HESI iNet

Penicillin G procaine 240,000 units intramuscularly is prescribed for a 4-year-old child who has a streptococcal respiratory infection. The medication vial is labeled 1,200,000 units/2 mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

0.4 mL

The healthcare provider prescribes digoxin elixir 125 mcg PO daily. The drug is available in a 60 ml. bottle labeled, "Digoxin elixir 0.05 mg/mL." How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

2.5 mL

A Journalist asks the nurse working in the Emergency Department about the condition of a local politician recently admitted to the medical center following a publicly reported building fire. Which aclion should the nurse take? a. Direct the journalist to the agency's Communication/Marketing department. b. Document the official identification of the journalist before providing any information. c. Obtain verbal consent from a family member before discussing the client's condition. d. Provide only general information regarding the client's over-all condition.

a. Direct the journalist to the agency's Communication/Marketing department.

A client who is an avid hiker expresses concern about losing too much potassium while hiking. In teaching the client to prepare potassium-rich snack mix the nurse should encourage the cllent to include which items? (Select all that apply.) a. Dried apricots. b. Seedless raisins. c. Lightly salted peanuts. d. Dried bananas. e. Dried apples.

a. Dried apricots. b. Seedless raisins. d. Dried bananas.

A client who is admitted to the emergency room following a motorcycle accident is having difficulty breathing. While assessing the client's chest and lungs, the nurse notes that there are no breath sounds over the left flelds. Which actions should the nurse implement? (Select all that apply.) a. Elevate the head of the bed 45 degrees. b. Place client in Trendelenburg position. c. Withhold narcotic pain medication. d. Apply a high-flow oxygen by face mask. e. Obtain a chest tube insertion kit.

a. Elevate the head of the bed 45 degrees. d. Apply a high-flow oxygen by face mask. e. Obtain a chest tube insertion kit.

An adolescent female with an eating disorder is admitted to the in-patient psychlatric unit. Which intervention should the nurse implement? a. Encourage the client to weigh herself daily at bedtime. b. Allow the client to select an arts and crafts activity. c. Recommend exercise and recreation in the morning. d. Put the client in charge of choosing snacks for the unit.

a. Encourage the client to weigh herself daily at bedtime.

The nurse is planning care for a 16-year-old, who has juvenile idiopathic arthritis (JIA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? a. Exercise in a swimming pool. b. Splint affected joints during activity. c. Perform passive range of motion exercises twice daily. d. Begin a training program lifting weights and running.

a. Exercise in a swimming pool.

A 60-year-old female client asks the nurse about hormone replacement therapy (HRT) as a means of preventing osteoporosis. Which factor in the client's history is a possible contraindication for use of HRT? a. Her mother and sister have a history of breast cancer. b. Her 60-year-old sister has Alzheimer's disease. c. She is taking medication for high blood pressure. d. She had problems with "hot flashes" several years ago.

a. Her mother and sister have a history of breast cancer.

The home health nurse observes an older client with unilateral weakness place the walker in front of the chair for support while rising to a standing position. Which action should the nurse take? a. Hold the walker securely to prevent slipping when the client rises. b. Apply a gait belt to assist the client to rise out of the chair. c. Instruct the client to use the arms of the chair for support. d. Encourage client to use the weaker leg with the walker when rising.

a. Hold the walker securely to prevent slipping when the client rises.

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis? a. Hypoalbuminemia that results in a decreased colloidal oncotic pressure. b. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules. c. Decreased renin-angiotensin response related to an increase in renal blood flow. d. Decreased portacaval pressure with greater collateral circulation.

a. Hypoalbuminemia that results in a decreased colloidal oncotic pressure.

After taking lactulose for several days, which therapeutic response should the nurse expect for a client with hepatic encephalopathy? a. Improved mental status. b. Reduction in number of liquid stools. c. Ability to ambulate independently. d. Increase in urine output.

a. Improved mental status.

Arterial blood gas (ABG) results Indicate that a client with respiratory faiture who is being mechanically ventilated has respiratory acidosis. The ventilator rate is set at 6 breaths/minute, pressure support at 10 cm H20, and oxygen concentration at 30%. Which action should the nurse implement to help correct the client's acidosis? a. Increase in the ventilator rate. b. Provide manual resuscitation. c. Decrease the pressure support. d. Increase oxygen concentration.

a. Increase in the ventilator rate.

When teaching a client with Parkinson's disease, which rationale for the prescription of carbldopa-levodopa should the nurse include? a. Increases the amount of dopamine available for muscles to function correctly. b. Slows the scarring in the myelin sheath improving muscle tone and strength. c. Reduces the inflammatory process improving nerve transmission and function. d. Acts as an antiseizure medication reducing the tremors caused by the disease.

a. Increases the amount of dopamine available for muscles to function correctly.

A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has a good prognosis and refuses to write a "do not resuscitate" (DR) prescription. Which action should the nurse take? a. Initiate an ethics committee review of the case b. Place a DR bracelet on the client's arm. c. Ensure resuscitation equipment is available. d. Ask the family to review options with the client.

a. Initiate an ethics committee review of the case

While admitting a client to the surgical unit who had a pneumonectomy 4 hours ago, the call system alarm is initiated by a client in another room. Which action should the nurse implement? a. Investigate the reason for the call bell alarm then complete the admission assessment. b. Tell the unit clerk to ask the client via the intercom what is needed. c.Ask a coworker to respond to the client whose call bell is alarming. d. Complete the postoperative admission assessment then investigate the call bell alarm.

a. Investigate the reason for the call bell alarm then complete the admission assessment.

The nurse is assessing a client who was recently extubated. The client has oral medications prescribed. Which clinical findings indicate the client may be able to safely take oral medications? (Select all that apply.) a. Manages oral secretions. b. Alert and oriented. c. Ability to pass flatus. d. Dentures are in place. e. Gag reflex present.

a. Manages oral secretions. b. Alert and oriented. e. Gag reflex present.

A client recently diagnosed with Hodgkin's disease undergoes biopsy of cervical lymph nodes under local anesthesia. Which intervention is most important to include in this client's plan of care? a. Monitor for tracheal deviation and swelling at biopsy site. b. Assess for drainage on dressing covering cervical incision. c. Auscultate blood pressure every 15 minutes for one hour. d. Perform neurological assessment prior to discharge.

a. Monitor for tracheal deviation and swelling at biopsy site.

A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first? a. Place the client in Trendelenburg. b. Administer oxygen via face mask. c. Notify the operating room team. d. Administer a fluid bolus of 500 mL.

a. Place the client in Trendelenburg.

The nurse is communicating with a 12-year-old who is hearing impaired. Which action is best for the nurse to use when attempting to communicate with this child? a. Use a picture board to communicate needs. b. Attract the child's attention before speaking. c. Convey ideas by writing short sentences. d. Emphasize emotions with facial expressions.

a. Use a picture board to communicate needs.

An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing. When assessing this client, which additional finding Is the nurse likely to obtain? a. Jugular vein distension. b. Fatigue. c. Hepatomegaly. d. Lower extremity edema.

b. Fatigue.

Which assessment finding places a client at risk for problems associated with impaired skin integrity? a. Smooth nail texture. b. Scattered macula on the face. c. Capillary refill 5 seconds. d. Absence of skin tenting.

c. Capillary refill 5 seconds.

