Kaplan Diagnostic A
The nurse cares for the client receiving peritoneal dialysis. Which finding, if observed by the nurse during the procedure, indicate a malfunction in the system? a. There is a leak of fluid onto the dressing in the bed
A
The nurse cares for the client reporting and odor from a new double barrel colostomy. Which action does the nurse taken initially? a. Checks the appliance for leaks
A
The nurse cares for the client seen in the emergency department after being assaulted and robbed any mall parking lot. Which intervention by the nurse is the most appropriate initial response? a. Help the client to identify the clients immediate needs
A
The client diagnosed with depression reports the nurse, "I'm too tired to take a shower. Please don't bother with me today." Which action, if taken by the nurse, is most appropriate? b. Assist the client to meet hygiene needs that day
B
The hospitalized client says to the nurse, "I'm not sure I want to stay here. I feel so frightened and alone." Based on this statement, which approached by the nurse is most appropriate? c. "A hospital can be a frightening place. I will stay with you."
C
The nurse assesses the client who has a chest tube and a three-chamber water-seal drainage system connected dissection. Which occurrence requires an intervention by the nurse? c. There is continuous bubbling in the water-seal chamber
C
The nurse cares for a 10 day old infant being breast-fed. Which characteristics does the nurse expect the infant stool to have? c. Yellow, pasty, with a sour milk odor
C
64. To auscultate for breath sounds in the middle lobe of the long, the nurse places the stethoscope in which location? (picture) a. C b. D c. A d. B
4th or 5th intercostal place on the right side
15. The nurse cares for the client having a left total hip arthroplasty period in which position does the nurse placed the client after surgery? a. Legs abducted with the toes pointing upward
A
23. The nurse supervises a nursing assistive personnel (NAP) caring for the client after abdominal surgery. Which observation requires an intervention by the nurse? a. The NAP massages the client's leg using long, firm strokes
A
33. The nurse assesses the intravenous (IV) site on the left forearm of the child. Which finding causes the nurse to rule out the occurrence of infiltration of the IV? a. The fluid in that IV tubing becomes pink tinged when the tubing is pinched
A
40. The nurse cares for a client diagnosed with primary adrenocorticol insufficiency. The nurse expects to observe which laboratory finding? a. Decreased sodium and glucose; increased potassium
A
57. The nurse performs a venipuncture using an intravenous (IV) catheter for a client scheduled for surgery. Which technique does the nurse use? a. Pierces the skin and the vein in one swift motion
A
61. The nurse cares for the client diagnosed with a severe head injury. In planning care for this client, the nurse understands that which priority is highest? a. Turn the client every 2 hours
A
63. The 39 year old primipara come to the hospital at 29 weeks gestation and report symptoms of preterm labor. Which assessment by the nurse is most helpful in confirming this diagnosis? a. Regular contractions are noted on a monitor tracing
A
A four month old infant has stop breathing. Which action does the nurse take? a. Covers the infants nose and mouth with the nurses mouth
A
The client diagnosed with drug abuse says, "I have been taking drugs for so long, I can't imagine my life without them." Which an initial response by the nurse is best? a. "Using drugs has been the way that you have dealt with your problems." "
A
The client in the transition phase of labor reports lightheadedness and a tingling sensation in the fingers. Which action does the nurse take? a. Instructs the client to breathe into a paper bag help tightly against the mouth and nose
A
The client returns to the room after a subtotal thyroidectomy. The nurse is most concerned if a which observation is made? a. The client is having difficulty speaking
A
The new patient holds the two week old neonate E erect with the feet touching the table top. The baby responds by flexing and extending the legs. The parent says to the nurse, "look my baby is trying to walk!" Which response, if made by the nurse to the parent, is best? a. "Your baby is demonstrating the dance or step reflex. It will be replaced by deliberate movement in about 2 to 3 weeks."
