HESI Review

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. the nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value? A. 2000 mm^3 B. 5800 mm^3 C. 8400 mm^3 D. 11,500 mm^3

A. 2000 mm^3

The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit, determines that which clients would be the *most likely* candidates for parenteral nutrition (PN)? *Select all that apply.* A. A client with extensive burns B. A client with cancer who is septic C. A client who has had an open cholecystectomy D. A client with severe exacerbation of Crohn's disease E. A client with persistent nausea and vomiting from chemotherapy

A. A client with extensive burns B. A client with cancer who is septic D. A client with severe exacerbation of Crohn's disease E. A client with persistent nausea and vomiting from chemotherapy

The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the *best* time to perform this exam? A. After a shower or bath B. while standing to void C. After having a bowel movement D. While lying in bed before arising

A. After a shower or bath

The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that *further teaching is necessary* related to colorectal cancer if the client identifies which item as an associated risk factor? A. Age younger than 50 years B. History of colorectal polyps C. Family history of colorectal cancer D. Chronic inflammatory bowel disease

A. Age younger than 50 years

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? *Select all that apply.* A. Auscultating lung sounds B. Obtaining the client's temperature C. Assessing the strength of peripheral pulses D. Obtaining information about the client's respirations E. Performing a musculoskeletal and neurological examination F. Asking the client about a family history of any illness or disease

A. Auscultating lung sounds B. Obtaining the client's temperature D. Obtaining information about the client's respirations

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? A. Hemoglobin, 8.0 g/dL (80 mmol/L) B. Sodium, 145 mEq/L (145 mmol/L) C. Serum creatinine, 0.8 mg/dL (70.6 umol/L) D. platelets, 210,000 cells/mm^3 (210 x 10^3/uL/210 x 10^9/L)

A. Hemoglobin, 8.0 g/dL (80 mmol/L)

The clinic performing an admission assessment on a client votes the client is taking Azelaic acid period the nurse determines that which client complaint may be associated with the use of this medication? A. Itching B. Euphoria C. Drowsiness D. Frequent urination

A. Itching Rationale: Azelaic acid is a topical medication used to treat mild to moderate acne. Adverse effects include burning, itching, stinging, redness of the skin, and hypo pigmentation of the skin in clients with a dark complexion. the effects noted in the other options are not specifically associated with this medication.

Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the UAP that making this accusation has violated which legal tort? A. Libel B. Slander C. Assault D. Negligence

B. Slander

The nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 1 hour behind. Which action should the nurse take? A. Adjust the infusion rate to catch up over the next hour B. Increase the infusion rate to catch up over the next 2 hours C. Ensure that the fat emulsion rate is infusing at the prescribed rate D. Adjust the infusion rate to run wide open until the solution is back on time

C. Ensure that the fat emulsion rate is infusing at the prescribed rate

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of Surgery? A. Avoid oral hygiene and rinsing with mouthwash B. Verify that the client has not eaten for the last 24 hrs C. Have the client void immediately before going into surgery D. Report immediately any slight increase in blood pressure or pulse

C. Have the client void immediately before going into surgery

During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease? A. Diarrhea B. Hypermenorrhea C. Abnormal bleeding D. Abdominal distention

D. Abdominal distention

A client with non-Hodgkin's lymphoma is receiving daunorubicin (DaunoXome). Which finding would indicate to the nurse that the client is experiencing an adverse effect related to the medication? A. Fever B. Sores in the mouth and throat C. Complaints of nausea and vomiting D. Crackles on auscultation of the lungs

D. Crackles on auscultation of the lungs Rationale: Cardiotoxicity noted by abnormal electrocardiographic findings or cardiomyopathy manifested as heart failure (lung crackles) is an adverse effect of daunorubicin. Bone marrow depression is also an adverse effect. Fever is a frequent side effect and sores in the mouth and throat can occur occasionally. Nausea and vomiting is a frequent side effect associated with the medication that begins a few hours after administration and lasts 24 to 48 hours. Options 1, 2, and 3 are not adverse effects.

A client is being admitted to the hospital for treatment of acute cellulitis of the lower leg and asks the admitting nurse to explain what cellulitis means. The nurse bases the response on the understanding that cellulitis has which characteristic? A. An inflammation of the epidermis only B. A skin infection of the dermis and underlying hypodermis C. An acute superficial infection of the dermis and lymphatics D. An epidermal and lymphatic infection caused by Staphylococcus

B. A skin infection of the dermis and underlying hypodermis

The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN) bag of an assigned client is empty. Which solution should the nurse hang until another PN solution is mixed and delivered to the nursing unit? A. 5% dextrose in water B. 10% dextrose in water C. 5% dextrose in Ringer's lactate D. 5% dextrose in 0.9% sodium chloride

B. 10% dextrose in water

The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? *Select all that apply.* A. Pain and erythema B. Pallor and coolness C. Numbness nad pain D. Edema and blanched skin E. Formation of a red streak and purulent drainage

B. Pallor and coolness C. Numbness nad pain D. Edema and blanched skin

A Spanish-speaking client arrives at the ridge desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the *best* action for the nurse to take? A. Have one of the client's family members interpret B. Have the Spanish-speaking triage receptionist interpret C. Page an interpreter from the hospital's interpreter services D. Obtain a Spanish-English dictionary and attempt to triage the client

C. Page an interpreter from the hospital's interpreter services

The nurse reviews the electrolyte results fan assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? *Select all that apply.) A. ST depression B. Prominent U wave C. Tall peaked T waves D. Prolonged ST segment E. Widened QRS complexes

C. Tall peaked T waves E. Widened QRS complexes

The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy? A. Restrict all visitors B. Restrict fluid intake C. Teach the client and family about the need for hand hygiene D. Insert an indwelling urinary catheter to prevent skin breakdown

C. Teach the client and family about the need for hand hygiene

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? A. 100% oxygen via an aerosol mask B. Oxygen via nasal cannula at 6 L/minute C. Oxygen via nasal cannula at 15 L/minute D. 100% oxygen via a tight-fitting, nonrebreather face mask

D. 100% oxygen via a tight-fitting, nonrebreather face mask

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time? A. At the onset of menstruation B. Every month during ovulation C. Weekly at the same time of day D. 1 week after menstruation begins

D. 1 week after menstruation begins

The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation? A. The catheter advances easily B. The vein is distended under the needle C. The client does not complain of discomfort D. Blood return shows in the backlash chamber of the catheter

D. Blood return shows in the backlash chamber of the catheter

The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which *most* common sign or symptom of this type of cancer? A, Dysuria B. Hematuria C. Urgency on urination D. Frequency of urination

B. Hematuria

The nurse is completing a time tape for a 1000-mL intravenous (IV) bag that is scheduled to infuse over 8 hours. The nurse has just placed the 1100 marking at the 500-mL level. The nurse would place the mark for 1200 at which numerical level (mL) on the time tape? *Fill in the blank.*

375 mL Rationale: If the IV is scheduled to run over 8 hours, the hourly rate is 125 mL/hour. Using 500 mL as the reference point, the next hourly marking would be at 375 mL, which is 125 mL less than 500.

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is *most appropriate* for the nurse to make to the client at this time as it relates to these techniques?. A. "Use of an incentive spirometer will help prevent pneumonia." B. "Close monitoring of your oxygen saturation will detect hypoxemia." C. "Administration of intravenous fluids will prevent or treat fluid imbalance." D. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."

A. "Use of an incentive spirometer will help prevent pneumonia."

A client with a history of cardiac disease is due for a morning dose for furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? A. 3.2 mEq/L (3.2 mmol/L) B. 3.8 mEq/L (3.8 mmol/L) C. 4.2 mEq/L (4.2 mmol/L) D. 4.8 mEq/L (4.8 mmol/L)

A. 3.2 mEq/L (3.2 mmol/L)

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action *first* on arrival of the client A. Assess the patency of the airway B. Check tubes or drains for patency C. Check the dressing to assess for bleeding D. Assess the vital signs to compare with preoperative measurements

A. Assess the patency of the airway

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become *most* concerned with which sign that could indicate an evolving complication? A. Increasing restlessness B. A pulse of 86 beats/min C. Blood pressure of 110/70 mmHg D. Hypoactive bowel sounds in all 4 quadrants

A. Increasing restlessness

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? A. Weight loss and poor skin turgor B. Lung congestion and increased heart rate C. Decreased hematocrit and increased urine output D. Increased respirations and increased blood pressure

A. Weight loss and poor skin turgor

The nurse should make which statement to a pregnant client found to have a gynecoid pelvis? A. "Your type of pelvis has a narrow pubic arch." B. "Your type of pelvis is the most favorable for labor and birth." C. "Your type of pelvis is a wide pelvis, but it has a short diameter." D. "You will need a cesarean section because this type of pelvis is not favorable for a vaginal delivery."