Which dietary instruction should the nurse include when teaching a client how to reduce episodes of Raynaud's syndrome? a. Reduce saturated fat intake. b. Increase calcium intake. c. Eliminate caffeine intake. d. Avoid hot beverages.

c. Eliminate caffeine intake.

After receiving chemotherapy, a client who weighs 154 pound (70 kg) develops febrile neutropenia. The healthcare provider prescribes filgrastim 5 mcg/kg SUBQ every 12 hours. The available vial is labeled, filgrastim 300 mcg/mL. Based on the client's weight, how many milliliters should the nurse administer? (Enter the numerical value only, If rounding is required, round to the nearest tenth.)

1.2

A client with human immunodeficiency virus (HIV) begins active labor at 38 weeks gestation and receives a prescription for zidovudine 2 mg/kg IV, to be administered over 1 hour. The client weighs 185 lbs. Based on the client's weight, how many mg should the nurse prepare to administer? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

168mg

A client with a gram-positive bacterial skin infection is receiving daptomycin 500 mg IV every 24 hours. The pharmacy delivers a secondary infusion of 0.9% Sodium Chloride with daptomycin 500 mg/100 mL to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump? (Enter the numerical value only.)

200

The nurse plans to administer a bolus dose of IV Heparin based on the client's weight. The prescribed bolus dose is 100 units/kg. The client weighs 198 pounds. How many units of Heparin should the nurse administer? (Enter numeric value only.)

9000

The mother of an infant born with hypospadias is concerned because she has been told that her child cannot be circumcised according to her Jewish faith tradition. Which response is best for the nurse to provide? a. "Your faith is important, but correcting this problem is priority for your son." b. "Circumcising the penis now may contribute to frequent urinary infections." c. "During the surgery part of the foreskin is used to repair the meatus." d. "I understand your concern. Would you like to talk to the pediatrician?"

C. During the surgery part of the foreskin is used to repair the meatus. Infants born with hypospadias may require using the foreskin (D) in surgical correction of the meatus so circumcision is deferred until this time. In Jewish tradition, circumcision is usually conducted on the 8th day of life, but the desirable time for surgical repair of the meatus is 6-12 months of age.

A client is hospitalized for treatment of a myasthenic crisis and is concerned about what may have caused this illness. The client states, "I just had a little case of the sniffles and a bit of a sore throat and wham! Suddenly I couldn't get out of bed or do anything." Which response Is best for the nurse to provide this client? a. "Muscle weakness is an early sign of crisis and means that you need more rest." b. "The crisis may have been triggered by your cold. I bet it can feel pretty scary.' c. "You probably just did too much at one time. You need to pace your activities." d. "It was probably an overdose of your medication. Did you take a double dose?"

a. "Muscle weakness is an early sign of crisis and means that you need more rest."

Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis? a. Bagel with jelly and skim milk. b. Granola bar and grapefruit juice. c. Egg whites, toast, and coffee. d. Bran muffin, mixed fruit, and orange juice.

a. Bagel with jelly and skim milk.

After administering the ACE Inhibitor lisinopril, it is most important for the nurse to monitor which assessment finding? a. Blood pressure and risk for falls. b. Serum potassium and skin turgor. c. Heart rate and complaints of nausea. d. Eosinophil count and constipation.

a. Blood pressure and risk for falls.

A client is taken to the urgent care clinic after fainting while exercising at the gym. The client is weak, pale, and diaphoretic. Which intervention should the nurse implement first? a. Check blood glucose level. b. Auscultate heart sounds. c. Offer an oral hydration drink. d. Perform a 12-lead electrocardiogram.

a. Check blood glucose level.

A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? a. Offer information about ultrasonography and genotyping to determine sex assignment. c. Explain that corrective surgical procedures consistent with sex assignment can be delayed. c. Discuss the need for cortisol and aldosterone replacement therapy after discharge. d. Support the parents in their decision to assign sex of their child according to their preference.

a. Offer information about ultrasonography and genotyping to determine sex assignment.

During a 24-hour chart revlew of a client in acute renal failure, the nurse notices that a prescription, written 12 hours ago for every 6 hours serum potasslum levels, was not transcribed by the previous shift. Which is the best immediate action for the nurse to take? a. Order the lab work as prescribed and follow procedures for completing an incident report. b. Telephone the nurse responsible for the error at home to report the omission of the transcription. c. Call the healthcare provider and ask if the prescription is still needed since 12 hours have elapsed since it was written. d. Notify the nursing supervisor of the previous shift's omission in not transcribing the prescription.

a. Order the lab work as prescribed and follow procedures for completing an incident report.

The nurse finds a female client crying quietly in her room. What action should the nurse take first? a. Pull up a chair and sit beside the client. b. Review the client's record before attempting to intervene. c. Provide the client privacy and quietly close the door. d. Ask the client why she is crying

a. Pull up a chair and sit beside the client.

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement? a. Reduce the stimuli in the area before continuing the teaching. b. Provide the client with step-by-step written instructions. c. Reassure the client that the skill is not difficult to learn. d. Demonstrate the skill, speaking slowly and using simple terms.

a. Reduce the stimuli in the area before continuing the teaching.

A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse? a. Takes metformin hydrochloride for type 2 diabetes mellitus. b. Report of client's sobriety for the last five years. c. CT scan that was performed six months earlier. d. Metal hip prosthesis was placed twenty years ago.

a. Takes metformin hydrochloride for type 2 diabetes mellitus.

After experiencing symptoms caused by an abnormal heart rhythm, a client is placed on a temporary pacemaker. When the client expresses concern and fear of the pacemaker, how should the nurse respond? a. Use simple terms to describe how the pacemaker functions. b. Offer reassurance that the staff will monitor the pacemaker. c. Reinforce that the pacemaker is a temporary measure. d. Encourage discussion about the concerns and fears.

a. Use simple terms to describe how the pacemaker functions.

A client with a history of heart failure and type 1 diabetes mellitus is admitted with unstable angina. Which problem requires the most immediate Intervention by the nurse? a. Fluid volume excess. b. Acute anginal pain. c. Activity intolerance. d. Fatigue.

b. Acute anginal pain.

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client's history should the nurse further explore? a. Inadequate diversional activity. b. Alcohol use. c. Witness to an accident. d. Family history of dementia.

b. Alcohol use.

The nurse observes an elderly male client walking aimlessly in the hallway and staring straight ahead blankly. How should the nurse enter computer documentation of this finding? a. Demonstrates signs of early dementia. b. Appears confused and depressed. c. Ambulatory and disoriented to place. d. Wandering behavior with flat affect.

b. Appears confused and depressed.

A client is being treated for hepatic failure. On examination, the client has a weight gain of 4.4 lbs (2kg) in 24 hours and an elevated pulse rate. Which intervention should the nurse include in the plan of care? a. Review arterial blood gases results. b. Assess for dependent pitting edema. c. Document abdominal girth. d. Record usual eating patterns.

b. Assess for dependent pitting edema.

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete? a. Observe for edema around the ankles. b. Auscultate the client's bowel sounds. c. Count the apical and radial pulses simultaneously. d. Measure the client's capillary glucose level.

b. Auscultate the client's bowel sounds.

