LPN Passpoint Mastery

A nurse is about to give a client with type 1 diabetes insulin before breakfast on her first day postpartum. Which statement by the client indicates an understanding of insulin requirements immediately postpartum? "I will need less insulin now than during my pregnancy." "I will need more insulin now than during my pregnancy." "I will need less insulin now than before I was pregnant." "I will need more insulin now than before I was pregnant."

"I will need less insulin now than before I was pregnant."

A nurse is teaching the proper use of crutches to a school-age child with a femur fracture with no weight bearing. What will the nurse include with teaching about walking with crutches?

"After advancing both crutches the length of one step, move your 'good' leg forward."

One hour before a client is to undergo abdominal surgery, the physician orders atropine, 0.3 mg I.M. Before administration of the medication, the nurse explains that the drug is given because of what reason? "Atropine decreases salivation and gastric secretions." "Atropine controls the heart rate and blood pressure." "Atropine improves ventilation by increasing the respiratory rate." "Atropine enhances the effect of anesthetic agents."

"Atropine decreases salivation and gastric secretions."

Which statement reflects appropriate documentation in the medical record of a hospitalized client?

"Client's skin is moist and cool."

The nurse is discussing sleep hygiene with the parents of a 9-year-old child who plays video games regularly. Which teaching(s) will the nurse provide? Select all that apply. "Create a ritualistic approach to bed time." "Keep the room at 67°F (19.4°C) or cooler." "Have your child turn the video game off right before going to bed." "Encourage reading before bed as a healthy way to rest the mind." "Allow the child to keep a smart phone at the bedside in case of emergencies."

"Create a ritualistic approach to bed time." "Keep the room at 67°F (19.4°C) or cooler." "Encourage reading before bed as a healthy way to rest the mind."

A client arrives at the clinic for a scheduled amniocentesis. Which question should the nurse ask? "Have you had at least 1 L of water to drink?" "Have you emptied your bladder?" "Did you fast for the last 12 hours?" "Do you have any problems lying on your left side?"

"Have you emptied your bladder?"

A client with bulimia nervosa asks a nurse, "How can I ask for help from my family?" Which response is most appropriate? "When you ask for help, make sure you really need it." "Have you ever asked your family for help in the past?" "Ask family members to spend time with you at mealtime." "Think about how you can handle this situation without help."

"Have you ever asked your family for help in the past?"

On admission to the inpatient psychiatric unit, a client's facial expression indicates severe panic. The client repeatedly states, "I know the police are going to shoot me. They found out that I'm the child of the devil." What is the nurse's best response to initiate a therapeutic relationship with the client?

"Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?"

A 3-year-old child with Down syndrome, admitted to the pediatric unit with asthma, does not enunciate words well and holds on to furniture when walking. What question would be appropriate for the nurse to ask the parent?

"How does your child's condition today differ from their normal condition?"

A client is admitted with acute chest pain. When obtaining the health history, which question would be most helpful for the nurse to ask?

"How would you rate your pain on a scale of one to ten, with ten being the worst pain imaginable?"

A nurse reinforce teaches a group of police officers about the spread of TB. Which statement by an officer indicates that teaching has been effective?

"I could get TB if I inhale infected droplets when an infected individual coughs."

The nurse is interviewing a client suspected of having colon cancer about his past medical history. Which statement by the client should the nurse report to the physician? "I take medications for a duodenal ulcer." "I have always had a problem with hemorrhoids." "I have gained about 5 pounds over the past year." "I had some polyps removed last time I had a colonoscopy."

"I had some polyps removed last time I had a colonoscopy."

A client with schizophrenia becomes angry and tells the nurse to leave. Which response by the nurse would be best? "I will leave now but will be back soon." "Is it okay if I sit quietly with you?" "Why do you want to be left alone?" "I won't let anything happen to you."

"I will leave now but will be back soon."

A young client develops a fever and rash and is diagnosed with rubella. The client's mother has just given birth to another child. Which statement by the mother best indicates that she understands the implications of rubella?

"I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my children."

The nurse reinforces home care instructions given to a client with a diagnosis of hiatal hernia. Which statement made by the client indicates an understanding of the instructions?

"I'll sleep with my head elevated about 3 to 4 inches."

A client was hospitalized and treated for acute diverticulitis. The nurse has reinforced discharge education. Which statement by the client indicates that the client understands the discharge instructions? "I'll reduce my fluid intake." "I'll decrease the fiber in my diet." "I'll take all of my antibiotics." "I'll exercise to increase my intra-abdominal pressure."

"I'll take all of my antibiotics."

A client of a homecare nurse gives the nurse an envelope with a small amount of money in it, stating, "It's a tip for the good care you give me." Which statement would be the most appropriate response from the nurse?

"I'm grateful that you're satisfied with the care you're receiving, but I can't accept any form of gift."

While shopping, a nurse meets a neighbor who asks about a friend receiving treatment at the nurse's clinic. What is the nurse's most appropriate response? "I'm sorry, I can't disclose client information." "It might be best if you discuss this with the client directly." "You should probably try to call your friend for an update." "I can only say your friend is stable and seems to be doing well."

"I'm sorry, I can't disclose client information."

Which statement by the mother of a toddler with nephrotic syndrome indicates that the nurse's discharge teaching was effective?

"I've been checking the urine for protein so I'll be able to do it at home."

The chart documentation of a client with paranoid personality disorder is listed below: 10/15 1830 The client stays by oneself as much as possible during the afternoon. The client paced the hallway at times and was irritated if approached by staff or other clients. The client questioned another male client and accused that client of lying. At the beginning of the shift the nurse spoke to the client accused of lying.Which statement, from the client accused of lying, would require further intervention? "Now I know not to trust or even speak to that person." "I do not know what his problem is, but I know it is his issue." "I'm upset, but I'm not doing anything to lose my privileges." "If I have an opportunity, I will not let him get away with this."

"If I have an opportunity, I will not let him get away with this."

The parents of a pregnant adolescent are outraged that they are being refused medical information about their daughter's condition. What is the best response by the nurse to address their anger?

"If we obtain permission from her, we can include you in our discussions."

An older adult client who has recently been diagnosed with hypothyroidism lives independently in an apartment in a community development designed for older adults. The client asks the nurse assigned to the complex for advice about managing this condition. What is the best response by the nurse?

"Increase fiber and fluids in your diet."

A nurse is reinforcing education to the parents of an 18-month-old infant diagnosed with bilateral otitis media about the prescribed medication amoxicillin and clavulanate potassium. Which statement by the parents indicates the education has been effective?

"It can cause diarrhea."

A previously toilet-trained 4-year-old child begins wetting the bed after being hospitalized. Which statement should a nurse make to the parents?

"It is normal for a child to start wetting the bed again when hospitalized."

The mother of a 3-day-old, breast-fed infant expresses concern that her infant has had two recent diapers that contained a lot of loose, yellowish stool. Which explanation by the nurse is best? "It's normal for breast-fed infants to pass three or more loose, yellow stools per day." "Please save the next diaper so the nurses can examine the stools." "New parents tend to worry too much. Infants have frequent stools." "Eliminating dairy products from your diet can help clear this up."

"It's normal for breast-fed infants to pass three or more loose, yellow stools per day."

During a well-baby visit, a toddler's parent states that the parent keeps all medications out of the toddler's reach in the kitchen cabinet. Which is an appropriate response by the nurse?

"Medications should be kept in a locked location."

A client is being discharged after an acute myocardial infarction (MI). The client asks why metoprolol was prescribed. What education does the nurse reinforce? "Metoprolol will increase the heart rate." "Metoprolol increases the blood supply to the heart by dilating your coronary arteries." "Metoprolol makes the heart beat stronger to supply more blood to the body." "Metoprolol slow the heart rate and decreases the amount of work it has, so it can heal."

"Metoprolol slow the heart rate and decreases the amount of work it has, so it can heal."

The nurse is obtaining information from a pregnant client who is at 38 weeks' gestation and believes that she is going into labor. Which statement made by the client should be immediately reported to the health care provider? "I had a previous miscarriage 4 years ago during my first trimester." "I have had indigestion during my pregnancy." "My membrane ruptured 2 days ago." "I expelled a mucous plug yesterday."

"My membrane ruptured 2 days ago."

During her fourth clinic visit, a client who is 5 months pregnant tells the health care provider she was exposed to rubella during the past week and asks whether she can be immunized now. How would the nurse expect the health care provider to respond? "Yes, I will order the rubella immunization for you." "No, because the live viral vaccine is contraindicated during pregnancy." "Yes, and you should consider pregnancy termination because rubella has teratogenic effects." "No, because the vaccine can be given only during the first trimester."

"No, because the live viral vaccine is contraindicated during pregnancy."

A client with a mild concussion reports a headache. When offered acetaminophen, the client asks for a stronger pain medication. Which response by the nurse is appropriate?

"Opioids are avoided after a head injury because they may hide a worsening condition."

The parents of an infant report they are concerned about giving their child immunizations due to their association with autism. Which response by the nurse is appropriate?

"Studies do not support a link between autism and immunizations."

A client with rheumatoid arthritis reports flatulence and heartburn after taking piroxicam. Which instruction should the nurse reinforce to address the client's concern?

"Take an antacid at the same time that you take the medication."

The nurse is caring for a client on a regimen of four medications to treat tuberculosis (TB). The nurse discovers that the client is not taking all of the prescribed medications. What is appropriate for the nurse to say to the client?

"Taking many medications can be difficult. Tell me about the difficulties you're having."

An adolescent who is 14 weeks pregnant comes to the clinic for a prenatal examination. During the examination, the client says to the nurse, "I'm still not sure if I want to keep my baby." Which response by the nurse is best? "I will have the social worker talk to you about adoption." "You will need to discuss this with your health care provider." "Tell me more about how you are feeling about the baby." "Tell me why you do not want to keep the baby."

"Tell me more about how you are feeling about the baby."

The mother of a neonate expresses concern about how she will continue to breastfeed when she returns to work in 6 weeks. Which response by the nurse would be best? "At least you will have breastfed for 6 weeks." "One or two bottles a day is fine." "Why do you think you have to stop when you go back?" "Tell me what you would like to do when you return to work."

"Tell me what you would like to do when you return to work."

An infection control nurse has identified a problem related to infection control procedures on a medical unit that has a high census of clients diagnosed with tuberculosis. The nurse has decided to conduct an in-service education program for the staff about the required transmission-based precautions. The nurse determines that the program was successful based on which statement by the staff?

"The client needs to be placed in a private, negative air pressure room."

The nurse is reinforcing education for the parents of a toddler with congenital heart disease. Which information should the nurse include when reinforcing education regarding care?

"Try to maintain your child's usual lifestyle to promote normal development."

The nurse is teaching a group of high school seniors about marijuana use. Which information will the nurse provide? "Use of marijuana is a stage that most teenagers will go through." "People who use marijuana typically don't use other illicit drugs." "Use of marijuana can lead to psychological dependence." "Marijuana is legal in certain states, which confirms that it is safe to use."

"Use of marijuana can lead to psychological dependence."

A client is prescribed a corticosteroid inhaler along with a bronchodilator inhaler. Which instruction about these drugs should the nurse give the client?

"Use the bronchodilator first, then wait about 5 minutes before using the corticosteroid."

The parents of a child who is dying of leukemia ask a nurse about the family participating in the care of the child. What would be the best response by the nurse?

"We encourage all members of the family to be as involved with the care as desired and comfortable."

At a wellness visit, the parents report that their daughter, age 4, resists going to bed at night. After instruction by the nurse, which statement by the parents indicates effective teaching?

"We'll read her a story and let her play quietly in her bed until she falls asleep."

The nurse is reinforcing discharge instructions for a client with varicose veins. Which statement by the client indicates a need for further instruction? "Exercise will make me feel better." "I have to elevate my legs." "Lying down can relieve my symptoms." "Wearing tight clothes won't affect me."

"Wearing tight clothes won't affect me."

A man found wandering in a local park is unable to state who or where he is or where he lives. He is brought to the emergency department, where his identification is eventually discovered. The client's wife states that he was diagnosed with Alzheimer's disease 3 years ago and has had increasing memory loss. She tells the nurse she is worried about how she'll continue to care for him. Which response by the nurse would be most helpful? "Because of the nature of your husband's disease, you should start looking into nursing homes for him." "What aspect of caring for your husband is causing you the greatest concern?" "You may benefit from a support group called Mates of Alzheimer's Disease Clients." "Do you have any children or friends who could give you a break from his care every now and then?"

"What aspect of caring for your husband is causing you the greatest concern?"

A pregnant client asks questions about labor and delivery. During the nurse's explanations, the client states, "Is it true that a lot of other people are going to be in the room while I'm giving birth? I was expecting privacy." Which response would be appropriate for the nurse to make to this client? "Didn't you know that many people get involved when someone has a baby?" "What did the health care provider tell you about the delivery room?" "You can ask anyone you don't want in the room to leave." "You won't even know they're there."

"What did the health care provider tell you about the delivery room?"

A client who sustained an L1 to L2 spinal cord injury in a construction accident asks a nurse if he'll ever be able to walk again. Which response by the nurse is appropriate?

"What has your physician told you about your ability to walk again?"

Accompanied by her partner, a client seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse ask her first? "Do you have any chronic illnesses?" "Do you have any allergies?" "What is your expected due date?" "Who will be with you during labor?"

"What is your expected due date?"

The nurse is preparing to admit a client who came to the delivery area in the company of her husband. The client states, "I am in labor and I attended the facility clinic for prenatal care." Which question should the nurse ask her first? "Do you have any chronic illnesses?" "Do you have any allergies?" "What is your expected due date?" "Who will be with you during labor?"

"What is your expected due date?"

The nurse is caring for a client with pernicious anemia. Which question by the nurse explains the potential source of the anemia?

"What type of diet do you follow?"

A pregnant client in the first trimester comes to the clinic. During the visit, the client says, "My husband is so excited, but I'm worried because I'm not feeling the same way. Does this mean that I will be a bad mother?" Which response by the nurse would be most appropriate?

"What you're feeling right now is entirely normal for where you are at this stage."

A nurse is caring for a client who is a hospital employee. The client is diagnosed with genital herpes and is being treated for a urinary tract infection (UTI). A coworker asks the nurse about how the client is doing. What is the nurse's best response?

"Would you like me to let the client know you said hello?"

A client's spouse, severely upset over the client's condition and lack of improvement, reports feeling powerless. Which response by the nurse is best?

"Would you like to help with some comfort measures for your spouse?"

A 37-week gestation client is on bed rest for gestational hypertension. The nursing student and nurse are visiting the client in her home and need to perform external fetal monitoring (EFM). The student nurse asks the nurse if the student nurse is allowed to perform this skill. What is the nurse's most appropriate response? "Yes, but only after you read about the procedure in the regional policy and procedure manual." "No, as per policy, you need to demonstrate this skill successfully in the hospital setting first." "Yes, but I will demonstrate it once and then supervise you while you perform the procedure." "No, only certified registered nurses can perform this skill."

"Yes, but I will demonstrate it once and then supervise you while you perform the procedure."

The nurse is approached by the mother of a child with hypospadias. She says to the nurse, "Why did this have to happen to my baby? Why couldn't he be perfect? How could this have happened?" What should the nurse say in response?

"You seem upset. Tell me about it."

A client received chemotherapy 24 hours ago. Which precautions are necessary when caring for this client? Wearing sterile gloves Placing incontinence pads in the regular trash can Wearing personal protective equipment when handling blood, body fluids, or feces Using a urinal or bedpan to decrease the likelihood of soiling linens

Wearing personal protective equipment when handling blood, body fluids, or feces

The nurse is gathering data from a client that arrives in the clinic with generalized anxiety disorder (GAD). What statement made by the client does the nurse determine correlates with this diagnosis?

"I worry about things all of the time that I have no control over."

A nurse is reinforcing education for a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates that education has been effective?

"I'll eat plenty of fruits and vegetables."

A client receiving chemotherapy reports decreased energy leading to boredom from a lack of activity. Which statement by the client indicates an understanding of appropriate ways to deal with this lack of diversional activity?

"I'll play card games with my friends."

A 15-year-old girl visits the neighborhood clinic seeking information on how to prevent pregnancy. How should the nurse respond to her request?

"What precautions are you taking now when you have sex?"

A client reports experiencing vulvar pruritus. Which finding may indicate that the client has an infection caused by Candida albicans?

Cottage cheese-like discharge

A nurse is assigned to care for a client in skeletal traction for the treatment of a left femur fracture. Which nursing intervention should the nurse include in this client's care?

Encourage the use of isometric exercise.

The nurse is providing care to a pregnant adolescent client in the first trimester. Which intervention would the nurse identify as the highest priority? Schedule the client for a screening glucose tolerance test. Make sure the client receives nutritional counseling and reinforce the education. Teach the client that there is increased risk for having a macrosomic neonate. Monitor the client for signs and symptoms of placenta previa.

Make sure the client receives nutritional counseling and reinforce the education.

An adolescent client is hospitalized with anorexia nervosa. What data support a nursing diagnosis of disturbed body image?

The client expresses a fear of overeating at meals.

Which finding is considered normal in the neonate during the first few days after birth? Weight loss of 25% Birth weight of 4½ to 5½ lb (2,000 to 2,500 g) Weight loss, then return to birth weight Weight gain of 25%

Weight loss, then return to birth weight

A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects which medication to be administered to the client? antibiotic anticoagulant antihypertensive anticonvulsant

anticoagulant

One hour after receiving pyridostigmine, a client reports difficulty swallowing and excessive respiratory secretions. The nurse notifies the health care provider and prepares to administer which medication?

atropine

Following a liver transplant a client develops ascites. The nurse should teach the client to:

brace the abdomen with a pillow during coughing.

The diaphragm of the stethoscope is typically placed over which artery to obtain a blood pressure measurement? brachial brachiocephalic radial ulnar

brachial

A nurse is preparing to administer a medication to a client. Which method is best for verifying the client's identity?

check the client's identification bracelet

The client is being evaluated for hypothyroidism. The nurse should stay alert for:

decreased body temperature and cold intolerance.

During which phase do coronary arteries primarily receive blood flow? cardiac standstill diastole expiration systole

diastole

The nurse observes that a comatose client's response to painful stimuli is decerebrate posturing. The client exhibits extended and pronated arms, flexed wrists with palms facing backward, and rigid legs extended with plantar flexion. Decerebrate posturing as a response to pain indicates:

dysfunction in the brain stem.

A client newly diagnosed with type 2 diabetes is admitted to the metabolic unit for treatment initiation and education. Which information should the nurse reinforce to this client as a goal for treatment?

exercise and a weight-reduction diet

A client has developed compartment syndrome from full thickness burns on both arms. What treatment will the nurse prepare the client for?

fasciotomy

A 17-weeks' pregnant client comes to the clinic for a well visit. When determining maternal and fetal well-being, which data collection findings by the nurse are most important? Select all that apply. signs of orthostatic hypotension fetal heart rate the client's acceptance of the growing fetus presence of Braxton Hicks contractions fetal activity

fetal heart rate fetal activity

A health care provider tells a client to return 1 week after treatment to have a repeat culture done to verify the cure. This order would be appropriate for a woman with which condition?

gonorrhea

A nurse is transferring a client from a bed to a chair. Which action should the nurse take during client transfer?

help the client dangle the legs

A client with bulimia nervosa tells a nurse that their parents do not know about the eating disorder. Which goal is appropriate for this client and family? decreasing the chaos in the family unit learning effective communication skills spending time together in social situations discussing the client's need to be responsible

learning effective communication skills

A client who has just delivered a full-term baby tells the nurse that sudden infant death syndrome (SIDS) is a big fear. When reinforcing education the mother about SIDS, which factor does the nurse identify as being associated with SIDS?

low birth weight

A nurse in a family health clinic is caring for a client with anemia. What education does the nurse reinforce?

needs to have activities spaced to allow for rest periods

A newly hired graduate nurse and nurse mentor are discussing cardiac disease and its modifiable risks factors. The mentor knows the discussion was effective when the graduate nurse lists which factors as being modifiable? age and gender ethnic background family history of heart disease obesity and smoking

obesity and smoking

A client with depersonalization/derealization disorder spends much of the day in a dreamlike state, ignoring personal care needs. What situation is this behavior most likely related to? organic brain damage impaired memory perceptual impairment lack of information

perceptual impairment

When collecting data on a neonate, which finding would the nurse identify as expected? doll eyes "sunset" eyes positive Babinski sign pupils that don't react to light

positive Babinski sign

A client is diagnosed with disseminated intravascular coagulation (DIC) postpartum. The nurse recognizes that DIC may be related to which antepartum complication? severe pre-eclampsia urinary retention Rhogam administration fetal decelerations

severe pre-eclampsia

Which nursing data should be given the highest priority for a child with clinical findings related to tubercular meningitis?

signs of increased intracranial pressure (ICP)

A child is admitted to the pediatric unit with a fractured hip. The physician orders Russell traction. This type of traction is:

skin traction applied to a lower extremity, with the extremity suspended above the bed.

The nurse is caring for a post-op client following the removal of right cataract. What is the best position for the client after surgery?

supine

When gathering data on a preschool child, which observation indicates that a child has a potential Wilms tumor?

swelling within the abdomen

The nurse is instructing a client with newly diagnosed hypoparathyroidism about the regimen used to treat this disorder. The nurse should state that the physician probably will prescribe daily supplements of calcium and:

vitamin D.

The mother of a child with chickenpox (varicella) asks the nurse when her child may return to school. The nurse responds correctly by telling the mother that the child can return:

when all of the lesions are crusted over.

When explaining to the parents the optimal time for repair of hypospadias, the nurse should indicate which as the age of choice?

6 to 18 months

A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further?

cool, pale fingers

What should the nurse do to ensure a safe hospital environment for a toddler?

Move the equipment out of reach.

A nurse is caring for a client with pneumonia. When gathering data, which finding does the nurse anticipate?

crackles

A client lives with a parent and the client's three children. Which type of family does this describe?

extended

The nurse prepares to discharge a postoperative client with antiembolism stockings to help prevent deep vein thrombosis (DVT). Which information should the nurse provide to this client?

"Put the stockings on before you get out of bed each day."

The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for? Actinic Asymmetry Arcus Assessment

Asymmetry

When collecting data on a child with juvenile hypothyroidism, the nurse expects which finding?

Goiter

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?

Notify the physician.

Which of the following laboratory values supports a diagnosis of pyelonephritis?

Pyuria

An elderly client is admitted to an acute care facility with influenza. The nurse monitors the client closely for which most common complication of influenza?

Pneumonia

A nurse is assisting with testicular cancer screening. Which client has the highest risk of developing testicular cancer?

a 28-year-old

A child fell at camp and sustained a bruise to the thigh. Which description would accurately describe the bruise after 1 week?

greenish yellow

The nurse is reinforcing education for a client regarding back safety. Which response by the client indicates the education was effective?

"I'll carry objects close to my body."

A nurse is accompanying a client to the mall to do some shopping. A neighbor of the nurse approaches and tries to engage the nurse in conversation. What would be the most appropriate response by the nurse to the neighbor?

"Now is not a good time to talk. I will telephone you later."

The nurse reinforces information about self-detection for cancer to a group of adolescent male clients. Which statement made by one of the participants indicates that the client understands the information?

"The best time to check for testicular changes is after a warm bath."

A client with dissociative amnesia says, "You must think I'm really stupid because I have no recollection of the accident." Which response would be most appropriate? "Why would I think you're stupid?" "Have I acted like I think you're stupid?' "You'll be fine soon. Don't worry about it." "The brain sometimes protects us by not letting us remember traumatic events."

"The brain sometimes protects us by not letting us remember traumatic events."

The parent of an adolescent diagnosed with Legg-Calvé-Perthes disease (LCPD) asks the nurse, "What caused this condition?" Which nursing response is appropriate?

"The hip joint has been damaged due to lack of blood supply."

A client is receiving pilocarpine eye drops. Which statement made by the client shows correct understanding of the medication?

"The medication will help decrease pressure in my eyes."

A client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region, which radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. The nursing instructor asks the student where is the common formation site? How should the student reply?

"The most common renal calculi formation site is the kidney."

The newly-hired nurse is monitoring a client for adverse reactions during barbiturate therapy. The nurse preceptor asks what is the major disadvantage of barbiturate use. What is the best response by the newly-hired nurse?

"There is a potential for drug dependence with barbiturates."

The nurse is helping a client with a terminal illness understand advance directives. Which statement by the client demonstrates an understanding of these documents?

"They guide the client's treatment in certain health care situations."

A parent expresses concern over a toddler's eating habits, stating the toddler eats very little and consumes only a single type of food for weeks on end. Which instruction is most appropriate?

"This is normal toddler behavior."

A client with end-stage cardiomyopathy wants to be considered for a heart transplant but the healthcare provider is concerned that the client and family will not be able to adhere to the required lifestyle alterations. Which response should the nurse make that demonstrates client advocacy? "The spouse can help the client with smoking cessation." "With proper support, the client could make the necessary changes." "It is not easy to make and maintain these kinds of changes." "The client knows that death is imminent without a transplant."

"With proper support, the client could make the necessary changes."

A client in the final stages of terminal cancer tells the nurse: "I wish I could just be allowed to die. I'm tired of fighting this illness. I have lived a good life. I continue my chemotherapy and radiation treatments only because my family wants me to." What is the nurse's best response? "Would you like to talk with a psychologist about your thoughts and feelings?" "Would you like to talk with your minister about the significance of death?" "Would you like to meet with your family and your healthcare provider about this matter?" "I'll contact the healthcare provider to cancel your treatments."

"Would you like to meet with your family and your healthcare provider about this matter?"

A client on an inpatient psychiatric unit is pacing up and down the hallway. The client has a history of aggression. Which comment made by the nurse would be the most appropriate?

"You are pacing. Let's walk together and talk about it."

A school-age child needs an I.V. catheter inserted for administration of I.V. fluids. Which explanation by the nurse empowers the client to deal effectively with the procedure?

"You can help by keeping your arm as still as a tree."

A young adult was told that he had a significant reaction to the Mantoux test. The client asks the nurse what is the meaning of this significant reaction. How does the nurse appropriately respond?

"You have been exposed to tuberculosis."

A client who has just been diagnosed with hepatitis A asks, "How could I have gotten this disease?" What is the nurse's best response?

"You may have eaten contaminated restaurant food."

The nurse is preparing a client for chemotherapy to treat colon cancer. The client says, "I don't know about this treatment. After everything is said and done, it may not do a bit of good. This thing may get me anyway." Which response by the nurse would be most therapeutic?

"You're wondering whether you've made the right decision about the treatment."

A client is brought to the crisis unit by the police after having escaped unharmed from an apartment fire caused by the client smoking in bed. The nurse observes the client sitting silently, almost motionless. Which response by the nurse would be best?

"You've been through a very difficult experience. Let's move to a quiet area so we can talk."

The nurse is obtaining the history of a pediatric client, age 4. Which area usually takes longer to evaluate in a child than in an adult?

Developmental status

A client with suspected lung cancer is scheduled for thoracentesis as part of the diagnostic workup. The nurse reviews the client's history for conditions that might contraindicate this procedure. Which condition is a contraindication for thoracentesis? A seizure disorder Chronic obstructive pulmonary disease Anemia A bleeding disorder

A bleeding disorder

A nurse is caring for a client who required chest tube insertion for pneumothorax. To confirm pneumothorax resolution, what should the nurse anticipate the client will require?

A chest X-ray

The nurse just received the shift report on her group of clients. Based on the information she received, which client should she assess first?

A client who underwent a right nephrectomy yesterday and is complaining of pain

A nursing assistant is assisting a nurse with feeding clients. Which client should the nurse assign to the nursing assistant?

A client with bilateral blindness

A 4-year-old child had a subungual hemorrhage of the toe after a jar fell on the foot. Which statement regarding the rationale for using electrocautery to treat the injury is most accurate?

It's used to relieve pain and reduce the risk of infection.

Which of the following describes a preterm neonate? A neonate weighing less than 2,500 g (5 lb, 8 oz) A low-birth-weight neonate A neonate born at less than 37 weeks' gestation regardless of weight A neonate diagnosed with intrauterine growth retardation

A neonate born at less than 37 weeks' gestation regardless of weight

The nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents?

A new cast is needed every 1 to 2 weeks.

A child is brought to the emergency department with life-threatening bleeding that needs immediate intervention. The child's parents cannot be reached to give consent. The nurse continues to assist with the child's care based on which understanding about consent?

Consent is not needed in a life-threatening situation.

When administering gentamicin to a preschooler, which of the following monitoring schedules is best for determining the drug's effectiveness?

A serum trough and peak level with the third dose

The charge nurse is making client care assignments. Which client is most appropriate for a licensed practical nurse?

A stable 6-month-old infant with pneumonia

Since admission 4 days ago, a client has refused to take a shower, stating, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which action is most appropriate? Dismantle the showerhead, and show the client that there is nothing in it. Explain that other clients are reporting that the client has body odor. Ask a security officer to assist in giving the client a shower. Accept the client's fears, allowing the client to take a sponge bath.

Accept the client's fears, allowing the client to take a sponge bath.