B. "Your type of pelvis is the most favorable for labor and birth."

The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which *initial* action? A. Prepare the triage rooms B. Activate the emergency response plan C. Obtain additional supplies from the central supply department D. Obtain additional nursing staff to assist in treating the casualties

B. Activate the emergency response plan

Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the client's blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data? A. Excessive bleeding B. Crackles in the lungs C. Incompatibility of the infusion D. Chest pain radiating to the left arm

B. Crackles in the lungs

The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the *need for further teaching?* A. Taking a rectal temperature for a client who has undergone nasal surgery B. Taking an oral temperature for a client with a cough and nasal congestion C. Taking an axillary temperature for a client who has just consumed hot coffee D. Taking a temporal temperature on the neck behind the ear for a client who is diaphoretic

B. Taking an oral temperature for a client with a cough and nasal congestion

The nurse is preparing to hang the first bag of parenteral nutrition (PN) solution via the central line of an assigned client. The nurse should obtain which *most essential* piece of equipment before hanging the solution? A. Urine test strips B. Blood glucose meter C. Electronic infusion pump D. Noninvasive blood pressure monitor

C. Electronic infusion pump

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? A. Out-of-bed activities B. Bathroom privileges C. Immobilization of the affected leg D. Placing the affected leg in a dependent position

C. Immobilization of the affected leg

The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the *best* understanding of the dietary measures to follow if the client states an intention to increase the intake of which food? A. Milk B. Chicken C. Broccoli D. Legumes

D. Legumes

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? A. The client with colitis B. The client with Cushing's syndrome C. The client who has been overusing laxatives D. The client who has sustained a traumatic burn

D. The client who has sustained a traumatic burn

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be included in the teaching plan? *Select all that apply.* A. "The ductus arteriosus allows blood to bypass the fetal lungs." B. "One vein carries oxygenated blood from the placenta to the fetus." C. "The normal fetal heart tone range is 140 to 160 beats per minute in early pregnancy." D. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." E. "Two veins carry blood that is high in carbon dioxide and other waste products way from the fetus to the placenta."

A. "The ductus arteriosus allows blood to bypass the fetal lungs B. "One vein carries oxygenated blood from the placenta to the fetus." D. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta."

A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will *most likely* be prescribed for this client? A. 5% dextrose in lactated Ringer's solution B. 0.33% sodium chloride (1/3 normal saline) C. 0.45% sodium chloride (1/2 normal saline) D. 0.225% sodium chloride (1/4 normal saline)

A. 5% dextrose in lactated Ringer's solution

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is *most likely* at risk for a fluid volume deficit? A. A client with an ileostomy B. A client with heart failure C. A client on long-term corticosteroid therapy D. A client receiving frequent wound irrigations

A. A client with an ileostomy

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? *Select all that apply.* A. Allows for fetal movement B. Surrounds, cushions, and protects the fetus C. Maintains the body temperature of the fetus D. Can be used to measure fetal kidney function E. Prevents large particles such as bacteria from passing to the fetus F. Provides an exchange of nutrients and waste products between the mother and the fetus

A. Allows for fetal movement B. Surrounds, cushions, and protects the fetus C. Maintains the body temperature of the fetus D. Can be used to measure fetal kidney function

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply the medication to which body area? *Select all that apply.* A. Back B. Axilla C. Eyelids D. Soles of the feet E. Palms of the hands

A. Back D. Soles of the feet E. Palms of the hands Rationale: topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). The nurse should avoid areas of higher absorption to prevent systemic absorption.

The nurse is caring for a client who is postoperative following a pelvic exenteration and the health care provider changes the client's diet from NPO (nothing by mouth) status to clear liquids. The nurse should check which *priority* item before administering the diet? A. Bowel sounds B. Ability to ambulate C. Incision appearance D. Urine specific gravity

A. Bowel sounds

A postoperative client has been placed on a. clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? *Select all that apply.* A. Broth B. Coffee C. Gelatin D. Pudding E. Vegetable juice F. Pureed vegetables

A. Broth B. Coffee C. Gelatin

The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should *next* assess which item? A. Client's temperature B. Expiration date on the bag C. Time of last dressing change D. Tightness of tubing connections

A. Client's temperature

The nurse calls the health care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take? A. Contact the nursing supervisor B. Administer the dose prescribed C. Hold the medication until the HCP can be contacted D. Administer the recommended dose until the HCP can be located

A. Contact the nursing supervisor

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? *Select all that apply.* A. Contact the surgeon B. Instruct the client to remain quiet C. Prepare the client for wound closure D. Document the findings and actions taken E. Place a sterile saline dressing and ice packs over the wound F. Place the client in a supine position without a pillow under the head.

A. Contact the surgeon B. Instruct the client to remain quiet C. Prepare the client for wound closure D. Document the findings and actions taken

The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which *best* action? A. Continue with the instructions, verifying client understanding B. Walk around the client so that the nurse constantly faces the client C. Give the client a dietary booklet and return later to continue with the instructions D. Tell the client about the importance of the instructions for the maintenance of health care

A. Continue with the instructions, verifying client understanding

The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications. if the client selects which items from the dietary menu? A. Cream of wheat, blueberries, coffee B. Sausage and eggs, banana, orange juice C. Bacon, cantaloupe melon, tomato juice D. Cured pork, grits, strawberries, orange juice

A. Cream of wheat, blueberries, coffee

The nurse is creating a plan of care for the client with multiple myeloma and includes which *priority* intervention in the plan? A. Encouraging fluids B. Providing frequent oral care C. Coughing and deep breathing D. Monitoring the red blood cell count

A. Encouraging fluids Rationale: Hypercalcemia caused by bone destruction is a priority concern in the client with multiple myeloma. The nurse should administer fluids in adequate amounts to maintain a urine output of 1.5 to 2 L/day; this requires about 3 L of fluid intake per day. The fluid is needed not only to dilute the calcium overload but also to prevent protein from precipitating in the renal tubules. Options 2, 3, and 4 may be components of the plan of care but are not the priority in this client.

A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions by the nurse demonstrate cultural sensitivity and spiritual support? *Select all that apply.* A. Ensures that a close kin stays with the client B. Makes a referral for a Catholic priest to visit the client C. Removes the crucifix from the wall in the client's room D. Administers the sacrament of the sick to the client if death is imminent E. Offers to provide a means for praying the rosary if the client wishes F. Reminds the dietary department that meals served on Fridays during Lent do not contain meat

A. Ensures that a close kin stays with the client B. Makes a referral for a Catholic priest to visit the client E. Offers to provide a means for praying the rosary if the client wishes

The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? *Select all that apply.* A. Facial edema in the morning B. Weight loss of 20 lb (9 kg) in 1 month C. Serum calcium level of 12 mg.dL (3.0 mmol/L) D. Serum sodium level of 136 mg/dL (136 mmol/L) E. Serum potassium level of 3.4 mg/dL (3.4 mmol/L) F. Numbness and tingling of the lower extremities

A. Facial edema in the morning C. Serum calcium level of 12 mg.dL (3.0 mmol/L) F. Numbness and tingling of the lower extremities

A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred? A. Hyperventilation B. Elevated blood pressure C. Local rash at burn site D. Local pain at burn site

A. Hyperventilation Rationale: mafenide acetate is a Carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid base imbalance (hyperventilation). if this occurs, the medication will probably be discontinued for one to two days. Options three and four describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury.

The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? A. Increased calcium level B. Increased white blood cells C. Decreased blood urea nitrogen level D. Decreased number of plasma cells in the bone marrow

A. Increased calcium level Rationale: Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. An increased white blood cell count may or may not be present and is not related specifically to multiple myeloma.

Which clients have a high risk of obesity and diabetes mellitus? *Select all that apply.* A. Latino American man B. Native American man C. Asian American woman D. Hispanic American man E. African American woman

A. Latino American man B. Native American man D. Hispanic American man E. African American woman

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition *most likely* caused this serum phosphorus level? A. Malnutrition B. Renal insufficiency C. Hypoparathyroidism D. Tumor lysis syndrome

A. Malnutrition

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a PaCO2 of 30 mmHg. The nurse monitors the client for which clinical manifestations associated with these ABG results? *Select all that apply.* A. Nausea B. Confusion C. Bradypnea D. Tachycardia E. Hyperkalemia F. Lightheadedness

A. Nausea B. Confusion D. Tachycardia F. Lightheadedness

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the *most appropriate* nursing intervention? A. Notify the health care provider (HCP) B. Administer the prescribed pain medication C. Call and ask the operating room team to perform surgery as soon as possible D. Reposition the client and apply a heating pad on the warm setting to the client's abdomen

A. Notify the health care provider (HCP) Rationale: On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the HCP. Administering pain medication is not an appropriate intervention. Heat should never be applied to the abdomen of a client with suspected appendicitis because of the risk of rupture. Scheduling surgical time is not within the scope of nursing practice, although the HCP probably would perform the surgery earlier than the prescheduled time.

Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration fo the potassium? *Select all that apply.* A. Obtain an intravenous (IV) infusion pump B. Monitor urine output during administration C. Prepare the medication for bolus administration D. Monitor the IV site for signs of infiltration or phlebitis E. Ensure that the medication is diluted in the appropriate volume of fluid F. Ensure that the bag is labeled so that it reads the volume of potassium in the solution

A. Obtain an intravenous (IV) infusion pump B. Monitor urine output during administration D. Monitor the IV site for signs of infiltration or phlebitis E. Ensure that the medication is diluted in the appropriate volume of fluid F. Ensure that the bag is labeled so that it reads the volume of potassium in the solution

A client with parenteral nutrition (PN) infusing has disconnected the tubing from the central line catheter. The nurse assesses for the client and suspects an air embolism. The nurse should *immediately* place the client in which position? A. On the left side, with the head lower than the feet B. On the left side, with the head higher than the feet C. On the right side, with the head lower than the feet D. On the right side, with the head higher than the feet

A. On the left side, with the head lower than the feet

The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase (Elspar), an antineoplastic agent. The nurse contacts the health care provider before administering the medication if which disorder is documented in the client's history? A. Pancreatitis B. Diabetes mellitus C. Myocardial infarction D. Chronic obstructive pulmonary disease

A. Pancreatitis Rationale: Asparaginase (Elspar) is contraindicated if hypersensitivity exists, in pancreatitis, or if the client has a history of pancreatitis. The medication impairs pancreatic function and pancreatic function tests should be performed before therapy begins and when a week or more has elapsed between dose administrations. The client needs to be monitored for signs of pancreatitis, which include nausea, vomiting, and abdominal pain. The conditions noted in options 2, 3, and 4 are not contraindicated with this medication.

The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings should the nurse expect to note? *Select all that apply.* A. Pathological fracture B. Urinalysis positive for nitrites C. Hemoglobin level of 15.5 g/dL (155 mmol/L) D. Calcium level of 8.6 mg/dL (2.15 mmol/L) E. Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L)

A. Pathological fracture B. Urinalysis positive for nitrites E. Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L)

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based the sodium level. Which acceptable food items does the nurse instruct the client to consume? *Select all that apply.* A. Peas B. Nuts C. Cheese D. Cauliflower E. Processed oat cereals

A. Peas B. Nuts D. Cauliflower

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? *Select all that apply.* A. Platelets 35,000 mm^3 (35 x 10^9/L) B. Sodium 150 mEq/L (150 mmol/L) C. Potassium 5.0 mEq/L (5.0 mmol/L) D. Segmented neutrophils 40% (0.40) E. Serum creatinine, 1 mg/dL (88.3 umol/L) F. White blood cells, 3,000 mm^3 (3.0 x 10^9/L)

A. Platelets 35,000 mm^3 (35 x 10^9/L) B. Sodium 150 mEq/L (150 mmol/L) D. Segmented neutrophils 40% (0.40) F. White blood cells, 3,000 mm^3 (3.0 x 10^9/L)

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? A. Prednisone B. Ferrous sulfate C. Cyclobenzaprine D. Conjugated estrogen

A. Prednisone

The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client? A. Private room or cohort client B. Personal respiratory protection device C. Private room with negative airflow pressure D. Mask worn by staff when the client needs to leave the room

A. Private room or cohort client

A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the health care provider will request which prescriptions? *Select all that apply.* A. Radiation B. Chemotherapy C. Increased fluid intake D. Decreased oral sodium intake E. Serum sodium level determination F. Medication that is antagonistic to antidiuretic hormone

A. Radiation B. Chemotherapy E. Serum sodium level determination F. Medication that is antagonistic to antidiuretic hormone

The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action *next*? A. Reassess the client B. Conduct a staff meeting to describe the fall C. Document int the nurse's notes that an incident report was completed D. Contact the nursing supervisor to update information regarding the fall

A. Reassess the client

The ambulatory care nurse is discussing preoperative procedures with a Japanese/American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? A. Reflecting a cultural value B. An acceptance of the treatment C. Client agreement to the required procedures D. Client understanding of the preoperative procedures

A. Reflecting a cultural value

A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? *Select all that apply.* A. Remove the IV catheter at that site B. Apply warm moist packs to the site C. Notify the health care provider (HCP) D. Start a new IV line in a proximal portion of the same vein E. Document the occurrence, actions taken, and the client's response

A. Remove the IV catheter at that site B. Apply warm moist packs to the site C. Notify the health care provider (HCP) E. Document the occurrence, actions taken, and the client's response

The nurse is caring for a client with several broken ribs. The client is *most likely* to experience what type of acid-base imbalance? A. Respiratory acidosis from inadequate ventilation B. Respiratory alkalosis from anxiety and hyperventilation C. Metabolic acidosis from calcium loss due to broken bones D. Metabolic alkalosis from taking analgesics containing base products

A. Respiratory acidosis from inadequate ventilation

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? A. Return of distal pulses B. Brisk bleeding from the site C. Decreasing edema formation D. Formation of granulation tissue

A. Return of distal pulses

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding? A. Rhythmic respirations with periods of apnea B. Regular rapid and deep, sustained respirations C. Totally irregular respiration in rhythm and depth D. Irregular respirations with pauses at the end of inspiration and expiration

A. Rhythmic respirations with periods of apnea

A client had a 100-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action *first?* A. Slow the IV infusion B. Sit the client up in bed C. Remove the IV catheter D. Call the health care provider (HCP)

A. Slow the IV infusion

The nurse is monitoring the intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. On inspection of the site, the nurse notes redness and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and should take which actions? *Select all that apply.* A. Stop the infusion B. Notify the health care provider (HCP) C. Prepare to apply ice or heat to the site D. Restart the IV at a distal part of the same vein E. Prepare to administer a prescribed antidote into the site F. Increase the flow rate of the solution to flush the skin and subcutaneous tissue

A. Stop the infusion B. Notify the health care provider (HCP) C. Prepare to apply ice or heat to the site E. Prepare to administer a prescribed antidote into the site Rationale: Redness and swelling and a slowed infusion indicate signs of extravasation. If the nurse suspects extravasation during the intravenous administration of an antineoplastic medication, the infusion is stopped and the HCP is notified. Ice or heat may be prescribed for application to the site and an antidote may be prescribed to be administered into the site. Increasing the flow rate can increase damage to the tissues. Restarting an IV in the same vein can increase damage to the site and vein.

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? *Select all that apply.* A. The acuity level of the clients B. Specific requests from the staff C. The clustering of the rooms on the unit D. The number of anticipated client discharged E. Client needs and workers' needs and abilities

A. The acuity level of the clients E. Client needs and workers' needs and abilities

A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can be determined. The nurse informs the client that she should be able to find out the sex at 12 weeks' gestation because of which factor? A. The appearance of the fetal external genitalia B. The beginning of differentiation in the fetal groin C. The fetal testes are descended into the scrotal sac D. The internal differences in males and females become apparent

A. The appearance of the fetal external genitalia

Which identifies accurate nursing documentation notations? *Select all that apply.* A. The client slept through the night B. Abdominal wound dressing is dry and intact without drainage C. The client seemed angry when awakened for vital sign measurement D. The client appears to become anxious when it is time for respiratory treatments E. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema

A. The client slept through the night B. Abdominal wound dressing is dry and intact without drainage E. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? A. The client who is taking diuretics B. The client with hyperaldosteronism C. The client with Cushing's syndrome D. The client who is taking corticosteroids

A. The client who is taking diuretics

The home health care nurse is caring for a client with cancer who is complaining of acute pain. The *most appropriate* determination of the client's pain should include which assessment? A. The client's pain rating B. Nonverbal cues from the client C. The nurse's impression of the client's pain D. Pain relief after appropriate nursing intervention

A. The client's pain rating

The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function? A. The passage of flatus B. Absent bowel sounds C. The client's ability to tolerate food D. Bloody drainage from the colostomy

A. The passage of flatus

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. the nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? A. Tinnitus B. Diarrhea C. Constipation D. Decreased respirations

A. Tinnitus Rationale: Salicylic acid is absorbed readily through the skin, and systemic toxicity can result period symptoms include tinnitus, dizziness, hyperpnea comma and psychological disturbances period constipation and diarrhea are not associated with salicylism.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? A. Twitching B. Hypoactive bowel sounds C. Negative Trousseau's sign D. Hypoactive deep tendon reflexes

A. Twitching

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq.L (2.5 mol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? *Select all that apply.* A. U waves B. Absent P waves C. Inverted T waves D. Depressed ST segment E. Widened QRS complex

A. U waves C. Inverted T waves D. Depressed ST segment

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? A. Urinary output of 20 mL/hour B. Temperature of 37.6° C (99.6° F) C. Blood pressure of 100/70 mm Hg D. Serous drainage on the surgical dressing

A. Urinary output of 20 mL/hour

The nurse is caring for a client who takes ibuprofen for pain. the nurse is gathering information on the client's medication history, and determines it is necessary to contact the health care provider (HCP) if the client is also taking which medications? *Select all that apply.) A. Warfarin B. Glimepiride C. Amlodipine D. Simvastatin E. Hydrochlorothiazide

A. Warfarin B. Glimepiride C. Amlodipine

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? A. pH 7.25, PaCO2 50 mmHg B. pH 7.35, PaCO2 40 mmHg C. pH 7.50, PaCO2 52 mmHg D. pH 7.52, PaCO2 28 mmHg

A. pH 7.25, PaCO2 50 mmHg

The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to provide an example of the concept of acculturation. The nurse educator should make which *most appropriate* response? A. "A group of individuals identifying as a part of the Iroquois tribe among Native Americans." B. "A person who moves from China to the United States (U.S.) and learns about and adapts to the culture in the U.S." C. "A group of individuals living in the Azores that identify autonomously but are a part of the larger population of Portugal." D. "A person who has grown up in the Philippines and chooses to stay there because of the sense of belonging to his or her cultural group."