The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take? a. Listen to the ethics committee discussions and then inform the client what actions should be taken. b. Develop self-awareness of the nurse's personal values to avoid imposing these values on the client. c. Educate the client about current nursing literature findings related to the client's ethical dilemma. d. Challenge members of the healthcare team whose opinions differ from the wishes of the client.

b. Develop self-awareness of the nurse's personal values to avoid imposing these values on the client.

A client is ambulating with a two-wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client's elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, what action should the nurse implement? a. Offer to adjust the height of the walker. b. Encourage the client to continue using the walker as observed. c. Demonstrate more coordinated movement of the legs and walker. d. Explain the need to remove the wheels from the walker.

b. Encourage the client to continue using the walker as observed.

Which diet should the nurse recommend for a client who is in acute renal failure? a. High protein, low carbohydrate, low sodium, low potassium. b. Low protein, high carbohydrate, low sodium, low potassium. c. Low protein, high carbohydrate, low sodium, high potassium. d. High protein, low carbohydrate, low sodium, high potassium.

b. Low protein, high carbohydrate, low sodium, low potassium.

The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take? a. Complete an adverse occurrence report. b. Monitor for signs of bleeding. c. Obtain blood for coagulation studies. d. Notify the healthcare provider.

b. Monitor for signs of bleeding.

During the admission assessment, the nurse identifies multiple bruises at various stages of heating on a client recently diagnosed with aplastic anemia. The nurse reviews the client's stat serum laboratory values which reveal platelets 50,000/mm° (5 x 10°L), white blood cells 3,000/mm° (3 % 10°/L.), and red bloods cells 2.5 million/mm? (2.5 x 10*°). Which actions should the nurse Implement? (Select all that apply.) a. Implement contact precautions. b. Monitor for signs of bleeding. c. Provide a soft-bristle tooth brush. d. Initiate sepsis protocol Infuse blood products as prescribed.

b. Monitor for signs of bleeding. c. Provide a soft-bristle tooth brush. d. Initiate sepsis protocol Infuse blood products as prescribed.

The nurse determines that an older female client has kyphosis, has lost two inches of height in the last three years, and has a recent history of spinal vertebral fractures. What underlying pathology explains these manifestations? a. Rate of bone resorption that exceeds rate of bone deposition. b. Progressive weakening of the muscle fibers of the lower back. c. Deterioration of the myelin sheath surrounding nerve fibers. d. Vertebral compression caused by increased bone density.

b. Progressive weakening of the muscle fibers of the lower back.

A young client who is being taught to use an inhaler for symptoms of asthma tells the nurse the intention to use the inhaler but, plans to continue smoking cigarettes. In evaluating the client's response, what is the best initial action by the nurse? a. Review factors surrounding client's beliefs about smoking cessation. b. Revise the plan of care based on the client's plans to continue smoking. c. Inform the health care provider of this statement made by the client. d. Explain that denial of illness can interfere with the treatment regimen.

b. Revise the plan of care based on the client's plans to continue smoking.

After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse? a. Circumferential edema of right foot. b. Right foot pale with sluggish capillary refill. c. Complaint of throbbing right leg pain. d. Increased temperature to lower extremity.

b. Right foot pale with sluggish capillary refill.

A client uses triamcinolone, a corticosteroid ointment, to manage pruritus caused by a chronic skin rash. The client calls the clinic nurse to report Increased erythema with purulent exudate at the site. Which action should the nurse implement? a. Explain that the client needs to complete all prescribed doses of the medication. b. Schedule an appointment for the client to see the healthcare provider, c. Instruct the client to continue the ointment until all erythema is relieved. d. Advise the client to apply plastic wrap over the ointment to promote healing.

b. Schedule an appointment for the client to see the healthcare provider,

Which laboratory value should the nurse review prior to administering the initial dose of a statin medication? a. Serum electrolytes. b. Serum liver enzymes c. Capillary blood glucose. d. Complete blood count.

b. Serum liver enzymes

The parent of an adolescent tells the clinic nurse, "My child has athlete's feet. I have been applying triple antibiotic ointment for two days, but there has been no improvement." Which instruction should the nurse provide? a. Antibiotics take two weeks to become effective against infections such as athlete's foot. b. Stop using the ointment and encourage complete drying of feet and wearing clean socks. c. Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration. d. Continue using the ointment for a full week, even after the symptoms disappear.

b. Stop using the ointment and encourage complete drying of feet and wearing clean socks.

The nurse learns that a client does not know the purpose of the antipsychotic medication ziprasidone. How should the nurse best explain the purpose of this medication? a. This medication helps people with schizophrenia. b. This medication will help you think more clearly. c. This is an antipsychotic medication to calm you down. d. An antipsychotic medication promotes socialization.

b. This medication will help you think more clearly.

A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires Immediate Intervention by the nurse? a. Orientation to person and place only. b. Unequal bilateral hand grip strengths c. Pupillary changes to ipsilateral dilation. d. Left-sided facial drooping and dysphagia.

b. Unequal bilateral hand grip strengths

The nurse working in a disaster area assesses an adult client who has partial-thickness burns on the lower legs, or approximately 10% of the lower body. Which color of triage tag should the nurse place on this client? a. Black. b. Yellow. c. Red. d. Green.

b. Yellow.

A 26-year-old client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? a. muscle cramping and dry, flushed skin. b. palpitations and shortness of breath. c. bradycardia and constipation. d. lethargy and lack of appetite.

b. palpitations and shortness of breath.

The nurse documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment? a. "The fire is burning my skin away right now." b. "The voices are telling me to kill the next person I see." c. "The nurse at night is trying to poison me with pills." d. "The snakes on the wall are going to eat me."

c. "The nurse at night is trying to poison me with pills."

A client with stage I bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 1 to 10 scale. Which intervention should the nurse implement? a. Give maximum dosage when score reaches 10. b. Educate client on signs and symptoms of narcotic dependency. c. Administer opioid and non-opioid medication simultaneously. d. Alternate IV and IM analgesic medications.

c. Administer opioid and non-opioid medication simultaneously.

A pediatric home care nurse schedules a visit to the home of a 4-week-old newborn who had a low thyroxine (T4) and a high thyrold stimulating hormone (TSH) at birth, and was diagnosed with congenital hypothyroidism or cretinism. Which instruction is most important for the nurse to provide the parents of this child? a. Monitor the infant's daily intake and weekly weight. b. Offer a low sodium formula between breast feedings. c. Administer supplemental thyroid hormone daily. d. Stimulate the infant during feedings to ensure adequate intake.

c. Administer supplemental thyroid hormone daily.

Two days after admission for a fractured wrist from a fall while intoxicated, a male client with a history of mental illness and alcohol abuse becomes anxious, agitated, and diaphoretic. His vital signs are temperature 99.6 °F (37.6 °C), heart rate 112 beats/minute, respirations 26 breaths/minute, and blood pressure 190/108. He tells the nurse that bugs are crawling in his bed. Which prescription should the nurse administer? a. Buspirone. b. Codeine. c. Chlordiazepoxide. d. Risperidone.

c. Chlordiazepoxide.

In assessing a 70-year-old client with Alzheimer's disease, the nurse notes that the client has deep inflamed cracks at the corners of the mouth. Which intervention should the nurse include in this client's plan of care? a. Scrub the lesions with warm soapy water. b. Notify the healthcare provider of the need for oral antibiotics. c. Ensure that the client gets adequate B vitamins in foods or supplements. d. Encourage the client to drink orange juice for added vitamin C.

c. Ensure that the client gets adequate B vitamins in foods or supplements.