A school-age client reports pain. After rating the pain on an age-appropriate pain scale, the nurse determines that the client's pain is minor. Which of the following drugs should the nurse administer?

Acetaminophen

Which intervention does the nurse educator include in his or her preparation as an example of primary prevention?

Administering a measles, mumps, and rubella immunization to an infant

A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should include which measure?

Administering large doses of I.V. antibiotics as prescribed

The nurse is teaching the client about risk factors for diabetes mellitus. Which risk factor for diabetes mellitus is nonmodifiable?

Advanced age

When gathering data on a preschool-age child, the nurse finds multiple contusions over the body. Which statement indicates the findings that should be documented?

All lesions, including location, shape, and color, should be documented.

A 2-year-old is brought to the emergency department with suspected croup. The child appears frightened and cries as the nurse approaches. The nurse needs to auscultate the child's breath sounds. What is the most appropriate way for the nurse to approach the child?

Allow the child to handle the stethoscope before listening to the lungs.

Which situation demonstrates correct principles of confidentiality?

An emergency department nurse reports suspected child abuse.

An infant who has been in foster care since birth requires a blood transfusion. Who will the nurse approach to give written, informed consent for the procedure?

An infant who has been in foster care since birth requires a blood transfusion. Who will the nurse approach to give written, informed consent for the procedure?

A 10-year-old child falls, injures the left shoulder, and is taken to the emergency department. While the child waits to be seen by the primary health care provider, what is the priority nursing action?

Apply ice to the injured shoulder.

The client calls the nurse in the clinic and states that the cast feels very rough around the edges and is scratching the skin. What is the best response by the nurse?

Apply moleskin or pink tape around the edges.

A client with schizophrenia reports that hallucinations have decreased in frequency. Which intervention would be appropriate to begin addressing the client's problem with social isolation? Suggest that the client stay away from group activities. Name the client the leader of the client support group. Suggest that the client play solitaire. Ask the client to participate in a group sing-along.

Ask the client to participate in a group sing-along.

A client with left hemiparesis is having difficulty swallowing a potassium chloride 20 mEq tablet. What should the nurse do?

Ask the health care provider for an order to administer a different consistency through a different route.

A 2-month-old with a history of hydrocephalus is admitted to the pediatric unit with pneumonia. The infant's respiratory status deteriorates and the physician explains to the family that the infant requires intensive care. The grandmother convinces the parents to refuse transfer and institute comfort measures. Which action should the nurse take?

Ask to speak to the parents privately without the grandmother present.

A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply. Assist the client to the floor. Turn the client to the side. Place a pillow under the client's head. Give the prescribed dose of oral phenytoin. Insert an oral suction device to remove secretions in the mouth.

Assist the client to the floor. Turn the client to the side. Place a pillow under the client's head.

The parent of a 6-month-old infant with atopic dermatitis asks for advice on bathing the child. Which instructions or information should the nurse give to the parent?

Bathe the infant every other day.

The nurse is about to give a full-term neonate his first bath. Which of the following should the nurse do first? Bathe the neonate only after his vital signs have stabilized Clean the neonate with medicated soap Scrub the neonate's skin to remove the vernix caseosa Wash the neonate from feet to head

Bathe the neonate only after his vital signs have stabilized

An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant?

Bulb syringe with tubing

An older adult client has experienced an episode of acute pulmonary edema. Fearful of a repeat episode, the client asks what precautions should be taken to prevent another episode. What instruction should the nurse give to this client? Limit calorie intake. Restrict carbohydrates. Measure weight twice per day. Call the health care provider if he gains more than 3 lb (1.4 kg) in 1 day.

Call the health care provider if he gains more than 3 lb (1.4 kg) in 1 day.

The nurse is caring for a client diagnosed with a cerebral aneurysm, who reports a severe headache. Which action should the nurse perform first?

Call the physician immediately.

The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? Change the client's position. Prepare for emergency cesarean section. Check for placenta previa. Administer oxygen.

Change the client's position.

A client who underwent abdominal surgery 2 hours ago reports abdominal pain and feeling "full and uncomfortable." Which action should the nurse perform first?

Check the patency of the nasogastric (NG) tube.

A nurse is monitoring a client receiving intravenous (IV) fluid via pump. The alarm of the pump starts to beep for occlusion. What should the nurse do first?

Check the roller clamp.

The nurse is caring for a terminally ill school-age child. Which resource might be most helpful in caring for this child?

Child life specialist

The nurse is documenting in the client's health record. Which information is most appropriate for the nurse to record as objective data? Select all that apply. Client seems to be very depressed. Client's blood pressure is 120/80 mm Hg; pulse 76 bpm; respirations 14 breaths/min. Client's dressing is intact with scant amount of serous drainage. Client ambulated to end of hallway. Client appeared angry and belligerent all shift.

Client's blood pressure is 120/80 mm Hg; pulse 76 bpm; respirations 14 breaths/min. Client's dressing is intact with scant amount of serous drainage. Client ambulated to end of hallway.

A nurse on the orthopedic floor is caring for a group of clients who are in various stages of recovery after knee replacement surgery. One client is ready for discharge. How should the nurse proceed with discharge planning?

Complete the discharge instructions for the client who is being discharged, and allow time for him to ask questions.

An actively laboring client who is 6 cm dilated and who attended natural childbirth classes asks the nurse for pain medication. What is the most appropriate action by the nurse? Remind the client that she wanted a natural childbirth. Contact the health care provider for pain medication. Engage the client in distraction techniques. Remind client that pain medication is given prior to pushing.

Contact the health care provider for pain medication.

A client is being discharged from the hospital after a total hip replacement. The physician has ordered home health services for the client. What's the most appropriate action for the nurse to take?

Contact the home health agency and provide a report of the client's condition and needs.

A nurse is observing the external fetal monitoring strip (shown) of a client who is in labor. Which nursing interventions should the nurse implement? Increase the IV fluid rate to boost intravascular volume. Continue to monitor the fetal heart rate. Elevate the client's legs. Call the health care provider.

Continue to monitor the fetal heart rate.

A client has a nasogastric (NG) tube. The physician prescribes an oral medication that is not available in liquid form. Which action should the nurse utilize to administer the tablet form to this client?

Crush the tablets and prepare a liquid form, and then insert it into the NG tube using a syringe.

A pregnant client comes to the facility for her first prenatal visit. When providing teaching, the nurse should be sure to cover which topic? Labor techniques Danger signs during pregnancy Signs and symptoms of pregnancy Tests to evaluate for high-risk pregnancy

Danger signs during pregnancy

A client with a fluid volume deficit is receiving an I.V. infusion of dextrose 5% in water and lactated Ringer's solution at 125 ml/hour. Which data collection finding indicates the need for additional I.V. fluids?

Dark amber urine

For a client with cardiomyopathy, the highest priority nursing diagnosis is: Decreased cardiac output related to reduced myocardial contractility. Excess fluid volume related to fluid retention and altered compensatory mechanisms. Ineffective coping related to fear of debilitating illness. Anxiety related to actual threat to health status.

Decreased cardiac output related to reduced myocardial contractility.

A client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs?

Decreased hearing acuity

The health care provider prescribes a digoxin elixir for a toddler with heart failure. What action should the nurse take first before administering this drug?

Determine the apical pulse.

A nurse is preparing to administer ferrous sulfate to a client. What is the nurse's appropriate action?

Dilute with juice and administer through a straw.

A client tells the nurse that she doesn't want to sign the hepatitis B vaccination consent form because she heard that, "vaccinations can cause autism." What's the most appropriate nursing interaction? Telling the client that such information hasn't been substantiated Supporting the client's decision because all vaccines have associated risks Encouraging the client to discuss the issue with the pediatrician at the infant's 2-week check-up Discussing the purpose of the vaccine and providing the client with written information

Discussing the purpose of the vaccine and providing the client with written information

A client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?

During early pregnancy, herpes simplex infection may cause spontaneous abortion or premature birth.

A 76-year-old client is admitted to a long-term care facility with Alzheimer's-type dementia. The client has been wearing the same dirty clothes for several days. The nurse contacts the family and asks them to bring in clean clothing. Which intervention would best prevent further regression in the client's personal hygiene? Encouraging the client to perform as much self-care as possible Making the client assume responsibility for physical care Assigning a staff member to take over the client's physical care Accepting the client's desire to go without bathing

Encouraging the client to perform as much self-care as possible

The child of an alert and oriented elderly client asks what parent's most recent blood glucose level was. What is the nurse's best response?

Explain that this information cannot be disclosed without the client's permission.

Encouraging children to engage in fantasy play and participate in their own care is a useful developmental approach for which pediatric age-group?

Preschool age (3 to 5 years)

The nurse is caring for a client scheduled for surgery who, on the morning of the scheduled operation, states a desire to cancel it. What would be the best response by the nurse?

Explore reasons why the client wishes to cancel the surgery, clarify concerns, and reinforce that there can be a change.

A 1-month-old infant is admitted to the pediatric unit and diagnosed with bacterial meningitis. Which findings by the nurse support the diagnosis?

fever, change in feeding pattern, vomiting, or diarrhea

At a previous visit, the parents of an infant with cystic fibrosis received instruction in the administration of pancrelipase. At a follow-up visit, which finding suggests the need for further teaching?

Fatty stools

A client is admitted with Meniere disease. Which instruction should the nurse reinforce in client teaching?

Get up slowly, turning the entire body.

A 4-year-old child has a tick embedded in the scalp. Which method should the nurse use to remove the tick?

Grasp the tick with tweezers and apply slow, outward pressure.

An adolescent is diagnosed with iron deficiency anemia. After emphasizing the importance of consuming dietary iron, the nurse asks the child to select iron-rich breakfast items from a sample menu. Which selection demonstrates knowledge of dietary iron sources?

Ham and eggs

The nurse is caring for a child whose mother is deaf and untrusting of staff. She frequently cries at the bedside, but refuses intervention from the social worker or the chaplain. Which issue is most important for the nurse to address with the mother to promote a trusting relationship?

communication barriers between the mother and staff

Which of the following would be an effective relaxation strategy for a school- age child to use during a painful procedure?

Having the child take a deep breath and blow it out until told to stop

A client with a history of atrial arrhythmia is receiving propranolol, 10 mg by mouth three times per day. The nurse knows that propranolol inhibits the action of sympathomimetics at beta1-receptor sites. Where are these sites mainly located? Uterus Blood vessels Bronchi Heart

Heart

A child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to his mother. Which data should the nurse obtain first?

Heart rate, respiratory rate, and blood pressure

A client who was casted for a recent fracture of the right ulna reports severe pain, numbness, and tingling of the right arm. What would be the nurse's most appropriate response?

Immediately report the client's symptoms.

After receiving an oral dose of codeine for an intractable cough, the client asks the nurse, "How long will it take for this drug to work?" How should the nurse respond?

In 30 minutes

After a stroke, a client develops aphasia. The nurse expects to observe which data collection finding in this client?

Inability to speak clearly

A nurse is reinforcing education for a client with a family history of atherosclerosis. To decrease the risk of atherosclerosis, what should the nurse encourage the client to do? Avoid focusing on weight. Increase activity level. Follow a regular diet. Maintain a high-stress lifestyle.

Increase activity level.

Which documentation is most important when preparing a preschool-age child for surgery?

Informed consent

A client in the early stage of labor states that she has a thick, yellow discharge from both of her breasts. Which action by the nurse is most appropriate? Telling her that her milk is starting to come in because she is in labor Completing a thorough breast examination and documenting the results in the medical record Obtaining a specimen of the discharge for culture and telling the client that she might have mastitis Informing the client that the discharge is colostrum, which is a normal finding

Informing the client that the discharge is colostrum, which is a normal finding

A severely dehydrated teenager admitted to the hospital with hypotension and tachycardia undergoes evaluation for electrolyte disturbances. Her history includes anorexia nervosa and a 20-lb (9.1-kg) weight loss in the last month. She is 5' 7" (1.7 m) tall and weighs 80 lb (36.3 kg). Which nursing intervention that takes highest priority would the nurse implement? Initiating caloric and nutritional therapy as ordered Instituting behavioral modification therapy as ordered Addressing the client's low self-esteem Developing a contract with the client that permits privileges with weight gain

Initiating caloric and nutritional therapy as ordered

A 9-year-old child is being discharged from the hospital after severe urticaria caused by an allergy to nuts. Which instructions would be included in discharge education for the child's parents?

Instruct parents and child on how to use an epinephrine administration kit.

The nurse is reinforcing education for the parents of a child that has been diagnosed with celiac disease. To help promote a normal life for the child, which intervention should the nurse reinforce for the parents to use?

Introduce the child to a peer with celiac disease.

The parent of an adolescent who is going to camp during the summer expresses concern about a recent outbreak of methicillin resistant staphylococcus aureus (MRSA) at the camp. What education can the nurse reinforce in order to help with prevention of this infection? Select all that apply. Request a prescription for an antibiotic prior to going. Use an antibiotic ointment prophylactically on skin. Keep cuts and scrapes clean and covered. Wash hands with soap and water regularly. Avoid sharing towels and razors with others.

Keep cuts and scrapes clean and covered. Wash hands with soap and water regularly. Avoid sharing towels and razors with others.

The nurse is assisting with the care of a neonate born to a mother with type 1 diabetes. When gathering data on the neonate, the nurse would suspect that the neonate is experiencing hypoglycemia based on which finding?

Lethargy

An adolescent, age 17, with acute lymphoblastic leukemia is discharged with written information about chemotherapy administration and the outpatient appointment schedule. The child now is in the maintenance phase of chemotherapy but has missed clinic appointments for blood work and admits to omitting some chemotherapy doses. To improve the client's compliance, the nurse should include which intervention in the plan of care?

Letting the client participate in the planning and scheduling of treatments

A client is diagnosed with prehypertension. Which of the following would most likely be included in the client's treatment plan? Diuretics Lifestyle modification instructions Beta-adrenergic blockers Angiotensin-converting enzyme (ACE) inhibitors

Lifestyle modification instructions

The nurse is caring for a client with bronchogenic carcinoma. Which nursing interventions are essential in the care of the client receiving a chemotherapeutic regimen? Select all that apply. Maintain a patent airway. Alleviate anxiety by explaining procedures and care delivery. Ensure that the client eats three full meals per day. Instruct the client on signs and symptoms of infection. Reassure the client that everyone does well with the regimen.

Maintain a patent airway. Alleviate anxiety by explaining procedures and care delivery. Instruct the client on signs and symptoms of infection.

A hospitalized client, with a productive cough, chills, and night sweats is suspected of having active tuberculosis (TB). What is the nurse's most important intervention?

Maintain the client on respiratory isolation

An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most appropriate for this child?

Maintaining a consistent, structured environment

Which intervention is the most critical for a client with myxedema coma?

Maintaining a patent airway

A 4-year-old girl has a urinary tract infection (UTI). When teaching the parents how to help her avoid recurrent UTIs, the nurse should emphasize which preventive measure?

Making sure she avoids bubble baths

A client in the third stage of labor delivers the placenta and the fundus is noted at 1 to 2 cm above the umbilicus. Which initial nursing action should the nurse take next? Massage the fundus. Give methergine orally. Perform vaginal examination. Obtain vital signs

Massage the fundus.

A client in the third stage of labor delivers the placenta and the fundus is noted at 1 to 2 cm above the umbilicus. Which initial nursing action should the nurse take next? Massage the fundus. Give methergine orally. Perform vaginal examination. Obtain vital signs.

Massage the fundus.

When assisting to plan nursing care to maintain skin integrity for an adult female bed-bound client, which interventions should the nurse include? Select all that apply. Apply a pleasantly scented dusting powder to the axillae and groin, beneath the breasts, and between the toes. Monitor the skin for breakdown daily during client's bath. Apply deodorant or antiperspirant immediately after shaving under the arms. Keep skin clean and dry to prevent breakdown. Always use alcohol for back rubs. Turn and reposition the client every two hours.

Monitor the skin for breakdown daily during client's bath. Keep skin clean and dry to prevent breakdown. Turn and reposition the client every two hours.

For which adverse reaction should the nurse monitor a client during the initial phase of lithium carbonate therapy? Anemia Dehydration Nausea and vomiting Decreased cerebral perfusion

Nausea and vomiting

A client who's taking antipsychotic medication develops a very high temperature, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. The nurse suspects what severe complication of antipsychotic therapy? Agranulocytosis Thrombocytopenia Anticholinergic effects Neuroleptic malignant syndrome (NMS)

Neuroleptic malignant syndrome (NMS)

A nurse is caring for a client with multiple sclerosis. The client informs the nurse that a lawyer is coming to prepare a living will and requests the nurse to sign as witness. Which action should the nurse take?

Note that the nurse caring for the client cannot be a witness.

A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first?

Notify hospital security or the local authorities.

A nurse is seen accessing a client's medical record in an area where she doesn't provide care. Which action by the nurse is best?

Notify the charge nurse and nursing supervisor of the incident.

When caring for a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should take which of the following actions? Prepare for epidural anesthesia Prepare for catheterization Start IV infusion of 0.9% normal saline Notify the obstetrician

Notify the obstetrician

The nurse is monitoring a client, who is six hours post embolectomy, for an acute arterial occlusion of the left leg. When a Doppler ultrasound fails to detect a pedal pulse, the nurse notifies the surgeon who requests that the client be prepared for immediate surgery. The client refuses to consider additional surgery. What is the nurse's initial intervention? Reinforce the risks of not having the surgery Notify the provider immediately Notify the nursing supervisor Record the client's refusal in the nurses' notes

Notify the provider immediately

A nurse reporting for the scheduled shift finds an assignment that includes the nurse's aunt, who was admitted during the night with a fractured hip. What should the nurse do in response to the client assignment?

Notify the supervisor and provide care until another nurse can be assigned to the client.

A child is diagnosed with diabetes insipidus has developed a viral illness including congestion, nausea, and vomiting. What instructions should the nurse reinforce?

Obtain an alternate route for desmopressin acetate administration.

A client is diagnosed with a conductive hearing loss. After performing the Weber's test, where will the nurse document that this client heard sounds?

On the affected side by bone conduction

The nurse mentor is observing a newly hired nurse while she performs a head-to-toe assessment. The mentor knows the newly hired nurse is effective in evaluating a client's posterior tibial pulse when she palpates which area?

On the inner aspect of the ankle, below the medial malleolus

A client seeks care for low back pain of 2 weeks' duration. Which data collection finding suggests a herniated intervertebral disk?

Pain radiating down the posterior thigh

A nurse is providing postoperative care for a client recovering from abdominal surgery. The client is receiving morphine through a patient-controlled analgesia pump. Which finding indicates that the client is obtaining adequate pain relief?

Pain rating of 2 or 3 on a scale of 0 to 10

The nurse is formulating a short-term goal for a client suffering from a severe obsessive-compulsive disorder (OCD). Which of the following appropriate short-term goals will the nurse expect the client to exhibit after one week?

Participate in a daily exercise group

A client diagnosed with renal calculi is experiencing severe pain despite having received pain medication. A nurse pages a physician. Which intervention can the nurse perform while awaiting the physician's response?

Perform nonpharmacologic pain interventions.

A nurse is caring for a client with an ileostomy. What is the most common complication of this procedure? Peristomal skin irritation Stoma stenosis Urinary calculi Cholelithiasis

Peristomal skin irritation

A school-age child begins to have a seizure while walking to the bathroom after an appendectomy. The nearby staff do not have the child's medical history. What is the nurse's first action?

Position the child on the side.

A nurse is positioning a client with flaccid left-sided hemiparesis in bed following a cerebral vascular accident (CVA). Which is the nurse's best intervention?

Position the left arm supported on a pillow.

The nurse is caring for clients with complex anxiety disorders and has noted an increase in the use of PRN antianxiety medications over the past several months. Which action by the nurse can best address the apparent increase in PRN antianxiety medication administration? Present the nurse's concerns to the facility's Quality Improvement Committee. Present the concerns to the pharmacist responsible for approving the prescriptions. Review medical records to determine which nurses administered the medications. Present the nurse's concerns to the facility's Procedure and Policy Committee.

Present the nurse's concerns to the facility's Quality Improvement Committee.

An adolescent client with diabetes checks the blood glucose at 9:00 p.m. before going to bed. It has been 4 hours since dinner and the regular insulin dose. The current blood glucose is 60 mg/dl (3.3 mmol/L). The client feels a little "shaky." Which action does the nurse take?

Provide the client with a snack.

A client is scheduled for an endoscopy. On admission, the nurse asks the client if he has an advance directive, and the client states, "No." What should the nurse do next?

Provide the client with information about an advance directive.

An average-weight client reports of generalized steady abdominal pain. The nurse should suspect an abdominal aortic aneurysm, if the abdominal pain is accompanied by which finding? Pulsating mass in the periumbilical area Elevated cardiac enzymes Positive Babinski's sign Pink, frothy sputum

Pulsating mass in the periumbilical area

A client with pneumonia is admitted to the medical-surgical unit. Which painless, noninvasive procedure used to measure SaO2 will the nurse perform on this client?

Pulse oximetry

The nurse is planning care for a 10-year-old child in the acute phase of rheumatic fever. Which activity would be most appropriate for the nurse to schedule in the care plan?

Reading books

An alert and oriented adult client who is a Jehovah's Witness refuses a life-saving blood transfusion. The client's partner, who is not a Jehovah's Witness, requests that the client receive the blood. Which is the most appropriate action by the nurse?

Respect the client's right to refuse the transfusion.

An older adult client who has chronic respiratory disease comes to the clinic for a 6- month check. The nurse informs the client that it's time for the pneumococcal and flu vaccines. What would be the nurse's best explanation to the client for these injections?

Respiratory infections can cause severe hypoxia and possibly death in clients with chronic respiratory diseases.

A client in the terminal stage of cancer is receiving a continuous infusion of morphine for pain management. Which data collection finding suggests that the client is experiencing an adverse effect of this drug? Voiding of 350 ml of concentrated urine in 8 hours Respiratory rate of 8 breaths/minute Irregular heart rate of 82 beats/minute Pupils constricted and equal

Respiratory rate of 8 breaths/minute

A client in the manic phase of bipolar disorder constantly belittles other clients and demands special favors from the nurses. Which nursing intervention would be most appropriate for this client? Ask other clients and staff members to ignore the client's behavior. Set limits, with clear and consistent consequences, for behavior. Offer the client an antianxiety drug when he is belittling others or demanding special treatment. Distract the client with a variety of stimulating activities when negative behaviors occur.

Set limits, with clear and consistent consequences, for behavior.

A client is admitted to an acute care facility with osteomyelitis. Which organism usually causes this infection?

Staphylococcus aureus

A client in the behavioral health unit with a history of noncoercive paraphilia is experiencing an auditory hallucination. What is the priority nursing action? Stay with the client. Call the health care provider. Give the client medication. Alert the staff on the unit.

Stay with the client.

One minute after birth, a neonate has an Apgar score of 7. What should the nurse do? Administer oxygen via nasal prongs as ordered. Begin cardiopulmonary resuscitation (CPR). Stimulate breathing by rubbing the neonate's back. Encourage the mother to hold the neonate close.

Stimulate breathing by rubbing the neonate's back.

A 2-year-old child with a tracheostomy suddenly becomes diaphoretic and has an increased heart rate, an increased respiratory rate, and a decreased oxygen saturation level. Which of the following should be the nurse's first action?

Suction the tracheostomy.

The nurse is caring for a preschool child just diagnosed with impetigo. What is the most important action the nurse should take to prevent the spread of impetigo to others?

Teach child and family good handwashing techniques.

A 14-year-old adolescent tells the nurse about being in love with a 22-year-old neighbor and that they've had sex on several occasions. The client doesn't want the parents to know because the client is in love and is afraid the parents will be angry. What is the nurse's best course of action? Tell the adolescent that any information shared is privileged and confidential. Tell the adolescent that the law requires the nurse to report the sexual contact because of the age difference. Tell the adolescent that the nurse won't say anything to the parents, but that the client must tell the physician. Tell the adolescent that the nurse will consult the unit's charge nurse and be back to talk later.

Tell the adolescent that the law requires the nurse to report the sexual contact because of the age difference.

Which of the following correctly defines puerperium? The first hour after birth The 6 weeks following birth The days spent in the hospital The duration of breast-feeding

The 6 weeks following birth

A client has an indwelling urinary catheter and is prescribed physical therapy. As the client is being placed in a wheelchair, which action by the assistant would need further clarification by the nurse?

The catheter bag is placed on the client's lap for safe transport.

The nurse observes a client's health and home environment. Which finding requires the nurse to obtain a referral from the health care provider for an assistive device?

The client does not demonstrate any confidence in an ability to walk.

After a motor vehicle crash, a client has a chest tube inserted that begins to drain a large amount of dark red fluid. Which explanation best describes what caused this type of drainage from the chest tube insertion?

The client has experienced a hemothorax instead of a pneumothorax.

The nurse is talking with a client that is grieving over the death of a spouse. Which action exhibited by the client would cause the nurse to suggest counseling?

The client refuses to acknowledge the spouse's family and blames them for the death.

Teaching for women in their childbearing years who are receiving antipsychotic medications should include which of the following facts? Increased libido is an adverse effect of these medications. Incidence of dysmenorrhea increases. The client should continue using contraception during periods of amenorrhea. Amenorrhea is irreversible.

The client should continue using contraception during periods of amenorrhea.

A client reports an intermittent milky vaginal discharge. The client is not sexually active and does not report itching or burning. Which factor is the most likely cause of the milky discharge?

normal fluctuation in estrogen and progesterone levels

A client who is paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?

The client uses a mirror to inspect skin.

A nurse is caring for a client with anorexia nervosa. When assisting with the development of the client's plan of care, which goal would the nurse identify as the highest priority? The client will establish adequate daily nutritional intake. The client will make a contract with the nurse that sets a target weight. The client will identify self-perceptions about body size as unrealistic. The client will verbalize the possible physiological consequences of self-starvation.

The client will establish adequate daily nutritional intake.

A client with a recent history of a stroke has been discharged from the rehabilitation facility with a walker. On a return visit to the health care provider, the nurse observes the gait. Which observation indicates the need to reinforce client education about walker use?

The client's arms are fully extended when using the walker.

A home care nurse is caring for a paralyzed client who needs regular position changes and back massages. A person identifying themself as a family friend inquires if they can be of any help to the family. What should be the nurse's response be?

The nurse should ask the person to talk to the family directly.

The parent of a female child asks the nurse why the child seems to have so many urinary tract infections (UTIs). Which response by the nurse would be the most accurate?

The urethra is in close proximity to the anus.

The nurse obtains data from a client on bed rest reporting an itchy rash with an erythematous, slightly edematous areas on the back, posterior lower legs, and posterior elbows. What education should be reinforced regarding contact dermatitis? The disorder is contagious. This is an allergic reaction. Based on the location, it is likely that detergents in the bed linens caused the rash. The skin is infected wherever the rash has developed. Oatmeal baths are a good treatment for a rash of this type because of the large area involved. Washing with antibacterial soap will help the rash.

This is an allergic reaction. Based on the location, it is likely that detergents in the bed linens caused the rash. Oatmeal baths are a good treatment for a rash of this type because of the large area involved.

A nurse manager of the pediatric unit discovers that she is overbudget on supplies. How could each nurse assigned to the unit help with cost containment?

Use care pathways to specify care and identify daily outcomes.

A nurse is assisting a client with a knowledge deficit about the effects of alcohol on the body. When assisting with the development of the client's plan of care, which goal would the nurse identify as the highest priority? Test blood chemistries daily. Verbalize the results of substance use. Talk to a pharmacist about the substance. Attend a weekly aerobic exercise program.

Verbalize the results of substance use.

A parent reports that their teenager is losing hair in small, round areas on the scalp. The nurse interprets this as suggesting which condition?

alopecia

A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?

contact

A nurse is caring for a client who is undergoing treatment for acute alcohol dependence. The client tells the nurse, "I don't have a problem. My wife made me come here." Which defense mechanism does the nurse determine the client is using? projection and suppression denial and rationalization rationalization and repression suppression and denial

denial and rationalization

The nurse is watching the health care provider check reflexes during a physical assessment. The RN elicits a positive Babinski reflex. The nurse is aware that this reflex is characterized by what?

dorsiflexion of the great toe with fanning of the other toes

A 47-year-old male client with an unresolved hemothorax is febrile, with chills and diaphoresis. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:

empyema

The nurse is caring for a client diagnosed with body dysmorphic disorder. When the client verbalizes disapproval of her physical features, the nurse should:

encourage verbalizations about fears and stressful life situations.

The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are: tracheal. fine crackles. bronchial. friction rubs.

fine crackles.

A client admitted for acute pyelonephritis is about to start antibiotic therapy. Which symptom would the nurse expect to find in this client?

flank pain on the affected side

An 18-month-old child comes to the primary health care provider's office for a well-baby checkup. Which foods should the nurse recommend as providing the best sources of dietary iron for the child?

peanut butter, green vegetables, and raisins

A pregnant client with vaginal bleeding asks a nurse how the fetus is doing. Which response is best?

"I'll tell you what the monitors show."

While assisting a client with a chronic obstructive pulmonary disease (COPD) to ambulate in the hallway, the nurse observes that the client becomes short of breath after walking 100 ft. What is the best action of the nurse?

