Comprehensive

The nurse is preparing to discontinue a clients NG tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client? 1. "Take a deep breath when I tell you, and hold it while I remove the tube." 2. " take a deep breath when I tell you, and bear down while I remove the tube." 3. " take a deep breath when I tell you, and slowly exhale while I remove the tube." 4. "Take a deep breath when I tell you, and breathe normally while I remove the tube."

1. "Take a deep breath when I tell you, and hold it while I remove the tube."

A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching? 1. "I should avoid alcohol" 2. "I can go back to work right away" 3. "My partner should get the vaccine" 4. "A condom should be used for sexual intercourse."

2. "I can go back to work right away"

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect? 1. Serous 2. Bloody 3. Serosanguineous 4. Bloody, with frequent small clots

2. Bloody

the nurse teaches a client newly diagnosed with type 1 diabetes about storing Humulin N insulin. Which statement indicates to the nurse that the client understood the discharge teaching? 1. "I should keep the insulin in the cabinet during the day only" 2. "I know I have to keep my insulin in the refrigerator at all times" 3. "I can store the open insulin bottle in the kitchen cabinet for 1 month" 4. "the best place for my insulin is on the window sill, but in the cupboard Is just as a good"

3. "I can store the open insulin bottle in the kitchen cabinet for 1 month"

A client with terminal cancer arrives at the emergency department dead on arrival. After an autopsy is prescribed, the client's family requests that no autopsy be performed. Which response to the family is most appropriate? 1. "the decision is made by the medical examiner" 2. "an autopsy is mandatory for any client who is DOA" 3. "I will contact the medical examiner regarding your request" 4. "it is required by federal law. Tell me why you don't want the autopsy done"

3. "I will contact the medical examiner regarding your request"

A 6-year-old child has just been diagnosed with localized Hodgkin's disease and chemotherapy is planned to begin immediately. The mother of the child asks the nurse why radiation therapy was not prescribed as a part of the treatment. What is the nurse's best response? 1. "It's very costly, and chemotherapy works just as well" 2. "I'm not sure. I'll discuss it with the health care provider" 3. "Sometimes age has to do with the decision for radiation therapy" 4. "The health care provider would prefer that you discuss treatment options with the oncologist"

3. "Sometimes age has to do with the decision for radiation therapy"

A client received 20 unites of Humulin N insulin subcutaneously at 08:00. At what time should the nurse plan to assess the client for a hypoglycemic reaction? 1. 1000 2. 1100 3. 1700 4. 2400

3. 1700

Levothyroxine is prescribed for a client diagnosed with hypothyroidism. Upon review of the client's record, the nurse notes that the client is taking warfarin. Which modification to the plan of care should the nurse review with the client's health care provider? 1. A decreased dosage of levothyroxine 2. An increased dosage of levothyroxine 3. A decreased dosage of warfarin sodium 4. An increased dosage of warfarin sodium

3. A decreased dosage of warfarin sodium

What action should the nurse consider when counseling a client of the Amish tradition? 1. Speak only to the husband 2. Use complex medical terminology 3. Avoid using scientific or medical jargon 4. Stand close to the client and speak loudly

3. Avoid using scientific or medical jargon

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? 1. Restricting fluids 2. Placing a pillow under the knees 3. Encouraging active range of motion exercises 4. Applying a heating pad to the lower extremities

3. Encouraging active range of motion exercises

The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching insturctions should include which statement? 1. "Your hair will need to be shaved" 2. "You will receive spinal anesthesia" 3. "You will need to ambulate after surgery" 4. "Brushing your teeth needs to be avoided for at least 2 weeks after surgery"

4. "Brushing your teeth needs to be avoided for at least 2 weeks after surgery"

The nurse has reviewed with the preoperative client the procedure for the administration for the administration of an enema. Which statement by the client would indicate the need for further instruction? 1. "The enema will be given while I am sitting on the toilet" 2. "I should try and hold the fluid in as long as possible after it is instilled" 3. "I know that there will be some cramping after the enema administration" 4. "I should tell the nurse if cramping occurs during the installation of the fluid"

1. "The enema will be given while I am sitting on the toilet"

The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs? 1. Actual or life-threatening concerns 2. Completing care in a reasonable time frame 3. Time constraints related to the client's needs 4. Obtaining needed supplies to care for the client

1. Actual or life-threatening concerns

A client with diabetes mellitus is told that amputation of the leg is necessary to sustain life. The client is very upset and tell the nurse, "this is all my health care provider's fault. I have done everything ive been asked to do!" which nursing interpretation is best for this situation? 1. An expected coping mechanism 2. An ineffective defense mechanism 3. A need to notify the hospital lawyer 4. An expression of guilt on the part of the client