The client with which type of wound is most likely to need immediate intervention by the nurse? a. Ulceration. b. Contusion. c. Laceration. d. Abrasion.

c. Laceration.

The nurse is performing intake interviews at a psychlatric clinic. A female client with a known history of drug abuse reports that she had a heart altack four years ago. Use of which substance places the client at highest risk for myocardial infarction? a. Marijuana. b. Benzodiazepine. c. Methamphetamine. d. Alcohol.

c. Methamphetamine.

A client's tumor measures 2 cm before and after receiving a course of radiotherapy. What physiological mechanism renders this response to radiation therapy for cancers? a. Cellular anchorage that is necessary for cancer cell growth is removed. b. Cell growth is disrupted during the resting phase of the cell cycle. c. Production of ionizing energy damages DNA, hence stops replication. d. Reduction of contact inhibition results in cell death by phagocytosis.

c. Production of ionizing energy damages DNA, hence stops replication.

While adding water to the chest tube drainage system, the nurse knocks over the container causing the blood to spill into the adjacent chamber. Which action should the nurse take? a. Increase suction to 30 cm. b. Assess tubing for fluctuation with respirations. c. Replace chest tube drainage system. d. Mark drainage in both chambers.

c. Replace chest tube drainage system.

A client with hypothyroidism reports difficulty falling asleep because of feelings of depression. Which action should the nurse implement? a. Withhold next scheduled dose of levothyroxine. b. Request a PRN sedative-hypnotic to help with insomnia. c. Review most recent thyroid function test results. d. Encourage increased exercise and activity during the day.

c. Review most recent thyroid function test results.

The nurse uses the Glasgow coma scale (GCS) to assess a client who has had a stroke. When the nurse calls out the client's name, the client does not open eyes, does not respond to a painful stimulus, and does not make any spoken sound during the assessment. Which statement based on the GCS reflects correct documentation in the electronic medical record of the client's neurological status? a. GCS indicates no function. b. Comatose with no score using GCS. c. Score of 3 on the GCS. d. Unable to assess client using GCS.

c. Score of 3 on the GCS.

When using a Yankauer oral-tip catheter to suction a client's oropharynx, which action should the nurse take before inserting the catheter into the oropharynx? a. Assess the nares for a deviated septum. b. Apply suction by occluding the port. c. Turn on the continuous suction device. d. Ask the client to begin swallowing.

c. Turn on the continuous suction device. Rationale: The continuous suction device should be turned on (B) prior to inserting the Yankauer tip or tonsillar tip catheter into the client's mouth so that suction can be applied as soon as it is in place. (A) is an action implemented prior to nasogastric tube (NGT) placement. (C) should be assessed prior to insertion of a nasal suction catheter or NGT. Suction should not be applied while a catheter is inserted (D) because it can traumatize tissue and remove oxygen in the upper airways.

Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that the client is experiencing a complication of the procedure? a. *I feel sick to my stomach and am going to throw up." b. "I am having pain in my lower back when I move my legs." c. "My throat hurts badly when I swallow and when I talk." d. "I have a headache that gets worse when I sit up"

d. "I have a headache that gets worse when I sit up"

The nurse-manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client is pleading for the nurse to release her arms. The nurse explains to the nurse-manager that the client needs to be restrained in the wheelchair so that the nurse can change her bed linens. What is the priority action by the nurse-manager? a. Determine if the client has a PRN prescription for an antianxiety agent. b. Contact the healthcare provider to ensure that a prescription for restraints was written. c. Close the door to the room to avoid disturbing other clients in nearby rooms. d. Advise the staff nurse to remove the restraints from the client's wrists.

d. Advise the staff nurse to remove the restraints from the client's wrists.

A client with hematuria secondary to a urinary tract infection has a prescription for IV administration of the cephalosporin cefoperazone. Which action should the nurse implement? a. Hold the scheduled dose and consult with the healthcare provider. b. Monitor the client's PT/IN before administering the dose. c. Administer the prescribed dose of medication as scheduled. d. Assess the client's blood pressure before and after the dose.

d. Assess the client's blood pressure before and after the dose.

Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. What instruction should the nurse give the parents if their child becomes pale, cool, and lethargic? a. Assist the child to a recumbent position. b. Provide a quiet time by holding or rocking the toddler. c. Encourage oral electrolyte solution intake. d. Contact their healthcare provider immediately.

d. Contact their healthcare provider immediately.

While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the alr valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next? a. Reposition the stethoscope in the antecubital fossae over the palpable brachial pulse point. b. Release the air and reinflate the cuff to 30 mm Hg above the client's previous systolic reading. c. Inflate the cuff quickly to a higher mm of Hg reading than the previously auscultated systolic sound d. Continue the blood pressure assessment until the last Korotkoff sound is heard.

d. Continue the blood pressure assessment until the last Korotkoff sound is heard.

A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first? a. Demonstrate the proper use of personal protective equipment. b. Offer to assist the UAP with the collection of the specimen. c. Provide the UAP with the infection control policy. d. Determine the UAP's knowledge about HIV transmission.

d. Determine the UAP's knowledge about HIV transmission.

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate Is 14 breaths/minute. Which action should the nurse implement? a. Encourage the client to take deep breaths. b. Increase the liter flow of oxygen. c. Remove the mask to deflate the bag. d. Document the assessment data.

d. Document the assessment data.

The nurse is teaching a client about the initiation of a prescribed abstinence therapy using disulfiram. What information should the client acknowledge understanding? a. Admit to others that he is a substance abuser. b. Completely abstain from heroin or cocaine use. c. Attend monthly meetings of alcoholics anonymous. d. Remain alcohol free for 12 hours prior to the first dose.

d. Remain alcohol free for 12 hours prior to the first dose.

The nurse is developing a plan of care for a client who reports intermittent claudication and who is newly diagnosed with type 2 diabetes. Which outcome should the nurse include in the plan of care for this client? a. The client will express acceptance of their newly diagnosed health status. b. The client's blood pressure readings will be less than 160/90 mmH. c. The client's skin on the lower legs will be intact at the next clinic visit. d. The nurse will show the client how to perform stress management techniques.

d. The nurse will show the client how to perform stress management techniques.

A male client being treated for testicular cancer with chemotherapy has a decreased alpha fetoprotein radioimmunoassay (AFP). Which nursing intervention should the nurse implement? a. Advise the client that the treatment is having a beneficial effect. b. Instruct the client to obtain prostate-specific antigen (PSA) testing. c. Inform the client that his chemotherapy dose will probably be increased d. Discuss options for hospice care with the client and family members.

a. Advise the client that the treatment is having a beneficial effect.

A client with a C-7 spinal cord injury is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor? a. An acutely distended bladder. b. Profuse forehead diaphoresis. c. Skeletal traction misalignment. d. A severe pounding headache.

a. An acutely distended bladder.