Assess the client's SpO2 status.

Which trait is the most important for ensuring that a nurse-manager is effective?

Communication skills

The nurse is caring for an adolescent with cancer who is well informed about the medical condition and treatment. The adolescent refused the morning medications and states intentions of refusing all future medications. What is the best action by the nurse?

Document the adolescent's choice and offer to discuss feelings about the medication.

The nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which of the following interventions should the nurse include in the plan of care?

Encourage the client's communication attempts by allowing him time to select or write words.

The nurse is caring for a client with peripheral vascular disease who is scheduled for a venogram. The client reports allergy to several food items. The nurse should be most concerned about allergy to which food? Eggs Shellfish Peanuts Tomatoes

Shellfish

A client with type 2 diabetes was diagnosed with retinopathy. While a nurse reviews the client's medication dosage, the client states, "I can't read the names on the medicine bottles, so I hope I'm taking the right pills at the right time." What should the nurse do with this information?

Teach the client how to tell the difference between the medicine bottles.

A nurse is obtaining data on a 1-day-old neonate in the nursery. Which findings would indicate possible asphyxia in utero? Select all that apply. The neonate grasps the nurse's finger when put in the palm of the neonate's hand. The neonate does stepping movements when held upright with the sole of the foot touching a surface. The neonate's toes do not curl downward when the soles of the feet are touched. The neonate does not respond when the nurse claps hands. The neonate turns toward the nurse's finger when touching the cheek. The neonate displays weak, ineffective sucking.

The neonate's toes do not curl downward when the soles of the feet are touched. The neonate does not respond when the nurse claps hands. The neonate displays weak, ineffective sucking.

The nurse is caring for a client with asthma and impending anaphylaxis from hypersensitivity to a drug. What is the priority action by the nurse?

administer bronchodilators

The licensed practical nurse (LPN) is caring for multiple clients that require various skills. Which client task should the LPN ask the registered nurse (RN) to complete?

administer intravenous push (IVP) medication

When prioritizing a client's plan of care based on Maslow's hierarchy of needs, the nurse's first priority would be:

administering pain medication.

After suctioning a tracheostomy, the nurse determines the effectiveness of the suctioning. Which findings will the nurse document that indicates the airway is now patent?

clear breath sounds and nonlabored respirations

A multidisciplinary oncology team notes that a client who has been undergoing chemotherapy is now experiencing pancytopenia. When reviewing the laboratory data, which values support this diagnosis? Select all that apply. decreased white blood cells increased white blood cells decreased platelets increased platelets decreased red blood cells Increased RBCs

decreased white blood cells decreased platelets decreased red blood cells

A family is experiencing the death of an infant from Sudden Infant Death Syndrome (SIDS). What initial reaction does the nurse anticipate the family will exhibit?

feelings of blame or guilt

A pregnant client with a history of cardiac dysfunction has been taking propranolol, a beta-adrenergic blocker, to treat hypertension. During labor, the nurse should assess for what adverse effect of this drug? uterine hypotonus uterine hypertonus hypotension tachycardia

hypotension

The nurse is caring for a preschooler with human immunodeficiency virus (HIV). The preschooler is being prepared to be discharged. What is the most important thing for the nurse to reinforce?

infection control

A nurse is reinforcing education with a client on use of an incentive spirometer. The nurse identifies the teaching as successful when the client demonstrates which technique?

inhales slowly and deeply through the mouthpiece

An older adult client has been admitted to the medical-surgical unit after surgery. While the nurse is off the floor, the client falls out of bed, resulting in a fracture of the right leg. The nurse finding the client states that the "side rails were left down and the bed was in the high position." Which charge is most appropriate for the nurse's actions?

negligence

A client states, "I can't eat because my bowels have turned against me." The nurse determines that the client is exhibiting which behavior? hysteria depersonalization illness anxiety somatic delusion

somatic delusion

A nurse is preparing to give a neonate their first bath. Which action would be the priority? giving a tub bath using water and mild soap giving the bath right after birth using hexachlorophene soap

using water and mild soap

The nurse is reinforcing education with parents about therapeutic management of their neonate diagnosed with congenital hypothyroidism. Which response by a parent would indicate the need for further education?

"As my baby grows, his thyroid gland will mature and he won't need medications."

A 13-year-old client tells the nurse, "I have not yet started my period, but all my friends have." Which nursing response is appropriate?

"Some individuals do not start menstruating until age 15 or 16."

The nurse is preparing to administer penicillin VK 0.5 g to a child with glomerulonephritis. The nurse has available an oral solution of penicillin VK 250 mg/5 mL. How many milliliters should the nurse administer with each dose? Record your answer using a whole number.

10

A client who's receiving phenytoin to control seizures is admitted to the health care facility for observation. The physician orders measurement of the client's serum phenytoin level. Which serum phenytoin level is therapeutic?

10 to 20 mcg/ml

A 10-year-old child with a concussion is admitted to the pediatric unit. The nurse would place this child in a room with which roommate?

A 12-year-old child with a fractured femur

Which of the following would the nurse identify as a neurotransmitter?

Acetylcholine

A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?

Acute pain

Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis?

Acute pain related to sickle cell crisis

A 3-year-old child has had surgery to remove a Wilms tumor. Which action should the nurse take first when the parent asks for pain medication for the child?

Assess the child's pain using a smiley face pain scale.

A child with thoracic water-seal drainage is on the elevator. The transport aide has placed the drainage system on the stretcher. What action should the nurse on the elevator take first?

Assist the aide in placing the drainage system lower than the child's chest.

Which of the following complications is most common after an abdominal aortic aneurysm resection? Renal failure Hemorrhage and shock Graft occlusion Enteric fistula

Hemorrhage and shock

Which sexually transmitted disease is preventable through infant vaccination?

Hepatitis B

A client undergoes cerebral angiography to evaluate for neurologic deficits. Afterward, the nurse checks frequently for signs and symptoms of complications associated with this procedure. Which findings should the nurse notify the physician of because they indicate spasm or occlusion of a cerebral vessel by a clot?

Hemiplegia, seizures, and decreased level of consciousness (LOC)

For a client with impaired gas exchange, which position is best?

High Fowler's

A home care nurse assesses for disease complications in a client with bone cancer. The nurse knows that bone cancer may cause which electrolyte disturbance? Hyperkalemia Hypercalcemia Hyponatremia Hypomagnesemia

Hypercalcemia

The physician prescribes digoxin for a client with heart failure. During digoxin therapy, which electrolyte imbalance may predispose the client to digoxin toxicity? Hypermagnesemia Hypercalcemia Hypernatremia Hypokalemia

Hypokalemia

Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?

Ineffective airway clearance

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

Ineffective airway clearance related to edema of the respiratory passages

Which of these findings best correlates with a diagnosis of osteoarthritis?

Joint stiffness that decreases with activity

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. While monitoring the client, which clinical findings that commonly accompany respiratory alkalosis would the nurse expect to assess?

Light-headedness or paresthesia

A nurse is caring for a client who is at risk for skin breakdown. To decrease the risk, the nurse must help ensure that the client remains adequately hydrated. Which action can the nurse take to help determine the client's fluid needs?

Measure intake and output.

The nurse is assisting with the care of an infant following surgical repair of esophageal atresia and tracheoesophageal fistula. Which nursing intervention takes the highest priority during the first 24 hours following the surgical repair? Perform daily weights. Monitor for excessive secretions. Encourage maternal-infant bonding. Provide gastrostomy feedings.

Monitor for excessive secretions.

A client comes to the emergency department with an acute asthma attack. The client is anxious, restless, and diaphoretic, and his respirations are labored. A nurse administers a high-flow nebulizer treatment as prescribed. Which finding suggests that this treatment has been effective?

Oxygen saturation increases and respiratory effort decreases.

A nurse is the first to respond to a client who is unresponsive. Which action should the nurse perform immediately? Palpate for a pulse. Deliver two breaths. Start chest compressions. Defibrillate with 200 joules.

Palpate for a pulse.

What is the nurse's most important intervention for a client having a tonic-clonic seizure?

Protect the client from further injury

To obtain the most accurate measurement of an infant's height (length), the nurse should measure which of the following?

Recumbent height with the infant supine

A nurse approaches a client who recently had a colostomy and finds the client crying. Which action is appropriate?

Sit down with the client and offer to talk about anything.

A client who returned from a cystoscopic examination complains of pain while attempting to void. Which intervention should a nurse suggest to ease the client's pain while attempting to void?

Sit in a warm sitz bath.

When assisting with an electrocardiogram (ECG), the nurse would expect to place the client in which position? Fowler's Supine Lateral Prone

Supine

The nurse is assisting the health care provider in applying a cast. Which intervention should be provided during immediate cast care?

Support the cast with the palms of her hand.

A 16-year-old client is admitted to the emergency department following an accident. The client sustained a head injury, is unconscious, and has compound fractures of the right tibia and fibula. No family members accompanied the client and none can be reached by phone. The surgeon instructs the nurse to take the client to the operating room immediately. Which of the following actions should the nurse take regarding informed consent?

Take the client to the operating room for surgery without informed consent.

The nurse is caring for a child with a fractured leg. The child's mother becomes concerned when she visits her son and notices him sucking his thumb, a behavior that he had previously given up. What does this behavior indicate?

The child is responding to stress.

The nurse is instructing unlicensed assistive personnel (UAP) on the proper care of a client in Buck's extension traction following a fracture of his left fibula. Which observation indicates that the education was effective?

The weights are allowed to hang freely over the end of the bed.

A client diagnosed as having panic disorder is admitted to the inpatient psychiatric unit. Until admission, he or she had been a virtual prisoner in the house for 5 weeks because of agoraphobia, afraid to go outside even to buy food. The nurse, when planning care for this client, determines which action as this client's overall goal?

To help the client function effectively in his or her environment

On evening rounds at a nursing home, a nurse finds an unresponsive client with deep, gurgling respirations and puffiness on the right cheek. The client has no voluntary motion or muscle tone in the right arm or leg. What should the nurse do first?

Turn the client on the right side, and elevate the head of the bed 15 degrees.

The nurse suspects that a client with a temperature of 103.6° F (39.8° C) and an elevated white blood cell count is in the initial stage of sepsis. The nurse reviews the client's chart and expects to find which disorder, which is the most common cause of sepsis in hospitalized clients?

Urinary tract infection (UTI)

The nurse is reviewing the report of a client's routine urinalysis. Which value should the nurse consider abnormal?

Urine pH of 3.0

A nurse is caring for several client's with human immunodeficiency virus (HIV) infection. Which client does the nurse suspect has acquired immunodeficiency syndrome (AIDS) wasting syndrome?

a client who has lost 12% of her body weight, with weakness, fever, and chronic diarrhea for the past 35 days

A client was admitted with injury to the thalamus. Which manifestation would the nurse observe during data collection?

aching sensation over half of the body

A child is diagnosed with diabetes insipidus. Which characteristics will the nurse recognize in the health history?

abrupt onset of polyuria, nocturia, and polydipsia

A client has been admitted after reporting acute abdominal pain in the mid-epigastric region, back tenderness, nausea, and vomiting. The nurse recognizes these findings to be associated with which condition?

acute pancreatitis

Clients diagnosed with a chronic illness exhibit a general pattern of adaptation. What are the stages of the pattern of adaptation? Select all that apply. alarm exhaustion awareness resistance retrospective thinking

alarm exhaustion resistance

Echocardiography reveals vegetation on a client's heart valves. The nurse knows that this finding indicates: bacterial invasion. inadequate nutrition. hypertension. diabetes mellitus.

bacterial invasion.

An older adult man reports urine retention. Which factor does the nurse discuss with the client that may be contributing to the problem?

benign prostatic hyperplasia

A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation shown, which laboratory result is the priority for the nurse to report to the health care provider?

blood culture

A client is being treated at a community mental health clinic. A nurse has been instructed to observe for any behaviors indicating dissociative identity disorder (DID). Which behavior would be included? delusions of grandeur reports of fatigue changes in dress, mannerisms, and voice refusal to make a follow-up appointment

changes in dress, mannerisms, and voice

A female client with genital herpes simplex is being treated in the outpatient department. The nurse teaches her about measures that may prevent herpes recurrences and emphasizes the need for prompt treatment if complications arise. Genital herpes simplex increases the risk of:

cancer of the cervix.

A nurse is reviewing a newly admitted client's chart. Based on this progress notes entry, the nurse knows these data are consistent with which condition?

carbon monoxide poisoning

The nurse is reinforcing education for the family of a child with seizures. When should the nurse inform them to call emergency medical services in the event of a seizure?

continuous vomiting for 30 minutes after the seizure

A primigravida client experiences a normal vaginal birth. The next day, the nurse monitors the client's lochia for color, amount, and the presence of clots. Which finding best describes lochia on the first postpartum day? bright red, large amount, with many clots pink, moderate amount, with no clots white, scant amount, with no clots dark red, moderate amount, with a few small clots

dark red, moderate amount, with a few small clots

The nurse is caring for a client with a cognitive disorder. Which characteristic does the nurse observe that correlates with a cognitive disorder? catatonia depression feeling of dread deficit in memory

deficit in memory

A licensed practical nurse (LPN) is working on a wing of a medical-surgical unit that is also staffed with a registered nurse and a certified nursing assistant (CNA). When providing care, which task would be most appropriate for the LPN to delegate to the CNA?

encouraging a client to drink fluids

While caring for a client with chronic obstructive pulmonary disease (COPD), a licensed practical nurse observes and reports that the client is short of breath, restless, irritable, and disoriented. After nursing interventions fail to reverse the client's escalating respiratory distress, what medical intervention should the nurse be prepared to assist with?

endotracheal intubation

The nurse is reinforcing education with parents of a child with growth hormone deficiency. What sport should the nurse encourage?

gymnastics

A client reports slipping on a throw rug while going to the bathroom at night. Which data should be gathered for prevention of further falls?

home safety

A client is receiving the drug epoetin alfa. Which findings would indicate the effectiveness of the drug?

increase in red blood cells

A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6° F (37° C). To help correct respiratory alkalosis, the nurse should:

instruct the client to breathe into a paper bag.

The nurse is caring for a client who recently underwent a total hip replacement. The nurse should:

instruct the client to limit hip flexion while sitting.

A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which data collected by the nurse suggest that the decongestant has been effective?

less sneezing

A nurse presents a client with the informed consent form for an abdominal paracentesis. The client asks the nurse what the procedure involves. The nurse should

notify the physician that the client doesn't understand the procedure.

The nurse is caring for a client immediately after the client has received electroconvulsive therapy (ECT) for the treatment of severe depression. What is a priority intervention for this client? orient the client to the surroundings reinforce education about depression offer oral fluids of the client's choice administer an opioid analgesic for a headache

orient the client to the surroundings

The nurse is caring for a child with life threatening salicylate poisoning. Which treatment will the nurse prepare the child for?

peritoneal dialysis

A child is seeing the health care provider for bone and joint pain. Which other signs and symptoms may suggest leukemia?

petechiae

A client requires a chest tube to be inserted in the right upper chest. Which action is part of the nurse's role?

preparing the chest tube drainage system

When assisting in developing a plan of care for a hospitalized child, the nurse knows that children in which age-group are most likely to view illness as a punishment for misdeeds?

preschool age

Which client requires immediate nursing intervention? The client who complains of epigastric pain after eating. complains of anorexia and periumbilical pain. presents with a rigid, boardlike abdomen. presents with ribbonlike stools.

presents with a rigid, boardlike abdomen.

The health care provider has ordered sulfasalazine for a child with juvenile rheumatoid arthritis. The nurse questions the order when reading that the client has an allergy to what medication?

sulfamethoxazole-trimethoprim

A 32-year-old primigravida client has lost weight since her last office visit. Which nutritional instructions should the licensed practical nurse reemphasize? Select all that apply.

"Increase your calorie intake by 300 cal/day." "Increase your intake of all minerals, especially iron."

A client is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?

"Apply acyclovir ointment to the lesions every 3 hours, six times per day for 7 days."

A client is receiving terbutaline to stop preterm labor. The health care provider plans to discharge the client in the morning with a terbutaline infusion pump. Which instruction should the nurse include when teaching the client about the drug? "Report adverse reactions such as bradycardia, diarrhea, and hypertension." "Continue regular activities while receiving the infusion." "Assess the insertion site for signs of infection." "Avoid acetaminophen while the drug is infusing."

"Assess the insertion site for signs of infection."

A client becomes neutropenic 11 days after his last chemotherapy cycle. It's obvious that the client understands his condition when he states:"I'll monitor my temperature frequently and go to the nearest emergency department if my temperature rises above 38° C (100.4° F)." "I've found that eating fresh fruit and vegetables reduces the side effects of chemotherapy and also gives me more energy." "I find that going out for a quiet dinner and a movie relieves the stress and anxiety of my cancer treatment." "I love working in my garden; it gives me a lot of inner peace and tranquility."

"I'll monitor my temperature frequently and go to the nearest emergency department if my temperature rises above 38° C (100.4° F)."

A client understands what resources are available to help him perform wound care at home when he states the following:

"Before I go home, I'll speak to the home health care nurse to make sure I have the supplies I need."

The nurse in the pediatrician's office is teaching the mother of a 3-year-old about car seat safety. The mother questions the nurse as to why her son requires a car seat when he weighs 35 lb (15.9 kgs). Which response by the nurse is best?

"He should ride in the car seat until he's at least 40 pounds (18 kgs) and 4 years old."

A schizophrenic client states, "I hear the voice of King Tut." Which response by the nurse would be therapeutic? "I don't hear the voice, but I know you hear what sounds like a voice." "You shouldn't focus on that voice." "Don't worry about the voice as long as it doesn't belong to anyone real." "King Tut has been dead for years."

"I don't hear the voice, but I know you hear what sounds like a voice."

The nurse is gathering data from a client who states, "I do not know what is wrong, but my urine has a very strong odor." The client's urinalysis, vital signs, and physical assessment findings are within normal ranges. Which finding, given by the client, may suggest to the nurse the reason for the client's strong urine odor?

"I eat asparagus 3 to 4 times a week."

During chemotherapy for lymphoma, a child, age 15, is at risk for stomatitis. Which statement by the child supports a nursing diagnosis of Deficient knowledge related to mouth care?

"I remove white patches on my tongue and cheeks with my toothbrush."

After a nurse reinforces discharge education to the parents of a child with hypospadias, which statement by the parent indicates that additional education is needed?

"I should bathe my child in the tub daily."

A client with anorexia nervosa attended psychoeducational sessions on principles of adequate nutrition. Which statement by the client indicates the education was effective? "I should eat while I'm doing things to distract myself." "I should eat all my food at night just before I go to bed." "I should eat small amounts of food slowly at every meal." "I should eat only when I'm with my family and trying to be social."

"I should eat small amounts of food slowly at every meal."

When the nurse is reinforcing education about fluid intake with the parents of a child with a urinary tract infection (UTI), which statement by a parent would indicate the need for further education?

"I should offer my child carbonated beverages about every 2 hours."

A nurse has instructed a client about taking ferrous sulfate liquid preparation. Which statement by the client indicates the need for additional education?

"I should take the iron with an antacid to prevent gastric distress."

A client with Parkinson's disease visits the physician's office for a routine checkup. The nurse notes that the client takes benztropine, 0.5 mg by mouth daily, and asks when the client takes the drug each day. Which response indicates that the client understands when to take benztropine?

"I take the medication at bedtime."

A nurse is caring for a client with a terminal illness. The nurse determines that a client has entered the first stage of the grieving process when the client makes which statement?

"I think they mixed up my test results."

A nurse determines that an adolescent with a fractured left femur understands the instructions to perform only touch-down weight bearing when making what statement?

"I will allow my left leg to touch the floor without placing weight on it."

When reinforcing discharge education for a client with ulcerative colitis, the nurse emphasizes the importance of regular examinations. Which statement by the client indicates an understanding of the instructions?

"I will need to have routine screenings because having ulcerative colitis places me at risk for colon cancer."

A nurse is reinforcing education for a client who has been prescribed buspirone for long-term treatment of anxiety. The nurse determines that the education has been effective when which statement is made by the client? "I will take the medicine only when I feel an anxiety attack coming on." "I will not take the medicine with my meals." "I will not stop the medicine if I become pregnant." "I will not take the medicine with grapefruit juice."

"I will not take the medicine with grapefruit juice."

A client recently diagnosed with colon cancer states, "I am having trouble sleeping because of thoughts of how life will change after surgery." What is the best response by the nurse?

"I will sit and talk with you about how you are feeling."

A client with nephritis is taking the diuretic furosemide as prescribed. To avoid potassium depletion, the nurse reinforces education on prevention techniques. Which client statement indicates an accurate understanding of this education?

"I'll eat such foods as apricots, dates, and citrus fruits."

Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is SIDS most likely to occur?

1 week to 1 year, peaking at 2 to 4 months

During the admission data collection, a client reports that she frequently has nightmares and memories of a rape that occurred 3 years ago. She feels depressed and asks the nurse, "Do you think I will ever get better? I don't know what is wrong with me." The nurse's most supportive response would be: "It sounds like you have some unresolved pain about the trauma. Take time here to talk and allow yourself to heal." "I'm not sure what is wrong, but the medication will help you soon enough." "It's important to talk to your physician about an issue such as this." "Don't feel bad; the treatment will help you."

"It sounds like you have some unresolved pain about the trauma. Take time here to talk and allow yourself to heal."

A teenager with heart failure who has been prescribed digoxin asks the nurse, "What will this drug do for my heart?" What is the best response by the nurse? "It will cause vasodilation and help with chest pain." "It will decrease the workload of the heart." "It will cause sodium excretion." "It will increase your heart rate."

"It will decrease the workload of the heart."

A client has been diagnosed with a pulmonary embolism. When the nurse informs the family members, they become very upset and say they do not understand what that means. Which statement by the nurse to the family would be most effective?

"It's a blood clot that has occluded a pulmonary blood vessel."

A client with end-stage liver cancer states that no extraordinary measures are to be used to prolong the client's life. The client asks the nurse about the necessary steps to make these wishes known and legally binding. Which response by the nurse would be most appropriate?

"Let's talk to the charge nurse about getting your wishes in an advance directive."

After being admitted to the hospital with sickle cell crisis, a client asks a nurse how he can prevent another crisis. Which response by the nurse is best?

"Make sure that you drink plenty of fluids."

A nurse is reinforcing the teaching plan with a client diagnosed with dissociative identity disorder (DID). Which statement by the client indicates that the education has been effective? "I'll probably never be able to regain my memories of the fire." "I have problems with my memory due to my abuse of tranquilizers." "If I concentrate hard enough, I'll be able to bring up memories of the car accident." "My brain has temporarily hidden my memories of the rape to protect me."

"My brain has temporarily hidden my memories of the rape to protect me."

A client with a history of alcoholism returns to the hospital 3 hours later than the time specified on his day pass. His breath smells of alcohol and his gait is unsteady. What should the nurse say? "Why are you 3 hours late?" "How much did you drink tonight?" "I'm disappointed that you weren't responsible with your day pass." "Please go to bed now. We'll talk in the morning."

"Please go to bed now. We'll talk in the morning."

What is the most important postoperative instruction the nurse must give a client who has just returned from the operating room after receiving a subarachnoid block? "Avoid drinking liquids until the gag reflex returns." "Avoid eating milk products for 24 hours." "Notify a nurse if you experience blood in your urine." "Remain supine for the time specified by the physician."

"Remain supine for the time specified by the physician."

A client tells the nurse that people from Mars are going to invade the earth. Which response by the nurse would be therapeutic? "That must be frightening to you. Can you tell me how you feel about it?" "There are no people living on Mars." "What do you mean when you say they're going to invade the earth?" "I know you believe the earth is going to be invaded, but I don't believe that."

"That must be frightening to you. Can you tell me how you feel about it?"

A client delivers a neonate prematurely at 28 weeks' gestation. The neonate is placed in the neonatal intensive care unit (NICU). Three days later, the client's husband seems withdrawn and barely speaks to the staff when visiting his child in the NICU. Which of the following nursing action should the nurse take? Ask the father to stop visiting the baby until he is ready to interact with the staff. Ask the father if he would want to talk about his feelings regarding the newborn and being in the intensive care. Provide counseling to the father. Ask him to hold the baby.

Ask the father if he would want to talk about his feelings regarding the newborn and being in the intensive care.

The nurse is making an initial visit to the home of a client who ambulates with a walker. Which finding should the nurse identify as a safety hazard when completing an assessment of the client's home?

Electrical cords are covered with a carpet.

A client who has a pulmonary embolism has the potential to develop chest pain. What would be the nurse's best explanation for this when reinforcing education for the client?

It is pleuritic pain due to inflammation.

A client in the 13th week of pregnancy develops hyperemesis gravidarum. Which laboratory finding indicates the need for intervention? Urine specific gravity 1.010 Serum potassium 4 mEq/L Serum sodium 140 mEq/L Ketones in urine

Ketones in urine

In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure? Cyanosis of the lips Bilateral crackles Productive cough Leg edema

Leg edema

The nurse is caring for a client with hypothyroidism. For which medication will the nurse reinforce instructions?

levothyroxine

When obtaining the health history from a client with retinal detachment, the nurse expects the client to report:

light flashes and floaters in front of the eye.

The nurse is gathering data from a child that has a rash on the face, trunk, and extremities, but not on the palms of the hand. Which disorder should the nurse suspect this child may have?

measles

The nurse is caring for a client post-transurethral resection of the prostate (TURP) with bladder irrigation. After surgery, what color would the nurse expect the urine to be?

pink to dark red

A client has elevated levels of triiodothyronine (T3), thyroxine (T4), and calcitonin. The nurse is aware that these hormones are produced by which gland?

thyroid gland

A neonate requires surgical repair of a patent ductus arteriosus. The neonate's 16-year-old mother is present along with her parents, the neonate's grandparents. The neonate's mother states that she "isn't with the father anymore." The nurse must obtain informed consent for the surgery from the neonate's grandparents because the mother is a minor. the neonate's mother and father because both parents are minors. the neonate's mother because she's considered an emancipated minor. the court because the neonate's mother hasn't requested legal emancipation.

the neonate's mother because she's considered an emancipated minor.

A nurse who works on a palliative care unit has participated in several clinical scenarios that have required the application of ethics. Ethics is best defined as

the principles that determine whether an act is right or wrong

A client with bipolar disorder has abruptly stopped taking prescribed medication. Which behavior would indicate the client is experiencing a manic episode? binge eating relationship avoidance sudden relocation thoughtless spending

thoughtless spending

A nurse is caring for a client who had a lumbar laminectomy 2 days ago. Which finding should the nurse report to the health care provider?

urine retention or incontinence

A nurse is repositioning a client in bed. What should the nurse do to maintain proper body mechanics?

use a wide stance for support

A nurse suspects that a coworker is taking and using narcotics from the medication cart. What would the nurse do first?

Report the suspicion to the nurse manager.

A client with schizophrenia hears a voice telling him he is evil and must die. The nurse understands that the client is experiencing: a delusion. flight of ideas. ideas of reference. a hallucination.

a hallucination.

A client with schizophrenia is admitted to a health care facility. When collecting data about the client, the nurse should document which symptoms as negative symptoms of schizophrenia? (Select all that apply.) delusions hallucinations apathy blurred affect lack of motivation

apathy blurred affect lack of motivation

A client with a history of chronic obstructive pulmonary disease (COPD) arrives in the emergency department with an oxygen saturation of 84%. Which diagnostic study does the nurse prepare the client for to evaluate cellular metabolism? arterial blood gas (ABG) analysis complete blood count (CBC) electrocardiogram (ECG) lung scan

arterial blood gas (ABG) analysis

A client has been prescribed a diet that limits purine-rich foods. Which would the nurse teach the client to avoid eating?

anchovies, sardines, kidneys, sweetbreads, and lentils

The nurse is collecting data on a male client diagnosed with gonorrhea. Which symptom likely prompted the client to seek medical attention?

foul-smelling discharge from the penis

A client with emphysema will be discharged from the hospital in a few days. While reinforcing education, what should the nurse instruct the client to avoid to prevent possible exacerbation of the disorder?

fumes

A client reports abdominal pain. Which question asked by the nurse would provide the most information about the client's pain?

"What does the pain feel like?"

A nurse is reinforcing education to a client on how to prevent the development of phimosis. What is the priority education for this client?

proper cleaning of the prepuce

After reinforcing education to a client on how to correctly self-administer daily maintenance dose of 3 units of regular insulin and 4 units of NPH insulin, which client statement demonstrates that the education has been successful?

"After taking my insulin out of the refrigerator, I'll draw up the clear insulin first to the line for 3 units and then cloudy insulin until there's a total of 7 units in the syringe."

While in a skilled nursing facility, a client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter's home, where six other family members are living. During her visit to the clinic, she asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:

"All family members will need to be treated."

A client has symptoms of acute asthma every time the family eats at a Chinese restaurant. Which instruction should the nurse reinforce for this client to avoid complications?

"Avoid Chinese food because it's a trigger for you."

The nurse is caring for a client with posttraumatic stress disorder (PTSD) and the family informs the nurse that loud noises cause a serious anxiety response. Which explanation by the nurse would help the family understand the client's response?