A
The nurse cares for four clients. Which client is the nurse see first? a. A five-year-old child with croup and who has respirations of 35
A
The nurse cares for the client diagnosed with chronic obstructive pulmonary disease (COPD). Which priority does the nurse rank at highest? a. Offer the client small, frequent feedings
A
The nurse cares for the client displaying symptoms of a panic attack. Suddenly the client says to the nurse, "Get out of here, and leave me alone." The nurse takes which action? a. Decreases environmental stimuli and remains with the client
A
The nurse cares for the client in active labor. Fetal heart rate (FHR) is 150. After the apex of the contraction, the fetal heart rate drops to 125. When the contraction is completed, the fetal heart rate is 130. The nurse understands these rate changes indicate which condition? a. This indicates a late deceleration
A
The nurse cares for the client newly diagnosed with type I diabetes. The client receives intermediate acting insulin 20 units every morning. The client ask the nurse, "Why can't I take an 'insulin pill' like my grandparent does?" Which action by the nurse is best? a. Explain to the client the difference between insulin and oral hypoglycemic agents
A
The nurse cares for the client receiving hemodialysis three times a week. The client takes the digoxin and furosemide, and a multivitamin. The nurse identifies that the digoxin should be given at which time? a. After a low level is obtained
A
The nurse cares for the client receiving parenteral nutrition (PN) through a single lumen subclavian catheter. The client has an order for a unit of packed red blood cells (RBCs). Which action does the nurse take? a. Administer the RBCs are a newly inserted peripheral IV line
A
The nurse cares for the client with a chest tube attach to a three-chamber water sealed drainage system. While attempting to get out of bed, the client accidentally disconnect the chest tube from the water-seal drainage system. Which action does the nurse take first? a. Inserts the end of the chest tube in a container of sterile saline solution
A
The nurse cares for the client with a tracheostomy that was performed yesterday. Which symptom requires an intervention by the nurse? a. The client secretions from the tracheostomy are thick, yellow, and dry
A
The nurse conducts a class about eating disorders at the junior high school. The nurse mentions which common characteristics of people who are at risk for anorexia nervosa? a. Distorted body image
A
The nurse instructs the client how to apply nitroglycerin ointment. The nurse is concerned if the client makes which statement? a. "I can't put the ointment on my chest because I am so hairy."
A
The nurse performed a physical assessment of a school age child. Which behavior demonstrates the proper procedure for examining the deep tendon reflexes? a. The nurse compares the reflexes on both sides of the body to see if they are symmetrically equivalent
A
The nurse prepares to assess the blood pressure of the six year old child following an accident. A blood pressure cuff of appropriate size is unavailable. Which action does the nurse take? a. Uses another site appropriate for the size of the bailable cost to obtaining reading
A
The nurse provides morning care for the client with a cuffed tracheostomy tube. Before performing oral hygiene? The nurse notes the tracheostomy cuff is deflated. Which action does the nurse take next? a. Inflate the tracheostomy cuff, and continues with oral hygiene
A
The nurse supervises care provided in a day care center. Which food, if offered during snack time to a four-year-old child, is best? a. Two carrot sticks
A
The nurse takes care of the client admitted to rule out epilepsy. Which action is the highest priority for the nurse? a. Protect the client from injury
A
The nurse teaches the client newly diagnosed with type I diabetes. Which statement by the nurse best explains the rationale for rotating injection sites for this client? a. "You may damage the tissues causing erratic absorption of insulin if you don't rotate sites."
A
The nurse teaches the client, scheduled for a total right hip arthroplasty, preoperatively. Teaching includes postoperative exercises. Which exercise, if perform by the client, indicates further teaching is necessary? a. The client performs straight leg lifts
A
The nurse understands that the initial nursing action taken for a prolapse of the umbilical cord is effective if which observation is made? a. The fetal heart rate (FHR) is maintained at 150
A
The nursing team consists of one RN, one LPN/LVN, and an experienced nursing assistive personnel (NAP). These tasks need to be completed: a straight catheterization for urinary retention for a client after a cholecystectomy, tracheostomy care for a client two days after a laryngectomy, and a blood glucose determination for a client receiving parenteral nutrition (PN) through a central venous catheter. Which task does the nurse assigned to each team member? a. Performs a tracheostomy care, assign the catheterization to the LPN/LVN, and ask that NAP to check the blood glucose level
A
The parent arrives from overseas to visit. The child discovers the parent depressed, disheveled, and suspicious of family members. The nurse include which nursing order in the care plan? a. Encourage family involvement in clients treatment.
A
The results of a recent complete blood count (CBC) for the female client are white blood cells (WBC) 1000 cells/mm3 (1.0 x 10^9/L), Platelets 200,000/mm3 (200 x 10^9), Hemoglobin (Hgb) 14 g/dL (8.69 mmol/L), hematocrit (Hct) 39% (0.39). Which is the most important nursing goal for this client? a. prevent infection
A
The client diagnosed with human immunodeficiency virus (HIV) returns for evaluation of a Mantoux skin test. Which observation indicates the nurse this client has a significant reaction to the test? b. There is a 5 mm area at induration on the inner aspect of the left forearm
B
Before discharge, the nurse teaches the client who underwent surgery for an ileal conduit. Which instruction, if provided by the nurse to the client, is most important? b. "Drink at least 2000 mL of fluid every day."
B
During the admission assessment, the client with a history of schizophrenia tells the nurse, "I must submerge myself and hot water to atone for my sins." The nurse is most concerned if which observation is made? b. The client sits in the bathroom and turned the water faucet on full force
B
12. The nurse teaches the client about ferrous sulfate. Which statement by the client indicates to the nurse that the client understands the education? b. "I should take this medication with orange juice."