1. An expected coping mechanism

A client has refused to eat more than a few spoonful's of breakfast. The HCP has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has lost a significant amount of weight during the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client beings crying and tries to eat more. Based on the nurse's actions, the nurse may be accused of which violation? 1. Assault 2. Battery 3. Slander 4. Invasion of privacy

1. Assault

A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder? 1. Cardiovascular disease 2. Frequent urinary tract infections 3. A history of migraine headaches 4. Frequent upper respiratory infections

1. Cardiovascular disease

The nurse inspects the color of drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)? 1. Dark Red drainage 2. Dark brown drainage 3. Green tinged drainage 4. Light yellowish brown drainage

1. Dark Red drainage

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheotomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube? 1. Deflate the cuff on the tube 2. Place the inner cannula into the tube 3. Ensure that the client is able to speak 4. Ensure that the client is able to swallow

1. Deflate the cuff on the tube

The nurse has admitted a client to the clinical nursing unit after undergoing a right mastectomy. The nurse should plan to place the right arm in which position? 1. Elevated on a pillow 2. Level with the right atrium 3. Dependent to the right atrium 4. Elevated above shoulder level

1. Elevated on a pillow

To perform cardiopulmonary resuscitation the nurse should use the method pictured to open the airway in which situation? 1. If neck trauma is suspected 2. In all situations requiring CPR 3. If the client has a history of seizures 4. If the client has a history of headaches

1. If neck trauma is suspected

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence? 1. Inability to pass flatus 2. Loss of anal sphincter control 3. Severe, constant pain with rapid onset 4. Firm, nontender mass palpable at the lower right costal

1. Inability to pass flatus

The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client? 1. Provide authority, action, and participation 2. Display an attitude of detachment, confrontation, and efficiency 3. Demonstrate confidence in the client's ability to deal with stressors 4. Provide hope and reassurance that the problems will resolve themselves

1. Provide authority, action, and participation

The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice? 1. The nail beds 2. The skin in the sacral area 3. The skin in the abdominal area 4. The membranes in the ear canal

1. The nail beds

The home care nurse is visiting a client who is in a body cast. While performing an assessment, the nurse plans to evaluate the psychosocial adjustment of the client to the cast. What is the most appropriate assessment for this client? 1. The need for sensory stimulation 2. The amount of home care support available 3. The ability to perform activities of daily living 4. The type of transportation available for follow-up care

1. The need for sensory stimulation

The nurse is performing an assessment on a client with dementia. Which piece of data gathered during the assessment indicates a manifestation associated with dementia? 1. Use of confabulation 2. Improvement in sleeping 3. Absence of sundown syndrome 4. Presence of personal hygienic care

1. Use of confabulation

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding? 1. Waves of loud gurgles auscultated in all 4 quadrants 2. Low pitched swishing auscultated in 1 or 2 quadrants 3. Relatively high pitched gurgles or clicks auscultated in all 4 quadrants 4. Very high pitched, loud rushes auscultated especially in 1 or 2 quadrants

1. Waves of loud gurgles auscultated in all 4 quadrants

A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? 1. assessment of vital signs 2. Completion of abdominal examination 3. Insertion of the prescribed nasogastric tube 4. Thorough investigation of precipitating events

1. assessment of vital signs

The health care provider's prescription reads levothyroxine, 150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg per tablet. The nurse should administer how many tablet (s) to the client? Answer: 1.5 tablets

1.5 tablets

A client who is positive for human immunodeficiency virus delivers a newborn infant. The nurse provides instructions to help the client with care of her infant. Which client statement indicates the need for further instruction? 1. "I will be sure to wash my hands before and after bathroom use" 2. "I need to breast feed, especially for the first 6 weeks postpartum" 3. "Support groups are available to assist me with understanding my diagnosis of HIV" 4. "My newborn infant should be on antiviral medications for the first 6 weeks after deliver"

2. "I need to breast feed, especially for the first 6 weeks postpartum"

The nurse is the first responder after a tornado has destroyed many homes in the community. Which victim should the nurse attend to first? 1. A pregnant woman who exclaims "my baby is not moving" 2. A child who is complaining "my leg is bleeding so bad, I am afraid it is going to fall off!" 3. A young child standing next to an adult family member who is screaming "I want my mommy!" 4. An older victim who is sitting next to her husband sobbing, "my husband is dead. My husband is dead"

2. A child who is complaining "my leg is bleeding so bad, I am afraid it is going to fall off!"

The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and should include which action in the plan? 1. Ensure that the knots are at the pulleys 2. Check the weights to ensure that they are off of the floor 3. Ensure that the head of the bed is kept at a 45-to90-degree angle 4. Monitor the weights to ensure that they are resting on a firm surface

