multiple question - Select all answer choices that apply. A client who has apnea during sleep would require which of the following interventions? Select all that apply. a) Teach client pursed-lip breathing b) Assess sleep routine/hours c) Restrict family members from sleeping in the room d) Refer to primary healthcare provider e) Have client keep a sleep diary

B, D, E

Choice Multiple question - Select all answer choices that apply. A home health care nurse is making an initial visit to a 68-year-old male client who was recently discharged from a rehabilitation facility after experiencing a stroke. The client has significant left-sided weakness and needs assistance with dressing and hygiene. The client lives alone with his 68-year-old wife. The wife has chronic obstructive pulmonary disease (COPD) and uses oxygen intermittently. Assessment findings include: vital signs within normal parameters and intact pink, moist skin. The client denies any problems with urinary and bowel elimination. Based on the client's assessment, the nurse would most likely initiate referrals to which discipline? Select all that apply. a) skilled nursing service b) physical therapy c) speech therapy d) occupational therapy e) home health aide

B, D, E

Choice Multiple question - Select all answer choices that apply. A nurse is preparing discharge instructions for a client with resistant depression who was prescribed a new medication regimen that includes phenelzine, a monoamine oxidase inhibitor (MAO inhibitor). If the teaching was successful, what foods would the client state that he/she needs to avoid? Select all that apply. a) Cottage cheese. b) Wine. c) Fruit. d) Aged cheese. e) Salami. f) Milk.

B, D, E

Choice Multiple question - Select all answer choices that apply. Which infections require contact precautions? Select all that apply: a) Measles b) Methicillin-resistant staphylococcus aureus c) Tuberculosis d) Pertussis e) Clostridium difficile

B, E

A child is admitted with a fever and a diagnosis of chicken pox. The parents report the fever did not decrease despite several doses of aspirin (acetylsalicylic acid). The nurse assesses confusion, palmar rash, and persistent vomiting. What is the priority nursing action? a) Monitor ammonia levels b) Initiate IV fluids c) Observe for potential seizures d) Apply ice bags to axillae

C

A client diagnosed today with a deep vein thrombosis in the right leg. The nurse should instruct the client to: a) ambulate twice a shift. b) do active leg exercises hourly with both legs. c) keep the right leg elevated above heart level. d) assess the edema of the right leg every 4 hours.

C

A client has been hospitalized for 3 days and is now experiencing symptoms of pneumonia, confirmed by chest X-ray. Which of the following is a priority for preventing this type of pneumonia? a) Prophylactic antibiotics for all hospitalized clients b) Staff education for early recognition of community-acquired pneumonia (CAP) on admitted clients c) Staff education for prevention of hospital-acquired pneumonia (HAP) d) Pneumovax injection at the first sign of pneumonia in the hospitalized client

C

A client is admitted for a revascularization procedure for arteriosclerosis in his left iliac artery. To promote circulation in the extremities, the nurse should: a) encourage the client to raise and lower his leg four times every hour. b) position the client on a firm mattress. c) position the left leg at or below the body's horizontal plane. d) keep the involved extremity warm with blankets.

C

A client is experiencing dryness in the nares while receiving oxygen via nasal cannula at 4 L/minute. Which medication should the nurse apply to help alleviate the dryness? a) Sterile water b) Antibiotic ointment c) Lubricant jelly d) Petroleum jelly

C

A client on a psychiatric care unit has muscle spasms in the neck, stiffness in other muscles, and the eyes are rolling upward. The client had two PRN doses of haloperidol in the last 6 hours. Of the drugs that have been prescribed for the client as needed (see chart), the nurse should administer: a) diphenhydramine. b) lorazepam. c) benztropine. d) amantadine.

C

A client reports a pain level of 8 on a scale of 0 to 10. Which is the best intervention? a) Administer prescribed pain medication. b) Notify the healthcare provider. c) Further assess the pain. d) Provide alternative methods of pain relief.

C

A client who comes to the crisis center in a very distressed state tells the nurse, "I just cannot get over being fired last week. I have asked for help. I have talked to friends. I have tried everything to get through this, but nothing is working. Help me!" Which initial crisis intervention strategy should the nurse use? a) referral for counseling b) support system assessment c) emotion management d) unemployment assistance

C

A client who just underwent a mastectomy is due to arrive at the post-surgical care unit. Which of the following actions should the nurse prioritize when attempting to establish an effective relationship with the client? a) Explain and answer questions about the Health Insurance Portability and Accountability Act (HIPAA). b) Assess the client's knowledge of her activity limitations. c) Recognize and address the client's anxiety. d) Address the client's potential learning needs.