B
13. The nurse gives discharge instructions about home care for orchitis to the client. Which statement indicates to the nurse that teaching has been successful? b. "It will help if I use a scrotal support."
B
3. The nurse teaches the client about the schedule cardiac catheterization. Which statement, if made by the client to the nurse, indicates that the teaching was effective? b. "I may experience a little pounding sensation in my chest during the procedure."
B
35. The charge nurse notes that during a staff meeting designed to discuss client care concerns, a nurse that is a non-native speaker of English remains silent. Which action does the charge nurse take? b. Allow extra time during the meeting for questions and summarize the discussion of the group
B
39. The client scheduled for a vaginal hysterectomy tells the nurse, "I want to read my medical record." Which action does the nurse take? b. Relays the clients request to read medical medical record to the nurses supervisor
B
4. During the second stage of labor, the client's partner asks the nurse, "Can I go get a cup of coffee from the cafeteria?" Which response by the nurse is best? b. "It would be best if you stayed here at this time."
B
5. The nurse discovers that client lying face down on the floor. Which action does the nurse take first? b. Determine whether the client is responsive
B
54. The nurse observes cardiopulmonary resuscitation (CPR) Being performed on an 8-months-old client. The nurse intervenes if which observation is made by the nurse? b. The clients neck is hyperextended
B
6. A nurse works 3 weeks at a 100-bed suburban hospital after working several months at a 40-bed rural hospital. The nurse prefers the total client care delivery system that was used at the rural hospital, rather then the team leading system of client care that is used at the suburban hospital. Which action does the nurse take? b. Discuss his thoughts about the type of client care delivery system with the nurses supervisor
B
A client receives digoxin 0.25 mg and furosemide 40mg once a day. Which action does the nurse take? b. Increased oral intake of potassium rich foods
B
A prominent member of society is hospitalized with a diagnosis of urinary tract calculi. People are calling and asking about the clients condition. Which action does the nurse take? b. Suggest that they speak to a family member
B
The client hospitalized for treatment of a bleeding peptic ulcer reports substernal chest pain. The nurse finds the client diaphoretic and cool with vital signs: BP 110/56 mm Hg, T 98.4°F (36.8°C), P 76 bpm, RR 28 breaths/min. The client IV of 0.9% NaCl in fuses at 80 mL/hr. Lab results show potassium 3.2 mEq/L (3.2 mmol/L), sodium 140 mEq/L (140 mmol/L), and chloride 93 mEq/L (93 mmol?L). Cardiac monitoring shows multifocal premature ventricular contractions (PVCs). The nurse identifies which condition is the most likely cause of the clients PVCs? b. Hypokalemia
B
The clients adult children bring their 70-year-old parent, in the early stages of Alzheimer's disease, to the medical clinic. Which symptom does the nurse expect the client to exhibit? b. The client cannot remember what the client had for breakfast that morning
B
The college student has a Mantoux test performed as part of a routine physical examination. To evaluate the test, the nurse performs which action? b. Palpate the injection site to assess front area of induration
B
The healthcare provider orders tobramycin for a 3-year-old child. The nurse enters the clients room to administer the medication and discovers that the child does not have an identification bracelet. Which action by the nurse is the most appropriate? b. Ask the parents at the child's bedside to state their child's name
B
The nurse admits a 2-month-old infant for surgical correction of hypospadias. Which assessment does the nurse complete? b. Inspect the position of the urinary meatus
B
The nurse cares for a 6 lbs. 7 oz. (2947 gm) Baby delivered two hours ago. Which observation of the infant, if made by the nurse, is expected? b. The infant has find crackles and a respiratory rate of 44
B
The nurse cares for the client diagnosed with Alzheimer's disease. The client wanders from room to room. Which action does the nurse take? b. Attaches a picture of the clients family to the door of the clients room
B
The nurse cares for the client diagnosed with low back pain. The clients partner tells the nurse, "My partner has increased alcohol intake since the back injury several months ago." Based on this information, which symptoms does the nurse observe? b. Course motor tremors, increased pulse, and increased anxiety
B
The nurse cares for the client diagnosed with septic shock syndrome. An initial nursing assessment of this client would most likely reveal which symptoms? b. Fever and hypotension
B
The nurse cares for the client in labor at 35 weeks gestation. Which statement, if found by the nurse in the clients medical records, is unexpected? b. Results of the complete blood count (CBC) reveal red blood cells (RBC) 4.9 million/mm3 (4.9 x 10^12/L), hematocrit 45% (0.45 the volume fraction), hemoglobin 15 g/dL (150 g/L)