2. Check the weights to ensure that they are off of the floor

An infant born with an imperforate anus returns from surgery after requiring a colostomy. The nurse assesses the stoma and notes that it is red and edematous. Based on this finding, which action should the nurse take? 1. Elevate the buttocks 2. Document the findings 3. Apply ice immediately 4. Call the health care provider

2. Document the findings

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse note intermittent bubbling in the water seal chamber. Which action is the most appropriate nursing action? 1. Check for an air leak 2. Document the findings 3. Notify the HCP 4. Change the chest tube drainage system

2. Document the findings

The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which lab result would the nurse expect to note if the client does have appendicitis? 1. Leukopenia with a shift to the left 2. Leukocytosis with a shift to the left 3. Leukopenia with a shift to the right 4. Leukocytosis with a shift to the right

2. Leukocytosis with a shift to the left

The nurse is creating a plan of care for a client in skin traction. The nurse should monitor for which priority finding in this client.? 1. Urinary incontinence 2. Signs of skin breakdown 3. The presence of bowel sounds 4. Signs of infection around the pin sites

2. Signs of skin breakdown

A client with TB whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client? 1. Five blood cultures are negative 2. Three sputum cultures are negative 3. A blood culture and a chest x-ray are negative 4. A sputum culture and a tuberculin skin test are negative

2. Three sputum cultures are negative

A client diagnosed with diabetes mellitus is instructed by the health care provider to obtain glucagon for emergency home us. The client asks a home care nurse about the purpose of the medication. What is the nurse's best response to the client's question? 1. "it will boost the cells in your pancreas if you have insufficient insulin" 2. "it will help to promote insulin absorption when your glucose levels are high" 3. "it is for the times when your blood glucose is too low from too much insulin" 4. "it will help to prevent lipoatrophy from the multiple insulin injections over the years"

3. "it is for the times when your blood glucose is too low from too much insulin"

The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions? 1. "iron supplements will give me diarrhea" 2. "meat does not provide iron and should be avoided" 3. "the iron is best absorbed if taken on an empty stomach" 4. "on the days that I eat green leafy vegetables or calf liver I can omit taking the iron supplement"

3. "the iron is best absorbed if taken on an empty stomach"

A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? Refer to the chart. 1. "you should avoid all school-age children during pregnancy." 2. "there is no need to be concerned if you don't have a fever or rash within the next 2 days." 3. "you were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk" 4. "be sure to tell the health care provider in 2 weeks as additional screening will be prescribed during your second trimester"

3. "you were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk"

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1. Bradycardia and hyperactivity 2. Decreased respiratory rate and depth 3. Headache, restlessness, and confusion 4. Bradypnea, dizziness, and paresthesias

3. Headache, restlessness, and confusion

A depressed client verbalizes feelings of low self esteem and self-worth typified by statements such as "I'm such a failure. I cant do anything right." How should the nurse plan to respond to the client's statement? 1. Reassure the client that things will get better 2. Tell the client that this is not true and that we all have a purpose in life 3. Identify recent behaviors or accomplishments that demonstrate the client's skills 4. Remain with the client and sit in silence; this will encourage the client to verbalize feelings

3. Identify recent behaviors or accomplishments that demonstrate the client's skills

The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? 1. Anxiety 2. Unrealistic outlook 3. Lack of ability to cope effectively 4. Disturbances in thoughts and ideas

3. Lack of ability to cope effectively

The nurse is providing care to a Puerto Rican American client who is terminally ill. Numerous family members are present most of the time and many of the family members are every emotional. What is the most appropriate nursing action for this client? 1. Restrict the number of family members visiting at one time 2. Inform the family that emotional outbursts are to be avoided 3. Make the necessary arrangements so that family members can visit 4. Contact the health care provider to speak to the family regarding their behaviors

3. Make the necessary arrangements so that family members can visit

The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? 1. Document the findings 2. Arrange for hearing testing 3. Notify the health care provider 4. Cover the ears with gauze pads

3. Notify the health care provider

The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management? 1. Engaging in immoral acts 2. Always reinforcing self-approval 3. Observing rigid rules and regulations 4. Having the need always to make the right decision

3. Observing rigid rules and regulations

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? 1. Apply restraints to the client 2. Ask the family to stay with the client 3. Place a clock and calendar in the client's room 4. Ask the laboratory to perform electrolyte studies

3. Place a clock and calendar in the client's room

A client comes to the ED after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1. Begin to teach relaxation techniques 2. Encourage the client to discuss the assault 3. Remain with the client until the anxiety decreases 4. Place the client in a quiet room alone to decrease stimulation