The nurse who is working on a post surgical intensive care unit receives report regarding the assigned clients for the upcoming shift. Which client should the nurse assess first? a. An adult who has a collapsed lung related to a fall from ladder 8 hours ago and now has 100 mL chest tube drainage. b. A young adult who had an abdominoperineal resection 3 days ago and is currently complaining of chills. c. An older adult who had a mastectomy 2 days ago and has 50 mL serosanguinous fluid in the Jackson-Pratt (JP) drain. d. A teenager who had a gunshot wound repair yesterday and has quarter-size dark drainage on the dressing.

a. An adult who has a collapsed lung related to a fall from ladder 8 hours ago and now has 100 mL chest tube drainage.

When is the best time for the nurse to assess a client for residual urine? a. Immediately after the client voids. b. Just prior to the client voiding. c. After draining the urinary catheter bag. d. When the client's bladder is distended.

a. Immediately after the client voids.

The nurse Is reviewing the laboratory values for a client with acute pancreatitis who reports of the abdominal pain is not as severe as it was on admission. Which laboratory test should the nurse review to evaluate the client's clinical recovery? a. Lipase. b. Creatinine. c. Bilirubin. d. Glucose.

a. Lipase.

A female client is admitted to the hospital with a diagnosis of right lower quadrant (RLQ) abdominal pain and a possible ectopic pregnancy. She tells the nurse that her pain is gone, but she is now experiencing a generalized abdominal aching. Her blood pressure has decreased and her pulse has Increased over the past two hours. While waiting for the healthcare provider to arrive, which intravenous solution is best for the nurse to initiate? a. Normal Saline (NS) at 20 mL/hour. b. Lactated Ringer's (LR) at 150 mL/hour. c. D5W/0.45 NS at 125 mL/hour. d. Dextrose 10% (D10W) at 83 mL/hour.

a. Normal Saline (NS) at 20 mL/hour.

A client who was recently diagnosed with anorexia nervosa collapses at an outpatient clinic. While taking the blood pressure, the client begins to demonstrate cloudy consciousness, stupor, and has slurred speech. The nurse obtains a blood glucose 50 mg/dL (2.77 mmol/L), heart rate of 116 beats/minute, and blood pressure of 88/50 mmHg.. Which intervention is most important for the nurse to implement? a. Position client with head flat and feet elevated b. Suggests obtaining a medical alert bracelet to be always worn. c. Encourage the client to eat low-carbohydrate and high-protein meals. d. Reinforce the need to continue the outpatient clinic therapy.

a. Position client with head flat and feet elevated

The mother of a one-month-old infant calls the clinic to report that the back of her infant's head is flat. How should the nurse respond? a. Position the infant on the stomach occasionally when awake and active. b. Turn the infant on the left side braced against the crib when sleeping. c. Prop the infant in a sitting position with a cushion when not sleeping. d. Place a small pillow under the infant's head while lying on the back.

a. Position the infant on the stomach occasionally when awake and active.

An older woman who lives alone talks with the clinic nurse about her fears of falling at home. Which interventions should the nurse suggest? (Select all that apply.) a. Recommend installing grab bars by toilets, bathtub, and shower. b. Have the home health nurse assess the home for fall risks. c. Encourage exercise to improve balance and mobility. d. Wear an emergency response pendant at home. e. Request that a family member move in with her.

a. Recommend installing grab bars by toilets, bathtub, and shower. b. Have the home health nurse assess the home for fall risks. d. Wear an emergency response pendant at home.

The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client demonstrates an understanding of the use of allopurinol to treat gout? a. "I need to take the prescribed amount of the drug to get rid of my gout." b. "I need to take this drug every day to keep from having any flareups." c. "The pain and swelling can be controlled by taking this drug every day. d. "I should take this drug when I have gout attacks to reduce symptoms."

b. "I need to take this drug every day to keep from having any flareups."

A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol, a synthetic prostaglandin E drug. How should the nurse respond? a. "You may have an increased chance of having preeclampsia." b. "You may be at higher risk for having a spontaneous miscarriage." c. "This medication will have no effect on your unborn child." d. "You may experience postpartum hemorrhaging after delivery."

b. "You may be at higher risk for having a spontaneous miscarriage."

The nurse is caring for an adolescent client with an intestinal obstruction who presents with severe, colicky abdominal pain, nausea, vomiting, and abdominal distention. Which pathophysiologic mechanism supports the client's clinical presentation? a. An incompetent lower esophageal sphincter. b. A weakened diaphragm with high, abdominal pressure c. Intestinal scar tissue buildup from a chronic condition. d. A history of having Helicobacter pylori infection.

b. A weakened diaphragm with high, abdominal pressure

A middle-aged client is returned from the intensive care unit to the surgical unit following a right pneumonectomy for cancer of the lung. The client has a patient control analgesic (PCA) pump and 2 right chest tubes which are clamped for the surgeon to release serosanguineous drainage. Which assessment finding requires immediate intervention by the nurse? a. Pain at level of 5 on a scale of 1 to 10 with use of PCA. b. Absence of lungs sounds on the operative side. c. A high-pitched, course sound over the trachea. d. Requests to see his family at his bedside immediately.

b. Absence of lungs sounds on the operative side.

A postoperative client has a large amount of serosanguineous drainage on the surgical dressing and the nurse notes that the operative report Indicates that the client has a Penrose drain near the incision. What intervention should the nurse implement when changing the client's dressing? a. Place sterile gauze dressings under the Penrose drain. b. Apply sterile gloves before removing the soil dressing. c. Cover the Penrose drain with a saline moistened gauze. d. Wear a face mask or shield during the dressing change.

b. Apply sterile gloves before removing the soil dressing.

An adult recently diagnosed with glaucoma, tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client? a. Wear prescription glasses. b. Eat a diet high in carotene. c. Avoid frequent eye pressure measurements. d. Maintain prescribed eyedrop regimen

d. Maintain prescribed eyedrop regimen

An older client has been diagnosed with chronic venous insufficiency. To promote venous return, which action should the nurse encourage the client to take? a. Sit at the side of the bed for 15 minutes before standing. b. Wear cotton socks and enclosed toe shoes whenever outside. c. Lie down in bed 2 times a day. d. Drink 8 to 10 ounces of water a day.

b. Wear cotton socks and enclosed toe shoes whenever outside.

The charge nurse is making assignments on a cardiac unit. Which client is best to assign to a new graduate who is orienting to the unit? A client: a. with pneumonia whose serum potassium level is 6.5 mg/dl. b. with atrial fibrillation, whose saline lock is infiltrated c. who is receiving a heparin infusion and has developed hematuria. d. with hypertension whose blood pressure is 230/118.

b. with atrial fibrillation, whose saline lock is infiltrated

The charge nurse is making client assignments in the Intensive Care Department. The healthcare team consists of one nurse with 10 years experience, one nurse with 5 years experience, and a new graduate nurse who just completed a 12-week internship. Which client should the nurse assign to the new graduate nurse? a. A client with Adult Respiratory Distress Syndrome who is on a ventilator. b. A client in end-stage liver failure who is experiencing esophageal bleeding. c. A client with chest tubes secondary to a stab wound to the chest. d. A client with multisystem failure secondary to a motor vehicle collision.

c. A client with chest tubes secondary to a stab wound to the chest.

A client with cancer complains of fever, chills, malaise, and headache following administration of a colony- stimulating factor. Which nursing intervention is most beneficial in helping to reduce the flu-like symptoms? a. Monitor lab values for an increase in WBCs. b. Administer antiemetics before, during, and after therapy. c. Administer acetaminophen q4h. d. Monitor vital signs q4h for 24 hours.

c. Administer acetaminophen q4h.