B
The nurse cares for the client in the psychiatric Hospital. The client has not slept for several nights, talks rapidly, and pieces before wringing the hands. Which is the highest nursing priority during the first few days of hospitalization for this client? b. Provide rest, food, and liquids for the client
B
The nurse cares for the client is experiencing third trimester bleeding, consisting of dark red spotting. The client is not reporting uterine pain and tenderness. The nurse realizes that these symptoms are indicative of which situation? b. Placenta previa
B
The nurse cares for the client who just delivered an 8 lbs. 4 oz. baby. The nurse knows which finding is most significant? b. The woman's vital signs change from blood pressure (BP) 136/78 mm Hg, polls 76 bpm to BP 124/66 mm Hg, pulse 90 bpm
B
The nurse discovers the client in the bathroom attempting self-harm. Which action does the nurse take first? b. Stays with the client and continually monitors for self-destructive behaviors
B
The nurse discusses foods that are included on a diabetic diet. Which food, if selected by the client diagnosed with type I diabetes, indicates the nurse teaching is successful? b. Turkey, asparagus, and blueberries
B
The nurse evaluates the lab results for the client diagnosed with rheumatoid arthritis. The nurse expects elevations in which laboratory data? b. C-reactive protein and erythrocye sedimentation rate (ESR)
B
The nurse is assigned to care for four clients. Which client is the nurse see first? b. An 18 year old client who had a C-section one hour ago and who has saturated three peripads
B
The nurse performs a quality assurance evaluation of the client assignments given to members of the nursing staff. The nursing staff consists of three RNs in one LPN/LVN. The nurse determines the assignments are appropriate if the LPN/LVN is assigned to which client? b. The client diagnosed with a left femur fracture and being treated with traction
B
The nurse performs discharge teaching with the client diagnosed with emphysema. Which statement, it's made by the client, indicates teaching was successful? b. "I should drink fluids with all my meals and in between meals."
B
The nurse teaches a client diagnosed with tuberculosis (TB) prior to discharge. Which statement, if made by the client to the nurse, indicates the teaching is effective? b. "If I cough or sneeze, I should cover my mouth with a disposable tissue."
B
The nurse teaches the client about and arteriovenous fistula in the right arm of the client prior to discharge. Which information about care of the fistula does the nurse include? b. Place the fingers over the fistula once a day
B
The nurse understands that the test for phenlketonuria (PKU) is most reliable at which timeframe? b. After a source of protein has been ingested
B
The patient of an 18 month old toddler ask the nurse, (Which toy is most appropriate for my child?) The nurse from recommend which toy? b. A stuffed animal
B
The school age client receives prednisone. It is most important for the nurse to assess which information while the client receives this medication? b. The clients blood glucose
B
The nurse cares for the adolescent being evaluated for type I diabetes. Which statement does the nurse expect the parents to make? c. My child has started to wet the bed at night
C
10. The nurse makes environmental rounds on the client care unit. Which problem does the nurse addressed first? c. The call light and occupied isolation room is broken
C
16. The adolescent receives 10 units of intermediate-acting insulin every morning at 0700. If the client requires the insulin dosage reduced, the nurse expects the client to present with which symptom? c. Experiences confusion at 1600
C
2. The health care provider orders a continuous intravenous aminophylline infusion for a two year old client. It is most important for the nurse to intervene for which situation? c. The clients serum theophylline level is 25 mcg/mL
C
22. The parents of the 18 month old toddler with a fractured femur visits with the child in the hospital. The parents say they must go home, the child screams, cries, and hits the parents. Which statement does the nurse suggest the parents tell the child? c. "We will return when the sun comes up."
C
29. The client receives parenteral nutrition (PN) via the internal jugular vein. Which action does the nurse take if the next container of PN solution is not available when it is needed? c. Hangs a container of 10% D/W until the new solution is available
C
32. Which situation suggests a nurse is addicted to the use of alcohol or habit-forming medications? c. The nurse cannot be found on the unit for half an hour during the assigned shift
C
44. The nurse gives a client morphine 10mg intramuscularly (IM). After administering the medication, the nurse notes the order for morphine was deleted by the healthcare provider the previous day and replaced with an order of hydromorphone 4mg IM. Which documentation is best? X-c. "Morphine 10 mg given IM for reports of abdominal pain instead of hydromorphone 4mg IM. Incident reported to healthcare provider."