"Environmental triggers can cause the client to react emotionally."

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?

"Family members should continue to talk to the client."

The nurse is reinforcing preoperative education for a client having a total hip arthroplasty and explaining which actions to avoid postoperatively. Which statements made by the client indicate the need for additional education? Select all that apply. "I will keep my legs apart while lying in bed." "I will periodically tighten my leg muscles." "I will rotate my feet internally." "I will bend from my waist to pick items up from the floor." "I will sleep in a side-lying position on the unaffected side."

"I will rotate my feet internally." "I will bend from my waist to pick items up from the floor."

The parent of a child with a history of closed-head injury asks the nurse why the child would begin having seizures without warning. Which response by the nurse is the most accurate?

"It's not unusual to develop seizures after a head injury because of brain trauma."

A client exhibits signs of mild anxiety. Which response by the nurse is most likely to reduce the client's anxiety?

"Let's talk about what is bothering you."

A 15-month-old child is being discharged after treatment for severe otitis media and bacterial meningitis. Which statement by the parents indicates effective discharge teaching?

"We'll go to the physician if our child pulls on his ears or won't lie down."

A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?

"Weigh yourself daily and report a gain of 2 lb in 1 day."

A young client has been arrested for assault and battery. The client has been admitted to the forensic psychiatric facility for a pretrial evaluation. Which client goal is most appropriate for the client?

Accept responsibility for personal behavior.

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? Acute pain related to biliary spasms Deficient knowledge related to prevention of disease recurrence Anxiety related to unknown outcome of hospitalization Imbalanced nutrition: Less than body requirements related to biliary inflammation

Acute pain related to biliary spasms

A client arrives in the emergency department with hives and redness after a bee sting stating, "I can't breathe! I am going to die." What action is anticipated by the nurse?

Administer an injection of epinephrine stat.

The nurse is caring for an infant diagnosed with thrush. Which instruction should the nurse give to a client's mother who will be administering nystatin oral solution?

Administer the drug right after meals by swabbing the mouth.

A nurse is preparing to reinforce education with a 13-year-old child with asthma on how to administer breathing treatments. Which principle should the nurse keep in mind when planning the education session?

Adolescents are worried about appearing different from their peers.

Which method is best when approaching a 2-year-old child to listen to breath sounds?

Ask the child if the child would like the nurse to listen to the front or the back of the chest first.

The nurse is giving instructions to parents of a school-age child diagnosed with sickle cell disease. The instructions should include which of the following?

Avoid areas of low oxygen concentration such as high altitudes.

An unconscious client is admitted to the emergency department. During rapid data collection, which pulse will the nurse palpate in this client?

Carotid

When inspecting a client's skin, the nurse finds a vesicle on the client's arm. How will the nurse document his findings about this client's vesicle?

Circumscribed, elevated, and filled with serous fluid

A 9-year-old child presents to a school nurse and reports arm and leg pain. Upon assessment, the nurse identifies numerous purple to yellow ecchymotic areas. When asked, the child says that the bruises are the result of "being in trouble at home." Which action by the nurse is most appropriate?

Contact the authorities immediately.

A nurse is collecting data on a client admitted with a diagnosis of small bowel obstruction. When evaluating the client's pulse rate, what should the nurse remember?

Count the apical or radial pulse for 60 seconds.

What is the most likely reason for a temperature of 99.8° F (37.7° C) during the first 24 hours postpartum? Puerperal infection Mastitis Dehydration Chorioamnionitis

Dehydration

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance? Talking with the client's family about his angry feelings Performing an assessment for tardive dyskinesia Learning to effectively express needs to staff and others Demonstrating control over aggressive behavior

Demonstrating control over aggressive behavior

A couple in the antenatal unit is not satisfied with the care they are receiving. They have spent the past 15 minutes expressing dissatisfaction to the nurse about the care the client is receiving today. What is the most appropriate response by the nurse? Explain that the unit is short staffed and that the nurses are doing the best they can. Call the nurse manager to speak with the couple. Encourage them to talk for 10 more minutes and then remind them that there are other tasks to perform on the unit. Encourage the family to identify their frustrations and fears.

Encourage the family to identify their frustrations and fears.

The nurse is caring for a client with a subdural hematoma. Which is the priority outcome?

Ensure airway patency and optimal oxygen levels and protect from injury.

The parents of an adolescent girl have recently learned that their daughter has a terminal illness. At first, as they try to cope, they display avoidance behaviors. Then they demonstrate behaviors that indicate possible acceptance of the diagnosis. Which of the following behaviors would indicate acceptance?

Expression of feelings, such as sorrow and anger, about the child's condition

The client with Addison's disease is admitted to a medical-surgical unit. The nurse educator is discussing with the student why this client at risk for development of hypoglycemia and asks the following question: "The decreased adrenal cortical function of which substances leads to decreased glucose availability?"

Glucocorticoids

What should a male client older than age 50 do to help ensure early identification of prostate cancer? Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly. Have a transrectal ultrasound every 5 years. Perform monthly testicular self-examinations, especially after age 50. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels checked yearly.

Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.

A client with obesity is admitted to the hospital for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client?

Identify alternative ways for the client to lose weight.

A home health nurse is caring for a client diagnosed with a functional neurologic symptom disorder manifested by paralysis in the left arm. An organic cause for the deficit has been ruled out. Which nursing intervention is most appropriate for this client?

Identify primary or secondary gains that the physical symptom provides.

A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority?

Impaired gas exchange

The physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test may be used to determine a client's response to oral anticoagulant drugs? Bleeding time Platelet count International Normalized Ratio (INR) Partial thromboplastin time (PTT)

International Normalized Ratio (INR)

A client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by nonopioid antitussive agents. The physician prescribes codeine, 10 mg by mouth every 4 hours. When discussing this medication with a nursing colleague, which statement that accurately describes codeine will the nurse include?

It is a centrally acting antitussive and can cause dependence.

A nurse is administering iron dextran IM. A client asks why the skin is pulled to the side before the needle is inserted. Which statements are appropriate for the nurse to make? Select all that apply. It prevents medication leaking into subcutaneous tissue. It prevents staining of the skin. It prevents injection pain. It allows another injection to be given at the same location. It prevents an infection.

It prevents medication leaking into subcutaneous tissue. It prevents staining of the skin.

A nurse provides care for a client who developed hives after having an allergic reaction to strawberries. Which finding indicates to the nurse that the client has experienced improvement of symptoms?

Itching is relieved.

The nurse has just administered a drug to a child. Which organ is most responsible for drug excretion in children?

Kidneys

A client is admitted with chronic obstructive pulmonary disease (COPD). Which nursing actions should the nurse perform for this client? Select all that apply. Maintain adequate airway for client. Educate client on smoking and other triggers. Teach pursed lips breathing technique to client . Decrease the calories in the diet . Assess pulse oximetry .

Maintain adequate airway for client. Educate client on smoking and other triggers. Teach pursed lips breathing technique to client . Assess pulse oximetry .

A nurse is reviewing a client's chart and sees a health care practitioner's order for electroconvulsive therapy (ECT). Which following indication would the nurse expect to find that is the appropriate use for this therapy?

Major depression with psychotic features

At 8 a.m., a licensed practical nurse (LPN) collects data on a client who is scheduled for surgery at 10 a.m. During the data collection, the nurse detects dyspnea, a nonproductive cough, and back pain. What is the nurse's priority action?

Make sure that the health care provider is immediately notified of these findings.

The nurse is weighing a 3-month-old infant of Mediterranean descent during a routine examination in a family health center. The nurse recognizes the bluish discoloration of the skin on the lower back as which condition?

Mongolian spots

A client is admitted with myasthenia gravis. Which nursing intervention should be priority?

Monitor respiratory status.

The therapeutic team has identified the need to formulate strategies to maintain a safe environment for a client with schizophrenia displaying inappropriate behavior. Which strategy must be initiated immediately? Monitor the client's behavior. Identify the client's thought process that leads to the client's behavior. Explore with the client's reasons for demonstrating this behavior. Teach appropriate ways to communicate and interact with others.

Monitor the client's behavior.

A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention would the nurse use to determine if TPN is providing adequate nutrition?

Monitoring the client's weight every day

A postpartum client with diabetes wants to breast-feed but is concerned about the effects of breast-feeding on her health. Which response would be most appropriate? Mothers with diabetes who breast-feed have a hard time controlling their insulin needs. Mothers with diabetes shouldn't breast-feed because of potential complications. Mothers with diabetes shouldn't breast-feed; insulin requirements usually are doubled. Mothers with diabetes may breast-feed; insulin requirements may decrease from breast-feeding.

Mothers with diabetes may breast-feed; insulin requirements may decrease from breast-feeding.

The nurse is caring for a client who exhibits pinpoint pupils and decreased blood pressure, pulse, respirations, and temperature. These signs may indicate which disorder? Opiate intoxication Amphetamine intoxication Cannabis intoxication Alcohol intoxication

Opiate intoxication

The nurse would explain to the parents of a newborn with a cleft lip and palate that they will need to schedule an appointment with which specialist?

Otolaryngologist

After collecting data on a newly admitted 5-year-old child, the nurse assists in making the nursing diagnosis of Parental role conflict related to child's hospitalization. Which defining characteristic would most suggest this diagnosis?

Parents' failure to use available support systems or agencies to assist in coping

A 36-year-old client with a history of schizophrenia is admitted to the emergency department with a fever of 102° F (38.9° C), severe headache, photophobia, nuchal rigidity, and nausea. A physician believes that a lumbar puncture is necessary to help confirm his suspicions of meningitis. The nurse is asked to witness the informed consent. How can the nurse best assess the client's mental status before witnessing the consent? Perform a brief mental status examination to determine whether the client is oriented to person, place, time, and purpose. Converse with the client for a few minutes before witnessing the consent. Review the client's medical history and the results of the physical examination in the client's medical record. Ask a family member if the client is capable of consenting to the procedure

Perform a brief mental status examination to determine whether the client is oriented to person, place, time, and purpose.

The nurse is inserting an indwelling catheter into a female client before a surgical procedure. There is difficulty with the insertion and the nurse inserts the catheter into the vagina. Which action by the nurse should be performed next?

Perform the procedure again using a new catheter and kit.

Which measure should a home healthcare nurse implement to minimize the potential for lawsuits?

Perform thorough, accurate, and timely documentation.

The nurse is caring for a child with a seizure disorder. Which nursing intervention would be included to support the goal of avoiding injury, respiratory distress, or aspiration during a seizure?

Place a hand under the child's head for support.

A client who lost her home and dog in an earthquake tells the admitting nurse that she finds it harder and harder to "feel anything." She says she cannot concentrate on the simplest tasks, fears losing control, and thinks about the earthquake incessantly. She becomes extremely anxious whenever the earthquake is mentioned and must leave the room if people talk about it. When reviewing the data, the nurse suspects this client has which disorder?

Posttraumatic stress disorder (PTSD)

A nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. What action should the nurse take to assist the client with coping?

Provide a referral to the Cancer Society or another support program.

Which nursing intervention is the best way to help reduce the occurrence of poisoning in children?

Provide education to those who care for children.

The nurse is caring for a client who is in the panic level of anxiety. Which action is the nurse's highest priority? Encourage the client to discuss feelings. Provide for the client's safety needs. Decrease environmental stimuli. Respect the client's personal space.

Provide for the client's safety needs.

A nurse is developing a plan of palliative care for a client with end-stage cardiomyopathy. Which action is appropriate to include in the care plan? Provide nonpharmacological measures to reduce discomfort. Discourage family members from assisting with care if they ask to help. Administer pain medication only when the client asks for it. Whisper when speaking near the client.

Provide nonpharmacological measures to reduce discomfort.

In providing psychosocial care to a 6-year-old child who has had abdominal surgery for Wilms tumor, which activity initiated by the nurse would be most appropriate?

Provide the child with supplies and ask the child to draw how he or she feels.

A client with cirrhosis is admitted to the hospital. While reviewing the client's file, the nurse determines which data collection findings indicate that this client has deficient vitamin K absorption caused by this hepatic disease? Dyspnea and fatigue Ascites and orthopnea Purpura and petechiae Gynecomastia and testicular atrophy

Purpura and petechiae

Which nursing intervention is essential in caring for a client with compartment syndrome?

Removing all external sources of pressure, such as clothing and jewelry

A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation, incoherent speech, agitation, frantic and aimless physical activity, and grandiose delusion. Which nursing diagnosis takes highest priority for the client at this time?

Risk for injury

A client is admitted in a disoriented and restless state after sustaining a concussion from a car accident. Which nursing diagnosis takes highest priority in this client's plan of care?

Risk for injury

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes highest priority?

Risk for injury related to neurologic deficit

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?

Risk for injury related to neurologic deficit

A child is brought to the school nurse with the index finger of the left hand partially amputated and hanging by a shred of skin. Bleeding is moderate. What is the appropriate action by the nurse?

Securely wrap the hand and finger and place them in a cold water-filled baggie.

A client has a history of schizophrenia. Because she has a history of noncompliance with antipsychotic therapy, she'll receive fluphenazine decanoate injections every 4 weeks. Before discharge, what should the nurse include in her teaching plan? Asking the physician for droperidol to control any extrapyramidal symptoms that occur Sitting up for a few minutes before standing to minimize orthostatic hypotension Notifying the physician if her thoughts don't normalize within 1 week Expecting symptoms of tardive dyskinesia to occur and to be transient

Sitting up for a few minutes before standing to minimize orthostatic hypotension

The nurse is collecting data on an 8-month-old infant during a wellness checkup. Which of the following is a normal developmental task for an infant this age?

Sitting without support

A client with borderline personality disorder dramatically expresses feelings about each nurse on the staff, stating that only one nurse is understanding and trustworthy — the nurse the client is talking to at the time. The nurse realizes this client is demonstrating which type of behavior?

Splitting

The nurse is working in a psychiatric facility on an anxiety disorder unit. The unit is locked and clients have scheduled group and family therapy sessions. Which other standard is maintained on this unit for a client diagnosed with panic disorder? Clients may come and go as they desire. Clients may eat anything that is facility prepared. Suicide precautions are instituted. A security guard is present at the door.

Suicide precautions are instituted.

A newly pregnant client tells a nurse that she has not been taking her prenatal vitamins because they make her feel nauseated. What information should the nurse reinforce to the client? Switch to another brand of prenatal vitamins. Take the vitamin on a full stomach. Consume orange juice with it for better absorption. Wait until the morning to take the vitamin.

Take the vitamin on a full stomach.

A preparing to assist a client in coping with stress? What nursing interventions will be effective? Select all that apply. Teach relaxation exercises. Design a nurse-centered plan of care. Minimize environmental stimuli. Encourage verbalization of feelings. Suggest increasing workload to distract oneself. Establish a trusting relationship.

Teach relaxation exercises. Minimize environmental stimuli. Encourage verbalization of feelings. Establish a trusting relationship.

A school nurse suspects that a 13-year-old has structural scoliosis. Asking the adolescent to perform which maneuver would be the nurse's priority when gathering data for this condition?

The child bends over and touches the toes while the nurse observes from behind.

A 9-month-old infant is scheduled for an inguinal hernia repair. The divorced parents share joint custody of the infant. What determines who can give informed consent for the procedure?

The divorce decree should specify which parent has the right to sign the informed consent form.

A nurse gives a client the wrong medication. After assessment of the client, the nurse completes an incident report. What is the next anticipated step?

The incident report would be used to promote quality care and risk management.

A client with suspected renal insufficiency is scheduled for a comprehensive diagnostic workup. The nurse develops a teaching plan to explain the diagnostic tests. Which portion of the kidney does the nurse plan to include as the "working" or functional unit?

The nephron

A father expresses concern over his toddler's eating habits. He states the toddler eats very little and consumes only a single type of food for weeks on end. Which instruction is most helpful?

This is normal toddler behavior.

The nurse is caring for a client with quadriplegia. Which nursing intervention takes priority?

preventing atelectasis

Which phrase would the nursing student expect to describe the volume of air inspired and expired with a normal breath?

Tidal volume

A client with rheumatoid arthritis is being discharged with a prescription for aspirin, 600 mg by mouth every 6 hours. The nurse should instruct the client to notify the physician if which adverse drug reaction occurs?

Tinnitus

A client whose husband just left her has a recurrence of anorexia nervosa. The nurse caring for her realizes that this exacerbation of anorexia nervosa results from which effort of the client? To manipulate her husband To gain control of one part of her life To commit suicide To live up to her mother's expectations

To gain control of one part of her life

A client is being returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside?

Tracheostomy set

A client asks the reason for being placed in traction prior to surgery. Which response by the nurse is most appropriate?

Traction helps to prevent trauma and overcome muscle spasms.

A client with metastatic cancer is experiencing neuropathic pain. Which alternative therapy is most beneficial in treating this type of pain? Cryotherapy Biofeedback Herbal therapy Transcutaneous electrical nerve stimulation (TENS)

Transcutaneous electrical nerve stimulation (TENS)

A client with severe angina and electrocardiogram changes is seen in the emergency department. In terms of serum testing, the nurse can expect which laboratory test to be ordered? Creatine kinase Lactate dehydrogenase Myoglobin Troponin

Troponin

The nurse is caring for a client diagnosed with left-sided cerebrovascular accident, with expressive aphasia and right-sided weakness. When administering care for this client, which intervention should the nurse delegate to unlicensed assistive personnel (UAP)? Accompany the client to speech therapy. Perform active range-of-motion exercises for the client's upper extremities. Begin educating the client on simple sign language phrases. Turn and position the client every 2 hours.

Turn and position the client every 2 hours.

A nurse caring for a client diagnosed with schizophrenia should perform which intervention when the client becomes suspicious and refuses to take their medication? Tell the client they must take the medication now, Attempt to coax the client into taking the medication by calling them "Honey." Wait for a short time and then attempt to administer the medication Document that the client is noncompliant

Wait for a short time and then attempt to administer the medication

A client is recovering from an attack of gout. When reinforcing education, the nurse should include the need to lose weight for which reason?

Weight loss will decrease uric acid levels and decrease stress on joints.

A client transferred to a long-term care facility has a stage II pressure ulcer on her coccyx. Who should the nurse consult about the care of this client?

Wound care nurse

A nurse working in the triage area of an emergency department sees that several pediatric clients arrive simultaneously. Which child is treated first?

a 2-month-old infant with stridorous breath sounds, sitting up in his or her mother's arms and drooling

Which client would be most at risk for secondary Parkinson disease caused by pharmacotherapy?

a 30-year-old client with schizophrenia taking chlorpromazine

A nurse is assigned to care for a client with peptic ulcer disease. Which finding will the nurse report immediately to the health care provider?

heart rate 126 bpm

A client with borderline personality disorder becomes angry when he is told that today's psychotherapy session with the nurse will be delayed 30 minutes because of an emergency. When the session finally begins, the client expresses anger. Which response by the nurse would be helpful in dealing with the client's anger? "If it had been your emergency, I would have made the other client wait." "I know it's frustrating to wait. I'm sorry this happened." "Can we talk about how this is making you feel right now?" "I really care about you and I'll never let this happen again."

"Can we talk about how this is making you feel right now?"

The nurse explains hospital policies to a newly admitted adult client. Which statement by the client indicates the need for further teaching?

"I have the right to leave the building unassisted to smoke."

Which statement by a female adolescent reveals an early indicator of anorexia nervosa?

"I jog three times per day for a total of 5 hours per day."

A client is admitted to the behavioral health unit for treatment of pedophilia and tells the nurse that the client doesn't want to talk about sexual behaviors. Which response from the nurse is most appropriate?

"I know this must be difficult for you."

Which statement made by the nurse to the client and parents about diabetic ketoacidosis is most accurate?

"It's a life-threatening situation."

A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which homecare instruction should the nurse reinforce?

"Monitor your temperature for signs of infection."

Which statement made by the parent of a 16-month-old child with cystic fibrosis should alert a nurse to investigate further?

"My child is not walking yet."

A pregnant client asks the nurse whether she can take castor oil for her constipation. How should the nurse respond? "Yes, it produces no adverse effects." "No, it can initiate premature uterine contractions." "No, it can promote sodium retention." "No, it can lead to increased absorption of fat-soluble vitamins."

"No, it can initiate premature uterine contractions."

A client with Parkinson disease tells the nurse of plans to take St. John's wort for depression in addition to the prescribed carbidopa-levodopa. What is the nurse's best response?

"St. John's wort can cause a toxic reaction with the Parkinsonian drugs."

A nurse has forgotten the computer password and asks to use another nurse's password to log on to the computer. Which response by the coworker demonstrates safe computer usage?

"Would you like me to help you contact information services to reset your password?"

A school nurse is performing a scoliosis screening on a group of students. Which student would most commonly develop this condition?

13-year-old girl

The nurse is administering K-dur to a client diagnosed with hypokalemia. The health care provider has ordered K-dur 20 mEq PO tid. Calculate how many tablets will the nurse administer from a unit dose of 10 mEq/tablet?

2

The nurse is caring for a child with a urinary tract infection. The health care provider has ordered cephalexin 125 mg by mouth every 8 hours. Cephalexin is available 250 mg per 5 mL. How many milliliters should the nurse administer per dose? Record your answer using one decimal place.

2.5

The nurse is preparing to give a 9-year-old client a preoperative I.M. injection. Which size needle should the nurse use?

22G, 1"

A nurse is caring for a client with pneumonia who was prescribed ceftriaxone oral suspension 600 mg once daily. The medication label indicates that the strength is 125 mg/5 mL. How many milliliters of medication should the nurse pour to administer the correct dose? Record your answer as a whole number.

24

A nurse is obtaining data from a client who is at risk for cardiac tamponade due to chest trauma sustained in a motorcycle accident. What is the client's pulse pressure if the blood pressure is 108/82 mm Hg? Record your answer using a whole number.

26

After a 3-month trial of dietary therapy, a client with type 2 diabetes still has blood glucose levels above 180 mg/dl. The physician adds glyburide, 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take glyburide:

30 minutes before breakfast.

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what percentage of the total body surface area has been burned?

36%

A client undergoes a purified protein derivative (PPD) test for tuberculosis. After injecting PPD, when should the nurse plan to read the test results?

48 hours after injection

An intradermal skin test to detect tuberculosis infection is administered to a high-risk adolescent client. How long after the test is administered should the nurse wait to evaluate the results?

48 to 72 hours

The nurse is gathering data from a group of clients during clinic visits. Which client does the nurse determine is at the greatest risk for the development of type 2 diabetes?

48-year old client that had gestational diabetes with her second child

The nurse is working in a pediatric emergency department. Which client would the nurse see first?

5-year-old client with orbital cellulitis

A client with pneumonia has just finished dinner. The nurse must calculate the client's fluid intake before taking the tray from the room. The client had 6 oz of soup, 4 oz of milk, and 8 oz of juice. How many milliliters of fluid should the nurse record on the client's intake record? Record your answer using a whole number.

540

A client delivers a full-term neonate who weighed 7 lb, 8 oz. (3,402 g) at birth 2 days ago. When weighing the neonate, which weight would the nurse expect? 5 lb, 10 oz. (2,551 g) 6 lb, 6 oz. (2,891 g) 9 lb, 6oz. (4,252 g) 6 lb, 12 oz. (3,061 g)

6 lb, 12 oz. (3,061 g)

The charge nurse in a labor and delivery unit has one RN and one LPN caring for multiple clients at different stages of labor. Which client should be assigned to the LPN? A client in the second stage of labor who is requesting to go the bathroom. A client admitted 2 hours ago in the first stage of labor who is requesting to walk around the unit. A client who is in the fourth stage of labor with fundus above the umbilicus and bleeding with moderate amount of clots. A client in the third stage of labor with a moderate amount of blood trickling in a steady stream.

A client admitted 2 hours ago in the first stage of labor who is requesting to walk around the unit.

The nurse is reviewing the laboratory values of a client's urinalysis. He or she correctly identifies a urine sample with a pH of 5.2 as being which type of solution?

Acidic

The nurse is caring for a client who has been diagnosed with delirium. Which of the following is characteristic of delirium? Acute onset and lasts about 1 month Slowly evolving onset and lasts about 1 week Slowly evolving onset and lasts about 1 month Acute onset and lasts hours to a number of days

Acute onset and lasts hours to a number of days

A nurse is reviewing laboratory data of an oncology client who has an absolute neutrophil count (ANC) of 450/mm3 (0.45 × 109/L) following the third infusion of chemotherapy. Which intervention(s) would the nurse expect to be included in the plan of care? Select all that apply. Administration of filgrastim subcutaneously Placing the client in protective (reverse) isolation Encouraging a diet of fresh fruits and vegetables Ensuring that visitors follow good hand hygiene and are afebrile Keeping dedicated equipment in the room for the client's use only Advising the client to avoid showering during hospitalization

Administration of filgrastim subcutaneously Placing the client in protective (reverse) isolation Ensuring that visitors follow good hand hygiene and are afebrile Keeping dedicated equipment in the room for the client's use only

The nurse documents, "The client described her husband's abuse in an emotionless tone and with a flat facial expression." When reviewing the documentation, the nurse recognizes this statement is describing which aspect of the client's disposition?

Affect

A client has just been diagnosed with hepatitis A. During assessment, which signs and/or symptoms would the nurse anticipate to find? Severe abdominal pain radiating to the shoulder. Anorexia, nausea, and vomiting. Eructation and constipation. Abdominal ascites.

Anorexia, nausea, and vomiting.

The nurse is developing a teaching plan for a client diagnosed with diabetes insipidus. The nurse should include information about which hormone lacking in clients with diabetes insipidus?

Antidiuretic hormone (ADH)

A child with a Wilms tumor has had surgery to remove a kidney and has received chemotherapy. The nurse should include which instructions at discharge?

Avoid contact sports.

When teaching the mother of a 17-month-old child about toilet training, which instruction would initially be most appropriate?

Be sure the child is ready before starting to toilet train.

Which statement best explains why it is important to monitor behavior in a client who has stopped using phencyclidine (PCP)? Fatigue can cause feelings of being overwhelmed. Nausea and vomiting can occur during withdrawal. Bizarre behavior can be a precursor to a psychotic episode. Memory loss and forgetfulness can cause unsafe conditions.

Bizarre behavior can be a precursor to a psychotic episode.

A 65-year-old client comes to the physician's office for a follow-up appointment after having a basal cell lesion removed from his face. The nurse teaches the client to inspect his skin for signs of melanoma. For which sign should the nurse tell him to look?

Black or purple irregularly shaped nodules

The nurse monitors a client receiving enoxaparin, 30 mg subQ b.i.d after hip replacement surgery. Which adverse reaction is the client most likely to experience?

Bleeding

An 18-month-old Hispanic toddler admitted to the hospital with bronchitis has red marks on his upper chest over both sides of his body. The mother states that she has been treating him at home. Which treatment has the mother most likely been administering to her toddler?

Coin rubbing

The nurse is caring for a client with a postoperative wound evisceration. Which action should the nurse perform first?

Cover the protruding internal organs with sterile gauze moistened with sterile saline solution.

The nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?

Elevate the head of the bed to 30 degrees.

Which nursing action best addresses the outcome: The client will be free from falls?

Encourage use of grab bars and railings in the bathroom and halls.

A client who recently developed paralysis of the arms is diagnosed with functional neurologic symptom disorder after tests fail to uncover a physical cause for the paralysis. Which intervention should the nurse include in the plan of care?

Exercising the client's arms regularly

A 22-year-old client with an external fixation device attached to his left thigh is unable to bear weight on his left leg. He asks a nurse if he can take a shower on his third postoperative day. After a review of the physician's orders, the nurse notes an order stating, "Client may shower ten (10) days after surgery." In order to meet the client needs, what appropriate action will the nurse take?

Explain that he is not permitted to shower, but the nursing assistant can help him with a sponge bath.

A 16-year-old client comes to the physician's office for a physical examination that's required to play sports. The mother reports that her son is unusually tired during the day. She explains that he works at a part-time job, is socially active, and gets about 7 hours of sleep each night. Physical examination reveals that the client grew 3" during the past year. Which intervention by the nurse is most appropriate?

Explaining that his sleep requirements have increased related to the increased metabolic demands of growth

The nurse is reinforcing education with the parents of a child with a recurrent urinary tract infection (UTI). Which statement should the nurse include?

Follow-up urine cultures are necessary to detect recurrent infections and antibiotic effectiveness.

While out of bed walking, a client reports dizziness and requests to go back to the room. The nurse obtains the blood pressure machine and obtains vital signs on the client. The client's pulse is 50 and the blood pressure machine reads 80/40 mmHg. The nurse notes the client is scheduled to receive verapamil and atenolol. Which actions by the nurse are best? Select all that apply. Give the medications and check vital signs later. Call the supervisor and ask what to do. Give the scheduled medications. Hold the medications. Call the healthcare provider and provide a report of the events and vital signs.

Give the medications and check vital signs later. Call the supervisor and ask what to do. Give the scheduled medications. Hold the medications. Call the healthcare provider and provide a report of the events and vital signs.