When preparing a client who is to undergo a resection of a leiomyosarcoma of the uterus, the nurse notices that apixaban is listed on the medication reconciliation list. Which assessment finding requires immediate nursing intervention? a. Abdominal redness and itching. b. Nausea and dry mouth. c. Bleeding gums. d. Finger joint pain.

c. Bleeding gums.

A client with rheumatold arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make? a. Evidence of spread of the disease to the kidneys. b. Representative of a decline in the client's condition. c. Confirmation of the autoimmune disease process. d. Indication of the onset of joint degeneration.

c. Confirmation of the autoimmune disease process.

Following a traumatic delivery, an infant receives an initial Apgar score of 3. Which intervention is most Important for the nurse to implement? a. Page the pediatrician STAT. b. Inform the parents of the infant's condition. c. Continue resuscitative efforts. d. Repeat the Agar assessment in 5 minutes.

c. Continue resuscitative efforts.

A client has a new prescription for the maximum recommended dosage of piperacillin/tazobactam for nosocomial pneumonia. The nurse should report which laboratory finding to the healthcare provider before administering the prescribed dose? a. Elevated white blood cell count. b. Presence of gram positive bacteria in the sputum. c. Decreased creatinine clearance d. Elevated cholesterol and lipoproteins.

c. Decreased creatinine clearance

A successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status. What action should the nurse take to assist this client in diminishing his anxiety? a. Reinforce the reality of his financial situation. b. Direct him to drink a glass of red wine at bedtime. c. Teach him to limit sugar and caffeine intake. d. Encourage him to initiate daily rituals.

c. Teach him to limit sugar and caffeine intake.

The nurse is educating a client in end-stage kidney failure who requires dialysis three times a week. Which information is important for the nurse to include about the client's daily diet? a. The intake of protein should be increased to stimulate the kidney's nephrons function. b. The intake of protein should be increased due to its loss through the filter membrane. c. The protein intake should be decreased to prevent nitrogenous waste buildup. d. The intake of protein should be decreased due to the progressively failing function of the kidney.

c. The protein intake should be decreased to prevent nitrogenous waste buildup.

The nurse plans to administer a low dose prescription for dopamine to a cilent who is in septic shock. Which physiologic parameter should the nurse use to evaluate a therapeutic response to dopamine? a. Pupil response. b. Heart sounds. c. Urinary output. d. Temperature.

c. Urinary output.

Which client is the most likely candidate for total parenteral nutrition (TPN)? a. A client diagnosed with type 1 diabetes in diabetic ketoacidosis. b. An obese client who is on a medically supervised starvation diet. c. An older client who is having a laparoscopic cholecystectomy. d. A client experiencing an acute exacerbation of Crohn's disease.

d. A client experiencing an acute exacerbation of Crohn's disease.

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients? a. Ensure supplemental oxygen and respiratory medications are available at all times. b. Use nasal or cough tissues followed by hand washing at all times. c. Get annual flu and Pneumococcal vaccine polyvalent (PPSV23) vaccines. d. Avoid large crowded areas during the colder months of the year

d. Avoid large crowded areas during the colder months of the year

In conducting a pain assessment of a client with osteoarthritis, which action should the nurse include? a. Collect dietary history of calcium-rich food intake. b. Measure vital sign changes after physical activity. c. Ask if pain lessens with elevation of the extremity. d. Observe client during movement of affected joints.

d. Observe client during movement of affected joints.

A client who takes nonsteroidal antiinflammatory drugs (NSAIDs) every day for rheumatoid arthrits Is being treated for anemia. Which intervention is most important for the nurse to include in the plan of care? a. Offer dietary selections rich in iron. b. Monitor liver function test results. c. Protect skin from bruising. d. Observe for gastrointestinal bleeding.

d. Observe for gastrointestinal bleeding.

The charge nurse is making assignments on an in-patient psychiatric unit. The staff consists of two psychiatric technicians and one practical nurse (PN). Which team assignment is best to assign to the PN? a. Detoxification precaution check lists. b. Routine morning vital signs and weights. c. Administration of routine medications. d. One-on-one observation of a suicidal client.

d. One-on-one observation of a suicidal client.

Prior to obtaining an axillary temperature, the nurse should perform which action? a. Check the last oral temperature reading. b. Position the client's arm at heart level. c. Ask when the client last ate or drank. d. Place a protective sheath over the thermometer.

d. Place a protective sheath over the thermometer.

A client in the third trimester of pregnancy com- plains of frequent nasal stiffness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement?

d. Record the respiratory findings in the clients record as normal

An older client with a history of Type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. The client is lethargic, moderately confused, and cannot remember when taking the last dose of insulin or eating. Which action should the nurse implement first? a. Administer the client's usual dose of insulin. b. Obtain a serum potassium level. c. Assess pupillary response to light. d. Start an intravenous infusion of normal saline.

d. Start an intravenous infusion of normal saline.

The nurse notes that a client's legs become dusky-red whenever the client is sitting with both feet dangling. Which follow-up assessment should the nurse complete? a. Ankle brachial index (ABI). b. Joint range of motion. c. Calf diameter. d. Skin elasticity.

a. Ankle brachial index (ABI).

The healthcare provider prescribes oral vancomycin for a female client who has Clostridium difficile in the stool. Which action should the nurse take before administering the first dose? a. Assess body temperature. b. Auscultate bowel sounds. c. Check serum creatinine. d. Measure oxygen saturation.

a. Assess body temperature.

The nurse is assessing the mood of a depressed male client. When asked how he feels, the client looks down and states, "I don't know I just can't think " Which activity should the nurse suggest that this client perform? a. Complete a written self-esteem assessment. b. Review the client handbook about unit therapies c. Set daily goals in the community meeting. d. Read, "The Depression Recovery Book."

a. Complete a written self-esteem assessment.

An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan? a. Decreased abdominal girth. b. Prothrombin time within normal limits. c. Improved level of consciousness. d. Clear, dark amber-colored urine.

a. Decreased abdominal girth.

While assessing a client who had a laparotomy the previous day, the nurse notices that 300 ml of dark red fluids has drained from the nasogastric tube In the last hour. Which action should the nurse take first? a. Determine the clients vital signs b. Monitor urinary output hourly. c. Notify the surgeon immediately. d. Assess the client's level of pain.

a. Determine the clients vital signs

Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client's right radial pulse. Which action should the nurse take first? a. Elevate the client's right hand on one or two pillows. b. Notify the healthcare provider of the finding immediately. c. Measure the client's blood pressure and apical pulse rate. d. Complete a neurovascular assessment of the right hand.

a. Elevate the client's right hand on one or two pillows.

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

a. Explain that the client may be placed in five positions

A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior? a. Silence allows the client to reflect on what was said. b. The nurse is respecting the client's loss. c. The nurse is stating disapproval of the statement. d. Silence is reflecting the client's sadness.

a. Silence allows the client to reflect on what was said.