B. "A person who moves from China to the United States (U.S.) and learns about and adapts to the culture in the U.S."

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse should determine whether this method of family planning would be *most appropriate*? A. "Did you ever had surgery?" B. "Do you plan to have any other children?" C. "Do either of you have diabetes mellitus?" D. "Do either of you have problems with high blood pressure?"

B. "Do you plan to have any other children?"

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client *needs further instructions* if the client made which statement? A. "I need to wear a MedicAlert tag or bracelet" B. "I need to restrict my activity while this catheter is in place" C. "I need to keep the insertion site protected when in the shower or bath D. "I need to check the markings on the catheter each time the dressing is changed

B. "I need to restrict my activity while this catheter is in place"

A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's *best* response? A. "How often do you have sexual relations?" B. "Please share with me more about your concerns." C. "You are still young and have nothing to be concerned about." D. "You should not have a decline in testosterone until you are in your 80s."

B. "Please share with me more about your concerns."

A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? A. 3 mg/dL (1.05 mmol/L) B. 15 mg/dL (5.25 mmol/L) C. 29 mg/dL (10.15 mmol/L) D. 35 mg/dL (12.25 mmol/L)

B. 15 mg/dL (5.25 mmol/L)

When communicating with a client who speaks a different language, which *best* practice should the nurse implement? A. Speak loudly and slowly B. Arrange for an interpreter to translate C. Speak to the client and family together D. Stand close to the client and speak loudly

B. Arrange for an interpreter to translate

A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? *Select all that apply.* A. Restrict fluids B. Assess for airway patency C. Administer oxygen as prescribed D. Place a cooling blanket on the client E. Elevate extremities if no fractures are present F. Prepare to give oral pain medication as prescribed

B. Assess for airway patency C. Administer oxygen as prescribed E. Elevate extremities if no fractures are present

The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: T 97.2F orally, pulse 52 BPM, BP 101/58 mmHg, respiratory rate 11 BPM, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take *next?* A. Document the findings B. Attempt to arouse the client C. Contact the health care provider (HCP) immediately D. Check the medication administration history on the PCA pump

B. Attempt to arouse the client

A client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication? A. Glucose level B. Calcium level C. Potassium level D. Prothrombin time

B. Calcium level Rationale: Tamoxifen may increase calcium, cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet count, and serum calcium level should be assessed. These blood levels, along with cholesterol and triglyceride levels, should be monitored periodically during therapy. The nurse should assess for hypercalcemia while the client is taking this medication. Signs of hypercalcemia include increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, and deep bone and flank pain.

The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage form the wound. Which nursing intervention is *most appropriate?* A. Clamp the surgical drain B. Change the dressing as prescribed C. Notify the health care provider (HCP) D. Remove and replace the perineal packing

B. Change the dressing as prescribed

The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride. The nurse also needs to hang an IV infusion of piperacillin/tazobactam. The client has one IV site. The nurse should plan to take which action *first?* A. Start a second IV site B. Check compatibility of the medication and IV fluids C. Mix the prepackaged piperacillin/tazobactam per agency policy D. Prime the tubing with the IV solution, and back prime the medication

B. Check compatibility of the medication and IV fluids

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which *best* action? A. Refuse to float to the ICU based on lack of unit orientation B. Clarify with the team leader to make a safe ICU client assignment C. Ask the nursing supervisor to review the hospital policy on floating D. Submit a written protest to nursing administration, and then call the hospital lawyer

B. Clarify with the team leader to make a safe ICU client assignment

The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride and plans to use an IV infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action? A. Initiate the intravenous line without the use of a pump B. Contact the electrical maintenance department for assistance C. Plug in the pump cord in the available plug above the room sink D. Use an extension cord from the nurses' lounge for the pump plug

B. Contact the electrical maintenance department for assistance

A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription? A. Discontinue the PN B. Decrease PN rate to 50 mL/hour C. Start 0.9% normal saline at 25 mL/hour D. Continue current infusion rate prescriptions for PN

B. Decrease PN rate to 50 mL/hour

Which nursing action is *essential* prior to initiating a new prescription for 500 mL of fat emulsion (lipids) to infuse at 50 mL/hour? A. Ensure that the client does not have diabetes B. Determine whether the client has an allergy to eggs C. Add regular insulin to the fat emulsion, using aseptic technique D. Contact the health care provider (HCP) to have a central line inserted for fat emulsion infusion

B. Determine whether the client has an allergy to eggs

The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which action to correct the error? *Select all that apply.* A. Document a late entry into the client's record B. Draw 1 line through the error, initialing and dating it C. Try to erase the error for space to write in the correct data D. Use without to delete the error to write in the correct data E. Write a concise statement to explain why the correction was needed F. Document the correct information and end with the nurse's signature and title

B. Draw 1 line through the error, initialing and dating it F. Document the correct information and end with the nurse's signature and title

The nurse is caring for a client following a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? A, Placing cool compresses on the affected arm B. Elevating the affected arm on a pillow above heart level C. Avoiding arm exercises in the immediate postoperative period D. Maintaining an intravenous site below the antecubital area on the affected side

B. Elevating the affected arm on a pillow above heart level

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client? A. Coma B. Flushing C. Dizziness D. Tachycardia

B. Flushing

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription? A. Adding a dose of heparin sodium B. Holding the next dose of warfarin C. Increasing the next dose of warfarin D. Administering the next dose of warfarin

B. Holding the next dose of warfarin

The nurse is providing medication instructions to a client with breast cancer who is receiving cyclophosphamide. The nurse should tell the client to take which action? A. Take the medication with food B. Increase fluid intake to 2000 to 3000 mL daily C. Decrease sodium intake while taking the medication D. Increase potassium intake while taking the medication

B. Increase fluid intake to 2000 to 3000 mL daily Rationale: Hemorrhagic cystitis is an adverse effect that can occur with the use of cyclophosphamide. The client needs to be instructed to drink copious amounts of fluid during the administration of this medication. Clients also should monitor urine output for hematuria. The medication should be taken on an empty stomach, unless gastrointestinal upset occurs. Hyperkalemia can result from the use of the medication; therefore, the client would not be told to increase potassium intake. The client would not be instructed to alter sodium intake.

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? *Select all that apply.* A. Bites from ticks or deer flies B. Inhalation of bacterial spores C. Through a cut or abrasion in the skin D. Direct contact with an infected individual E. Sexual contact with an infected individual F. Ingestion of contaminated undercooked meat

B. Inhalation of bacterial spores C. Through a cut or abrasion in the skin F. Ingestion of contaminated undercooked meat

When caring for a client with an internal radiation implant, the nurse should observe which principles? *Select all that apply.* A. Limiting the time with the client to 1 hour per shift B. Keeping pregnant women out of the client's room C. Placing the client in a private room with a private bath D. Wearing a lead shield when providing direct client care E. Removing the dosimeter film badge when entering the client's room

B. Keeping pregnant women out of the client's room C. Placing the client in a private room with a private bath D. Wearing a lead shield when providing direct client care Rationale: The time that the nurse spends in the room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The client must be placed in a private room with a private baht. Lead shielding can be used to reduce the transmission of radiation. The dosimeter film badge must be worn when in the client's room. Children younger than 16 years of age and pregnant women are not allowed in the client's room.