C
9. During a routine prenatal visit, the nurse auscultates the fetal heart rate (FHR). If the fetal position is left sacrum posterior (LSP), at which site does the nurse expect to find the fetal heart (FHT)? c. Above umbilicus, on the mothers left
C
A nurse who is three months pregnant is assigned to pass medications to a group of clients. The nurse asks another nurse to administer which medication? c. Cyclophosphamide
C
A postpartum client reports tenderness in the groin and pain in the calf of the right leg. Which action does the nurse take first? c. Check the areas for warmth and edema
C
An hour and a half after admission to the nursery, the nurse observe spontaneous jerky movements of the lambs and infant born to a mother with just station on diabetes mellitus (GDM). Based on these signs, which condition does the nurse expect in the infant? c. Hypoglycemia
C
The RN observes the nursing student insert a urinary catheter in a preschool age child. Which action, if observed by the nurse, requires an intervention? c. The nursing student wipes around the circumference of the labia using a sterile cotton ball
C
The client tells the nurse, "I have been menstruating constantly for one year." It is most important for the nurse to ask the client which question? c. "How many pads do you use in one hour?"
C
The healthcare provider orders activity therapy for the depressed client. The clients partner asks the nurse, "How will this help my partner?" Which statement, if made by the nurse, is best? c. "Activity therapy promotes socialization and increases self-esteem."
C
The healthcare provider orders pancreatin capsules for the preschool child. Which statement, it's made by the parents to the nurse, indicates the need for further teaching about this medication? c. "We should give our child this medication first thing in the morning."
C
The nurse cares for the adolescent diagnosed with full thickness burns on the upper chest and partial thickness burns on the hands, arms, and face. Which method does the nurse encourage the client to use to communicate? c. The foot
C
The nurse cares for the client after a right modified radical mastectomy. Which action does the nurse take? c. elevate the clients right arm and keeps the hand at the highest point
C
The nurse cares for the client after the delivery of an 8 lbs. 7 oz. newborn. Which measures by the nurse received the highest priority during the first day postpartum? c. Observed for signs of hemorrhage and infection
C
The nurse cares for the client diagnosed with anorexia nervosa. Which goal is the highest priority initially? c. Maintain the clients fluid and electrolyte balance
C
The nurse cares for the client diagnosed with heart failure (HF). During a clinic visit, the client states, "I have not been feeling like my old self for about two weeks." It is most important for the nurse to ask which question? c. "Do you have chest pain when you inhale?"
C
The nurse cares for the client diagnosed with the ménière's disease. Which signs and symptoms does the nurse expect the client to exhibit? c. Vertigo, tinnitus, and neurosensory hearing loss
C
The nurse cares for the client following a right total hip arthroplasty. The client has an IV of 0.9% NaCl and has a Hemovac drain in place. Prior to discharge from the post anesthesia care unit, which finding justifies the nurse calling the healthcare provider? c. The client cannot move the toes of the right foot
C
The nurse cares for the client following a total right hip arthroplasty. During the immediate postoperative period, it is most important for the nurse to assist the client with which activity? c. Coughing and deep breathing
C
The nurse cares for the client prior to cataract surgery. The nurse administers the preoperative medication. Ten minutes later, the nurse finds the client on the floor at the foot of the bed. Which action does the nurse takes initially? c. Stays with the client and calls for assistance
C
The nurse cares for the client with a history of chronic alcohol abuse, nutritional problems, and confabulation. In planning for the clients nursing care, which action is the first priority of the nurse? c. Start a intravenous line of D5W with thiamine as ordered
C
The nurse cares for the client with an above-knee (AKA) amputation performed four days ago. The nurse teaches the client about care of the residual limb prior to being fitted with a temporary prosthesis. Which intervention is most important for the nurse to include an instruction? c. Wrap the residual limb with an elastic bandage during the day
C
The nurse cares for the school- aged Child diagnosed with cystic fibrosis (CF). The healthcare provider orders aerosol therapy. The nurse knows which is the expected outcome? c. The child manages respiratory secretions without difficulty
C
The nurse developed a care plan for a client diagnosed with acute phase rheumatoid arthritis. The nurse understands that which school of nursing care is primary? c. Maintain optimal joint mobility, and prevent further deformity
C
The nurse finds one of the housekeeping staff sleeping in an unoccupied client room. Which action does the nurse take? c. Reports the situation to the nurses supervisor
C
The nurse needs to complete several tasks before getting the report to the next shift. The client on the second day after surgery needs the below knee amputation (BKA) re-wrapped. An elderly client needs discharge teaching about atenolol and hydrochlorothiazide. In which order does the nurse complete the tasks? c. Teaches the client's adult child about the medications, ask another nurse to rewrap the BKA, and then gives the report to the next shift
C
The nurse observed the student nurse section a client. The nurse determines that proper suctioning technique is used if which action is observed? c. Apply suction as the catheter is withdrawn from no more than 10 seconds
C
The nurse observes and LPN/LVN irrigate an abdominal wound for the client. Which action, if observed by the nurse, requires an intervention? c. The LPN/LB inputs on sterile gloves and pours the irrigating solution into the sterile container
C
The nurse provides care for a client following a left above knee amputation (AKA). The client tells the nurse, "I feel like I still have my left leg." Which statement by the nurses best? c. "The brain sends signals to the residual land that cause it feel like your leg is still there."