C

A client with unstable angina is scheduled to have a cardiac catheterization. The nurse explains to the client that this procedure is being used to: a) assess the functional adequacy of the valves and heart muscle. b) open and dilate blocked coronary arteries. c) assess the extent of arterial blockage. d) bypass obstructed vessels.

C

A graduate nurse receives an order to perform an IV insertion but has not performed this skill since the third year of the nursing program. What actions should the graduate nurse take at this time? a) Approach another nurse in the clinic to cover this skill. b) Explain that an in-service would need to be completed, as would practice sessions on IV insertions, prior to performing this skill. c) Quickly review the procedure and perform the IV insertion. d) State that it is not within the scope of practice as a nurse working in a clinic.

C

A middle-aged client being admitted to the hospital has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client reports having "indigestion." The nurse connects the client to a cardiac monitor, which reveals 8 premature ventricular contractions (PVCs) per minute. The nurse should next: a) call the health care provider (HCP). b) obtain a portable chest radiograph. c) start an IV infusion. d) draw blood for laboratory studies.

C

A multigravid client at 34 weeks' gestation who is leaking amniotic fluid has just been hospitalized with a diagnosis of preterm premature rupture of membranes and preterm labor. The client's contractions are 20 minutes apart, lasting 20 to 30 seconds. Her cervix is dilated to 2 cm. The nurse reviews prescriptions (see chart). Which prescription should the nurse initiate first? a) Obtain the urine specimen. b) Administer betamethasone. c) Initiate fetal and contraction monitoring. d) Start the intravenous infusion.

C

A nurse is caring for a client with frequent episodes of ventricular tachycardia. The lab calls with a critically high magnesium level of 11 mg/dL on this client. What is the nurse's priority action? a) Arrange for an emergency hemodialysis session. b) Obtain an order for furosemide 80 mg IV push. c) Obtain an order for calcium gluconate 2 g IV push over 2-5 minutes. d) Increase the rate of the client's IV fluid to 150 ml/hour.

C

A nurse is reviewing her shift assignment. Which child should she assess first? a) A 14-year-old child who is postoperative and has a nasogastric tube and an indwelling urinary catheter b) A 5-month-old infant with I.V. fluids infusing c) An 11-month-old infant receiving chemotherapy through a central venous catheter d) An 8-year-old child in traction with a femur fracture

C

The Orthodox Jewish family of a client admitted for cochlear implantation expresses outrage at their child being served a pork dish after they identified their religion to the nursing staff. The best response of the nurse would be to: a) apologize and reassure them that it won't happen again. b) reciprocate their anger and call the kitchen to complain. c) recognize their request and respectfully take corrective action. d) quickly remove the offending food and order a replacement.

C

The health care provider (HCP) has determined that a preterm labor client at 34 weeks' gestation has no fetal fibronectin present. Based on this finding, the nurse would anticipate that within the next week: a) the fetus will develop mature lungs. b) the client will develop preeclampsia. c) the client will not develop preterm labor. d) the fetus will not develop gestational diabetes.

C

The managers of the physical and occupational therapy neurologic departments tell a nurse-manager of an adult neurologic rehabilitation unit that they're concerned that clients have been arriving late for therapy. In response, the nursing staff of the rehabilitation unit complains that therapy schedules don't allow sufficient time for performing nursing interventions. Which action by the nurse-manager is the best solution to this problem? a) Meet with the managers of physical and occupational therapy and determine how to reschedule clients; then inform the nursing staff. b) Tell the nursing staff that nurses need to determine how to transport clients to therapy according to the schedules developed by the therapists. c) Ask several staff nurses to work with the therapy staff to help solve the scheduling problem and offer herself as a resource. d) Meet with physical and occupational therapy managers to identify scheduling solutions.

C

The nurse is instructing a client with vulvovaginal candidiasis on the use of the prescribed nystatin vaginal tablets. Which statement indicates that the client requires additional teaching? a) "I will need to refrigerate the nystatin tablets." b) "I will finish all the tablets even if I am feeling better." c) "I can get up to do other activities after inserting the medicine." d) "I should report increased skin irritation to my doctor."

C

The widow of a client who successfully completed suicide tearfully says, "I feel guilty because I am so angry at him for killing himself. It must have been what he wanted." After assisting the widow with dealing with her feelings, which intervention is most helpful? a) Provide her with the local suicide hotline number. b) Suggest she receive individual therapy by the nurse. c) Refer her to a group for survivors of suicide. d) Encourage her to receive counseling from a chaplain.