A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? A. Lesion is painful to touch B. Lesion is highly metastatic C. Lesion is a nevus that has changes in color D. Skin under the lesion is reddened and warm to touch E. Lesion occurs in body area exposed to outdoor sunlight

B. Lesion is highly metastatic C. Lesion is a nevus that has changes in color

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Metabolic alkalosis

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? *Select all that apply.* A. Open doors to client rooms B. Move beds away from windows C. Close window shades and curtains D. Place blankets over clients who are confined to bed E. Relocate ambulatory clients from the hallways back into their rooms

B. Move beds away from windows C. Close window shades and curtains D. Place blankets over clients who are confined to bed

The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse should take which action? A. Roll the bottle of solution gently B. Obtain a different bottle of solution C. Shake the bottle of solution vigorously D. Run the bottle of solution under warm water

B. Obtain a different bottle of solution

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? A. Obtain a new IV bag B. Obtain new IV tubing C. Wipe the spike end of the tubing with povidone iodine D. Scrub the spike end of the tubing with an alcohol swab

B. Obtain new IV tubing

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? A. Milk B. Oranges C. Bananas D. Chicken

B. Oranges

A client is diagnosed as having a bowel tumor. The nurse should monitor the client for which complications of this type of tumor? *Select all that apply.* A. Flatulence B. Peritonitis C. Hemorrhage D. Fistula formation E. Bowel perforation F. Lactose intolerance

B. Peritonitis C. Hemorrhage D. Fistula formation E. Bowel perforation

The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? A. Positive patch test B. Positive culture results C. Abnormal biopsy results D. Wood's light examination indicative of infection

B. Positive culture results

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a PaCO2 of 30 mmHg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would *most likely* be noted in this condition? A. Sodium level of 145 mEq/L (145 mmol/L) B. Potassium level of 3.0 mEq/L (3.0 mmol/L) C. Magnesium level of 1.3 mEq/L (0.65 mmol/L) D. Phosphorus level of 3.0 mEq/dL (0.97 mmol/L)

B. Potassium level of 3.0 mEq/L (3.0 mmol/L)

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? *Select all that apply.* A. Peas B. Raisins C. Potatoes D. Cantaloupe E. Cauliflower F. Strawberries

B. Raisins C. Potatoes D. Cantaloupe F. Strawberries

The nurse is assessing a client's peripheral intravenous (IV) site after completion of a vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is *best?* A. Check for the presence of blood return B. Remove the IV site and restart at another site C. Document the findings and continue to monitor the IV site D. Call the health care provider (HCP) and request that the vancomycin be given orally

B. Remove the IV site and restart at another site

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is a risk for developing the potassium deficit because of which situation? A. Sustained tissue damage B. Requires nasogastric suction C. Has a history of Addison's disease D. Uric acid level of 9.4 mg/dL (559 umol/L)

B. Requires nasogastric suction

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? *Select all that apply.* A. Respirations that are shallow B. Respirations that are increased in rate C. Respirations that are abnormally slow D. Respirations that are abnormally deep E. Respirations that cease for several seconds

B. Respirations that are increased in rate D. Respirations that are abnormally deep

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PaCO2 of 30 mmHg (30 mmHg), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? A. Metabolic acidosis, compensated B. Respiratory alkalosis, compensated C. Metabolic alkalosis, uncompensated D. Respiratory acidosis, uncompensated

B. Respiratory alkalosis, compensated

The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that *further instruction is required* by the UAP? A. Placing a safety knot in the safety device straps B. Safely securing the safety device straps to the side rails C. Applying safety device straps that do not tighten when force is applied against them D. Securing so that 2 fingers can slide easily between the safety device and the client's skin

B. Safely securing the safety device straps to the side rails

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? A. Red, hard skin B. Serous drainage C. Purulent drainage D. Warm, tender skin

B. Serous drainage

A client has been discharged to home on parenteral nutrition (PN). With each visit, the home care nurse should assess which parameter *most* closely in monitoring this therapy? A. Pulse and weight B. Temperature and weight C. Pulse and blood pressure D. Temperature and blood pressure

B. Temperature and weight

The nurse is testing the extra ocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique which assessment technique to assess for muscle weakness in the eye? A. Test the corneal reflexes B. Test the 6 cardinal positions of gaze C. Test visual acuity, using a Snellen eye chart D. Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin

B. Test the 6 cardinal positions of gaze

The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure? A. To examine the testicles while lying down B. That the best time for the examination is after a shower C. To gently feel the testicle with 1 finger to feel for a growth D. Tat TSEs should be done at least every 6 months

B. That the best time for the examination is after a shower

A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition? A. Rupture of the bladder B. The development of a vesicovaginal fistula C. Extreme stress caused by the diagnosis of cancer D. Altered perineal sensation as a side effect of ration therapy

B. The development of a vesicovaginal fistula

Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which Laboratory test will be prescribed? A. Potassium level B. Triglyceride level C. Hemoglobin A1C D. Total cholesterol level

B. Triglyceride level Rationale: isotretinoin can Elevate triglyceride levels period blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on triglycerides has been evaluated. There is no indication that isotretinoin effects potassium, hemoglobin A1c, or total cholesterol levels.

A client with acute myelocytic leukemia is being treated with busulfan (Myleran, Busulfex). Which laboratory value would the nurse specifically monitor during treatment with this medication? A. Clotting time B. Uric acid level C. Potassium level D. Blood glucose level

B. Uric acid level Rationale: Busulfan (Myleran, Busulfex) can cause an increase in the uric acid level. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute kidney injury. Options 1, 3, and 4 are not specifically related to this medication.

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries to the back and legs. In elevating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the *most* reliable indicator for determining the adequacy? A. Vital signs B. Urine output C. Mental status D. Peripheral pulses

B. Urine output

The health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? *Select all that apply.* A. Sunscreen should be applied every eight hours B. Use sunscreen when participating in outdoor activities C. Wear a hat, opaque clothing, and sunglasses when in the sun D. Avoid sun exposure in the late afternoon and early evening hours E. Examine your body monthly for any lesions that may be suspicious

B. Use sunscreen when participating in outdoor activities C. Wear a hat, opaque clothing, and sunglasses when in the sun E. Examine your body monthly for any lesions that may be suspicious Rationale: The client should be instructed to avoid sun exposure between the hours of brightest sunlight: 10 a.m. and 4 p.m. Sunscreen, a hat, opaque clothing, and sunglasses should be warm for outdoor activities. The client should be instructed to examine the body monthly for appearances of any cancerous or pre-cancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced.

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin and may be lacking in a vegan diet? A. Vitamin A B. Vitamin B12 C. Vitamin C D. Vitamin E

B. Vitamin B12

The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the *need for more education* about urinary stoma care? A. "I change my pouch every week." B. "I change the appliance in the morning." C. "I empty the urinary collection bag when it is two-thirds full." D. "When I'm in the shower I direct the flow of water away from my stoma."

C. "I empty the urinary collection bag when it is two-thirds full."

As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that *further teaching is needed* if the client makes which statement? A. "I should avoid blowing my nose." B. "I may need a platelet transfusion if my platelet count is too low." C. "I'm going to take aspirin for my headache as soon as I get home." D. "I will count the number of pads and tampons I use when menstruating."

C. "I'm going to take aspirin for my headache as soon as I get home."

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? A. "It connects the pulmonary artery to the aorta." B. "It is an opening between the right and left atria." C. "It connects the umbilical vein to the inferior vena cava." D. "It connects the umbilical artery to the inferior vena cava."

C. "It connects the umbilical vein to the inferior vena cava."

The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse's best response? A. "It promotes the fertilized ovum's chances of survival." B. "It promotes the fertilized ovum's exposure to estrogen and progesterone." C. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus." D. "It promotes the fertilized ovum's exposure to luteinizing hormone and follicle-stimulating hormone."

C. "It promotes the fertilized ovum's normal implantation in the top portion of the uterus."

A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? A. "Come to the emergency department." B. "Apply calamine lotion immediately to the exposed skin areas." C. "Take a shower immediately, lathering and rinsing several times." D. "It is not necessary to do anything if you cannot see anything on your skin."

C. "Take a shower immediately, lathering and rinsing several times."

Silver sulfadiazine is prescribed for a client with a partial thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a *need for further teaching* about the treatments? A. "The medication is an antibacterial." B. "The medication will help heal the burn." C. "The medication is likely to cause stinging every time it is applied." D. "The medication should be applied directly to the wound."

C. "The medication is likely to cause stinging every time it is applied." Rationale: Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria gram positive bacteria, and yeast. It is applied directly to the wound to assistant healing. It does not cause stinging when applied.

Tamoxifen citrate is prescribed for a client with metastatic breast carcinoma. The client asks the nurse if her family member with bladder cancer can also take this medication. The nurse *most appropriately* responds by making which statement? A. "This medication can be used only to treat breast cancer." B. "Yes, your family member can take this medication for bladder cancer as well." C. "This medication can be taken to prevent and treat clients with breast cancer." D. "This medication can be taken by anyone with cancer as long as their health care provider approves it."

C. "This medication can be taken to prevent and treat clients with breast cancer." Rationale: Tamoxifen is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentrations of receptors. Tamoxifen is used to treat metastatic breast carcinoma in women and men. Tamoxifen is also effective in delaying the recurrence of cancer following mastectomy. Tamoxifen reduces DNA synthesis and estrogen response.

A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication. When implementing the plan, the nurse should make which statement to the client? A. "You can take aspirin as needed for headache." B. "You can drink beverages containing alcohol in moderate amounts each evening." C. "You need to consult with the health care provider (HCP) before receiving immunizations." D. "It is fine to receive a flu vaccine at the local health fair without HCP approval because the flu is so contagious."