A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy test and ultrasound were negative, so an exploratory laparotomy was completed during the night. When coffee ground material is observed in the drainage from the nasogastric tube (NGT), which Intervention should the nurse implement? a. Verify correct placement of the nasogastric tube b. Perform gastroccult test on the nasogastric drainage. c. Listen for evidence of diminished bowel sounds. d. Irrigate the nasogastric tube with water until clear.

a. Verify correct placement of the nasogastric tube

A client is receiving a continuous infusion of normal saline at 125 ml/hour post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and a headache. Urine output is 800 mL over the past 24 hours with a central venous pressure of 15 mmH. The nurse notes respiratory crackles and bounding central pulses. Vital signs: temperature 101.2 °F (38.4° C), heart rate 96 beats/minute, respirations 24 breaths/minute, and blood pressure of 160/90 mmH. Which intervention should the nurse implement first? a. Review last administration of IV pain medication. b. Decrease IV fluids, to keep vein open rate. c. Administer PRN dose of acetaminophen. d. Calculate total intake and output for last 24 hours.

b. Decrease IV fluids, to keep vein open rate.

The nurse notes that the influenza immunization rates are much lower for certain demographic groups than for others. Which intervention is likely to be most useful in increasing the rates of immunization in these under-served immunization groups? a. Reports describing influenza rates during times of greatest prevalence. b. Designation of clinics conveniently located in target neighborhoods. c. Legislative proposals that mandate influenza vaccinations for all. d. Radio announcements about the availability of the influenza vaccine.

b. Designation of clinics conveniently located in target neighborhoods.

A middle-aged male client, admitted to a critical care unit several weeks ago because of serious injuries sustained in a motor vehicle accident, is currently in stable condition. Based on this client's age and recent life-threatening crisis, which intervention is should the nurse Implement? a. Provide a routine schedule of activities to facilitate trust. b. Encourage the client to reflect on personal goals and priorities. c. Discuss the cause of the accident with the client and his family. d. Allow long periods of uninterrupted rest in order to reduce fatigue.

b. Encourage the client to reflect on personal goals and priorities.

Which action should the nurse take first after obtaining a urine specimen for culture and sensitivity from an indwelling urinary catheter? a. Ensure that the drainage bag is attached to the bed frame. b. Ensure continued sterility of the specimen container c. Securely fasten the clamp on the drainage bag. d. Label the container with the client's identifiers.

b. Ensure continued sterility of the specimen container

While intervlewing an elderly client, the nurse observes that the client's hands tremble uncontrollably while reaching for a glass of water. How shoul the nurse document this finding? a. Muscle flaccidity. b. Intention tremor. c. Transient ischemic attack. d. Sensory dysfunction.

b. Intention tremor.

The nurse provides dietary instructions about iron rich foods to a client with iron deficlency anemia. Which food selection made by the client indicates a need for additional instructions? a. Oranges. b. Kidney beans. c. Liver. d. Leafy green vegetables.

b. Kidney beans.

A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client responds to treatment, the client's serum sodium level increases from 120 to 125 mEg/L or mmol/L (SI). Based on this finding, which intervention should the nurse implement? a. Withhold next scheduled dose of treatment. b. Maintain the prescribed fluid restriction. c. Increase neurologic checks to every 2 hours. d. Assess for increasing fluid volume overload.

b. Maintain the prescribed fluid restriction.

Which long-term outcome is most important for the nurse include in the plan of care for an older adult client with chronic pyelonephritis? a. Maintains blood pressure within normal limits. b. Manages activities of daily living independently. c. Restricts fluid intake to 1 L/day. d. Measures oral temperature daily.

b. Manages activities of daily living independently.

The nurse is caring for a child newly diagnosed with attention deficit hyperactive disorder (ADHD). The child's mother asks about information of the treatment options.. Which Information is most helpful for the nurse to provide? a. Emphasize the addictive nature of popular medications. b. Offer effective time management strategies. c. Explore the combination of medication and behavioral therapies d. Discuss dietary changes such as increasing protein intake.

b. Offer effective time management strategies.

In observing a client's face, which assessment finding requires the most immediate intervention by the nurse? a. Cornea are jaundiced. b. Oral mucosa is cyanotic c. Face is flushed and diaphoretic. d. Eyelids are matted and crusted.

b. Oral mucosa is cyanotic

A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. while planning care, the nurse is most concerned about preventing which complication related to these findings? a. Atelectasis. b. Exit site infection. c. Peritonitis. d. Outflow obstruction.

c. Peritonitis.

The mother of a 14-month-old tells the nurse that she feeds her child nothing but prepared toddler foods and feels they provide the best nutrition for her child, but is concerned about the cost. How should the nurse respond? a. Advise the mother that these foods will only be needed until the growth spurt of the toddler years is complete. b. Reassure the mother that beginning to replace prepared foods with table foods can provide the needed nutrients c. Affirm that these prepared foods are the best way to ensure that the toddler gets all the needed nutrients. d. Teach the mother how to develop a budget to allow her to continue to provide the needed prepared toddler foods.

b. Reassure the mother that beginning to replace prepared foods with table foods can provide the needed nutrients

After placing a 36-week-gesation newborn in an isolette and drying the infant with several blankets, what Should the nurse implement next? a. Administer the vitamin K injection. b. Remove the wet blankets and linens from the isolette. c. Place erythromycin opthalmic ointment in both eyes. d. Open the door to assess the infant's vital signs.

b. Remove the wet blankets and linens from the isolette.

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products, such as milk, to help coat and protect their ulcer. Which is the best follow-up action by the nurse? a. Remind the client that it is also important to switch to decaffeinated coffee and tea. b. Review with the client the need to avoid foods that are rich in milk and cream. c. Reinforce this teaching by asking the client to list dairy foods that he might select. d. Suggest that the client also plan to eat frequent small meals to reduce discomfort.

b. Review with the client the need to avoid foods that are rich in milk and cream.

After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without rellef. Her vital signs are heart rate 122 beats/minute, respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70 mmH. The nurse obtains a 12- lead electrocardiogram (ECG). Which assessment finding is most critical? a. Irregular pulse rate. b. ST elevation in three leads. c. Complaint of radiating jaw pain. d. Bile colored emesis.

b. ST elevation in three leads.

The nurse is teaching a husband how to care for his wife who recently had a stroke and has residual weakness on her right side. What style shoes should the nurse recommend the client wear when ambulating with her husband's assistance? a. Slip-on rubber shower shoes. b. Tennis shoes with Velcro. c. Rubber soled slippers. d. Leather soled loafers.

b. Tennis shoes with Velcro.

The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The client receives a prescription for clonidine 0.2 mg PO taken twice daily. Which action should the nurse take? a. Monitor for signs of signs of bleeding or hemorrhage. b. Compare daily electrolyte levels prior to each morning dose. c. Advise to sit up slowly from a reclining position. d. Administer the medication on an empty stomach.

c. Advise to sit up slowly from a reclining position.

During the admission assessment of a terminally ill client, the client expresses being an agnostic. Which is the best nursing action in response to this statement? a. Invite the client to a healing service for people of all religions. b. Provide information about the hours and location of the chapel. c. Document the statement in the client's spiritual assessment. d. Offer to contact a spiritual advisor of the client's choice.

c. Document the statement in the client's spiritual assessment.

A client with uremia is experiencing uremic frost. Which action should the nurse Implement? a. Provide frequent skin care and apply lotion. b. Evaluate bony prominences for breakdown. c. Explain that hemodialysis is needed. d. Monitor the client's oral fluid intake.

c. Explain that hemodialysis is needed.