The nurse is reviewing a client's prenatal history. Which of the following is a significant factor in anticipating complications in labor and birth? History of postpartum hemorrhage (PPH) Urinary tract infection at 16 weeks gestational age Gravida 4, Para 3 Amniocentesis performed at 14 weeks gestational age

History of postpartum hemorrhage (PPH)

The nurse is caring for a child with a diagnosis of croup. What advice should the nurse give to the parent when concern is expressed about the child waking at night due to the cough?

Hold child in the bathroom with a hot shower running, allowing steam to fill room.

After surgery to repair a cleft lip, an infant has a Logan bar in place. Which postoperative nursing action is appropriate?

Holding the infant semi-upright during feedings

When collecting data on a child with impetigo, the nurse expects which findings?

Honey-colored, crusted lesions

A mother is discontinuing breast-feeding after 3 months. The nurse should advise her to include which item in her infant's diet?

Iron-fortified formula alone

Atropine is being administered to a child with sinus bradycardia. Which statement is most accurate about the administration of this medication? It increases heart rate. It raises blood pressure. It dilates bronchial tubes. It decreases heart rate.

It increases heart rate.

During an annual checkup, a client tells the nurse that she and her husband have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end? It should begin early in the third trimester and end 1 month after delivery. It should begin before conception and end 3 months after delivery. It should begin when the client learns she's pregnant and end after delivery. It should begin at about 5 months' gestation and end at facility discharge.

It should begin before conception and end 3 months after delivery.

A client with cancer is being evaluated for possible metastasis. Which of the following is a common metastasis site for cancer cells? Liver Colon Reproductive tract White blood cells (WBCs)

Liver

On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which of the following actions by the nurse is the most appropriate? Reassess the client in 2 hours. Administer oxytocin as prescribed. Massage the uterine fundus gently. Notify the physician or nurse-midwife.

Massage the uterine fundus gently.

A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What does Brudzinski's sign indicate?

Meningeal irritation

A nurse is caring for a postoperative thyroidectomy client at risk for hypocalcemia. What intervention should the nurse implement in this client's care?

Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

The nurse is observing pupillary responses from a client. Which method should the nurse use to evaluate pupil accommodation?

Observe for pupil constriction and convergence while focusing on an object coming toward the client.

A nurse is assisting with planning care for a client with retinal detachment. The client has both eyes patched but is alert and oriented. What measure should the nurse include in the care plan to promote safety?

Place the call bell within the client's reach and ensure the client knows how to use it.

A 4-year-old is hospitalized following alleged sexual abuse. The child is withdrawn and exhibits poor eye contact. Which nursing strategies encourage client communication? Select all that apply. Use touch by rubbing the shoulders or back. Provide paper and crayons and encourage coloring. Provide a videotape on sexual abuse. Engage in play with toys and dolls. Read a book to establish a rapport.

Provide paper and crayons and encourage coloring. Engage in play with toys and dolls. Read a book to establish a rapport.

The nurse is supervising a student nurse who is performing tracheostomy care for a client. Which action performed by the student would require nurse intervention?

Remove inner cannula and clean using universal precautions.

The nurse is preparing a teaching plan for an elderly client with depression who will continue on a prescription for venlafaxine after discharge. Because of age-related cognitive changes the nurse should use which approach to client teaching? Repeat new information frequently. Provide detailed information. Avoid using pictures. Limit teaching to one session.

Repeat new information frequently.

A client treated with terbutaline for preterm labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan? Report a heart rate greater than 120 beats/minute to the health care provider. Take terbutaline every 4 hours, during waking hours only. Call the health care provider if the fetus moves 10 times in an hour. Increase activity daily if not fatigued.

Report a heart rate greater than 120 beats/minute to the health care provider.

When checking a client's medication profile, the nurse notes that the client is receiving a drug that is contraindicated in clients with glaucoma. The nurse knows that this client has a history of glaucoma and has been receiving the medication for the past 3 days. What should the nurse do first?

Report the information to the physician to ensure client safety.

A child is admitted with a tentative diagnosis of clinical depression. Which data collection finding is most significant in confirming this diagnosis?

Sadness

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

Scale

A nurse meets a neighbor and new baby at the local market. The neighbor states that she received outstanding nursing care from one of the nurse's colleagues during her labor and childbirth. What is the best way for the nurse to recognize her nursing colleague's professional efforts? Post accolades to the nurse at the nurses' station. Send the colleague an anonymous card. Share the feedback with the nursing colleague directly. It is a breach of confidentiality to share this information with the colleague.

Share the feedback with the nursing colleague directly.

A nurse is gathering data from a neonate. When checking the rooting reflex, which action would the nurse most likely do? Place an object in the neonate's palm. Stroke the sole of the neonate's foot. Stroke the neonate's cheek. Touch the neonate's lips.

Stroke the neonate's cheek.

How does the nurse assess the rooting reflex of a neonate? Placing an object in the neonate's palm Stroking the sole of the neonate's foot Stroking the neonate's cheek Touching the neonate's lips

Stroking the neonate's cheek

A client with type 2 diabetes comes to the clinic with a diabetic foot ulcer on his left heel that hasn't responded to treatment. Which action should a nurse take after assessing the ulcer?

Suggest a consult with a wound care specialist.

A client with chronic obstructive pulmonary disease (COPD) tells the nurse, "I no longer have enough energy to make love to my husband." Which nursing intervention would be most appropriate?

Suggest methods and measures that conserve energy.

A client who's 7 months pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping her cope with these cramps? Suggesting that she walk for 1 hour twice per day Advising her to take over-the-counter calcium supplements twice per day Teaching her to dorsiflex her foot during the cramp Instructing her to increase milk and cheese intake to 8 to 10 servings per day

Teaching her to dorsiflex her foot during the cramp

A nurse is caring for a client with end-stage testicular cancer who has been referred to hospice care. Which criterion excludes the client from hospice care? The client's girlfriend prefers not to discuss death around him. The client entered a clinical trial through the National Cancer Institute. The client's primary care provider prescribes weekly blood transfusions to be given at home. The client explains that he is not ready to complete his will.

The client entered a clinical trial through the National Cancer Institute.

A client is being admitted to the labor and birth unit. Her GTPAL classification is 5-2-1-1-2. When providing shift report, which information would the nurse state? Select all that apply. The client has had four previous pregnancies. The client has had five previous pregnancies. The client has had one full-term child, one abortion, and one premature child. The client has had two full-term children, one premature child, and one abortion. The client has three living children and is pregnant again. The client has two living children and is pregnant again

The client has had four previous pregnancies. The client has had two full-term children, one premature child, and one abortion. The client has three living children and is pregnant again.

The nurse is preparing to administer chlorpromazine to a client with schizophrenia. Which circumstance, if noted in this client's history, would cause the nurse to notify the health care provider for accuracy of the prescription? The client is also receiving labetalol. The client is diagnosed with intractable hiccups. The client had surgery and is restless. The client has a history of nausea and vomiting.

The client is also receiving labetalol.

A postpartum client recovering from spinal anesthesia with morphine reports that her nose itches. Which would the nurse suspect as the cause? The client may be having a reaction to a material she encountered in the delivery room. Postpartum itching is common after birth because of hormonal changes. The client may be still be partially sedated and imagining this feeling. The client is experiencing a common effect due to a morphine-based anesthetic.

The client is experiencing a common effect due to a morphine-based anesthetic.

A client states to the nurse, "I was watching television and the person in the commercial was trying to send me a message to be careful about who I talk with in this place because they will betray me." What behavior disturbance is the client displaying to the nurse? The client is displaying disorganized thinking. The client is having delusions of reference. The client is experiencing poor executive functioning. The client is having problems with working memory.

The client is having delusions of reference.

A client received treatment for depression for the past three weeks. The nurse determines that the treatment is effective based on observation of which behavior? The client talks about the difficulties of returning to college after discharge. The client spends most of the day sitting alone in the corner of the room. The client wears a hospital gown and shoes instead of street clothes. The client shows little to no emotion when visitors leave.

The client talks about the difficulties of returning to college after discharge.

A primary health care provider has instructed a client to check the radial pulse each morning before taking digoxin. After the nurse reinforces education with the client on how to take a radial pulse, which client behavior indicates an accurate understanding of the technique?

The client uses the middle three fingertips to palpate the radial artery.

The media requests information from a nurse caring for a client who is a criminal. Which statement best shows the nurse's understanding of confidentiality requirements when the client is a criminal?

The nurse shouldn't provide the media with any information about the client.

A 10-year-old child is in the hospital for the first time. The nurse has provided support and teaching to help the family and child adjust and to reduce their anxiety related to the child's hospitalization. Which of the following would the nurse view as unexpected?

The parents choose to leave to let the child build a relationship with the staff.

The nurse is caring for a neonate with a rectal temperature of 97.4 F (36.3 C). What is the priority nursing intervention for this neonate? Notify the manager immediately. Observe the neonate in the nursery for 2 hours. Obtain another temperature in 4 hours. Wrap the neonate in two warm blankets and place a cap on the head.

Wrap the neonate in two warm blankets and place a cap on the head.

The physician teaches a client about the need to increase her intake of calcium. At a follow-up appointment, the nurse asks the client which foods she has been consuming to increase her calcium intake. Which answer suggests that teaching about calcium-rich foods was effective?

Yogurt and kale

A nurse on the pediatric unit is caring for a group of preschool children. Which situation takes priority?

a child who develops a fever during a blood transfusion

The nurse is assigned to care for the following clients. Which client should the nurse see first?

a client diagnosed with hypothyroidism and a heart rate of 48 beats per minute

The nurse is making assignments for the next shift. Which clients can be assigned to a licensed practical nurse/licensed vocational nurse (LPN/LVN)? Select all that apply. a client who just had coronary artery bypass graft (CABG) a client who needs initial admission assessment a client who needs assistance with colostomy irrigation a client who is receiving insulin glargine subcutaneously a client who has C3 to C5 spine injury

a client who needs assistance with colostomy irrigation a client who is receiving insulin glargine subcutaneously

A few minutes after beginning a blood transfusion, the nurse notes that the client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing: a hemolytic reaction to mismatched blood. a hemolytic reaction to Rh-incompatible blood. a hemolytic allergic reaction caused by an antigen reaction. a hemolytic reaction caused by bacterial contamination of donor blood.

a hemolytic allergic reaction caused by an antigen reaction.

The nurse is participating in a discharge planning conference for a school-age child with newly diagnosed diabetes mellitus. The parents express concern about the accommodations needed when the child returns to school. Which recommendations does the nurse expect the team to make? Select all that apply. a schedule for blood glucose testing with target ranges and interventions a written plan for the school to follow regarding insulin administration home schooling to decrease the risk of complications no participation in physical education or recess education for appropriate school staff about care that will be rendered

a schedule for blood glucose testing with target ranges and interventions a written plan for the school to follow regarding insulin administration education for appropriate school staff about care that will be rendered

Which finding observed in a client taking finasteride should the nurse immediately report to the health care provider?

azotemia

The nurse is reinforcing anticipatory guidance on safety topics to a group of parents who have preschool-age children. When reinforcing education, what is appropriate to cover for the preschool level? Select all that apply. bathtub safety bike helmet use information on drugs and alcohol peer pressure water safety

bathtub safety bike helmet use water safety

A pregnant client at term arrives at the hospital experiencing contractions every 4 minutes. After a brief evaluation, she is admitted, and a nurse applies an electronic fetal monitor. When reviewing the client's history, which finding would the nurse identify as placing the client at increased risk for fetal distress? maternal weight gain of 30 lb (13.6 kg) maternal age of 22 years blood pressure of 146/94 mm Hg treatment for syphilis at 15 weeks' gestation

blood pressure of 146/94 mm Hg

A nurse is examining the following laboratory values in the chart of a client with chronic renal failure. Which value indicates that hemodialysis is an effective treatment for this client?

blood urea nitrogen (BUN)

The clinic nurse is reviewing the laboratory results of a client diagnosed with acute renal failure. What two values reflect the kidney's ability to excrete waste?

blood urea nitrogen (BUN) and creatinine

A client is in the last trimester of pregnancy. The nurse should instruct her to notify her obstetrician immediately if she notices: blurred vision. hemorrhoids. increased vaginal mucus. dyspnea on exertion.

blurred vision.

A nurse is caring for a client who is receiving enteral feedings through a feeding tube. Which action takes priority in this client's care? flushing the tube after each feeding checking placement of the tube aspirating to determine residual volume auscultating bowel sounds every shift

checking placement of the tube

The nurse is reinforcing education about treatments for the parents of a child diagnosed with pneumonia. What does the nurse identify as the best action to help in promoting a clear airway?

chest physiotherapy

An infant is diagnosed with bronchopulmonary dysplasia. What is a priority problem that the nurse expects to see in the plan of care?

decreased oxygen saturation

The nurse is working with a client who has a heroin addiction. What is an underlying cause common to most abusers? difficulty in effectively coping with stress difficulty in effectively interacting socially difficulty in effectively performing in work-related settings difficulty in effectively setting limits

difficulty in effectively coping with stress

While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand?

diphenhydramine hydrochloride

A client recovering from alcohol use needs to develop effective coping skills to handle daily stressors. Which intervention is most useful to the client? determining the client's verbal skills helping the client avoid conflict discussing examples of successful coping behavior educating the client about accepting uncomfortable situations

discussing examples of successful coping behavior

A nurse working as part of a multidisciplinary team is caring for a school-age child who has cerebral palsy. The child has difficulty eating using regular utensils and requires extensive assistance. The nurse advocating for the child would seek out which team member to assist in promoting the child's independence?

occupational therapist

During data collection of a newly admitted client, the nurse observes a reddened area on the left heel. The nurse applies pressure to the reddened area and notes that it does not blanch when pressure is relieved. When documenting the findings, which appropriate stage would the nurse assign to this pressure sore?

stage I

A nurse gathers data on a client who has developed a paralytic ileus. Which type of bowel sounds should the nurse anticipate hearing?

three to four peristaltic sounds per minute

The nurse delegates data collection to a nursing student for a newly admitted client. What action by the student violates the client's security of information? writing the room number on the data collection sheet to be placed in the chart writing the client's telephone number on the admission sheet writing the client's telephone number on clinical rotation paperwork for postclinical conference documenting the client's vital signs on the admission record

writing the client's telephone number on clinical rotation paperwork for postclinical conference

The nurse is providing breast cancer education at a community facility. The American Cancer Society (Canadian Cancer Society) recommends that women get mammograms: yearly after age 40. after the birth of the first child and every 2 years thereafter. after the first menses and annually thereafter. every 3 years between ages 20 and 40 and annually thereafter.

yearly after age 40.

The nurse is changing a client's dressing. Which observations would require the nurse to immediately notify the health care provider? Select all that apply. approximated wound edges yellow, purulent drainage sutures in place client complains of increasing pain pink granulation tissue

yellow, purulent drainage client complains of increasing pain

A parent reports that their 6-year-old daughter recently started wetting the bed and running a low-grade fever. A urinalysis is positive for bacteria and protein. A diagnosis of a urinary tract infection (UTI) is made, and the child is prescribed antibiotics. Which interventions are appropriate? Select all that apply. Limit fluids for the next few days to decrease the frequency of urination. Assess the parent's understanding of UTI and its causes. Instruct the parent to administer the antibiotic as prescribed—even if the symptoms diminish. Provide instructions solely to the parent, not the child. Discourage taking bubble baths. Advise wiping from the back to the front after voiding and defecation.

Assess the parent's understanding of UTI and its causes. Instruct the parent to administer the antibiotic as prescribed—even if the symptoms diminish. Discourage taking bubble baths.

Which care intervention is appropriate for the fourth stage of labor? Assisting with breathing techniques Encouraging rest between contractions Observing the perineum for show and bulging Assessing lochia and the location and consistency of the fundus

Assessing lochia and the location and consistency of the fundus

The nurse is caring for a resident in a long-term care facility who has venous stasis ulcers and is being treated with an Unna boot. Which of the nursing activities is best for the nurse to delegate to a unlicensed assistive personnel (UAP)?

Assist the client in cleaning around the Unna boot.

A client admitted with tuberculosis reports concerns about paying for needed medications. The nurse should:

collaborate with the social worker to investigate possible availability of funds.

A client with a suspected brain tumor is scheduled for a computed tomography (CT) scan. What should the nurse do when preparing the client for this test?

Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

How can breast cancer prevention programs best serve women who are at risk and come from lower socioeconomic backgrounds? Provide access to health insurance. Increase support services. Increase access to health care. Develop screening and educational programs.

Develop screening and educational programs.

A 15-year-old client who sustained a spinal cord injury is on bedrest. Which intervention by the nurse might best help the adolescent cope with the prolonged bedrest?

Encouraging visitation by his friends

The nurse is caring for a child with a respiratory infection. Which precaution should the nurse take to adhere to infection control measures?

Enforce handwashing.

A licensed practical nurse (LPN) receives a report on several assigned clients at the beginning of the evening shift. The nurse would plan to collect data on which client first?

an older adult client with bacterial pneumonia experiencing periods of confusion

A nurse walking down the hospital corridor hears a call for help from a client who was admitted with vascular insufficiency. She finds the client lying on the floor. The nurse assesses the client and notifies the health care provider of the incident. What information should the nurse chart on the incident report form? The client fell to the floor. The client was observed on the floor. The client slipped while coming from the bathroom. The client climbed out of bed and fell to the floor.

The client was observed on the floor.

The nurse is caring for a child who has had a nephrectomy after diagnosis of a Wilms tumor. The nurse has determined the child's pain and is preparing to administer an oral opiate. Which method is the best choice for administering the medication?

an oral syringe

Reusable blood pressure cuffs and single-use disposable blood pressure cuffs are both available for use in the emergency department. In order to conserve resources, for which client would a clean, reusable blood pressure cuff be appropriate?

an 87-year-old female client in the emergency department for chest pain

A client is in the emergency department after being sexually assaulted by a stranger. Which nursing intervention has priority?

assisting in identifying family or friends who could provide immediate support

A client with long-standing rheumatoid arthritis has frequent reports of joint pain. The plan of care should be based on the understanding that chronic pain is most effectively relieved when analgesics are administered in which way?

at regularly scheduled intervals

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to: auscultate bowel sounds. palpate the abdomen. change the client's position. insert a rectal tube.

auscultate bowel sounds.

Which condition of the female reproductive system does the nurse prepare to report for identification and treatment of sexual partners? Select all that apply. bartholinitis candidiasis chlamydia trichomoniasis herpes simplex virus

chlamydia trichomoniasis

An older adult client is newly diagnosed with left-sided heart failure. Which sign most commonly associated with this type of heart failure would the nurse expect to find when obtaining data for this client? crackles arrhythmias hepatic engorgement hypotension

crackles

The nurse is gathering data from a client that is diagnosed with Kawasaki disease. What data does the nurse determine is associated with this diagnosis?

dry, cracked lips, strawberry tongue

A client is suspected of having developed an acute pulmonary embolism. Which symptom would a nurse most likely observe first?

dyspnea

A client is admitted to the hospital with signs and symptoms of diabetes mellitus. Which findings will the nurse most likely observe in this client? excessive thirst weight gain constipation excessive hunger urine retention Frequent, high-volume urination

excessive thirst excessive hunger Frequent, high-volume urination

A nurse who is caring for a client in labor with a history of rheumatic heart disease should gather what data to determine fetal well-being? urinalysis fetal heart tones laboratory test results of the mother other signs and symptoms of the client

fetal heart tones

A client who presents to the emergency department with reports of chest pain has been diagnosed with an acute myocardial infarction (MI). Which additional findings does the nurse expect in this client?

hypotension, rapid pulse, and shortness of breath

A 4-year-old child is diagnosed with thoracic scoliosis secondary to cerebral palsy. Which condition should the nurse monitor for that may be a contributing factor to scoliosis?

hypotonia

The nurse is collecting data on a client. She notes clubbed fingers. This finding indicates:

hypoxia.

The nurse is caring for a 14-year-old child in skeletal traction for treatment of a fractured femur. The child is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone?

identity

A client has a history of osteoarthritis. Which signs and symptoms would the nurse expect to find when gathering data on the client?

joint pain, crepitus, Heberden's nodes

A client with a spinal cord injury has a neurogenic bladder. When planning for discharge, the nurse anticipates that the client will need which procedure or program?

intermittent catheterization

When assessing the neonate of a client who used heroin during her pregnancy, the nurse expects to find: lethargy 2 days after birth. irritability and poor sucking. a flattened nose, small eyes, and thin lips. congenital defects such as limb anomalies.

irritability and poor sucking.

The nurse is caring for a postpartum client with diabetes who has developed an infection. The nurse would monitor this client for which complication? anemia ketoacidosis respiratory acidosis respiratory alkalosis

ketoacidosis

A nurse is providing nutritional information to a client with a diagnosis of gout. Which of the client's favorite foods should be limited?

liver

The nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully? increase in blood pressure increase in blood volume low serum potassium level high serum sodium level

low serum potassium level

The nurse is caring for a client in the immediate postoperative phase after undergoing gastric surgery. Which is the priority action by the nurse? monitoring gastric pH assessing bowel sounds providing nutritional support monitoring for symptoms of hemorrhage

monitoring for symptoms of hemorrhage

The nurse makes initial rounds for the clients. Five medications are scheduled for administration at the same time to five different clients. Which medication should the nurse administer first after initial rounds?

morphine sulfate to a client with a myocardial infarction reporting chest pain

A graduate nurse, working in a long-term facility, is caring for a client who has hearing loss. When observing the graduate, the nurse mentor would intervene if which action is taken by the graduate?

moves around and multitasks when speaking

In caring for a child immediately after a head injury, the nurse notes a blood pressure of 110/60, a heart rate of 78 beats/minute, dilated and nonreactive pupils, minimal response to pain, and slow response to name. Which symptom would cause the nurse the most concern?

nonreactive pupils

A person calls the neonatal intensive care unit stating that his child is receiving care there. He tells the nurse that he and the mother "aren't together," and requests information about his child's condition. The nurse should consult a lawyer before giving the caller any confidential information. provide only general demographic information to the caller. request that the caller bring proof of insurance to the hospital. obtain more data before giving the caller any confidential information.

obtain more data before giving the caller any confidential information.

During the first few days of recovery from ostomy surgery for ulcerative colitis, what should be the priority of client care? body image ostomy care sexual concerns skin care

ostomy care

A child has arrived in the emergency department. The nurse documents the following findings in the client's chart knowing that they are consistent with which disease process?

pneumonia

A child receives prednisone after a heart transplant. For which adverse reaction to prednisone would a nurse monitor in this child? weight loss hyperpyrexia anorexia poor wound healing

poor wound healing

The nurse is caring for a client with terminal lung cancer. What is the priority nursing intervention for this client?

providing pain control

The nurse caring for an infant with pyloric stenosis should be alert for which classic sign or symptom?

projectile vomiting

A nurse is monitoring a client who's receiving a blood transfusion for volume replacement. The client reports itching about 20 minutes after the infusion begins. What is the priority action by the nurse?

report the symptom so that the infusion can be stopped immediately

The nurse is admitting a client with substernal chest pain. Which diagnostic tests does the nurse anticipate the client will receive to confirm or rule out a diagnosis of myocardial infarction (MI)? Select all that apply. serum bilirubin serum troponin serum myoglobin urinalysis electroencephalogram 24-hour creatinine clearance

serum troponin serum myoglobin

Which activity in a child with muscular dystrophy should a nurse anticipate difficulty with first?

standing

The nurse is gathering data regarding the physical development of a 33-month-old who is playing. Which of the following activities would the nurse anticipate the toddler being able to complete with minimal assistance? Select all that apply. riding a bicycle washing and drying hands coloring a detailed picture removing his or her jacket using a spoon for eating

washing and drying hands removing his or her jacket using a spoon for eating

A child with muscular dystrophy has lost complete control of his lower extremities. There is some strength bilaterally in the upper extremities, but poor trunk control. Which mechanism would be the most important to have on the wheelchair?

wheelchair belt

A 2-month-old infant is given a preliminary diagnosis of bronchiolitis. Which symptom would the nurse expect to find?

wheezing on auscultation

A nurse is preparing to reinforce education with a client who uses alcohol. What client data would be most important for the nurse to obtain? sleep patterns decision making willingness to learn communication skills

willingness to learn

As part of a prenatal nutritional education program for a 17-year-old pregnant client who is concerned about weight gain, a nurse is reinforcing the information. Which statement by the nurse would be most appropriate? "If you stay away from fast foods, your weight gain will be minimal." "You're young. You'll be able to lose the weight after the baby is born with no problem." "During pregnancy, you need to gain weight to help make sure your baby is healthy." "Keep your calories to around 1000 per day so you gain only the proper amount of weight."

"During pregnancy, you need to gain weight to help make sure your baby is healthy."

A 40-year-old client with mild dementia related to end-stage acquired immunodeficiency syndrome (AIDS) is preparing for discharge. She has decided against further curative treatment. Before discharge, she develops ocular cytomegalovirus (CMV). Her physician recommends treatment with a ganciclovir-impregnated implant, which requires a surgical procedure. The client's husband feels the implant won't help the client and asks the nurse if the implant will cure CMV. Which response best answers the husband's question while promoting client advocacy?

"The implant won't cure the virus, but it may help preserve her vision. If she can't see you or her surroundings, it may worsen her dementia and make caring for her at home more difficult."

An adolescent female client at the health clinic is considering having sexual intercourse. The client tells the nurse that she wants to begin taking oral contraception because "Birth control pills would mean I don't have to worry about pregnancy or HIV." What is the most appropriate initial response from the nurse?

"The pill will not protect you from getting sexually transmitted infections, and it isn't 100% effective for preventing pregnancy."

An adult client arrives at the emergency department and has just learned that a parent has died as a result of an automobile accident. The client states, "No, I don't believe it. It can't be true." How should the nurse respond?

"This is shocking news. May I sit with you for a while?"

A nurse is working with a client who is afraid of dying after a biopsy result came back positive for cancer. What is the best reflective response by the nurse to enhance client communication? "Do not be afraid." "Everything will be okay." "Everyone is afraid to die." "You are afraid to die."

"You are afraid to die."

The nurse is reinforcing education for the parents of a child with hypopituitarism about realistic expectations of height for their child, who is successfully responding to growth hormone replacement. What statement should the nurse include?

"Your child will attain the eventual adult height at a slower rate."

A client's blood glucose level is 45 mg/dL. Which signs and symptoms should the nurse be alert for in this client?

Decreased level of consciousness (LOC), anxiety, confusion, headache, and cool, moist skin

A client calls the clinic and informs the nurse that there is a foul odor coming from the cast. What is the best response by the nurse?

Tell the client to come to the clinic immediately since the foul odor may be a sign of infection.

The nurse is reviewing a nursing care plan for a client with a psychophysiological disorder. Nursing interventions should address which symptoms? only the physical symptoms that are life threatening only the physical symptoms that are distressing the client physical symptoms as well as psychosocial and spiritual problems only psychosocial symptoms

physical symptoms as well as psychosocial and spiritual problems

A nurse has completed 4 hours of an 8-hour shift on a medical-surgical unit when the nurse receives a phone call from the nursing supervisor. The nursing supervisor informs the nurse that the nurse needs to give report to the other two nurses on the medical-surgical unit and immediately report to the telemetry unit to assist with staff needs on that unit. The nurse informs the supervisor that the nurse has been busy with the current client assignment and feels this will overwhelm the nurses on the medical-surgical unit. The supervisor informs the nurse that the need is greater on the telemetry unit. This is an example of which type of ethical problem?

allocation of scarce nursing resources

The nurse should counsel parents to postpone which action until after their son's hypospadias has been repaired?

circumcision

A nurse is conducting a sexual awareness group of known pedophiles. What will the nurse highlight as the primary focus of this group?

cognitive restructuring

A client is admitted to the psychiatric unit with active psychosis. The physician diagnoses schizophrenia after ruling out several other conditions. Schizophrenia is characterized by: loss of identity and self-esteem. multiple personalities and decreased self-esteem. disturbances in affect, perception, and thought content and form. persistent memory impairment and confusion.

disturbances in affect, perception, and thought content and form.

A client sustained a femur fracture while skiing. After the client undergoes surgery to stabilize the fracture, what does the nurse determine will assist with healing of this fracture?

formation of new bone tissue

A client with a history of chronic renal failure is admitted with pulmonary edema following a missed dialysis treatment yesterday. The client's laboratory results are serum potassium 6.0 mEq/L, serum sodium 130 mEq/L, and serum bicarbonate 18 mEq/L. The nurse interprets that the client has which condition?

hyperkalemia

A child, age 8, is immobilized with a hip spica cast. To minimize the child's feelings of isolation, the nurse should:

let the child visit the playroom daily.

A nurse is reinforcing education with the parent of an ill child about childhood immunizations. The nurse should tell the parent that only inactivated virus vaccines should be administered to children with which disorder? diabetes mellitus leukemia asthma cystic fibrosis

leukemia

A nurse is caring for a client with borderline personality disorder. Which nursing intervention has priority? maintaining consistent, realistic limits giving instructions for meeting basic self-care needs arranging for participation in daytime activities to stimulate wakefulness scheduling the client to attend group therapy on a daily basis

maintaining consistent, realistic limits

A 10-year-old child with sickle cell anemia continues to wet the bed at night. The child feels frustrated about this and is too embarrassed to sleep over at a friend's house. Which response by the nurse would be most appropriate?