C. "You need to consult with the health care provider (HCP) before receiving immunizations." Rationale: Because antineoplastic medications lower the resistance of the body, clients must be informed not to receive immunizations without an HCP's approval. Clients also need to avoid contact with individuals who have recently received a live virus vaccine. Clients need to avoid aspirin and aspirin-containing products to minimize the risk of bleeding, and they need to avoid alcohol to minimize the risk of toxicity and side/adverse effects.

An adult client was burned in an explosion. The burn initiall affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were cirumferential clothes to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? A. 18% B. 24% C. 36% d. 48%

C. 36%

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which? A. Lub-dub sounds B. Scratchy, leathery heart noise C. A blowing or swooshing noise D. Abrupt, high-pitched snapping noise

C. A blowing or swooshing noise

The registered nurse is planning the client assignments for the day. Which is the *most appropriate* assignment for an unlicensed assistive personnel (UAP)? A. A client requiring a colostomy irrigation B. A client receiving continuous tube feedings C. A client who requires urine specimen collections D. A client with difficulty swallowing food and fluids

C. A client who requires urine specimen collections

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem? A. A defect in the cochlea B. A defect in cranial nerve VIII C. A physical obstruction to the transmission of sound waves D. A defect in the sensory fibers that lead to the cerebral cortex

C. A physical obstruction to the transmission of sound waves

The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted? A. A clotting time of 10 minutes B. An ammonia level of 20 mcg/dL (6 mcmol/L) C. A platelet count of 50,000 cells/mm^3 (50 x 10^9/L) D. A white blood cell count of 5000 cells/mm^3 (5.0 x 10^9/L)

C. A platelet count of 50,000 cells/mm^3 (50 x 10^9/L) Rationale: Bleeding precautions need to be initiated when the platelet count decreases. The normal platelet count is 150,000 to 450,000 cells/mmc) When the platelet count decreases, the client is at risk for bleeding. The normal white blood cell count is 4500 to 11,000 cells/mmc) When the white blood cell count drops, neutropenic precautions need to be implemented. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 10 to 80 mcg/dL.

The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation? A. An involuntary rhythmic, rapid, twitching of the eyeballs B. A dorsiflexion of the ankle and great toe with fanning of the other toes C. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed D. A lack of normal sense of position when the client is unable to return extended fingers to a point of reference

C. A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the *next* nursing action? A. Call for help B. Extinguish the fire C. Activate the fire alarm D. Confine the fire by closing the room door

C. Activate the fire alarm

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? A. Weight loss and dry skin B. Flat neck and hand veins and decreased urinary output C. An increase in blood pressure and increased respirations D. Weakness and decreased central venous pressure (CVP)

C. An increase in blood pressure and increased respirations

A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which *immediate* action? A. Induce vomiting B. Call an ambulance C. Call the Poison Control Center D. Bring the child to the emergency department

C. Call the Poison Control Center

The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the *most appropriate* action by the nurse? A. Call security B. Call the police C. Call the nursing supervisor D. Lock the co-worker in the medication room until help is obtained

C. Call the nursing supervisor

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the *most appropriate initial* nursing action? A. Call the police B. Cut up the photograph and throw it away C. Call the nursing supervisor and report the incident D. Call the laboratory and ask for the name of the individual who sent the photograph

C. Call the nursing supervisor and report the incident

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is *most likely* to stimulate further discussion between the client and the nurse? A. If it's any help, everyone is nervous before surgery B. I will be happy to explain the entire surgical procedure to you C. Can you share with me what you've been told about your surgery D. Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate

C. Can you share with me what you've been told about your surgery

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which *most appropriate* action? A. Measure abdominal girth B. Irrigate the NG tube C. Continue to monitor the drainage D. Notify the health care provider (HCP)

C. Continue to monitor the drainage

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client? A. Tea B. Gelatin C. Custard D. Ice pop

C. Custard

Which is the *best* nursing intervention regarding complementary and alternative medicine? A. Advising the client about "good" versus "bad" therapies B. Discouraging the client from using any alternative therapies C. Educating the client about therapies that he or she is using or is interested in using D. Identifying herbal remedies that the client should request form the health care provider

C. Educating the client about therapies that he or she is using or is interested in using

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action? A. Advise the client to read the labels of herbal therapies closely B. Tel the client that herbal substances are not safe and should never be used C. Encourage the client to discuss the use of an herbal substance with the health care provider (HCP) D. Tell the client that if he takes the herbal substance hw ill need to have his blood pressure checked frequently

C. Encourage the client to discuss the use of an herbal substance with the health care provider (HCP)

An Asian American client is experiencing a fever. The nurse plans care so that the client can self-treat the disorder using which method? A. Prayer B. Magnetic therapy C. Foods considered to be yin D. Foods considered to be yang

C. Foods considered to be yin

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. the nurse suspects Hyponatremia. What additional signs would then nurse expect to note in a client with Hyponatremia? A. Muscle twitches B. Decreased urinary output C. Hyperactive bowel sounds D. Increased specific gravity of the urine

C. Hyperactive bowel sounds

A client receiving parenteral nutrition (PN) complains of a headache. The nurse notes that the client has an increased BP, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse determines that the client is experiencing which complication of PN therapy? A. Sepsis B. Air embolism C. Hypervolemia D. Hyperglycemia

C. Hypervolemia

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client *needs additional teaching* if the client makes which statement? A. Aspirin can cause bleeding after surgery B.Aspirin can cause my ability to clot blood to be abnormal C. I need to continue to take aspirin until the day of surgery D. I need to check with my health care provider about the need to stop the aspirin before the scheduled surgery

C. I need to continue to take aspirin until the day of surgery

The nurse is analyzing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurred from the chemotherapy? A. Anemia B. Decreased platelets C. Increased uric acid level D. Decreased leukocyte count

C. Increased uric acid level Rationale: Hyperuricemia is especially common following treatment for leukemias and lymphomas because chemotherapy results in massive cell kill. Although options 1, 2, and 4 also may be noted, an increased uric acid level is related specifically to cell destruction.

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the health care provider and anticipates which prescription? A. Transfusing 1 unit packed red blood cells B. Administering a diuretic to increase urine output C. Increasing the amount of intravenous (IV) lactated ringer's solution administered per hour D. Changing the IV lactated ringer's solution to one that contains dextrose in water

C. Increasing the amount of intravenous (IV) lactated ringer's solution administered per hour

The nurse is reading a health care provider's (HCP's) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes notation that insensible fluid loss occurs through which type of excretion? A. Urinary output B. Wound drainage C. Integumentary output D. The gastrointestinal tract

C. Integumentary output

An adult female has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is *most likely* caused by which condition noted in the client's history? A. Dehydration B. Heart failure C. Iron deficiency anemia D. Chronic obstructive pulmonary disease

C. Iron deficiency anemia

The nurse working in the emergency department (ED) is assessing a client who recently returned from Liberia and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take *next?* A. Check the client's temperature B. Contact the health care provider C. Isolate the client in a private room D. Check a complete set of vital signs

C. Isolate the client in a private room

Which purposes of placental functioning should the nurse include in a prenatal class? *Select all that apply.* A. It cushions and protects the baby B. It maintains the temperature of the baby C. It is the way the baby gets food and oxygen D. It prevents all antibodies and viruses from passing to the baby E. It provides an exchange of nutrients and waste products between the mother and developing fetus

C. It is the way the baby gets food and oxygen E. It provides an exchange of nutrients and waste products between the mother and developing fetus

The nurse is planning to teach client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? *Select all that apply.* A. Oranges B. Broccoli C. Margarine D. Cream cheese E. Luncheon meats F. Broiled haddock

C. Margarine D. Cream cheese E. Luncheon meats

Chemotherapy dosage is frequently based on total body surface area (BSA), so it is important for the nurse to perform which assessment before administering chemotherapy? A. Measure the client's abdominal girth B. Calculate the client's body mass index C. Measure the client's current weight and height D. Ask the client about his or her weight and height

C. Measure the client's current weight and height Rationale: To ensure that the client receives optimal doses of chemotherapy, dosing is usually based on the total body surface area (BSA), which requires a current accurate height and weight for BSA calculation (before each medication administration). Asking the client about his or her height and weight may lead to inaccuracies in determining a true BSA and dosage. Calculating body mass index and measuring abdominal girth will not provide the data needed.