C

When a relief charge nurse posts assignments, a nurse notes that she is no longer assigned to a client whom she has cared for the previous 2 nights. How should the nurse respond to this assignment? a) Accept the assignment and discuss the situation with the charge nurse at a later time. b) Tell the charge nurse that she'd like to continue with the same assignment. c) Ask the nurse if there's a reason she changed the assignment. d) Tell the charge nurse she feels she's the best person to care for this particular client.

C

When teaching parents about signs that indicate levothyroxine overdose, which comment from a parent would indicate an accurate understanding? a) "I'll be concerned if I can feel my baby's heart rate in her arm or wrist." b) "I should suspect an overdose if my baby's suddenly lethargic." c) "I should be concerned if my baby loses weight." d) "I shouldn't worry if my baby does not sleep very much."

C

Choice Multiple question - Select all answer choices that apply. A client is scheduled to receive a blood transfusion. In addition to taking vital signs and verifying that the unit of blood cells is checked, what other assessments/actions would the nurse be responsible for? Select all that apply. a) Rapidly transfuse the blood for the first 15 minutes. b) Transfuse the blood over 5 hours. c) Stop the transfusion for reports of dyspnea or itching. d) Assess the client for chills or low back pain. e) Reduce intake of fluids during the transfusion.

C, D

Choice Multiple question - Select all answer choices that apply. A nurse is assisting in the discharge planning for a client with alcoholism. Which actions should be included in the discharge plan? Select all that apply. a) Discuss relapse prevention. b) Have the client slowly introduce himself to people from his former lifestyle. c) Strongly encourage participation in Alcoholics Anonymous (AA). d) Establish an exercise program. e) Provide nutritional information and counseling.

C, E, D, A

A 55-year-old black male is found to have a blood pressure of 150/90 mm Hg during a work-site health screening. What should the nurse do? a) Recommend he have his blood pressure rechecked in 1 year. b) Consider this to be a normal finding for his age and race. c) Recommend he see his physician immediately for further evaluation. d) Recommend he have his blood pressure rechecked within 2 weeks.

D

A client in an inpatient psychiatric unit tells the nurse, "I'm going to divorce my no-good husband. I hope he rots in hell. But I miss him so bad. I love him. When is he going to come get me out of here?" The nurse interprets the client's statements as indicative of which condition? a) autistic thinking b) auditory hallucinations c) associative looseness d) ambivalence

D

A client is in the recovery unit after surgery and is snoring with use of accessory muscles. What is the appropriate nursing intervention? a) Suction oral airway b) Prepare for intubation c) Apply oxygen d) Stimulate the client

D

A client is to receive epoetin injections. What laboratory value should the nurse assess before giving the injection? a) hemoglobin concentration b) partial thromboplastin time c) prothrombin time d) hematocrit

D

A client who is postmenopausal with an intact uterus asks the nurse why her hormone medicine has two drugs, estrogen and progesterone. Which statement by the nurse provides the client with accurate information? a) "The progesterone will help prevent cervical cancer." b) "The progesterone will help prevent breast cancer." c) "The progesterone will help prevent liver disease." d) "The progesterone will help prevent endometrial cancer."

D

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. What is the most important action by the nurse? a) Elevate the head of the bed to reduce intraocular pressure b) Preventing secondary acute tubular necrosis c) Lower the head of the bed to improve cerebral perfusion d) Preparing to administer hypertonic saline or mannitol per provider order

D

A client with diabetic ketoacidosis (DKA) has asked the unlicensed nursing assistant for another pitcher of water. It is the third such request over the past 4 hours. The nurse would recognize this request as which of the following manifestations? a) A catabolic state induced by insulin deficiency b) A result of increased activity while the blood glucose was high c) A result of increased urination d) An occurrence of the excess loss of fluid associated with osmotic diuresis

D

A family member expresses that a client who is aphasic after a cerebral vascular accident (CVA) has not been incontinent at home and questions why a urinary catheter has been inserted without consent. The nurse would recognize this treatment best aligns with which standard of care? a) Treatment without consent of the patient, which is an invasion of rights b) Inability to obtain consent for treatment because the patient was aphasic c) Treatment for the patient's benefit d) Treatment that does not need special consent

D

A nurse is analyzing a client's intake and output. The client has a temperature of 102° F (38.9° C) and is receiving 2400 mL of IV fluids per 24 hours because the client is to have nothing-by-mouth. Before planning nursing actions, the nurse should first determine: a) when the client last ate. b) the client's body mass index. c) the intravenous fluid intake during the last 8 hours. d) insensible fluid loss through the lungs and skin.

D

A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: a) Ineffective breathing pattern. b) Risk for falls. c) Impaired tissue integrity. d) Ineffective airway clearance.