C
The nurse teaches a client diagnosed with epilepsy about the disease and its management. Which statement is made by the client, indicates a need for further teaching? c. "I will take my medications when I have seizures."
C
The nurse teaches a client following a cholecystectomy. Which statement, if made by the client, indicates to the nurse that further instruction is needed? c. "I will need weekly injections of vitamin K for six weeks."
C
The nurse teaches a client receiving amitriptyline. Which statement, is made by the client to the nurse, indicates an adequate understanding of amitriptyline? c. "It maybe 3 to 4 weeks before I'll see a change due to amitriptyline."
C
The nurse teaches the client diagnosed with osteoporosis about dietary adjustments. Which menu, if selected by the client, indicate to the nurse the teaching was effective? c. Peanut butter and jelly sandwich, apple, and milk
C
The nurse teaches the client what to expect during a cardiac catheterization. Which statement if made by the client, indicates further teaching is necessary? c. "I may have chest pain for several days following the test."
C
The nurse uses an otoscope to examine the tympanic membrane of an adult as part of a physical assessment. Which behavior, if performed by the nurse, indicates an understanding of the procedure? c. The nurse pulls the auricle upward and backward to straighten the canal
C
The nurse works with the client who has a history of alcoholism. Which statement, if made by the client to the nurse, indicates that the client has gained some insight into alcoholism? c. "I know this is a lifelong problem, and I'll need continued support."
C
The parent asked the nurse, "How can I tell if my teenage child under the influence of marijuana?" Which statement by the nurses best? c. "Your child would be hungry, especially for junk food."
C
The parent brings the preschooler to the clinic for every team check up. The parent claims that the child fears "monsters" and "bogeymen" In the bedroom at night. Which statement by the parent indicates that the parents are dealing with their child's fears appropriately? c. They leave a night light on in the child's room
C
The parents bring their 9-month-old child to the clinic. Which observation by the nurse indicates a delay in development? c. The child uses a Palmer grasp to hold objects
C
The partner of a client with a history of myocardial infarction (MI) and heart failure (HF) Tells the nurse, "I do not want my partner to be kept alive on machines if the heart stops." Which action is most important for the nurse to take? c. Determine if the partner understands the consequences of this decision
C
Which is the best school for a 50-year-old client diagnosed with chronic bronchitis? c. Client will increase physical activity according to clients tolerance
C
Which principle best guides the nurse working with pregnant adolescents? c. Physical and emotional immaturity places the pregnant adolescent and infinite risk
C
Which technique, if explain by the nurse to a client, best describes the correct way to mix intermediate acting (isophane) and short acting (Regular) insulin? c. Short acting insulin is drawn up first. Then the intermediate acting is added to the syringe
C
The nurse cares for the clients scheduled for a liver biopsy. Which statement is made by the nurse is best? c. "You will be asked to exhale and hold your breath."
C=Percutaneous biopsy, or B=Transjugluar Biopsy.
50. The nurse cares for the client diagnosed with a loss of ability to use language following a stroke. Which action does the nurse take? d. Focus efforts on reducing the clients frustration when communicating
D
58. The nurse cares for the adolescent scheduled for surgery to repair extensive facial scarring sustained any motor vehicle accident. The nurse assesses the clients understanding of the operation. Which response, if made by the client to the nurse, indicated the client has the capacity for abstract thinking? d. "The healthcare provider talk to me about the different techniques involved and the risk of the skin graft being rejected."