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 174 beats/minute. On the basis of this finding, what is the *priority* nursing action? A. Document the finding B. Check the mother's heart rate C. Notify the health care provider (HCP) D. Tell the client that the fetal heart rate is normal

C. Notify the health care provider (HCP)

The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an *early* sign of this oncological emergency? A. Cyanosis B. Arm edema C. Periorbital edema D. Mental status changes

C. Periorbital edema

The nurse is caring for a restless client who is beginning nutritional therapy with parenteral nutrition (PN). The nurse should plan to ensure that which action is taken to prevent the client from sustaining injury? A. Calculate daily intake and output B. Monitor the temperature once daily C. Secure all connections in the PN system D. Monitor blood glucose levels every 12 hours

C. Secure all connections in the PN system

The nurse is instructing a client with hypertension on the importance of choosing food slow in sodium. The nurse should teach the client to limit intake of which food? A. Apples B. Bananas C. Smoked sausage D. Steamed vegetables

C. Smoked sausage

Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet? A. Pork roast, rice, vegetables, mixed fruit, milk B. Crab salad on a croissant, vegetables with dip, potato salad, milk C. Sweet and sour chicken with rice and vegetables, mixed fruit, juice D. Noodles and cream sauce with shrimp and vegetables, salad, mixed fruit, iced tea

C. Sweet and sour chicken with rice and vegetables, mixed fruit, juice

The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? A. The client rigidly extends the arms with pronated forearms and plantar flexion of the feet B. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended C. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column D. The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated

C. The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? A. The client fell out of bed B. The client climbed over the side rails C. The client was found lying on the floor D. The client became restless and tried to get out of bed

C. The client was found lying on the floor

The nurse manager is planning the clinical assignments for the day. Which staff members can be assigned to care for a client with herpes zoster? *Select all that apply.* A. The nurse who never had roseola B. The nurse who never had mumps C. The nurse who never had chickenpox D. The nurse who never had German measles E. The nurse who never received the varicella zoster vaccine

C. The nurse who never had chickenpox* E. The nurse who never received the varicella zoster vaccine

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the *best* action? A. Obtain a court order for the surgical procedure B. Ask the EMS team to sign the informed consent C. Transport the victim to the operating room for surgery D. Call the police to identify the client and locate the family

C. Transport the victim to the operating room for surgery

A client with severe acne is seen in the clinic and the healthcare provider prescribes isotretinoin. The nurse reviews the clients medication record and would contact the health care provider if the client is also taking which medication? A. Digoxin B. Phenytoin C. Vitamin A D. Furosemide

C. Vitamin A Rationale: Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. There are no contraindications associated with digoxin, phenytoin, or Furosemide.

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique? A. Using sterile sheets and linens B. Performing strict hand washing technique C. Wearing gloves and a gown only when giving direct care to the client D. Wearing protective garb, including mask, gloves, cap, shoes covers, gowns, and plastic apron

C. Wearing gloves and a gown only when giving direct care to the client

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? A. Stridor B. Crackles C. Wheezes D. Diminished

C. Wheezes

An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the *most appropriate* nursing response? A. "Oh, really? I will discuss this station with your son." B. "Let's talk about the ways you can manage your time to prevent this from happening." C. "Do you have any friends who can help you out until you resolve these important issues with your son?" D. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

D. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

The nurse is preparing a plan of care for a client, and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made? A. "I cannot have surgery" B. "I cannot have any medicine" C. "I believe the soul lives on after death" D. "I cannot have any food containing or prepared with blood

D. "I cannot have any food containing or prepared with blood

A staff nurse is precasting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the *need for further teaching* regarding pain management? A. "I will be sure to ask my client what his pain level is on a scale of 0 to 10." B. "I know that I should follow up after giving medication to make sure it is effective." C. "I know that pain in the older client might manifest as sleep disturbances or depression." D. "I will be sure to cue in to any indicators that the client may be exaggerating their pain."

D. "I will be sure to cue in to any indicators that the client may be exaggerating their pain."

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the *most appropriate* response to the client? A. "I will sign as a witness to your signature" B. "You will need to find a witness on your own" C. "Whoever is available at the time will sign as a witness for you" D. "I will call the nursing supervisor to seek assistance regarding your request"

D. "I will call the nursing supervisor to seek assistance regarding your request"

The nurse educator asks a student to list the 5 main categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a *need for further teaching* regarding CAM categories? A. "CAM includes biologically based practices" B. "Whole medical systems are a component of CAM" C. "Mind-body medicine is part of the CAM approach" D. "Magnetic therapy and massage therapy are a focus of CAM"

D. "Magnetic therapy and massage therapy are a focus of CAM"

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and 3 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse *most appropriately* assign to the licensed practical (vocational) nurse? A. A client who requires a bed bath B. An older client requiring frequent ambulation C. A client who requires hourly vital sign measurements D. A client requiring abdominal wound irrigations and dressing changes every 3 hours

D. A client requiring abdominal wound irrigations and dressing changes every 3 hours

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for *first*? A. A client who is ambulatory demonstrating steady gait B. A postoperative client who has just received an opioid pain medication C. A client scheduled for physical therapy for hte first crutch-walking session D. A client with a white blood cell count of 14,000 mm^3 (14 x 10^9/L) and a temperature of 38.4°C

D. A client with a white blood cell count of 14,000 mm^3 (14 x 10^9/L) and a temperature of 38.4°C

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess *first*? A. A postoperative client preparing for discharge with a new medication B. A client requiring daily dressing changes of a recent surgical incision C. A client scheduled for a chest x-ray after insertion of a nasogastric tube D. A client with asthma who requested a breathing treatment during the previous shift

D. A client with asthma who requested a breathing treatment during the previous shift

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign *priority* to which client? A. A client complaining of muscle aches, a headache, and history of seizures B. A client who twisted her ankle when rollerblading and is requesting medication for pain C. A client with a minor laceration on the index finger sustained while cutting an eggplant D. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

D. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

When assessing a lesion diagnosed as basal cell carcinoma, the nurse *most likely* expects to note which findings? *Select all that apply.* A. An irregularly shaped lesion B. A small papule with a dry, rough scale C. A firm, nodular lesion topped with crust D. A pearly papule with a central crater and a waxy border E. Location in the bald spot atop the head that is exposed to outdoor sunlight

D. A pearly papule with a central crater and a waxy border E. Location in the bald spot atop the head that is exposed to outdoor sunlight

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? A. A pink, edematous hand B. Fiery red skin with edema in the nail beds C. Black fingertips surrounded by an erythematous rash D. A white color to the skin, which is insensitive to touch

D. A white color to the skin, which is insensitive to touch

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? A. Each staff member is assigned a specific task for a group of clients B. A staff member is assigned to determine the client's needs at home and begin discharge planning C. A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an unlicensed assistive personnel (UAP) D. An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients

D. An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hyperventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? A. A decreased pH and an increased PaCO2 B. An increased pH and a decreased PaCO2 C. A decreased pH and a decreased HCO3- D. An increased pH and an increased HCO3-

D. An increased pH and an increased HCO3-

The Camp nurse asked the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are *most effective* when applied at which times? A. Immediately before swimming B. 5 minutes before exposure to the sun C. Immediately before exposure to the sun D. At least 30 minutes before exposure to the sun

D. At least 30 minutes before exposure to the sun. Rationale: Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreen should be reapplied after swimming or sweating.

A client has just undergone insertion of a central venous catheter at the bedside under ultrasound. The nurse would be sure to check which results before initiating the flow rate of the client's intravenous (IV) solution at 100 mL/hour? A. Serum osmolality B. Serum electrolyte levels C. Intake and output record D. Chest radiology results

D. Chest radiology results

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An unlicensed assistive personnel (UAP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the *best* approach in dealing with the UAP? A. Ignore the resistance B. Exert coercion on the UAP C. Provide a positive reward system for the UAP D. Confront the UAP to encourage verbalization of feelings regarding the change

D. Confront the UAP to encourage verbalization of feelings regarding the change

The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the *most appropriate* nursing action? A. Finish the bed bath and then administer the pain medication to the other client B. Ask the UAP to find out when the last pain medication was given to the client C. Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete D. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client

D. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client

A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should *next* assess the client for the presence of which condition? A. Thirst B. Polyuria C. Decreased BP D. Crackles on auscultation of the lungs

D. Crackles on auscultation of the lungs

A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action? A. Prepare to administer an antidote B. Draw a sample for type and crossmatch and transfuse the client C. Draw a sample for an activated partial thromboplastin time (aPTT) level D. Draw a sample for prothrombin time (PT) and international normalized ratio (INR)

D. Draw a sample for prothrombin time (PT) and international normalized ratio (INR)

The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer, and tells the staff that which is a *late* sign or symptom of this oncological emergency? A. Headache B. Dysphagia C. Constipation D. Electrocardiographic changes

D. Electrocardiographic changes

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn? A. Decrease heart rate B. Increased urinary output C. Increased blood pressure D. Elevated hematocrit levels

D. Elevated hematocrit levels

A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? A. Fatigue B. Weakness C. Weight gain D. Enlarged lymph nodes

D. Enlarged lymph nodes

The nurse is giving a report to an unlicensed assistive personnel (UAP) who will be caring for client who has hand restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently? A. Every 2 hours B. Every 3 hours C. Every 4 hours D. Every 30 minutes

D. Every 30 minutes

Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? A. Gloves and gown B. Gloves and goggles C. Gloves, gown, and shoe protectors D. Gloves, gown, goggles, and a mask or face shield

D. Gloves, gown, goggles, and a mask or face shield

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? *Select all that apply.* A. Diarrhea B. Black, tarry stools C. Hyperactive bowel sounds D. Gray-blue color at the flank E. Abdominal guarding and tenderness F. Left upper quadrant pain with radiation to the back