"A bladder training program may help to decrease nighttime wetting."

An adolescent is started on valproic acid to treat seizures. Which statement should be included when educating the adolescent?

"A common adverse effect is weight gain."

A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement made by the client about safer sex practices for persons with HIV is accurate?

"A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse."

A nurse is caring for a client with end-stage heart failure. Which statement by the client best demonstrates a good understanding of an advance directive? "I will rely on my doctor to know about my preferences." "Once I decide on an advance directive, I cannot change my mind." "A living will allows my decisions for health care to be known if I can't speak for myself." "A health care power of attorney will allow my daughter to use my funds to pay for my health care costs, if I can't do so."

"A living will allows my decisions for health care to be known if I can't speak for myself."

A health care provider is discussing a recent diagnosis of Alzheimer's disease (AD) with a client and family. Which statements by the family to the nurse concerning the condition indicate the need for further instruction? Select all that apply. "Alzheimer's disease is commonly caused by cerebral abscesses." "Chronic alcohol abuse plays a significant role in the development of Alzheimer's disease." "Multiple small brain infarctions typically lead to Alzheimer's disease." "The cause of Alzheimer's disease is currently unknown." "Not all causes of memory losses and dementia are the result of Alzheimer's disease."

"Alzheimer's disease is commonly caused by cerebral abscesses." "Chronic alcohol abuse plays a significant role in the development of Alzheimer's disease." "Multiple small brain infarctions typically lead to Alzheimer's disease."

A client who just gave birth is concerned about her neonate's Apgar scores of 7 and 8. She says she's been told scores lower than 9 are associated with learning difficulties in later life. Which response by the nurse is most therapeutic? "You shouldn't worry so much, your infant is perfectly fine." "You should ask about placing the infant in a follow-up diagnostic program." "You're right in being concerned, but there are good special education programs available." "Apgar scores are used to indicate a need for resuscitation at birth. Scores of 7 and above indicate no problem."

"Apgar scores are used to indicate a need for resuscitation at birth. Scores of 7 and above indicate no problem."

The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. When describing a healthy stoma, which statement should the nurse be sure to include?

"At first, the stoma may bleed slightly when touched."

A nurse reinforces education for a pregnant woman who is scheduled for a cesarean birth regarding prevention of complications that can develop after the birth. Which statement by the client indicates a need for further education?

"At least one complication I don't have to worry about is blood clots."

A client comes to the clinic for a follow-up appointment after diagnostic tests show gastroesophageal reflux disease. What instructions should the nurse reinforce? "Lie down and rest after each meal." "Avoid alcohol and caffeine." "Drink 16 ounces of water with each meal." "Eat three well-balanced meals every day."

"Avoid alcohol and caffeine."

A client with a peptic ulcer is about to begin a therapeutic regimen that includes a bland diet, antacids, and ranitidine. Before the client is discharged, the nurse should provide which instruction?

"Avoid aspirin and products that contain aspirin."

A nurse is caring for a client who is receiving spironolactone (Aldactone) to treat hypertension. Which instruction should the nurse give the client?

"Avoid salt substitutes."

A female client with a history of four urinary tract infections (UTIs) in the past 3 months comes to the urology clinic reporting of burning and urinary urgency and frequency. A health care provider makes the diagnosis of UTI. Which instructions should the nurse give the client to help prevent recurring infections? Select all that apply. "Increase the intake of carbonated beverages." "Avoid using irritating substances such as bubble bath and scented toilet paper." "Change laundry detergents frequently." "Take antibiotics until symptoms abate." "Clean the perineal area from front to back."

"Avoid using irritating substances such as bubble bath and scented toilet paper." "Clean the perineal area from front to back."

The nurse reinforces instructions for a client diagnosed with acute lymphocytic leukemia (ALL) who is preparing for allogeneic bone marrow transplant. Which statement made by the client indicates to the nurse that the client understands the instructions? "I should be able to travel almost immediately after the procedure is completed." "I will not need to make any dietary changes during the course of my treatment." "After my transplant, I'll have to remain in the hospital for about 3 months." "Before undergoing the bone marrow transplant, I will receive chemotherapy."

"Before undergoing the bone marrow transplant, I will receive chemotherapy."

The nurse is teaching a group of high school students about obesity. Which information will the nurse provide when discussing this topic?

"Calculating body mass index is preferred to weighing yourself on a scale."

A client is concerned about severe abdominal pain. During the focused assessment, the nurse asks which question to elicit as much information as possible about the pain?

"Can you describe the pain?"

A 15-year-old girl visits the neighborhood clinic seeking information on "how to keep from getting pregnant." What should the nurse say in response to her request?

"Can you tell me about the precautions you're taking now?"

The nursing instructor asks the nursing student why shouldn't the nurse palpate both carotid arteries at the same time. Which response by the student is correct?

"Checking both carotid arteries at the same time may impair cerebral circulation."

A mother is concerned that she might be spoiling her 2-month-old daughter by picking her up each time she cries. Which suggestion should the nurse offer?

"Continue to pick her up when she cries because young infants need cuddling and holding to meet their needs."

A client admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. The nurse includes which instruction in the discharge teaching? "Continue to take antacids, even if your symptoms subside." "You may take antacids with other medications." "Avoid taking antacids containing magnesium if you develop a heart problem." "Take antacids with meals."

"Continue to take antacids, even if your symptoms subside."

A nurse is reinforcing home care instructions for a client who has recently had a skin graft. Which instruction is appropriate for the nurse to give the client?

"Cover the area when in direct sunlight."

A client in active labor has severe second-degree burns on her buttocks. When questioned about the burns, the client replies, "I was trying to use that hot water thing to help my hemorrhoids." Which statement made by the nurse is therapeutic? "Who told you that you have hemorrhoids?" "Did your doctor order the hot water treatments?" "Did I hear you say you sustained this burns from hot water application to the buttocks?" "I am sorry the hot water did not help the hemorrhoids."

"Did I hear you say you sustained this burns from hot water application to the buttocks?"

A nurse is providing care for a pregnant 16-year-old client who says that she is concerned she may gain too much weight and wants to start dieting. What is the best response by the nurse?

"Dieting could deprive your baby of nutrients leading to developmental and growth problems."

A woman is brought to the emergency department by her husband, who reports that she accidentally fell down basement stairs and broke her arm. The client is quiet, withdrawn, and not making eye contact. During the examination, inspection reveals numerous bruises at different stages of healing over the client's legs, arms, and abdomen. Which nursing response(s) would be most appropriate to gather additional information? Select all that apply. "You have bruises all over your body. Your husband is really beating you, isn't he?" "Do you wish to tell me anything more about how you fell down the stairs?" "I've noticed several bruises on your body. Can you tell me how they happened?" "Your husband has no right to do this to you. Do you want me to call the police?" "I am a mandated reporter of any abuse. Do you understand that I have to report my suspicions?"

"Do you wish to tell me anything more about how you fell down the stairs?" "I've noticed several bruises on your body. Can you tell me how they happened?" "I am a mandated reporter of any abuse. Do you understand that I have to report my suspicions?"

A client with a urinary tract infection is prescribed co-trimoxazole. The nurse should provide which medication instruction?

"Drink at least eight 8-oz glasses of fluid daily."

A nurse is caring for a client receiving a hypertonic feeding solution via a nasogastric tube. The client's family member asks the nurse why the solution is being administered at room temperature. Which response would the nurse give to the family member?

"Giving cold or very warm formula stimulates gastric peristalsis."

A school-age child has a fever, joint inflammation, and a nonpruritic rash. Knowing that these are signs of rheumatic fever, the nurse should ask the parents:

"Has your child had strep throat recently?"

The nurse explains hospice care to the parents of a terminally ill toddler. How should the nurse best explain this type of nursing care?

"Hospice care provides an improved quality of life until death."

An infant is brought to the emergency department and pronounced dead with the preliminary finding of sudden infant death syndrome (SIDS). Which question to the parents is most appropriate?

"How did the infant look when you found him?"

The nurse is caring for a client with increased stress. Which client statement reflects that progress is being made toward stress management? "I still feel worked up most of the time." "I contacted my boss to talk about an alternate work schedule." "I think my health care provider wants me to try to manage my stress." "I am not sure I believe in relaxation therapy but I will try it."

"I contacted my boss to talk about an alternate work schedule."

A nurse is reinforcing education to a client diagnosed with renal calculi. Which statement made by the client suggests further instruction is indicated?

"I do not need to limit my intake of tea or cola."

The nurse is obtaining data about the early life of a client with borderline personality disorder (BPD). Which statement made by the client would correlate with this diagnosis? "I had an overprotective, ever-present mother." "I had a violent, chaotic family life." "I have a rigid, consistent daily schedule of activities." "I had an intact family whose members were stoic and emotionally reserved."

"I had a violent, chaotic family life."

The nurse is gathering data from a female client that states she has had difficulty conceiving. Which statement made by the client would the nurse find most significant related to the difficulty getting pregnant?

"I had gonorrhea that went untreated for about 3 months."

The daughter of a client diagnosed with Alzheimer's disease tells a nurse, "My mother is incompetent. You'll need to contact me or my sister if any decision must be made about my mother's care." Which response by the nurse is best? "Thank you for informing me of your wishes." "I'll tell the health care team that you and your sister will make all of your mother's health care decisions." "I'll need a physician's order that permits you and your sister to make care decisions." "I must respect your mother's rights until she is legally deemed incompetent."

"I must respect your mother's rights until she is legally deemed incompetent."

A client diagnosed with depression threatens suicide and is placed on constant observation. When the client asks to use the toilet, the nurse follows the client into the bathroom. The client says, "I don't need you to follow me into the bathroom. Give me some space." Which statement by the nurse would be considered the most appropriate? "You're right. I don't need to come into the bathroom. I will wait outside." "I must stay with you until we are sure you are not going to hurt yourself." "If you think you are going to be alright, I will check on you in 5 minutes." "There is nothing dangerous in the bathroom. I will wait for you in the hallway."

"I must stay with you until we are sure you are not going to hurt yourself."

A nurse is reinforcing nutritional counseling to the parent of a child with celiac disease. Which statement by the parent indicates understanding of the diet?

"I need to read food labels carefully to avoid gluten additives in foods."

The nurse is reinforcing education for a client in the first trimester of pregnancy. What statement made by the client demonstrates an understanding of the education? "I need to take supplemental folic acid to prevent neural tube defects." "I need to eat a lot of liver so that I won't become anemic." "I should limit my activities during the first trimester of pregnancy so that I won't have a miscarriage." "I should begin drinking 32 ounces of whole milk daily to increase my calcium intake."

"I need to take supplemental folic acid to prevent neural tube defects."

Which statement made by a client with a chlamydial infection indicates understanding of the potential complications?

"I need to treat this infection so it doesn't spread into my pelvis because I want to have children someday."

A nurse is obtaining data from a client with a urinary tract infection (UTI). Which statement should the nurse expect the client to make? Select all that apply. "I urinate large amounts." "I need to urinate frequently." "It burns when I urinate." "My urine smells sweet." "I need to urinate urgently."

"I need to urinate frequently." "It burns when I urinate." "I need to urinate urgently."

A pregnant client at 28 weeks gestation has been diagnosed with gestational diabetes and is started on insulin therapy.. After reviewing information about the use of insulin with the client, the nurse determines that the teaching was successful based on which client statement? "I won't use insulin if I'm feeling sick." "I need to use insulin every day." "Since I'm taking insulin, I don't need to watch what I eat." "I'll monitor my blood glucose levels twice per week."

"I need to use insulin every day."

A nurse reinforces home care instructions to a client who is being seen in the clinic for bacterial conjunctivitis of the right eye. Which client statement indicates an understanding of the instructions?

"I should use good hand washing to help to reduce the spread of this infection to others."

The nurse is teaching a 10-year-old soccer player about hygiene after sporting events or practice. Which client statement reflects an understanding of this education?

"I should wear shower shoes in the locker room."

The nurse is caring for a client asking for information about cocaine. Which statement by a client indicates that reinforcement of teaching about cocaine use has been effective? "I wasn't using cocaine to feel better about myself." "I started using cocaine more and more until I couldn't stop." "I'm not addicted to cocaine because I don't use it every day." "I'm not going to be a chronic user. I only use it on holidays."

"I started using cocaine more and more until I couldn't stop."

A nurse is attempting to administer lisinopril to a client. The client refuses to take the pill, stating that in the past he developed a rash as an allergic reaction to the medication. Which of the following is the best response by the nurse? "I will check your chart for documentation of the allergy." "A rash is a side effect not an allergic reaction." "If you do not take your medication, I will report your refusal to the charge nurse." "I will call the physician with this information."

"I will call the physician with this information."

The family of a laboring client is distressed to discover that the on-call physician is a male. The client's husband forbids the physician from providing care for his wife. What is the nurse's best strategy in which to provide care in labor and birth when confronted with a cultural conflict? "Your attitude toward the male physician could put the baby at risk." "Please try to understand that the physician is a professional and will be escorted by a female nurse." "Clients cannot always be guaranteed there will be a female physician on call." "I will make every effort to work with your cultural beliefs."

"I will make every effort to work with your cultural beliefs."

A client arrives in the outpatient department for a colonoscopy and states, "I wasn't able to drink all of that stuff. Could only drink 2 cups." What is the best response by the nurse?

"I will notify the health care provider and let him know that you were unable to drink the prep solution."

A nurse is reinforcing education for a client regarding the medication vardenafil. What statement made by the client demonstrates that education has been successful?

"I will take the medication 1 hour before sexual intercourse."

A staff member on the transplant unit is having problems logging into the computer to chart client information. The staff member asks a nurse for their personal identification number (PIN) to log in. What is the nurse's best response?

"I'll be happy to contact Information Services to assist you with the problem."

A nurse is caring for a female client who has been prescribed alprazolam for panic attacks. After reviewing information about the medication, the nurse determines that the client has understood the information based on which response?

"I'll discuss my plans for pregnancy with my health care provider."

A client with borderline personality disorder tells the nurse, "You're the only nurse who really understands me. The others are mean." The client then asks the nurse for an extra dose of antianxiety medication because of increased anxiety. What is the appropriate nursing response?

"I'll discuss your request with the team. Let's talk about what you think is increasing your anxiety."

A nurse is reinforcing education for a client with pernicious anemia requiring vitamin B12 replacement therapy. Which statement indicates that the client understands the treatment program?

"I'll need an injection of vitamin B12 every month for life."

A nurse is preparing to talk with a client who recently attempted suicide. Before engaging in the conversation, which statement by the nurse would be most appropriate? "I'll need to share information with the rest of your health care team if it's important to your care." "I promise I won't tell anyone about the information you share with me today." "I promise I won't tell anyone about what you've shared today unless I have your permission to do so." "Please don't tell me anything that you wouldn't want others on your health care team to know."

"I'll need to share information with the rest of your health care team if it's important to your care."

While pacing in the hall, a client with schizophrenia runs to the nurse and says, "Why are you poisoning me? I know you work for central thought control! You can keep my thoughts. Give me back my soul!" How should the nurse respond during the early stage of the therapeutic process? "I'm a nurse. I'm not poisoning you. It's against the nursing code of ethics." "I'm a nurse, and you're a client in the hospital. I'm not going to harm you." "I'm not poisoning you. And how could I possibly steal your soul?" "I sense anger. Are you feeling angry today?"

"I'm a nurse, and you're a client in the hospital. I'm not going to harm you."

After completing chemical detoxification and a 12-step program to treat drug addiction, a client is being prepared for discharge. Which remark by the client indicates to the nurse that he or she has a realistic view of the future? "I'm never going to use crack again." "I know what I have to do. I have to limit my crack use." "I'm going to take 1 day at a time. I'm not making any promises." "I can't touch crack again, but I sure could use a drink. I've earned it."

"I'm going to take 1 day at a time. I'm not making any promises."

A client in a semiprivate room is diagnosed with pediculosis corporis. A nurse will initiate treatment after moving the client to another room. The client's roommate asks the nurse for information about the client. How should the nurse respond?

"I'm sorry, but I can't share confidential information."

Which statement from a client with bulimia shows that the client understands the concept of relapse? "If I can maintain control, I'll have problems." "If I have problems, then I haven't learned much." "If this illness becomes chronic, I won't be able to handle it." "If I have problems, I can start over again and not feel hopeless."

"If I have problems, I can start over again and not feel hopeless."

A nurse is talking with a client who recently attempted suicide. The client asks the nurse not to tell anyone about their conversation. How should the nurse respond? "If information is important to your care, I'll need to share it with the rest of your health care team." "I promise I won't tell anyone about the information you share with me today." "I promise I won't tell anyone about the information you share with me today unless you give me permission to do so." "Please don't tell me anything that you wouldn't want others on your health care team to know."

"If information is important to your care, I'll need to share it with the rest of your health care team."

After receiving education about the treatment plan for acute lymphocytic leukemia (ALL) for a preschooler, the caregiver asks the nurse, "I saw a movie where a baby born to the parents was able to be a donor for stem cell transplant for the sibling with leukemia. Is that something we could do?" What is the nurse's best response?

"If this is something you are considering, I recommend you speak to the health care provider about a consult to a genetic counselor."

A client who has been taking imipramine, 125 mg P.O. daily, for 1 week wants to stop taking the medication because the client still feels depressed. Which response by the nurse would be most appropriate at this time? "This medicine may not be the most effective one for you. Let's call your health care provider for further evaluation." "Imipramine must build up to a therapeutic level; it may take 3 to 4 weeks to reduce depression." "The primary care provider may need to adjust the dosage for you to get the medication's maximum benefit." "Don't stop taking the medication abruptly because you may develop serious side effects."

"Imipramine must build up to a therapeutic level; it may take 3 to 4 weeks to reduce depression."

The nurse is caring for an adolescent client with asthma. The client is refusing the recommended inhaled corticosteroid (ICS) therapy stating, "These steroids have terrible side effects and make you fat, get acne, and stunt your growth." Which response(s) should the nurse provide to assist the client in adhering to treatment recommendations? Select all that apply. "Inhaled corticosteroids have less systemic effects compared to taking the pill forms." "Poorly controlled asthma can also contribute to slowed growth and delayed puberty." "Controlling environmental triggers can also help avoid exacerbations of your asthma." "When you have an asthma exacerbation you are often given higher doses of these steroids." "You have the right to refuse treatment, but I will have to let your health care provider know."

"Inhaled corticosteroids have less systemic effects compared to taking the pill forms." "Poorly controlled asthma can also contribute to slowed growth and delayed puberty." "Controlling environmental triggers can also help avoid exacerbations of your asthma." "When you have an asthma exacerbation you are often given higher doses of these steroids."

A client has been prescribed an anti-inflammatory for osteoarthritis, and the nurse has reinforced educating the client about taking the medication. Which statement by the client indicates that the nurse's education has been effective?

"It can take up to 2 to 3 weeks for me to feel the full effects from the medication."

A mother asks the nurse why her neonate is getting an injection of vitamin K. Which response by the nurse would be most appropriate? "It helps with coagulation." "The vitamin assists the gut to mature." "It gets the immune system functioning." "The vitamin prevents excess fluid production in the brain."

"It helps with coagulation."

On the second postpartum day, a client tells the nurse she feels anxious and tearful. Which response by the nurse would be appropriate? "It isn't unusual to have those feelings after delivery." "How have you coped with other problems in your life?" "To whom do you usually talk when you have problems?" "Don't worry. You'll be fine."

"It isn't unusual to have those feelings after delivery."

A client presents to the emergency department with flu-like symptoms. During data collection, the nurses note the client returned from vacation 3 weeks ago, had a blood transfusion 3 years ago, and the sclera appears yellow in color. After being diagnosed with Hepatitis A virus (HAV), the client states, "How could I have gotten hepatitis?" Which nursing response given is most accurate?

"It may have happened if the food handler in a restaurant had the virus."

A client with advanced cancer is about to begin hospice care at home. Which statement made by the client shows that the client understands the principles of hospice care? Select all that apply. "It will manage my pain and discomfort." "It will enhance the quality of my life." "It will prolong what's left of my life." "It will provide support for my family in dealing with my death." "It will provide aggressive treatment of my condition."

"It will manage my pain and discomfort." "It will enhance the quality of my life." "It will provide support for my family in dealing with my death."

A client who gave birth vaginally 16 hours ago states she doesn't need to void at this time. The nurse reviews the documentation and finds that the client hasn't voided for 7 hours. Which response by the nurse is indicated? "If you don't attempt to void, I'll need to catheterize you." "It's common for you to have a full bladder even though you can't sense it." "I'll need to contact your health care provider right away for instructions." "I'll come back and check on you in a few hours to see if you can go."

"It's common for you to have a full bladder even though you can't sense it."

The night before discharge, a client expresses guilt that she'll have to return to work in 3 weeks and leave her infant with a nanny. The client asks the nurse for an opinion about using a nanny. What should the nurse say first? "It's difficult to be a working parent, but having a nanny will provide your baby with a consistent caregiver while you're gone." "You should really think about taking a minimum of 6 weeks off to rest and recover." "I felt the same way with my kids, but it all seems to work out." "Parenting is full of hard decisions, but you're lucky to have a nanny, which is a better alternative than day care."

"It's difficult to be a working parent, but having a nanny will provide your baby with a consistent caregiver while you're gone."

A new mother who's breast-feeding asks how she can quickly lose the 40 lb she gained during pregnancy. Which response by the nurse is best? "The extra calories expended during breast-feeding will allow you to lose the weight gradually and effortlessly over the next few months." "It's important to avoid dieting while your milk supply is being established; a well-balanced diet with gradual weight loss is recommended." "Breast-feeding mothers should diet until their babies are weaned." "Relax and enjoy your infant. You shouldn't be worrying about your weight."

"It's important to avoid dieting while your milk supply is being established; a well-balanced diet with gradual weight loss is recommended."

The home health nurse visits an older adult client and their spouse to discuss home safety prior to discharge from the hospital. What information should the nurse focus on to optimize safety?

"It's important to have good lighting and clear, even flooring surfaces."

A neonate was born 2 days ago. The mother is being prepared for discharge and voices concern because her neonate's birth weight has declined by 2 oz. She states that she'll continue to breast-feed but will supplement after each breast-feeding with 4 oz of formula. Which response by the nurse would be best? "That's a good idea. It's difficult to determine if your breast-fed baby is getting enough to eat." "To determine if the baby is getting enough, you should weigh the baby before and after each feeding." "It's normal for a neonate to lose 6% to 10% of its birth weight. While supplementing is acceptable, remember that your baby's stomach can hold only about 3 oz (90 mL)." "Supplementing with formula is never recommended for breast-feeding infants."

"It's normal for a neonate to lose 6% to 10% of its birth weight. While supplementing is acceptable, remember that your baby's stomach can hold only about 3 oz (90 mL)."

During chemotherapy, a boy, age 10, loses his appetite. When teaching the parents about his food intake, the nurse should include which instruction?

"Let your child eat any food he wants."

The unlicensed assistive personnel tells the nurse that it is unreasonable to expect a response to all call lights within 10 minutes. Which statement by the nurse best illustrates appropriate assertive behavior by a supervisor?

"Let's discuss how we can meet our clients' needs."

A nurse is caring for an older adult client who was admitted with a hip fracture. The client is occasionally confused and has incidents of urinary incontinence. The nurse overhears the unlicensed assistive personnel state, "I am tired of changing that client's bed linen because she can't hold her urine. The client is with it mentally most of the time." Which response by the nurse is most appropriate?

"Let's go to a private area so that we can talk more about your frustration."

A client in the first trimester of pregnancy reports experiencing nausea every morning and asks about medicine to prevent it. Which response from the nurse would be most helpful? "Let's talk about some methods to control nausea without medication." "You shouldn't take medication during pregnancy, especially during the early weeks." "I'll ask the health care provider if you can have something prescribed to help." "You'll probably have a lot less nausea in just a few weeks."

"Let's talk about some methods to control nausea without medication."

A client is scheduled for a surgical procedure for removal of a pancreatic tumor. The client states to the nurse, "I don't think I'll live through the surgery. I'm scared." What is the best response by the nurse? "Well, you might be right. Not everyone makes it through surgery." "If you feel like this, you should say goodbye to your family." "Let's talk about your concerns and fears." "When I had surgery, I felt the same way."

"Let's talk about your concerns and fears."

A client with antisocial personality disorder says, "I always want to blow things off." Which response by the nurse is most appropriate? "Try to focus on what needs to be done and just do it." "Let's work on considering some options and strategies." "Procrastinating is a part of your illness that we'll work on." "The best thing to do is decide on some useful goals to accomplish."

"Let's work on considering some options and strategies."

The nursing instructor asks the nursing student why should an infant be quiet and seated upright when the nurse checks his or her fontanels. Which is the best response?

"Lying down and crying can cause the fontanels to bulge."

The nurse is reinforcing education to parents of a child prescribed sulfamethoxazole-trimethoprim for a urinary tract infection. What education should the nurse include?

"Make sure your child takes the medication for 10 days even if his symptoms improve in a few days."

A nurse is giving discharge instructions to the parents of a child with Kawasaki disease. Which statement by the parents shows an understanding of the treatment plan? "A regular diet can be resumed at home." "Black, tarry stools are considered normal." "My child should use a soft-bristled toothbrush." "My child can return to playing football next week."

"My child should use a soft-bristled toothbrush."

A child, age 15 months, is admitted to the health care facility. During the initial data collection, which statement by the mother most strongly suggests that the child has a Wilms' tumor?

"My child's abdomen seems bigger, and his diapers are much tighter."

A nurse is caring for a client with Raynaud phenomenon secondary to systemic lupus erythematosus (SLE). Which of the client statements shows an understanding of the nurse's teaching about this disorder? Select all that apply. "My hands get pale, bluish, and feel numb and painful when I'm really stressed." "I can't continue to wash dishes and do my cleaning because of this problem." "I don't need to report any other skin problems with my fingers or hands to my practitioner." "I probably got this disorder because I have lupus." "This problem is caused by a temporary lack of circulation in my hands." "Medication might help treat this problem."

"My hands get pale, bluish, and feel numb and painful when I'm really stressed." "I probably got this disorder because I have lupus." "This problem is caused by a temporary lack of circulation in my hands." "Medication might help treat this problem."

A 15-year-old child has been scheduled to have a cardiac catheterization. Which statements by the teen or parent indicate the need for further instruction? Select all that apply. "A consent will need to be signed by my parents for this procedure." "My health care provider will put me to sleep for the catheterization." "The sound waves will let the health care providers see how my heart moves." "This procedure provides visualization of the heart and great vessels with radiopaque dye." "They will pass a small catheter through one of my veins to look at the inside of my heart."

"My health care provider will put me to sleep for the catheterization." "The sound waves will let the health care providers see how my heart moves."

A client who lost her spouse suddenly 30 years ago tells a nurse during an interview, "My husband's shoes are at the side of the bed where he left them." The client's daughter informs the nurse that her mother constantly speaks about her deceased husband. Which statement by the daughter shows an understanding of maladaptive grief? "My mother is stuck in the anger stage of the grief process." "My mother is exhibiting a delayed response to grief." "My mother is exhibiting resolution of the grief process." "My mother is in a prolonged phase of the grief process."

"My mother is in a prolonged phase of the grief process."

A client hospitalized for treatment of hypertension is being prepared for discharge. Which statement from the client indicates an understanding of discharge instructions? "I should avoid meat and milk." "I should skip my medication dose if dizziness occurs." "My sodium intake shouldn't exceed 2,300 mg per day." "I should schedule a visit once per week for IV antihypertensive medications.

"My sodium intake shouldn't exceed 2,300 mg per day."

A client in the first trimester of pregnancy reports constant fatigue. Which response by the nurse is best? "Needs for rest and sleep typically increase during the first trimester of pregnancy." "I'll inform the health care provider; you'll most likely need some follow-up testing." "Have you tried having a cup of coffee when you awaken in the morning?" "Sometimes a pregnant woman feels fatigued when the baby's sleep pattern is opposite its mother's."

"Needs for rest and sleep typically increase during the first trimester of pregnancy."

A client is being discharged with a home oxygen delivery device. Which comments indicate that the client understands safety regarding home oxygen? Select all that apply. "No one can smoke within 10 feet (3 meters) of the oxygen." "I can carry my oxygen in a bag for easy portability." "I need to keep my oxygen away from electrical sources." "I should keep my oxygen away from direct heat." "I'll keep my oxygen out of the sun in all circumstances."

"No one can smoke within 10 feet (3 meters) of the oxygen." "I need to keep my oxygen away from electrical sources." "I should keep my oxygen away from direct heat."

A client asks a nurse, "Do you hear the voices speaking to me?" Which response by the nurse is best? "Stop asking about voices. No one is in your room except you." "Yes, I hear, but I won't listen." "What has the voice told you? Is it helpful advice?" "No, I don't hear anything, but I know you do. What are they saying?"

"No, I don't hear anything, but I know you do. What are they saying?"

The nurse is providing care for a pregnant 16-year-old client. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying: "Now isn't a good time to begin dieting because you are eating for two." "Let's explore your feelings further." "Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems." "The prenatal vitamins should ensure that the baby gets all the necessary nutrients."

"Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems."

The parents of a child with cystic fibrosis ask the nurse why their child must receive supplemental pancreatic enzymes. Which response by the nurse would be most appropriate?

"Pancreatic enzymes promote absorption of nutrients and fat."

A nurse is reinforcing education on preventing injuries with the parents of a toddler. Which instructions are appropriate for the nurse to give the parents? Select all that apply. "Educate the toddler about wearing a helmet when rollerblading." "Place locks on cabinets containing toxic substances." "Never allow a toddler to be near water at any time without adult supervision." "Don't allow the toddler to use pillows when sleeping."

"Place locks on cabinets containing toxic substances." "Never allow a toddler to be near water at any time without adult supervision."

The X-rays of a client who was brought to the emergency department after falling on ice reveal a leg fracture. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs?

"Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together."

The parents of a client with anorexia nervosa ask the nurse about the risk factors for this disorder. After reinforcement of the education plan by the nurse, which statement by the parents best indicates that it has been effective? "Risk factors include the inability to be still and emotional lability." "Risk factors include a high level of anxiety and disorganized behavior." "Risk factors include low self-esteem and problems with family relationships." "Risk factors include a lack of life experiences and opportunities to learn life skills."

"Risk factors include low self-esteem and problems with family relationships."

A client with type 1 diabetes must learn how to self-administer insulin. The physician has prescribed 10 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?

"Rotate injection sites within the same anatomic region, not among different regions."

A client says to the nurse, "I know that I'm going to die." Which response by the nurse would be best?

"Tell me why you think you are going to die."

A client with osteoarthritis uses a cane for assistance in walking. Which instruction should be reinforced when the client is using assistive devices for ambulation?

"The cane should be used on the unaffected side."

The nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client? "The client demonstrates the ability to care for the neonate completely by time of discharge." "The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment." "The client demonstrates an understanding of her physical needs related to labor and delivery." "The client demonstrates an understanding of the neonate's physical needs related to labor and delivery."

"The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment."

A client diagnosed with cancer tells the nurse about wanting to stop treatment and die at home. The healthcare team suggests another round of chemotherapy. What statement by the nurse to the healthcare team best reflects client advocacy?

"The client has expressed not wanting to pursue additional treatment."

The nurse is caring for a client who detected a lump in her right breast. The client asks the nurse " How do I find out if it's cancer?" Which statement by the nurse would be most appropriate? "You did a good job performing your breast self exams each month." "We'll know more once you have a mammogram." "The physician will need to perform a fine needle aspiration and biopsy to confirm the diagnosis. "The physician should be able see it on a chest X-ray."

"The physician will need to perform a fine needle aspiration and biopsy to confirm the diagnosis.

A client recovering from hip replacement surgery questions the need for admission to a rehabilitation center because there are family members available at home to provide care. Which response by the nurse is best?

"The rehabilitation staff can evaluate your progress and help you recover without risking injury."

A client who is being treated for unilateral lower extremity deep vein thrombophlebitis is being discharged. Which statement made by the client indicates to the nurse that additional discharge education is needed? "I should elevate my legs when sitting and should get up and walk around periodically." "I need to take my warfarin exactly the way my health care provider ordered it." "Tight compression hose rolled down behind the knee won't fall down and improves the circulation in my legs." "I should contact my health care provider immediately if I have frequent nosebleeds, bleeding from my gums, oozing from minor cuts, or if I see blood in my urine."

"Tight compression hose rolled down behind the knee won't fall down and improves the circulation in my legs."

As part of a primary cancer prevention program, an oncology nurse speaks to the public at a health fair. When someone asks about laryngeal cancer, which statement by the nurse would be most helpful? "To reduce the risk of developing laryngeal cancer you shouldn't smoke or drink alcohol." "Living in the city and breathing polluted air puts everyone at risk for all types of cancers." "Men and women both develop laryngeal cancer equally." "If you develop laryngeal cancer it would most likely be an adenocarcinoma, which are easier to cure."

"To reduce the risk of developing laryngeal cancer you shouldn't smoke or drink alcohol."

A client diagnosed with Alzheimer's disease (AD) tells the nurse that today a visitor is coming to have lunch. The nurse knows that the visitor isn't coming that day. Which response by the nurse would be most appropriate for this situation? "Where are you planning to have your lunch?" "You're confused and don't know what you're saying." "I think you need some more medication, and I'll bring it to you." "Today is Monday, March 8, and we'll be eating lunch in the dining room."

"Today is Monday, March 8, and we'll be eating lunch in the dining room."

The nurse suspects that a child, age 4, is being neglected physically. To best collect data on the child's nutritional status, the nurse should ask the parents which question?

"What did your child eat for breakfast?"

The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society guidelines, what information would be the most important for the nurse to give the women? "All women should perform breast self-examination two to three times yearly" "Every women should have a mammogram every 2 years beginning at age 40" "After the age of 50 you should have a hormonal receptor assay once yearly" "When you turn 40 you should have a physician conduct a clinical examination." "Women older than age 40 should have a mammogram and clinical examination every year"

"Women older than age 40 should have a mammogram and clinical examination every year"

The nurse is caring for a client with a social anxiety disorder who has difficulty sharing with the treatment team. The nurse believes using self-disclosure may assist the therapeutic relationship. Which approach to self-disclosure is most appropriate for the nurse to use?

"Would you like to hear how I cope when I feel anxious in new social situations?"

The nurse is reinforcing education to an adolescent about sexually transmitted infection (STI). What statement made by the client indicates that further education is required?

"You always know when you have gonorrhea."

A group of college students was walking back to their dorm at night when a stranger indecently exposes themselves to the group. One of the students became extremely upset and went to the clinic. Which response by the nurse would be most therapeutic?

"You appear upset. Can you tell me more about this?"

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?

"You must avoid coughing, sneezing, and blowing your nose."

In the emergency department, a client reveals to a nurse a plan for committing suicide and agrees to a voluntary admission to the psychiatric unit. The client asks, "How long do I need to stay here?" Which response by the nurse would be appropriate? "Once you've signed the papers, you have no say." "You must be safe before being discharged." "You need a lawyer to help you make that decision." "There must be a court hearing before you leave the hospital."

"You must be safe before being discharged."

When a nurse enters a client's room, the client frowns and states, "I've had my damn light on for 20 minutes. It's about time you got here. I'm sick of this place and the staff." The nurse's best response would be

"You seem upset this morning."

A nurse is discussing nutrition with a primigravida client. The nurse is informed that the client knows that calcium is important during pregnancy but that client and the client's family do not consume many milk or dairy products. What advice should the nurse give? "The prenatal vitamins that are recommended will satisfy all dietary requirements." "You could supplement your diet with 1800 mg of over-the-counter calcium tablets." "You should consume other nondairy foods that are high in calcium." "After the first trimester, calcium is not as important because all fetal organ structures are formed."

"You should consume other nondairy foods that are high in calcium."

The nurse is gathering information from a client with schizophrenia. The client states, "I am being poisoned by the staff here. I will not eat food or drink any liquids that they give me. They are trying to kill me!" What is the best response by the nurse? "That is just not true. I don't know why you think the staff would do that to you." "You will have to eat and drink sometime or you will die." "You sound upset. Would you like to discuss this further?" "I understand your concern, but no one is trying to kill you here."

"You sound upset. Would you like to discuss this further?"

A client with schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be appropriate? "Your behavior won't be tolerated. Go to your room immediately." "You're just doing this to get back at me for making you come to therapy." "Your cursing is interrupting the activity. Take time out in your room for 10 minutes." "I'm disappointed in you. You can't control yourself even for a few minutes."

"Your cursing is interrupting the activity. Take time out in your room for 10 minutes."

The mother of a client with bulimia nervosa asks a nurse if bulimia nervosa will stop her daughter from menstruating. Which response is best? "All women with anorexia nervosa or bulimia nervosa will have amenorrhea." "When your daughter is bingeing and purging, she won't have normal periods." "The eating disorder must be ongoing for your daughter's menstrual cycle to change." "Your daughter may have a normal or abnormal menstrual cycle, depending on the severity of her problem."

"Your daughter may have a normal or abnormal menstrual cycle, depending on the severity of her problem."

A woman, age 18, is highly dependent on her parents and fears leaving home to go away to college. Shortly before the fall semester starts, she complains that her legs are paralyzed and is rushed to the emergency department. When physical examination rules out a physical cause for her paralysis, the physician admits her to the psychiatric unit where she is diagnosed with functional neurologic symptom disorder. The client asks the nurse, "Why has this happened to me?" What is the most appropriate response? "You've developed this paralysis so you can stay with your parents. You must deal with this conflict if you want to walk again." "It must be awful not to be able to move your legs. You may feel better if you realize the problem is psychological, not physical." "Your problem is real but there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened." "It isn't uncommon for someone with your personality to develop this disorder during times of stress."

"Your problem is real but there is no physical basis for it. We'll work on what is going on in your life to find out why it's happened."

The nurse is precepting a graduate nurse and preparing to give infant immunizations. The preceptor asks the graduate, "Infant injections should only be given in which muscle?" What is the best response by the graduate nurse?

"vastus lateralis"

After laparoscopic cholecystectomy, a client reports abdominal pain. The nurse prepares morphine 2 mg. If the label on the morphine reads 10 mg/ml, how many milliliters should the nurse have in the syringe after the correct dose is drawn up? Record your answer using one decimal place.

0.2

The nurse is caring for a 15-year-old who has suffered third degree burns to 30% total burn surface area (TBSA). The health care provider has order morphine 0.5 mg by mouth every 3 to 4 hours as needed for pain. The elixir comes in 2mg/1 ml. How many milliliters would the nurse give? Record your answer using two decimal places.

0.25

The health care provider has ordered for a child with an open femur fracture morphine sulfate 10 mg PO times one dose. The elixir on hand is 100 mg/5 mL. How many milliliters will the nurse administer? Record your answer using one decimal place.

0.5

A client arrives to the clinic with reports of a rash. The nurse observes the client and documents the lesion as a papule. What is the best way for the nurse to document this finding?

0.5-cm elevated area

A client has just had total hip replacement surgery. The client's primary care provider orders 8,000 units of heparin to be administered subcutaneously. The label on the heparin vial reads "Heparin 10,000 units/mL." How many milliliters of heparin should the nurse draw up in the syringe to administer the correct dose? Record your answer using one decimal place.

0.8

A 2-year-old child has been diagnosed with cellulitis. The health care provider has order the client to get ceftriaxone 50 mg IM. The pharmacy sends 100 mg/2 mL. The nurse will administer the medication in the vastus lateralis. How many milliliters should be administered? Record your answer using a whole number.

1

A client is ordered to receive 1 g of neomycin sulfate orally every hour × 4 doses followed by 1 g orally every 4 hours for the remaining balance of the 24 days. Neomycin sulfate tablets are available in 500 mg per tablet. How many tablets should the nurse administer for each dose? Record your answer using a whole number.

2

Which child would be at increased risk for a respiratory syncytial virus (RSV) infection?

2-month-old child with broncho pulmonary dysplasia

The health care provider prescribed t-PA, a thrombolytic agent. The order is for 0.9 mg/kg over 1 hour. The client weighs 110 lb (50 kg). What is the total dose in milligrams the client will receive? Record your answer using a whole number.

45

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid as prophylaxis against tuberculosis. The client's teenage daughter asks the nurse how long the drug must be taken. What appropriate timeline does the nurse provide for the duration of prophylactic isoniazid therapy?

6 to 12 months

The physician prescribes norfloxacin, 400 mg by mouth twice daily, for a client with a urinary tract infection (UTI). The client asks the nurse how long to continue taking the drug. The nurse advises the client to take the medication for how many days?

7 to 10 days

The nurse, in collaboration with the health care practitioner, is performing vision evaluation on four clients. When reviewing the data collection, which client's criteria would suggest to the nurse that further visual evaluation is needed?

9-year-old with 20/20 vision in one eye and 20/40 vision in the other eye on two lines on the Snellen chart

A female client with human immunodeficiency virus (HIV) receives family-planning counseling. Which statement about safe sex practices for persons with HIV is accurate?

A latex condom with spermicide provides the best protection against HIV transmission during sexual intercourse.

A 5-year-old arrives in the clinic for a physical to enter school. Which potential child abuse findings should be brought to the health care provider's attention? Select all that apply. The child has abrasions on the knee. A patterned bruise is noted on the back. Parental description of accident does not match injury. The child clings to favorite blanket. Injuries in various stages of healing are documented.

A patterned bruise is noted on the back. Parental description of accident does not match injury. Injuries in various stages of healing are documented.

After undergoing testing, a client comes to a physician's office for a follow-up appointment. During the appointment, the physician informs the client that she has systemic lupus erythematosus (SLE). Which resource might be helpful for a nurse to recommend to this client?

A support group for clients with SLE

A client who is diagnosed with hyperthyroidism is admitted to the hospital. The nurse anticipates that the client's treatment is most likely to include which medication?

A thyroid hormone antagonist

A nurse caring for a client in active labor notes right sacrum anterior (RSA) position. Which location should the nurse anticipate to hear the fetal heart sound loudest? Above the umbilicus at the right upper quadrant. Above the umbilicus at the left upper quadrant. Below the umbilicus at the right lower quadrant. Below the umbilicus at the left lower quadrant.

Above the umbilicus at the right upper quadrant.

An 18-month-old is admitted with a diagnosis of meningitis. The toddler has a rectal temperature of 105 degrees F (40.5 degrees C). The nurse has inserted an intravenous catheter and started antibiotic therapy. Which of the following nursing actions are also indicated? Select all that apply. Bathe the toddler in a cool alcohol bath until shivering occurs. Administer an antipyretic per health care provider orders. Sponge the toddler with tepid water. Place a tracheostomy set at bedside. Reassess the toddler's temperature hourly.

Administer an antipyretic per health care provider orders. Sponge the toddler with tepid water. Reassess the toddler's temperature hourly.

A nurse is caring for a 12-year-old child with a diagnosis of eczema. Which nursing interventions are appropriate for a child with eczema?

Administer tepid baths, and use moisturizers immediately after the bath.

A 6-week-old infant who is not breathing is brought to the emergency department by the parents. A preliminary diagnosis of sudden infant death syndrome (SIDS) is made. Which nursing intervention is a priority?

Allow the parents to see their infant.

When reviewing medications for a pharmacology examination, the nursing student recognizes which drugs may be abused because of tolerance and physiologic dependence? Lithium and divalproex Verapamil and chlorpromazine Alprazolam and phenobarbital Clozapine and amitriptyline

Alprazolam and phenobarbital

The nurse educator is preparing a lecture on dementia. The educator will include that which is the most common cause of dementia in an elderly client?

Alzheimer's disease

Which medication can control the extrapyramidal effects associated with antipsychotic agents? Perphenazine Doxepin Amantadine Clorazepate

Amantadine

A client has a blockage in the proximal portion of a coronary artery. After learning about treatment options, the client decides to undergo percutaneous transluminal coronary angioplasty (PTCA). During this procedure, the nurse expects which medication to be administered to the client? Antibiotic Anticoagulant Antihypertensive Anticonvulsant

Anticoagulant

A client's blood studies reveal a deficiency in all of the blood's formed elements. The physician suspects that the client's bone marrow is failing to generate enough new cells. Which disorder is most likely affecting this client?

Aplastic anemia

A client who delivered by cesarean birth 3 days ago is bottle-feeding her neonate. While the nurse collects data, the client reports that her breasts are painful, hard, and warm to the touch. How should the nurse intervene? Apply an elastic bandage to bind the breasts. Instruct the client to stand in a warm shower and allow water to flow over her breasts. Notify the physician that the client is exhibiting early signs and symptoms of a breast infection. Tell the client to use a breast pump to clear the breasts of stagnant milk.

Apply an elastic bandage to bind the breasts.

A client with dissociative identity disorder (DID) requires hospitalization. Which intervention would most likely appear in the client's plan of care plan? Arrange to have staff check on the client every 15 to 30 minutes. Prevent all family from visiting until the third day of hospitalization. Make sure the staff understands the client will be on seizure precautions. Place the client in a quiet room away from the noise of the nurses' station.

Arrange to have staff check on the client every 15 to 30 minutes.

An adolescent client in her first trimester of pregnancy continues to smoke cigarettes. The client tells the nurse that she'd like to quit but she doesn't want to gain any more weight. What should the nurse do for this client? Ask permission to further discuss her smoking. Tell her that not everyone gains weight when they quit smoking. Realize that nothing can be done because the client doesn't want to quit smoking. Suggest that the client purchase nicotine chewing gum to help her stop smoking.

Ask permission to further discuss her smoking.

A child, age 8, reports leg pain shortly after being admitted with a fractured tibia sustained in a fall. The nurse uses which approach to best assess the severity of the pain?

Ask the child to rate the pain using a pain scale.

A client admitted to the hospital for an abdominal aneurysm repair tells a nurse that he has an advance directive. What action should the nurse take? Tell the client that the information will be noted in his chart, but it isn't necessary to include a copy of the advance directive. Instruct the client to give the advance directive to his lawyer. Ask the client for a copy of the advance directive to place on his chart. Tell the client that advance directives aren't valid when surgery is being performed.

Ask the client for a copy of the advance directive to place on his chart.

A client admitted to the hospital for an abdominal aneurysm repair tells a nurse that he has an advance directive. What action should the nurse take? Tell the client that the information will be noted in his chart, but it isn't necessary to include a copy of the advance directive. Instruct the client to give the advance directive to his lawyer. Ask the client for a copy of the advance directive to place on his chart. Tell the client that advance directives aren't valid when surgery is being performed.

Ask the client for a copy of the advance directive to place on his chart.

The nurse is caring for a client who has experienced the stillbirth of a full-term newborn. Which action(s) should the nurse include when caring for the client? Select all that apply. Ask the client if a name had already been chosen for the baby. Offer the client keepsakes such as footprints or a lock of hair. Wash and dress the newborn and have photos taken. Offer reassurance that the client can have more children. Offer to pray with the client as a means of spiritual support.

Ask the client if a name had already been chosen for the baby. Offer the client keepsakes such as footprints or a lock of hair. Wash and dress the newborn and have photos taken.

A client in college who has recently been diagnosed with human papillomavirus (HPV) infection comes to the health clinic and is anxious and tearful. Which nursing intervention would be most appropriate?

Ask the client to discuss concerns.

A nurse enters a postpartum client's room to collect data and observes the perineal pad is completely saturated with lochia rubra. Which action by the nurse is the priority? Vigorously massage the fundus. Immediately call the health care provider. Have the charge nurse review the finding. Ask the client when she last changed her perineal pad.

Ask the client when she last changed her perineal pad.

A client who's in active labor is yelling, "Get out of here!" As the nurse enters the client's room, she notices the client's estranged husband in the room. How should the nurse intervene? Do nothing; the client and her husband should attempt to work things out. Ask the husband to leave or phone security. Encourage the client to allow the husband to remain to witness the delivery of his baby. Notify the police immediately.

Ask the husband to leave or phone security.

A neonate begins to gag and turns a dusky color. What should the nurse do first? Calm the neonate. Notify the physician. Provide oxygen via a face mask as ordered. Aspirate the neonate's mouth then nose with a bulb syringe.

Aspirate the neonate's mouth then nose with a bulb syringe.

The nurse is caring for a child with glomerulonephritis. What action will the nurse take to prevent complications?

Assess blood pressure every 4 hours.

A nurse records a client's fingerstick blood glucose level and gives 2 units of regular insulin as ordered. At the next scheduled blood glucose assessment, the nurse realizes that the wrong client was tested and given insulin. What is the nurse's priority action related to this incident?

Assess both clients, and call the appropriate healthcare providers to notify them of the errors.

A client in labor for the past 10 hours shows no change in cervical dilation and has stayed at 5 to 6 cm for the past 2 hours. Her contractions remain regular at 2-minute intervals, lasting 40 to 45 seconds. Which of the following would be the nurse's initial action? Assess for presence of a full bladder. Suggest the placement of an internal uterine pressure catheter to determine adequacy of contractions. Encourage the mother to relax by assisting her with appropriate breathing techniques. Suggest to the physician that oxytocin augmentation be started to stimulate labor.

Assess for presence of a full bladder.

The nurse is developing the plan of care for a 9-year-old client with Down syndrome. How can the nurse best apply age-appropriate interventions?

Assess the client's current developmental level.

A client tells the nurse she has never had an orgasm and her partner is upset that he can't meet her needs. Which nursing intervention is most appropriate?

Assess the couple's perception of the problem.

A client with Parkinson disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the most appropriate action by the nurse?

Assess the nausea and weakness, and call physiotherapy to cancel or reschedule the appointment.

After total hip replacement, a client is receiving epidural analgesia to relieve pain. Which of the following is a nursing priority for this client?

Assessing for sensation in the legs

The nurse is caring for a client who just delivered triplets. Which intervention by the nurse is most important? Assessing fundal tone and lochia flow Applying a cold pack to the perineal area Administering analgesics, as ordered Encouraging the client to void by offering the bedpan

Assessing fundal tone and lochia flow

The nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?

Assessing the extremity for neurovascular integrity

During a panic attack, a client runs to the nurse and reports breathing difficulty, chest pain, and palpitations. The client is pale with his mouth wide open and eyebrows raised. What should the nurse do first?

Assist the client to breathe deeply into a paper bag.

The licensed practical nurse discovers a client with a pulse rate of 40 beats/minute. His blood pressure is 80/50 mm Hg and he reports dizziness. Which medication would the registered nurse use to treat the client's bradycardia? Atropine Dobutamine Amiodarone Lidocaine

Atropine

For a client who has had a stroke, which nursing intervention can help prevent contractures in the lower legs?

Attaching braces or splints to each foot and leg

When caring for the child with Wilms tumor preoperatively, which nursing intervention would be most important?

Avoid abdominal palpation.

A client is struggling with alcohol dependence. Which communication strategy is most effective for the nurse? Speak briefly and directly. Avoid blaming or lecturing the client. Confront feelings and examples of perfectionism. Determine if nonverbal communication will be more effective.

Avoid blaming or lecturing the client.

A client who has had a pacemaker inserted is ready for discharge. What information should the nurse reinforce in the discharge instructions to the client?

Avoid exposure to magnetic resonance imaging (MRI) equipment.

A client receiving chemotherapy for breast cancer develops myelosuppression. Which instructions should the nurse reinforce when the client is discharged? Select all that apply. Avoid people who have recently received attenuated vaccines. Avoid activities that may cause bleeding. Wash hands frequently. Increase intake of fresh fruit and vegetables. Avoid crowded places, such as shopping malls. Treat a sore throat with over-the-counter products.

Avoid people who have recently received attenuated vaccines. Avoid activities that may cause bleeding. Wash hands frequently. Avoid crowded places, such as shopping malls.

A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's plan of care? Avoiding using soap on the irradiated areas Applying talcum powder to the irradiated areas daily after bathing Wearing a lead apron during direct contact with the client Removing thoracic skin markings after each radiation treatment

Avoiding using soap on the irradiated areas

A client is unable to get out of bed and get dressed unless the nurse prompts every step. This is an example of which behavior? Word salad Tangential Perseveration Avolition

Avolition

The nurse is caring for a 28-year-old primigravida who is reporting severe back labor. Which nursing intervention is most effective in improving the comfort of the client? Patterned childbirth breathing Back massage with sacral pressure Hydrotherapy Epidural analgesia

Back massage with sacral pressure

The nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor. What information should the nurse provide to the parents? Select all that apply. The alarms may be turned down if the parents are in the next room. If the infant doesn't have any more apneic spells in 2 weeks, the monitor is no longer required. Be sure to keep the monitor on a flat surface away from other appliances. Develop a plan in case of a power failure. The parents should take a CPR course.

Be sure to keep the monitor on a flat surface away from other appliances. Develop a plan in case of a power failure. The parents should take a CPR course.

Which intervention by the nurse would be most helpful when discussing hypospadias with the parents of an infant with this defect?

Be there to listen to the parents' concerns.

During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term?

Beau's line

The nurse is assigned to care for a client who had a myocardial infarction. When arriving in the client's room, the nurse finds the client unresponsive and without a pulse. What is the priority intervention by the nurse? Begin cardiopulmonary resuscitation (CPR). Administer 2 L/min of oxygen by nasal cannula. Place a nitroglycerin tablet under the tongue. Administer epinephrine.

Begin cardiopulmonary resuscitation (CPR).

The nurse is working with adolescents. Which developmental rationale explains risk-taking behavior?

Belief in their own invulnerability persuades adolescents that they can take risks safely.

The nurse is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication of this condition?

Bone fracture

A client is resting comfortably 4 hours after delivering her first child. When measuring her heart rate, the nurse expects which normal finding? A thready pulse An irregular pulse Tachycardia Bradycardia

Bradycardia

A client who's pregnant with her second child comes to the clinic reporting a pulling and tightening sensation over her pubic bone every 15 minutes. She reports no vaginal fluid leakage. Because she has just entered her 36th week of pregnancy, she's apprehensive about her symptoms. Vaginal examination discloses a closed, thick, posterior cervix. These findings suggest that the client is experiencing: Braxton Hicks contractions. back labor. fetal distress. true labor contractions.

Braxton Hicks contractions.

When preparing to feed an infant with pyloric stenosis, which intervention should the nurse give highest priority?

Burp the infant frequently.

If a drug is available in suspension in a container, how should the nurse prepare the drug before administration?

By shaking or rolling the container so all drug particles are dispersed uniformly

A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. This client should be instructed to avoid which of the following? High volumes of fluid intake Aerobic exercise programs Caffeine-containing products Foods rich in protein

Caffeine-containing products

The nursing staff has just been trained how to use and care for a new blood glucose monitor. Which nursing intervention demonstrates proper use of a blood glucose monitor?

Calibrate the machine after installing a new battery.

In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the health care worker who witnesses this scene? Remaining with the client and staying calm Calling a security guard and another staff member for assistance Telling the client's husband that he must leave at once Determining why the husband feels so angry

Calling a security guard and another staff member for assistance

The health care team is performing cardiac compressions on an adult client. To assess the effectiveness of cardiac compressions during cardiopulmonary resuscitation (CPR), the nurse palpates which pulse site on this client?

Carotid

The skin in the diaper area of a 6-month-old infant is excoriated and red. Which instructions would the nurse give to the parent?

Change the diaper more often.

A preschooler with a history of heart failure is prescribed digoxin. Which nursing intervention is most important to perform before administering this drug to a child? Check apical heart rate for 1 minute. Obtain the child's blood pressure. Count the child's respiratory rate for 1 minute. Measure the child's urine output.

Check apical heart rate for 1 minute.

A client had a transurethral prostatectomy for benign prostatic hyperplasia (BPH). He is currently being treated with continuous bladder irrigation and is reporting an increase in severity of bladder spasms. What should the nurse do first for this client?

Check for the presence of clots, and make sure the catheter is draining properly.

A client is undergoing peritoneal dialysis. The dialysate dwell time is completed, and the clamp is opened to allow the dialysate to drain. The nurse notes that drainage has stopped and that only 500 mL has drained; the amount of dialysate instilled was 1,500 mL. Which intervention should be done first?

Check the catheter for kinks or obstruction.

A client with skeletal fracture to the right leg reports severe right leg pain. Which action should the nurse take first?

Check the client's alignment in bed.

Glulisine insulin is prescribed to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client "went for a test." What should the nurse do next?

Check the computerized care plan to determine what test was scheduled.

When checking a client's I.V. insertion site, the nurse notes normal color and temperature at the site and no swelling. However, the I.V. solutions haven't infused at the ordered rate; the flow rate is slow even with the roller clamp wide open. When the nurse lowers the I.V. fluid bag, no blood returns to the tubing. What should the nurse do first?

Check the tubing for kinks and reposition the client's wrist and elbow.

A client with head trauma develops a urine output of 300 ml/hour, dry skin, and dry mucous membranes. Which nursing intervention is most appropriate to perform immediately?

Check urine specific gravity.

A physician's order states to administer lorazepam, 20 mg by mouth twice per day, to treat anxiety. How should the nurse proceed?

Clarify the order with the prescribing physician because the amount prescribed exceeds the recommended dose.

The nurse is performing a dressing change as prescribed for a client with a red, granulating foot ulcer. Which action should the nurse perform when changing the dressing?

Clean the wound with normal saline solution.

After being treated with heparin for a pulmonary embolism, a client is prescribed warfarin using a sliding scale. Which action should the nurse take before administering this drug?

Closely monitor prothrombin time (PT) and international normalized ratio (INR) results to determine the dose of warfarin to administer.

A client diagnosed with acute myelocytic leukemia (AML) has been receiving chemotherapy. During the last two cycles of chemotherapy, the client developed severe thrombocytopenia requiring multiple platelet transfusions. The client is now scheduled to receive a third cycle. How can the nurse best detect early signs and symptoms of thrombocytopenia? Monitor daily platelet counts. Perform a cardiovascular assessment every 4 hours. Check the client's history for a congenital link to thrombocytopenia. Closely observe the client's skin for petechiae and bruising.

Closely observe the client's skin for petechiae and bruising.