D
11. The nurse observes a nursing assistive personnel (NAP) enter the room of the client diagnosed with tuberculosis (TB) to provide morning care. Which observation, if you made by the nurse, does not require an intervention? d. The NAP enters the room while wearing a particulate respirator and a gown
D
25. The nurse administers medications to the client diagnosed with bipolar disorder. The client approaches the nurse and begins to throw things. Which action does the nurse take? d. Sits down and asks the client what is bothering the client
D
43. The home health nurse changes dressings four times a week for the client diagnosed with stage III pressure ulcer. The hospital admitting nurse notes that the dressing was not applied as ordered. Which action is most important for the nurse to take? X-d. Document the discrepancy between what was ordered and the condition of the dressing
D
45. The spouse of the 60 - year - old client brings the client to the clinic. The spouse states that during the last week the client has become confused and has been drinking large quantities of water. Lab values indicate: blood glucose 1,215 mg/dL (67.43 mmol/L), see osomolality 400 mOsmol/kg H2O (400 mmol/kg H2O), potassium 4.5 mEq/L (4.5 mmol/L), sodium 145 mEq/L (145 mmol/L), and serum negative for keytones. The nurse expects the healthcare provider to initially order which treatment? d. 0.9% NaCl IV and regular insulin IV
D
49. To ensure a safe hospital environment for a 2-year-old toddler, which intervention does the nurse implement? d. Remove equipment from the bedside table
D
60. The nurse teaches the school age to how to use crutches correctly. Which action by the client requires intervention by the nurse? d. The clients weight is supported by the foam-rubber pad on the under arm peace
D
65. The nurse cares for a woman diagnosed with toxic shock syndrome. Which action does the nurse take first? d. Administers 0.9% NaCl at hundred and 150 mL/hr into the clients right forearm
D
66. The client diagnosed with Alzheimer's disease wanders around the unit disturbing other clients. The clients gate is steady. Which action by the nurse is most appropriate? d. Allow the client to assist the staff in distributing the clean linen
D
7. The nurse cares for the client diagnosed with a left traumatic below knee amputation (BKA) with a tourniquet in place. The client also has a tear from the perineum to the rectum. Which action is the nurse take first? d. Check the client's blood pressure and pulse
D
A nurse, at the outpatient clinic, and cares for the client who uses crack cocaine several times a week. Which assessment, it's made by the nurse, suggest that the client is in withdrawal? d. Pupils are dilated, appears diaphoretic
D
A parent brings the 4 month old infant to the clinic for diphtheria, tetanus toxoid, acellular pertussis (DTaP) and in activated polio vaccine (IPV) immunizations. Which statement indicates to the nurse if the parent understands when the child should return for the next DTaP? d. "My child will be cutting the two lower teeth when I bring my child back."
D
Immediately after a percutaneous liver biopsy, the nurse places the client in which position? d. Right side lying
D
The adolescent client had surgery yesterday for repair of a torn rotator cuff in the right shoulder. Although fentanyl 100 mcg intravenously is ordered every three hours PRN, the client has refused the medication since surgery. During morning rounds, the the nurse notes the client has teeth clenched and is diaphoretic. Which action does the nurse take first? d. Question the client, "Are you experiencing any pain?"
D
The client at 32 weeks gestation visits the healthcare provider. While the nurse palpates the woman's abdomen, the woman suddenly says, "I feel dizzy. I feel as if I'm going to faint." The nurse identifies which condition causes the clients response? d. Hypotensive syndrome causing a reduction in cardiac output
D
The client diagnosed with breast cancer receives tamoxifen citrate. The nurse identifies that tamoxifen has which action? d. Acts as an estrogen antagonist
D
The client diagnosed with rheumatoid arthritis receives a nursing diagnosis of "Activity intolerance related to fatigue." Which intervention it does the nurse include? d. Provide rest periods for the client between activities
D
The client has a radium implant for treatment of cervical cancer. Which intervention to the nurse implement? d. Keeps the unused linen in the room until the implant is removed
D
The client he was confused talks to the nurse about thoughts in relation to a fantasy world. Which action does the nurse take? d. Speaks to the client in simple sentences about present events
D
The client is they've reported victim of an assault. The police told the nurse they found the client is oriented, agitated, and wandering in a parking lot. Upon arrival in the emergency department (ED), the nurse observes that the client is calm and quiet. The nurse concludes the client's change in behavior is a result of which reason? d. At this time the client is in a state of denial
D
The client receives naproxen. The nurse teaches the client to report which most important symptom to the healthcare provider? d. Stomach pain in the afternoon
D
The healthcare provider asks the nurse to obtain a urine sample from a client with an indwelling catheter. To obtain the urine specimen, which action does the nurse take first? d. Clamps the catheter to being below the porthole
D
The healthcare provider orders neomycin for a client diagnosed with hepatic encephalopathy. The nurse understands which is the primary purpose of this treatment? d. Reduce bacterial production of ammonia in intestine and blood
D
The nurse assesses the client five hours after a right total knee arthroplasty. Which observation, it's made by the nurse, requires intervention? d. The continuous passive motion (CPM) Device flexes the clients right leg 90°
D
The nurse begins an intermittent IV infusion of penicillin that is to infuse over a 20 minute period. Which action can the nurse take while this medication infuses? d. Witness the signing of a consent form for a bronchoscopy