3. Remain with the client until the anxiety decreases

The emergency department nurse is caring a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? 1. Adhering to the mandatory abuse-reporting laws 2. Notifying the caseworker of the family situation 3. Removing the client from any immediate danger 4. Obtaining treatment for the abusing family member

3. Removing the client from any immediate danger

The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, PaCO2 of 58 mmHg, PaO2 of 80 mmHg, and HCO3 of 27 mEq/L. the nurse interprets that the client has which acid base disturbance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3. Respiratory acidosis

The nurse is caring for a client who has involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that that an informed consent has not be obtained for the procedure. Based on this information, what is the nurse's best determination in planning care? 1. The informed consent does not need to be obtained 2. The informed consent should be obtained from the family 3. The informed consent needs to be obtained from the client 4. The health care provider will provide the informed consent

3. The informed consent needs to be obtained from the client

During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem? 1. "I will drink 8 oz of water with each meal" 2. "I will eat 3 servings of cracked wheat bread each day" 3. "I will eat 2 saltine crackers before I get up each morning" 4. "I will eat fresh fruits and vegetables for snacks and dessert each day"

4. "I will eat fresh fruits and vegetables for snacks and dessert each day"

The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction? 1. "I will handle the area gently" 2. "I will wear loose-fitting clothing" 3. "I will avoid the use of deodorants" 4. "I will limit sun exposure to 1 hour daily"

4. "I will limit sun exposure to 1 hour daily"

A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy? 1. "This form of therapy can be applied to new situations" 2. "An advantage of this technique is that change is likely to last." 3. "Talking to oneself is a basic component of this form of therapy." 4. "This form of therapy provides a negative reinforcement when the stimulus is produced."

4. "This form of therapy provides a negative reinforcement when the stimulus is produced."

On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction? 1. "I need to urinate frequently throughout the day" 2. "the prescribed medication must be taken until it is finished" 3. "my fluid intake should be increased to at least 3000 mL daily" 4. "foods and fluids that will increase urine alkalinity should be consumed'

4. "foods and fluids that will increase urine alkalinity should be consumed'

An adolescent client is diagnosed with conjunctivitis, and the nurse provides information to the client about the use of contact lenses. Which client statement indicates the need for further information? 1. "I should obtain new contact lenses" 2. "I should not wear my contact lenses" 3. "my old contact lenses should be discarded" 4. "my contact lenses can be worn if they are cleaned ass directed"

4. "my contact lenses can be worn if they are cleaned ass directed"

When creating an assignment for a team consisting of a registered nurse, 1 LPN, and 2 unlicensed assistive personnel, which is the best client for the LPN? 1. A client requiring frequent temperature checks 2. A client requiring assistance with ambulation every 4 hours 3. A client on a mechanical ventilator requiring frequent assessment and suctioning 4. A client with a spinal cord injury requiring urinary catheterization every 6 hours

4. A client with a spinal cord injury requiring urinary catheterization every 6 hours

A client arrives at the clinic complaining of fatigue, lack of energy, constipation, and depression. Hypothyroidism is diagnosed, and levothyroxine is prescribed. What is expected outcome of the medication? 1. Alleviate depression 2. Increase energy levels 3. Increased blood glucose levels 4. Achieve normal thyroid hormone levels

4. Achieve normal thyroid hormone levels

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube? 1. Checking for normal serum electrolyte levels 2. Checking for normal pH of the gastric aspirate 3. Checking for proper nasogastric tube placement 4. Checking for the presence of bowel sounds in all 4 quadrants

4. Checking for the presence of bowel sounds in all 4 quadrants

Metformin is prescribed for a client with type 2 diabetes mellitus. What is the most common side effect that the nurse should include in the client's teaching plan? 1. Weight gain 2. Hypoglycemia 3. Flushing and palpitations 4. Gastrointestinal disturbances

4. Gastrointestinal disturbances

The nurse assess a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? 1. Incessant talking and sexual innuendoes 2. Grandiose delusions and poor concentration 3. Outlandish behaviors and inappropriate dress 4. Nonstop physical activity and poor nutritional intake

4. Nonstop physical activity and poor nutritional intake

A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate? 1. Allowing bathroom privileges only 2. Evaluate the head of the bed to 45 degrees 3. Wearing dark glasses to read or watch television 4. Placing an eye patch over the clients affected eye

4. Placing an eye patch over the clients affected eye

a client is about to undergo a lumbar puncture. The nurse descried to the client that which position will be used during the procedure? 1. Side lying with a pillow under the hip 2. Prone with a pillow under the abdomen 3. Prone in slight Trendelenburg position 4. Side lying with the legs pulled up and the head bent down onto the chest

4. Side lying with the legs pulled up and the head bent down onto the chest