A woman is brought to the labor and delivery unit after delivering a term infant and the placenta in the hospital parking lot 10 minutes ago. Which action should the nurse perform first? a. Inspect the perineum for lacerations. b. Collect specimen for hemoglobin and hematocrit. c. Massage the fundus and give an oxytocin agent d. Place the infant to breast for bonding

c. Massage the fundus and give an oxytocin agent

A client with heart failure reports increased of shortness of breath. The nurse administered furosemide 20 mg intravenously 60 minutes ago. Which action is most important for the nurse to implement? a. Auscultate the lungs. b. Review serum potassium. c. Measure urine output. d. Administer albuterol via nebulizer.

c. Measure urine output.

A client tells the nurse that he Is "very nervous" about the surgery he is scheduled to have in the morning. Which action should the nurse implement first? a. Provide the client with distractions to decrease his anxiety. b. Explore the client's perception of the impending surgery. c. Notify the healthcare provider about the client's expressed fears and anxiety. d. Present the client with information about the surgical procedure.

c. Notify the healthcare provider about the client's expressed fears and anxiety.

A mother brings her 3-year-old son to the emergency room and tells the nurse that he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102° F (38.9°C. He is drooling and becoming increasingly more restless. What action should the nurse take first? a. Put a cold cloth on his head and administer acetaminophen. b. Assist the child to lie down and examine his throat. c. Notify the healthcare provider and obtain a tracheostomy tray. d. Listen to lung sounds and place him in a mist tent.

c. Notify the healthcare provider and obtain a tracheostomy tray.

A primigravida client being treated for preeclampsla with magneslum sulfate delivered a 7-pound infant four hours ago by cesarean delivery. Which nursing problem has the highest priority? a. Impaired parenting related to inexperience. b. Acute pain related to abdominal incision. c. Risk for injury related to uterine atony. d. Ineffective breastfeeding related to fatigue.

c. Risk for injury related to uterine atony.

A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. Which is the priority nursing problem for this client? a. Altered sleep pattern. b. Imbalanced nutrition: less than. c. Risk for injury. d. Disturbed thought processes.

c. Risk for injury.

A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant? a. Chickenpox b. Mumps c. Sore throat d. Influenza

c. Sore throat

The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski reflex. Which action should the nurse lake in response to the finding? a. Ask the client to describe recent alcohol use. b. Keep the client's feet elevated when in bed. c. Assess the client's muscle strength and tone d. Complete thorough neurologic assessment

d. Complete thorough neurologic assessment

A nurse seeks to alter a provision of a state's Nurse Practice Act regarding nurse-client ratios, which the nurse believes to be unsafe. What action is most likely to impact a ruling by the state's Board of Nursing? a. Notify the state's Board about the matter anonymously. b. File a grievance at the medical center where the nurse is employed. c. Send a letter of concern to the American Nurses' Association. d. Consult with the appropriate state legislative representative.

d. Consult with the appropriate state legislative representative.

As part of the treatment plan for a client diagnosed with acute pancreatitis, the nurse plans to withhold oral fluids based on which pathophysiological process? a. Removing gastric secretions and to relieve abdominal distention. b. Reducing hydrochloric acid secretion. c. Restoring and maintaining a positive fluid balance. d. Decreasing the formation and secretion of pancreatic enzymes.

d. Decreasing the formation and secretion of pancreatic enzymes.

A 17-year-old client gave birth 12 hours ago. She states that she doesn't know how to care for her baby. To promote parent-infant attachment behaviors, which intervention should the nurse implement? a. Explore the basis of fears with the client. b. Provide a video on newborn safety and care. c. Ask if she has help to care for the baby at home. d. Encourage rooming-in while in the hospital.

d. Encourage rooming-in while in the hospital.

A client who is admitted with diabetic ketoacidosis (DKA) is demonstrating Kussmaul breathing and has a severe headache along with nausea. Her arterial blood gases (ABG) are: pH 7.50; PaCO, 30 mmH ; HCO, 24 mEq/L (24 mmol/L). Which assessment finding warrants Immediate intervention by the nurse? a. Muscle stiffness. b. Abdominal pain. c. Mental stupor. d. Fruity breath.

d. Fruity breath.

A client arrives in the Emergency Department (ED) with a deep, full-thickness burn over the anterior surface of both upper legs. Which priority intervention should the nurse implement? a. Start IV antibiotics. b. Administer tetanus immunization. c. Give IV analgesia. d. Give an IV bolus of normal saline.

d. Give an IV bolus of normal saline.

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRS)? a. Within the first trimester of pregnancy. b. During admission to labor and delivery. c. When the client has ankle edema. d. If the client has an elevated blood pressure.

d. If the client has an elevated blood pressure.

A 4-year-old girl returns to the pediatrician's office for a postoperative visit following hospitalization for minor surgery. When observing the child in the waiting area, which behavior should the nurse consider normal for this age child? a. Draws picture of self with facial features. b. "Talks" to an imaginary friend. c. Sits quietly in her mother's lap. d. Ignores other children in the play area.

d. Ignores other children in the play area.

While inserting an indwelling urinary catheter into a client, the nurse observes urine flow in the tubing. Which action should be taken next? a. Inflate the balloon with 5 ml of sterile water. b. Document the color and clarity of the urine. c. Ask the client to breathe deeply and slowly exhale. d. Insert the catheter an additional inch.

d. Insert the catheter an additional inch.

The nurse is reviewing a client's urinalysis results and identifies a specific gravity of 1.035. Which action should the nurse implement based on this finding? a. Explain that the urine finding is normal. b. Recommend the use of salt with meals. c. Tell client to report reduced urine output less than 1,000 mL/day. d. Instruct client to increase oral fluids to a minimum of 2,400 mL/day.

d. Instruct client to increase oral fluids to a minimum of 2,400 mL/day.

A terminally ill male hospice client who is at home is showing decreased awareness of his surroundings. His appetite is poor and he often refuses oral intake of solids and liquids. For the past several days he has been unable to get out of bed. Which action should the hospice nurse implement? a. Ask family to remain nearby, but in another room. b. Encourage family to speak often with the client. c. Teach family how to assist the client to a wheelchair. d. Instruct family to offer client only soft, bland foods

d. Instruct family to offer client only soft, bland foods

A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound tenderness. Which action should the nurse take? a. Obtain vital sign measurements. b. Measure capillary glucose level. c. Encourage ambulation in the room. d. Monitor for bloody diarrheal stools.

d. Monitor for bloody diarrheal stools.

During an evening shift on a medical unit, the only nurse on the unit is busy with an unstable client. The unit clerk, who is also both a certified medication aide and an unlicensed assistive personnel (UP), reports to the nurse that a healthcare provider is on the telephone and wishes to prescribe a PRN dose of an oral over-the- counter laxative for a client who is constipated. What instruction should the nurse provide the unit clerk? a. Be sure to write down what is prescribed and then repeat it back to the healthcare provider. b. Remain with this client and monitor the vital signs while the nurse takes the call. c. Ask the healthcare provider to remain on "hold" until the nurse can confirm the prescription. d. Tell the healthcare provider the nurse will return the phone call as soon as possible.

d. Tell the healthcare provider the nurse will return the phone call as soon as possible.