D
The nurse cares for a client six hours after he traditional cholecystectomy. It is most beneficial for the nurse to take which action before encouraging the client to cough and deep breathe? d. Administer analgesics as prescribed
D
The nurse cares for the adolescent diagnosed with orchitis. Which action is most important for the nurse to take? d. Elevate the scrotum on towels
D
The nurse cares for the adolescent undergoing peritoneal dialysis. The nurse infuses 2000 mL of dialysate solution. Later 1000 mL of solution returns. What action does the nurse take next? d. Turns the client from side to side
D
The nurse cares for the client after a left total hip arthroplasty. The client post operative orders include turning. To implement this order the nurse places the client in which position? d. Lying on the unoperated side with legs abducted
D
The nurse cares for the client after he traditional cholecystectomy. The T-tube drains 300 mL of greenish brown fluid. Which action does the nurse taken initially? d. Documents the description of the drainage from the T-tube
D
The nurse cares for the client diagnosed with a dramatic amputation of the left leg during automobile accident. The client frequently presses the call light without reason and makes angry remarks to the nursing staff. Which statement best explains the reason for the clients behavior? d. The client is responding to the change in body image
D
The nurse cares for the client diagnosed with a left tibia fracture. The client has a long - leg walking cast applied. Several hours later, the client states, "I can't feel my toes." It is most important for the nurse to take a which action? d. Check the skin temperature of the foot
D
The nurse cares for the client diagnosed with a right hip fracture being treated with bucks traction using a foam boot. The nurse observes and LPN/LVN replaced the phone boot after morning care. Which observation, it's made by the nurse, requires an intervention? d. The LPN/LVN attaches a weight to the spreader or footplate
D
The nurse cares for the client diagnosed with menopause. The client asks the nurse, "why is estrogen replacement therapy (ERT) given?" Which explanation by the nurse is most accurate? d. "Estrogen helps prevent the development of osteoporosis."
D
The nurse cares for the client diagnosed with right-sided pneumothorax. Which auscultation findings does the nurse hear? d. Reduction of breast sounds on the right side
D
The nurse cares for the client displaying confusion and agitation. As a nurse tries to admit the client to the unit, the client becomes more belligerent and agitated. The nurse takes which action? d. Approach is the client in a nonthreatening manner, and reduces environmental stimuli
D
The nurse cares for the client reporting retrosternal chest pain and shortness of breath. The blood pressure is 110/70 mm Hg; pulse rate 100 bpm and irregular; respirations 28 breaths/min. After attaching a cardiac monitor, which order does the nurse implement first? d. Administer oxygen per nasal prongs
D
The nurse changes the dressing on a client two days after a bowel resection. After opening a sterile pack and putting on the sterile gloves at the clients bedside, the nurse notes the dressing needed for the dressing change are missing. Which action does the nurse take next? d. Remains in place at the clients bedside while the nursing assistive personnel obtains the missing dressings, and then continues with the procedure
D
The nurse explains to a client why the healthcare provider has prescribed nitroglycerin. Which statement, it's made by the client to the nurse, demonstrates that the teaching was successful? d. "The medication will reduce my hearts workload."
D
The nurse plans care for an 18 month old child Buck's extension traction. Which action is most important for the nurse to perform? d. Complete thorough skincare every 2 hours
D
The nurse plans care for the client diagnosed with osteoporosis. The nurse recommends which exercise? d. Walking 1 mile daily
D
The nurse teaches a school age child and the parents about diabetes mellitus type I prior to discharge. The nurse tells the parents to take which action at the child suddenly becomes unconscious? d. Inject glucagon according to the package directions
D
The nurse teaches the client how to perform self monitoring blood glucose (SMBG) by using a blood glucose monitor. Which action, if performed by the client, indicates the teaching was successful? d. The client allows a large drop of blood to touch the test strip
D
The nurse teaches the client how to use a walker. Which observation, if made by the nurse, indicates that client is using the walker correctly? d. The client grasps the sides of the walker and stands between the back legs
D
The parent brings a five month old infant to the well baby clinic for a routine checkup. Which finding, if observed by the nurse is unexpected? d. The child has slight head lag when pulled to sitting position
D
The parent of a preschooler with a tracheostomy asks the nurse, "Why is my child section so frequently?" The nurses response is based on the knowledge that it is not as important to section the child when which situation occurs? d. The child's lung sounds are congested
D
The school nurse talks with a group of college students too will be traveling to an underdeveloped country on a field trip. The students expressed concerns about contracting hepatitis during the trip. Which statement, if may by student to the nurse, indicates that further teaching is necessary? d. "I shouldn't need any food I am unfamiliar with until I return."
D
1. The nurse cares for the client diagnosed as being in the manic phase of bipolar disorder. Which behavior indicates to the nurse the client condition is improving?
The client sits and eats with other clients on unit
8. During morning rounds, the client diagnosed with schizophrenia tells the nurse, "I know you are conspiring with my spouse to keep me locked away." Which statement by the nurse is the most appropriate? c. "I can see that you are frightened about being here but I am a nurse in a hospital."
c