D

A nurse is teaching a pregnant client how to distinguish prelabor contractions from true labor contractions. Which statement about prelabor contractions is accurate? a) They're regular. b) They start in the back and radiate to the abdomen. c) They become more intense during walking. d) They're usually felt in the abdomen.

D

A primiparous client develops uterine atony and postpartum hemorrhage 1 hour after a vaginal birth. The health care provider (HCP) has prescribed IM prostaglandin-F2a. After administration of the medication, the nurse should observe the client for which complication? a) hypotension b) constipation c) abdominal distention d) tachycardia

D

A toddler is diagnosed with a dislocated right shoulder and a simple fracture of the right humerus. Which behavior suggests that the child's injuries stem from abuse? a) Trying to move away from the nurse b) Not answering the nurse's questions c) Trying to sit up on the stretcher d) Not crying when moved

D

During admission, a multigravida in early active labor acts somewhat euphoric and tells the nurse that she smoked some crack cocaine before coming to the hospital. In addition to fetal heart rate assessment, the nurse should monitor the client for symptoms of which complication? a) ruptured uterus b) maternal hypotension c) placenta previa d) abruptio placentae

D

In an initial screening for lead poisoning, a 2-year-old child is found to have a lead level just above 10 mcg/dL (0.48 µmol/L). The nurse should: a) arrange a follow-up appointment in 6 months. b) assure the parents this is a normal lead level. c) obtain a consultation for chelation therapy. d) educate parents on ways to reduce lead in the environment.

D

Nurses on a pediatric unit have developed a program to decrease the infection rate on the unit. What is an expected outcome of this quality improvement program? a) preparation for accreditation of the organization b) evaluation of staff members' performances c) improvement in efficiency of care d) evaluation of the system and client outcomes

D

The health care provider (HCP) prescribes mirtazapine 30 mg PO at bedtime for a client diagnosed with depression. The nurse should: a) request to give the medication in the morning. b) give the medication in three divided doses. c) question the HCP's prescription. d) give the medication as prescribed.

D

The husband of a client who was diagnosed 6 years ago with Alzheimer's disease approaches the nurse and says, "I am so excited that my wife is starting to use donepezil for her illness." The nurse should tell the husband: a) the client will attain a functional level equal to that of 6 years ago. b) effectiveness in the terminal phase of the illness is scientifically proven. c) the adverse effects of the drug are numerous. d) the medication is effective mostly in the early stages of the illness.

D

The nurse is caring for an elderly client who has hip pain related to rheumatoid arthritis. The client is practicing appropriate self-care activities when the client chooses to sit in which type of chair? a) recliner chair with arms to support wrists and hands b) curved-back rocking chair c) couch with soft cushions to support thighs d) straight-back chair with elevated seat

D

The nurse is giving preoperative instructions to a client who will be undergoing rhinoplasty. The nurse should instruct the client that: a) after surgery, nasal packing will be in place for 7 to 10 days. b) the results of the surgery will be immediately obvious postoperatively. c) normal saline nose drops will need to be administered preoperatively. d) aspirin-containing medications should not be taken for 2 weeks before surgery.

D

Which is the priority of care for the nulliparous client who is in the active phase of the first stage of labor? a) Respecting the client's privacy by providing appropriate draping b) Providing information about the labor process to alleviate anxiety c) Educating the client on resting and conserving strength d) Implementing nonpharmacologic measures for pain relief

D

Which therapeutic modality would be used to treat an individual diagnosed with somatic symptom disorder? a) Suicide precautions b) Electroconvulsive therapy (ECT) c) Aversion therapy d) Relaxation exercises

D

Choice Multiple question - Select all answer choices that apply. The nurse is assessing a client who has fallen twice in the last 2 days. The client has been diagnosed with delirium tremens (DTs) following withdrawal from alcohol use. The nurse should further evaluate the client for which complications? Select all that apply. a) paralysis b) diaphoresis c) elevated temperature d) visual or auditory hallucinations e) disorientation

E, C, B, D

The nurse is caring for a homeless client with pneumonia. Laboratory testing reveals the following results: blood urea nitrogen (BUN) 180 mg/dl, creatinine 30 mg/dl (2652 mmol/L), potassium 6.2 mEq/L (6.2 mmol/L), and hemoglobin 6.2% (62 g/L). Based on the health care provider's order below, which drug order would the nurse question?

GENTAMICIN SULFATE Based on the high BUN, creatinine, and potassium levels, the client is in renal failure. Gentamicin sulfate is nephrotoxic and can exacerbate the renal failure. Ferrous sulfate and erythropoietin would be given to treat the client's anemia. Aluminum hydroxide gel would also be appropriate because it binds with phosphate, which is elevated in renal failure.