D. Gray-blue color at the flank E. Abdominal guarding and tenderness F. Left upper quadrant pain with radiation to the back

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed? A. Discontinuing the heparin infusion B. Increasing the rate of the heparin infusion C. Decreasing the rate of the heparin infusion D. Leaving the rate of the heparin infusion as is

D. Leaving the rate of the heparin infusion as is

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the *first priority* intervention is the event of this occurrence is which action? A. Immobilize the affected extremity B. Remove jewelry and constricting clothing from the victim C. Place the extremity in a position so that it is below the level of the heart D. Move the victim to a safe area away from the snake and encourage the victim to rest

D. Move the victim to a safe area away from the snake and encourage the victim to rest

Megestrol acetate, an antineoplastic medication, is prescribed for a client with metastatic endometrial carcinoma. The nurse reviews the client's history and should contact the health care provider if which diagnosis is documented in the client's history? A. Gout B. Asthma C. Thrombophlebitis D. Myocardial infarction

D. Myocardial infarction Rationale: Megestrol acetate suppresses the release of luteinizing hormone from the anterior pituitary by inhibiting pituitary function and regressing tumor size. Megestrol is used with caution if the client has a history of venous thromboembolism. Options 1, 2, and 3 are not contraindications for this medication.

A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? A. Performing a procedure without consent B. Threatening to give a client a medication C. Telling the client that he or she cannot leave the hospital D. Observing care provided to the client without the client's permission

D. Observing care provided to the client without the client's permission

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which *most appropriate* action in the care of this client? A. Obtain a court order for the surgery B. Have the charge nurse sign the informed consent immediately C. Send the client to surgery without the consent being signed D. Obtain a telephone consent from a family member, following agency policy

D. Obtain a telephone consent from a family member, following agency policy

The nurse is teaching a client who has iron deficiency anemia about food she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu? A. Nuts and milk B. Coffee and tea C. Cooked rolled oats and fish D. Oranges and dark green leafy vegetables

D. Oranges and dark green leafy vegetables

A client with small cell lung cancer is being treated with etoposide. The nurse monitors the client during administration, knowing that which adverse effect is specifically associated with this medication? A. Alopecia B. Chest pain C. Pulmonary fibrosis D. Orthostatic hypotension

D. Orthostatic hypotension Rationale: An adverse effect specific to etoposide is orthostatic hypotension. Etoposide should be administered slowly over 30 to 60 minutes to avoid hypotension. The client's blood pressure is monitored during the infusion. Hair loss occurs with nearly all the antineoplastic medications. Chest pain and pulmonary fibrosis are unrelated to this medication.

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? A. Intact skin B. Full-thickness skin loss C. Exposed bone, tendon, or muscle D. Partial-thickness skin loss of the dermis

D. Partial-thickness skin loss of the dermis

A client with ovarian cancer is being treated with vincristine (Vincasar). The nurse monitors the client, knowing that which manifestation indicates an adverse effect specific to this medication? A. Diarrhea B. Hair loss C. Chest pain D. Peripheral neuropathy

D. Peripheral neuropathy Rationale: An adverse effect specific to vincristine is peripheral neuropathy, which occurs in almost every client. Peripheral neuropathy can be manifested as numbness and tingling in the fingers and toes. Depression of the Achilles tendon reflex may be the first clinical sign indicating peripheral neuropathy. Constipation rather than diarrhea is most likely to occur with this medication, although diarrhea may occur occasionally. Hair loss occurs with nearly all the antineoplastic medications. Chest pain is unrelated to this medication.

While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. the nurse should take which *initial* action? A. Call the health care provider (HCP) B. Reinsert the implant into the vagina C. Pick up the implant with gloved hands and flush it down the toilet D. Pick up the implant with long-handled forceps and place it in a lead container

D. Pick up the implant with long-handled forceps and place it in a lead container

A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm^3 (300 x 10^9/L). The nurse should take which action after seeing the laboratory results? A. Report the abnormally low count B. Report the abnormally high count C. Place the client on bleeding precautions D. Place the normal report in the client's medical record

D. Place the normal report in the client's medical record

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention if noted in the plan *indicates the need for revision* of the plan? A. Wearing gloves when emptying the client's bedpan B. Keeping all linens in the room until the implant is removed C. Wearing a lead apron when providing direct care to the client D. Placing the client in a semiprivate room at the end of the hallway

D. Placing the client in a semiprivate room at the end of the hallway

A client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the health care provider (HCP), and the HCP initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued materials? A. Discard them in the unit trash B. Return them to the hospital pharmacy C. Save them for return to the manufacturer D. Prepare to send them to the laboratory for culture

D. Prepare to send them to the laboratory for culture

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure? A. Avoiding infection B. Taking in adequate fluids C. Preventing and recognizing hypoglycemia D. Preventing and recognizing hyperglycemia

D. Preventing and recognizing hyperglycemia

The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? *Select all that apply.* A. U waves B. Widened T wave C. Prominent U wave D. Prolonged QT interval E. Prolonged ST segment

D. Prolonged QT interval E. Prolonged ST segment

A client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed? A. Echocardiography B. Electrocardiography C. Cervical radiography D. Pulmonary function studies

D. Pulmonary function studies Rationale: Bleomycin is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis. Pulmonary function studies along with hematological, hepatic, and renal function tests need to be monitored. The nurse needs to monitor lung sounds for dyspnea and crackles, which indicate pulmonary toxicity. The medication needs to be discontinued immediately if pulmonary toxicity occurs. Options 1, 2, and 3 are unrelated to the specific use of this medication.

A client who is found unresponsive has arterial blood gas drawn and the results indicate the following: pH is 7.12, PaCO2 is 90mmHg, and HCO3- is 22 mEq/L. The nurse interprets the results as indicating which condition? A. Metabolic acidosis with compensation B. Respiratory acidosis with compensation C. Metabolic acidosis without compensation D. Respiratory acidosis without compensation

D. Respiratory acidosis without compensation

A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter? A. Elastic wrap B. Povidone iodine swab C. Adhesive bandage D. Sterile 2x2 gauge

D. Sterile 2x2 gauge

A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client? A. Tomato soup B. Boiled shrimp C. Instant oatmeal D. Summer squash

D. Summer squash

The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which *essential* action during the tubing change? A. Breathe normally B. Turn the head to the right C. Exhale slowly and evenly D. Take a deep breath, hold it, and bear down

D. Take a deep breath, hold it, and bear down

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? A. Inhale as rapidly as possible B. Keep a loose seal between the lips and the mouthpiece C. After maximum inspiration, hold the breath for 15 seconds and exhale D. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees

D. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees

The nurse is caring for a client having respiratory distress related to an anxiety attic. Recent arterial blood gas values are pH=7.53, PaO2=72 mmHg, PaCO2=32mmHg, and HCO3-=28 mEq/L. Which conclusion about the client should the nurse make? A. The client has acidotic blood B. The client is probably overreacting C. The client is fluid volume overloaded D. The client is probably hyperventilating

D. The client is probably hyperventilating

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? A. The client taking diuretics and has tenting of the skin B. The client with an ileostomy from a recent abdominal surgery C. The client who requires intermittent gastrointestinal suctioning D. The client with kidney disease and a 12-year history of diabetes mellitus

D. The client with kidney disease and a 12-year history of diabetes mellitus

The clinic nurse assess the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? *Select all that apply.* A. Presence of striae B. Palpable radial pulses C. Absence of any ecchymosis on the extremities D. Thinner and decrease in number of reddish papules E. Scarce amount of silvery-white scaly patches on the arms

D. Thinner and decrease in number of reddish papules E. Scarce amount of silvery-white scaly patches on the arms

The nurse monitors the client receiving parenteral nutrition (PN) for complications of the therapy and should assess the client for which manifestations of hyperglycemia? A. Fever, weak pulse, and thirst B. Nausea, vomiting, and oliguria C. Sweating, chills, and abdominal pain D. Weakness, thirst, and increased urine output

D. Weakness, thirst, and increased urine output

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the *need for follow-up* by the nurse? A. Glucose level of 99 mg/dL (5.65 mmol/L) B. Magnesium level of 1.5 mEq/L (0.75 mmol/L) C. Platelet level of 300,000 mm^3 (300 x 10^9/L) D. White blood cell count of 3000mm^3 (3.0 x 10^9/L)

D. White blood cell count of 3000mm^3 (3.0 x 10^9/L) Rationale: Silver sulfadiazine is used for the treatment of burn injuries. Adverse effects of this medication include rash and itching, blue green or gray skin discoloration, leukopenia, and interstitial nephritis. The nurse should monitor a complete blood count, particularly the white blood cells, frequently for the client taking this medication. If leukopenia develops, the healthcare provider is notified and the medication is usually discontinued. The white blood cell count noted an option for is indicative of leukopenia. The other laboratory values are not specific to this medication, and are also within normal limits.