A 25-year-old client comes to the emergency department with her clothes torn. She has visible cuts, bruises, and profuse vaginal bleeding. A nurse suspects that this client has been raped. What should the nurse do?

Collect forensic evidence.

A nurse must evaluate a client's splinted extremity for neurovascular damage. What is the priority action by the nurse?

Compare color and capillary refill of both extremities.

The nurse is administering medications to a client with advanced Alzheimer's dementia who is confused to person, place, and time. Prior to administering the medication, what action should the nurse perform to verify the client's identity?

Compare the name and ID number on the client's wristband to the medication administration record.

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. Which condition would benefit from hyperbaric oxygen therapy?

Compromised skin graft

At the beginning of the school day, a student has come to see the school nurse. Upon observing tearing, redness of the eye, and a light crust at the canthus, which action will the nurse take?

Contact the parent to retrieve the student.

A 76-year-old client who failed swallowing studies has a nasogastric (NG) tube in place for medication administration. When the nurse checks the client's medications, she notices that only tablets have been dispensed by the pharmacy. How should the nurse proceed?

Crush those tablets that may be crushed according to the manufacturer and administer them through the NG tube; request an alternate form of those that can't be crushed.

A child admitted with pneumonia has a history of cystic fibrosis (CF). Which statement made by the parents best demonstrates an understanding of cystic fibrosis?

Cystic fibrosis (CF) is an inherited disease characterized by an abnormality in the body's salt, water- and mucus-making cells.

A child with diabetes insipidus receives desmopressin acetate (DDAVP). When evaluating for therapeutic effectiveness, the nurse would interpret which finding as a positive response to this drug?

Decreased urine output

In a pediatric client, what is an early sign of acute renal failure (ARF)?

Decreased urine output

A client must be placed on airborne precautions for several days. To help meet the client's emotional needs, what should the nurse do?

Describe the reasons for isolation and how it's carried out, and provide reassurance.

The nurse is calculating the dosage of a weight-based medication for a preschool-age client. What should the nurse do first?

Determine the child's weight in kilograms.

A client with colorectal cancer being prepared for colostomy placement tells the nurse, "I am very nervous and unsure about this surgery." What should the nurse's initial action be when caring for this client? Determine what the client already knows about colostomies. Show the client pictures of colostomies to prepare for the surgery. Arrange for someone who has a colostomy to visit the client. Provide the client with written materials about colostomy care.

Determine what the client already knows about colostomies.

A nurse is caring for an adolescent who underwent surgery for a perforated appendix. What should the nurse keep in mind regarding the main life-stage task for the adolescent when providing care?

Developing identity and independence is the objective.

A client with an IV reports pain at the insertion site. Observation of the site reveals a vein that is red, warm, and hard. Which actions should the nurse take? Select all that apply. Slow the infusion rate while notifying the health care provider. Discontinue the infusion at the affected site. Restart the infusion distal to the discontinued IV site. Assess the client for skin sloughing. Apply a warm compress to the IV site. Document the assessment, nursing actions taken, and the client's response.

Discontinue the infusion at the affected site. Apply a warm compress to the IV site. Document the assessment, nursing actions taken, and the client's response.

The nurse is informed by an 18-year-old pregnant client of concerns that the client may not be able to provide self-care during pregnancy. The client states that prenatal care is expensive; furthermore, the client's job does not provide insurance. What is the best action by the nurse? Discuss the client's concerns with the health care provider. Discuss the possibility of adoption with the client. Discuss job opportunities with the client. Discuss community resources with the client.

Discuss community resources with the client.

A client is recovering from a stroke and will be discharged in a few days. When helping to develop this client's discharge plan, the nurse should include which interventions? Select all that apply. Discuss home care needs with the client before the day of discharge. Notify the primary health care provider when the client leaves the health care facility. Transport the client by stretcher to the discharge holding unit and wait until the client leaves. Encourage outside assistance from community agencies and resources. Instruct the client to ask the pharmacist for medication information after returning home.

Discuss home care needs with the client before the day of discharge. Transport the client by stretcher to the discharge holding unit and wait until the client leaves. Encourage outside assistance from community agencies and resources.

The nurse preceptor overhears a student nurse talking to a grieving mother, whose child was stillborn, about her own pregnancy and fears about experiencing a loss. The student nurse and mother make arrangements for the student to pick up the client's maternity clothes and baby furniture on the weekend. What is the preceptor's most appropriate action? Ensure that this is a mutually agreed upon decision. Discuss the situation with the nursing student after the visit has ended. Ask the client and student who initiated the idea for these arrangements. Immediately report the incident to the student's professor.

Discuss the situation with the nursing student after the visit has ended.

A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action? Notify security because the neonate's father is demanding to see his baby. Teach the grandparents how to scrub and gown before entering the nursery. Discuss the unit's policy with the charge nurse. Invite everyone into the large conference room to see the neonate.

Discuss the unit's policy with the charge nurse.

A parent is discussing his or her 12-year old child with the nurse at the clinic and tells the nurse that the child is having trouble at school being bullied and coming home and picking on a younger sibling. What does the nurse recognize this ego defense mechanism as?

Displacement

The nurse observes that a 2-hour-old neonate has acrocyanosis. Which nursing action is a priority? Activate the code blue or emergency system. Do nothing because acrocyanosis is normal in a neonate. Immediately take the neonate's temperature according to facility policy. Notify the health care provider of the need for genetic counseling.

Do nothing because acrocyanosis is normal in a neonate.

A client diagnosed with pneumonia refuses the prescribed oral antibiotic. The client is alert and oriented, vital signs are within normal range, and crackles are scattered throughout the posterior left lower lobe of the client's lung. Which actions should the nurse perform? Select all that apply. Mix the medication into the client's food without the client's knowledge. Document that the client refused to take the medication. Address the client's concern about the medication by clarifying its purpose. Leave the medication with the client in case the client decides to take it at a later time. Notify the physician.

Document that the client refused to take the medication. Address the client's concern about the medication by clarifying its purpose. Notify the physician.

A client has been receiving chemotherapy for cancer treatment. The client is competent and has been actively involved in decisions regarding care; however, the client has now decided to refuse treatment. What should the nurse do when the client refuses the next dose of chemotherapy? Persuade the client to take the medication as ordered. Ensure that the client understands the rationale for taking the medication. Ask the client's spouse to encourage the client to take the chemotherapy. Document the client's choice and offer to discuss feelings about the chemotherapy.

Document the client's choice and offer to discuss feelings about the chemotherapy.

While providing care for a married female, the nurse notes multiple areas of ecchymosis on her arms and trunk. The colors of the ecchymotic areas range from blue to purple to yellow. When the nurse asks the client how she got the bruises, the client responds, "Oh, I tripped." How should the nurse respond? Select all that apply. Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries. Contact the local authorities to report suspicions of abuse. Assist the client in developing a safety plan for times of increased violence. Call the client's husband to arrange a meeting to discuss the situation. Tell the client that she needs to leave the abusive situation as soon as possible. Provide the client with telephone numbers of local shelters and safe houses.

Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries. Assist the client in developing a safety plan for times of increased violence. Provide the client with telephone numbers of local shelters and safe houses.

During a clinic visit, the nurse notes that a 3-year-old preschooler, who measured 27 inches at the age of 2, now measures 29.5 inches. Based on the preschooler's measurement, how would the nurse proceed?

Document the finding.

A client who is 36 weeks pregnant appears anxious and tells the nurse that she will never be able to handle labor and delivery. What is the appropriate action by the nurse? Document this common concern during the third trimester. Obtain a referral order for psychotherapy. Discuss the concern with the client's partner. Assess the client for intimate partner violence.

Document this common concern during the third trimester.

The health care provider prescribes doxycycline for a client with Lyme disease. Which instructions should the nurse reinforce to the client about self-administration of doxycycline? Select all that apply. Drink a full glass of water with each dose. If you are using oral contraceptives, use another form of birth control while taking this drug. Take the drug with an antacid containing magnesium. Take doxycycline 2 hours before or 3 hours after any vitamins or products that contain iron. Avoid unnecessary or prolonged exposure to sunlight.

Drink a full glass of water with each dose. If you are using oral contraceptives, use another form of birth control while taking this drug. Take doxycycline 2 hours before or 3 hours after any vitamins or products that contain iron. Avoid unnecessary or prolonged exposure to sunlight.

A nurse is reinforcing education to a client with prostatitis who is receiving co-trimoxazole double strength. Which education is appropriate for this client?

Drink six to eight glasses of fluid daily while taking this medication.

Which intervention should the nurse perform as soon as possible when caring for a 21- week-old anencephalic neonate? Dry and dress the neonate in clothing with a hat, and swaddle him snuggly in blankets. Place the neonate in a warmer and initiate neonatal resuscitation efforts. Swaddle the neonate and attempt feedings. Transfer the neonate to the neonatal intensive care unit

Dry and dress the neonate in clothing with a hat, and swaddle him snuggly in blankets.

A client arrives at the emergency department reporting chest and stomach pain and a history of black, tarry stools for the past 2 months. Which orders should the nurse anticipate?

ECG, complete blood count, testing for occult blood, and comprehensive serum metabolic panel

A pregnant client comes to the clinic for a follow-up visit and reports swelling in the feet and ankles. Which recommendation would be most appropriate for the nurse to suggest? Limit oral fluid intake. Limit sodium intake. Elevate the feet daily. Increase fluid intake.

Elevate the feet daily.

A child with a fractured left femur receives a cast. A short time later, the nurse notices that the toes on the child's left foot are edematous. Which nursing action would be most appropriate?

Elevate the foot of the bed.

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees

A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative plan of care?

Elevating the stump for the first 24 hours

The nurse is caring for a breastfeeding client on her second postpartum day. The breast is enlarged, firm, and warm to touch. Which action is the nurse expected to take? Obtain vital signs Encourage the client to breast feed the baby more frequently and regularly. Send the breast milk for culture and sensitivity Assist the client to apply a cold compress to the breast

Encourage the client to breast feed the baby more frequently and regularly.

A nurse is planning care for a client after a tracheotomy. One of the client's goals is to overcome verbal communication impairment. Which nursing intervention should the nurse include when assisting with development of the care plan?

Encourage the client to communicate by allowing time to write words.

The nurse-midwife determines that a client is in the second stage of labor and the presenting part is descending rapidly. What action should the nurse take to prevent complications? Encourage the client to practice breathing exercises to decrease the urge to push. Leave the client and contact the healthcare provider. Ask client to tell you about her coping mechanisms for labor Provide update on the clients' progress to the family

Encourage the client to practice breathing exercises to decrease the urge to push.

A nurse is caring for a client who gave birth to a stillborn neonate at 36 weeks' gestation. Which action taken by the nurse is most helpful in helping the client cope with the loss of the baby? Be selective in providing the information that the client seeks. Encourage the client to see, touch, and hold the dead neonate. Provide information about possible causes of the stillbirth only if the client requests it. Let the child's father decide what information the client receives.

Encourage the client to see, touch, and hold the dead neonate.

A nurse is working in a clinic where a family member's spouse is treated for a sexually transmitted disease. The nurse is concerned about the risk to family members. What is the most appropriate action for the nurse to take?

Encourage the client to speak with the family member about the diagnosis if the client has not already done so.

A client with dissociative amnesia has been receiving therapy for the past several years to uncover memories that have been buried as a result of sexual abuse by the father during childhood. The client has just learned the father passed away. Which intervention would be most appropriate? Urge the client to seek inpatient therapy immediately. Encourage the client to verbalize any feelings that they may have. Encourage the client to repress their feelings about the father for the time being. Impress upon the client that the father's death should be helpful in the healing process.

Encourage the client to verbalize any feelings that they may have.

During the postpartum period, the nurse anticipates normal involution. Which action taken by the nurse promotes involution? Encourage the mother to breast feed. Encourage a sitz bath daily. Increase fluid intake. Encourage bed rest.

Encourage the mother to breast feed.

During the postpartum period, the nurse anticipates normal involution. Which action taken by the nurse promotes involution?

Encourage the mother to breast feed. Encourage a sitz bath daily. Increase fluid intake. Encourage bed rest.

The nurse is caring for a toddler hospitalized with a diagnosis of croup (laryngotracheobronchitis). The health care provider prescribes treatment with a mist tent. As the parent attempts to put the toddler in the crib, the toddler cries and clings to the parent. What would be the best approach for the nurse to take to gain the child's cooperation with the treatment?

Encourage the parent to stand next to the crib and stay with the child.

A client admitted to the psychiatric unit for treatment of repeated panic attacks comes to the nurses' station in obvious distress. After observing that the client is short of breath, dizzy, trembling, and nauseated, which action should the nurse first implement?

Escort the client to a quiet area and suggest using a relaxation exercise that he or she has been taught.

A client admitted to the psychiatric unit for treatment of repeated panic attacks comes to the nurses' station in obvious distress. After observing that the client is short of breath, dizzy, trembling, and nauseated, which action should the nurse first implement? Ask what the client is upset about Administer an antianxiety medication, as prescribed, and instruct the client to lie down in his room. Escort the client to a quiet area and suggest using a relaxation exercise that he or she has been taught. Reassure the client that the symptoms will disappear after he or she lies down and relaxes.

Escort the client to a quiet area and suggest using a relaxation exercise that he or she has been taught.

A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which care intervention is appropriate?

Establish an intermittent catheterization routine every 4 hours.

A client who is induced at 40 weeks' gestation with oxytocin drip is expressing fear and anxiety about the induced labor. Which interventions should the nurse implement? Select all that apply. Establish trust with the client. Explore the client's coping behaviors. Allow privacy by leaving the client alone in the room. Keep client informed about progress and procedures. Reduce the drip if the client reports pain.

Establish trust with the client. Explore the client's coping behaviors. Keep client informed about progress and procedures.

The nurse is teaching parents about otitis media. When discussing why children are predisposed to this disorder, the nurse should mention the significance of which anatomical feature?

Eustachian tubes

A nurse on the psychiatric unit realizes that she typically fails to administer medications according to schedule. What's the best way for the nurse to improve her medication administration practice?

Evaluate her current practice and devise an improvement plan.

A client with bulimia nervosa tells a nurse he/she was doing well until last week, after having a fight with a parent. Which nursing intervention would be most helpful? Examine the relationship between feelings and eating. Discuss the importance of therapy for the entire family. Encourage the client to avoid certain family members. Don't fight with parents.

Examine the relationship between feelings and eating.

A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, neck vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client?

Excess fluid volume

Topical treatment with 2.5% hydrocortisone is prescribed for a 6-month-old infant with eczema. The nurse advises the parent to use the cream for no more than 1 week based on which rationale?

Excessive use can have adverse effects, such as skin atrophy and fragility.

A client with human immunodeficiency virus (HIV) infection is preparing for discharge from the hospital when he reports to a nurse that he continually feels weak. How should the nurse intervene?

Explain to the client that he should schedule periods of rest throughout the day.

While assessing a home care client, the nurse notices a family member smoking near the client's oxygen. Which action by the nurse is best?

Explaining to the family member that oxygen is flammable and smoking must be avoided

A male nurse is assigned to care for a female client with a new colostomy. Upon entering the room, the spouse tells the nurse that it is considered immodest for a woman's body to be seen by any male that is not her husband in their Muslim culture. Which actions demonstrate culturally competent nursing care in this situation? Select all that apply. Explore the possibility of a female nurse being willing to swap clients. Explain that it is discriminatory to not accept male nursing care. Report to the charge nurse to make them aware of the situation. Notify the facility patient-advocate to make them aware of the situation. Explain that the unit is made up of mostly male nurses so it may not be possible.

Explore the possibility of a female nurse being willing to swap clients. Report to the charge nurse to make them aware of the situation. Notify the facility patient-advocate to make them aware of the situation.

After seeking help at an outpatient mental health clinic, a client who was raped while walking her dog is diagnosed with posttraumatic stress disorder (PTSD). Three months later, the client returns to the clinic, complaining of fear, loss of control, and helpless feelings. Which nursing intervention is most appropriate for this client?

Exploring the meaning of the traumatic event with the client

A client in the first stage of labor is agitated, upset, and crying. The client expressed concern about being in labor for 32 hours the last time she gave birth. Based on this information, the nurse should expect which nursing diagnosis in the client's plan of care? Anxiety related to the facility environment Fear related to a potentially difficult childbirth Compromised family coping related to hospitalization Acute pain related to labor contractions

Fear related to a potentially difficult childbirth

A client states to the nurse, "The voices are telling me to do terrible things." As part of the client's initial therapy, which action would be most likely included? Find out what the voices are saying. Let the client go to his room to decrease anxiety. Begin to talk to the client about an unrelated topic. Tell the client the voices aren't real.

Find out what the voices are saying.

A client with major depression frequently is irritable, abrasive, and uncooperative and refuses to participate in group activities. When working with this client, the nurse should use which approach? Firmness Cheerfulness Humor Aloofness

Firmness

The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point is most important for the nurse to stress?

Following safe-sex practices

The nurse notes that several assigned clients are developing signs of pressure injuries. Which action should the nurse take first?

Formally report the findings related to the ulcers to the nurse manager.

A nurse is preparing the family of a child with Kawasaki disease for discharge. Which instruction is most appropriate? Stop the aspirin when you return home. Immunizations can be given in 2 weeks. The child may return to school in 1 week. Frequent echocardiography will be needed.

Frequent echocardiography will be needed.

A toddler with hemophilia is hospitalized with multiple injuries after falling off a sliding board. X-rays reveal no bone fractures. When caring for the child, what is the nurse's highest priority?

Frequently monitoring the child's level of consciousness (LOC)

A client is admitted for treatment of glomerulonephritis. During the initial assessment, the nurse documents which finding (one of the classic signs of acute glomerulonephritis found in sudden onset)?

Generalized edema, especially of the face and periorbital area

When collecting data on a pregnant client with diabetes mellitus, the nurse stays alert for signs and symptoms of a vaginal or urinary tract infection (UTI). The nurse recognizes which condition makes this client more susceptible to such infections? Electrolyte imbalances Decreased insulin needs Hypoglycemia Glycosuria

Glycosuria

A middle-age female complains of anxiety, insomnia, weight loss, the inability to concentrate, and her eyes feeling "gritty." Thyroid function tests reveal the following: a thyroid-stimulating hormone (TSH) level of 0.02 units/ml, a thyroxine level of 20 g/dl, and a triiodothyronine level of 253 ng/dl. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these findings, the nurse would suspect:

Graves' disease.

A nurse determines that a client who used alcohol has nutritional problems. Which strategy is best for addressing the client's nutritional needs? Encourage the client to eat a diet high in calories. Help the client to recognize and follow a balanced diet. Provide the client with liquid protein supplements daily. Ask the client to monitor the calories consumed each day.

Help the client to recognize and follow a balanced diet.

A client in the early stages of labor who is admitted to the labor and delivery unit is noted to have not recently bathed or changed her clothes. Which action should the nurse take to help this client? Wait for the client to request a shower. Allow the client to wear what she prefers, even if it's soiled. Help the client to undress and suggest a quick bath to freshen up. Assist the client into a clean hospital gown and offer her deodorant.

Help the client to undress and suggest a quick bath to freshen up.

A client with benign prostatic hyperplasia (BPH) does not respond to medical treatment and is admitted to the facility for surgical intervention, transurethral resection of the prostate (TURP). In the postoperative period, the nurse reviews the laboratory values for which potential electrolyte imbalance?

Hyponatremia

A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important?

Immediately stop the transfusion, infuse normal saline solution, notify the blood bank, and call the physician.

At the scene of a trauma, which nursing intervention is appropriate for a child with a suspected fracture?

Immobilize the extremity and then move the child to a safe place.

A client with an exacerbation of chronic obstructive pulmonary disease (COPD) is admitted to the hospital. Which nursing diagnosis requires the nurse to collaborate with other health team members to achieve the best outcome for the client?

Impaired gas exchange

The nurse is caring for a 4-year-old with a full-thickness burn. Before sending the child to hydrotherapy for a scheduled wound debridement, which nursing action is a priority?

Implement pain control measures

A client is experiencing mild diarrhea through the colostomy. Which instruction is correct?

Increase intake of bananas.

When obtaining the vital signs of a client with multiple traumatic injuries, the nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?

Increased intracranial pressure (ICP)

Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Which additional manifestation should the nurse assess for to help identify necrotizing fasciitis?

Increased pain intensity

A client who's 30 weeks pregnant has a corrected atrial septal defect and minor functional limitations. The nurse asks the nurse practitioner which pregnancy-related physiologic change places the client at greatest risk for more severe cardiac problems. Which change does the practitioner identify? Decreased heart rate Increased plasma volume Decreased cardiac output Increased blood pressure

Increased plasma volume

The nurse is evaluating a child with acute poststreptococcal glomerulonephritis (APSGN) for signs of improvement. Which finding typically is the earliest sign of improvement?

Increased urine output

For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone. When caring for this client, the nurse should monitor for which adverse drug reactions?

Increased weight, hypertension, and insomnia

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?

Ineffective breathing pattern

The nurse is administering medication to a 6-week-old infant. Which factor is the nurse most correct to identify as likely to decrease the infant's ability for drug metabolism?

Inefficient liver function

A nurse is discussing skin turgor evaluation of an elderly client with her peers. While doing so, the nurse should include which information with her colleagues?

Inelastic skin turgor is a normal part of aging.

The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest?

Infection

The nurse is caring for a laboring client fluent in English, but the client defers to her mother-in-law when asked to sign the hospital consent forms. Which of the following factors contributes to the challenges the nurse faces in obtaining consent? Patterns of verbal communication Religious beliefs Influence of the extended family Gender identity

Influence of the extended family

A nurse is caring for a client who suffered a stroke. The family reports that the nurse on the previous shift failed to administer medications properly or maintain client privacy. What is the best action by the nurse?

Inform the charge nurse of the family's concerns.

A client with metastatic brain cancer is admitted to the oncology floor. According to the Patient Self-Determination Act of 1991 (PSDA), what is the hospital required to do concerning the execution of advance directives? Decide on a treatment plan if the client can't. Inform the client or legal guardian of his right to execute an advance directive. Respect individuals' moral rights. Advise clients not to execute an advance directive because it limits treatment options.

Inform the client or legal guardian of his right to execute an advance directive.

The nurse is reviewing shift documentation at 1500 and realizes that they forgot to administer a 1400 medication to a client. In which order, from first to last, should the nurse complete the listed actions? All options must be used.

Inform the client that the nurse missed administering the medication at the prescribed time. Administer the medication to the client as appropriate based on the medication's indication. Document the error per facility policy, and inform the nurse in charge and health care provider as needed. Reflect on causes of error and explore ways to avoid similar errors in the future. Implement changes in practice and evaluate effectiveness in preventing medication errors.

A famous pregnant client comes to the health care provider's office for a routine prenatal examination. While the client is in the office, the media arrives asking for information about the client. What should the nurse do? Immediately notify security to have the media removed. Inform the media that you can't comment about whether the person is being seen in the office. Phone the police to remove the members of the media from the office. Ask the media to wait until the client is finished with her health care provider's visit.

Inform the media that you can't comment about whether the person is being seen in the office.

The nurse must obtain data on a 10-month-old. The child is sitting on the parent's lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse would be best?

Initiate a game using stuffed animals.

A 3-month-old admitted to the pediatric unit with meningococcal meningitis has just been assessed by the registered nurse. Which nursing intervention has the highest priority at this time?

Instituting droplet precautions

The nurse explains to new parents the importance of maintaining their infant's safety during hospitalization. Which action best ensures the infant's safety? Identifying and confronting suspicious-looking visitors Encouraging the parents to room-in with the infant Keeping security cameras and alarms activated at all times Instructing the mother to notify staff when she showers to avoid leaving the infant unattended

Instructing the mother to notify staff when she showers to avoid leaving the infant unattended

The nurse is caring for a client with a cast on his left arm. Which data collection finding is most significant for this client?

Intact skin around the cast edges

A nurse on a psychiatric unit observes a client in the corner of the room moving their lips as if they were talking to themselves. Which action is the most appropriate? Ask the client why they are talking to themselves. Leave the client alone until they stops talking. Tell the client it isn't good to talk to themselves. Invite the client to join in a card game

Invite the client to join in a card game.

Which nursing intervention is essential in the care of an infant with cleft lip and palate?

Involve the parents in the infant's care.

The nurse is discussing bacterial/infective endocarditis with the parent of a teen who has been diagnosed with the disorder. Which statement about bacterial/infective endocarditis indicates an understanding of the condition? It is caused by bacteria invading only tissues of the heart. It is an infection of the valves and inner lining of the heart. It is an inappropriate fusion of the endocardial cushions in fetal life. It is caused by alterations in cardiac preload, afterload, contractility, or heart rate.

It is an infection of the valves and inner lining of the heart.

The nurse is caring for a 5-year-old with several tiny blisters near the mouth, several of which are draining clear fluid and others which have a yellowish crust. Which teaching will the nurse provide to the client's parent?

Keep the child home from school until antibiotic therapy has been administered for 24 hours.

When bathing a neonate who is one hour old, which nursing action is most important? Place on a table covered with blankets, and give a sponge bath. Bathe in a tub of warm water. Keep under a radiant warmer, and give a sponge bath. Wash only hands and head because the condition isn't stable enough to have a complete bath.

Keep under a radiant warmer, and give a sponge bath.

An 8-year-old child is suspected of having meningitis. Signs of meningitis include:

Kernig's sign.

Which of the following options best describes the anticipated actions in the taking-hold phase of the maternal attachment process? Meeting the mother's needs first Looking at the infant Kissing, embracing, and caring for the infant Talking about the baby

Kissing, embracing, and caring for the infant

The nurse is reinforcing education for a community class on back injuries. Which area should the nurse indicate is the most common area for vertebral herniation?

L4-L5, L5-S1 vertebrae

An unemployed woman, age 24, seeks help because she feels depressed and abandoned and doesn't know what to do with her life. Last week, her boyfriend broke up with her after she drove his car into a tree after an argument. The client's initial diagnosis is borderline personality disorder. Which collection data observed by the nurse support this diagnosis? Flat affect, social withdrawal, and unusual dress Suspiciousness, hypervigilance, and emotional coldness Lack of self-esteem, strong dependency needs, and impulsive behavior Insensitivity to others, sexual acting out, and violence

Lack of self-esteem, strong dependency needs, and impulsive behavior

A client who suffered blunt chest trauma in a car accident reports chest pain, which is exacerbated by deep inspiration. On auscultation, the nurse detects a pericardial friction rub — a classic sign of acute pericarditis. The physician confirms acute pericarditis and begins appropriate medical intervention. To relieve chest pain associated with pericarditis, the nurse should encourage the client to assume which position? Semi-Fowler's with head turned left Leaning forward while sitting Supine with arms at sides Prone with knee supports

Leaning forward while sitting

After collecting data on an adolescent with sickle cell anemia, the nurse assists with formulating a nursing diagnosis of Impaired skin integrity. Which finding best supports this nursing diagnosis?

Leg ulcers

The nurse is caring for a preschool aged child who has been prescribed a preoperative intramuscular (IM) injection at 07:00. To elicit the child's cooperation in administering this medication, the nurse should use which approach?

Let the preschooler choose which leg to use for the injection.

A nurse is reviewing a client's medication blood level values for a commonly administered psychiatric medication. Which medication, prescribed in individualized dosages according to the blood levels of the drug, would the nurse expect to find in this client's medication orders?

Lithium carbonate

While caring for a client, the nurse hears someone call for help. What should the nurse do?

Make sure the client is safe and then go see who's calling for help.

Which intervention should be included in the safety plan for the maternal- infant unit? Keeping the unit doors locked at all times Making sure that the spouse or significant other wears an identification band Limiting the number of visitors to two per client Limiting visiting to 2 hours per day

Making sure that the spouse or significant other wears an identification band

An adolescent client is admitted for a sickle cell crisis. Which intervention is most important for the nurse to implement?

Manage pain aggressively and continually.

A client in labor has been given an epidural anesthetic. When collecting data on the client immediately following the epidural administration, which finding would be most important for the nurse to report? Maternal respirations decrease from 20 breaths to 14 breaths/minute. Maternal blood pressure decreases from 130/70 to 98/50 mm Hg. Maternal pulse increases from 78 to 96 beats/minute. Maternal temperature increases from 99° F (37.2° C) to 100° F (37.8° C).

Maternal blood pressure decreases from 130/70 to 98/50 mm Hg.

Which information is most important for the nurse to reinforce with a client who abuses prescription drugs? Herbal substitutes are safer to use. Medication should be used only for the reason prescribed. The client should consult a health care provider before using a drug. Consider if family members influence the client to use drugs.

Medication should be used only for the reason prescribed.

The nursing staff is developing a care plan for a 10-year-old child who is receiving palliative care for end-stage leukemia. The child is experiencing breakthrough pain, rated as a 5 on a pain scale of 1 to 10. Which action by the nurse should be included in the child's care plan?

Meet with the pain management team to devise a more effective pain control plan.

A client with type 2 diabetes is obese and has not been successful at controlling the condition by diet alone. The primary health care provider has prescribed metformin. Why is metformin commonly used for clients with type 2 diabetes?

Metformin inhibits glucose production by the liver.

A client is admitted to the acute care unit due to a chronic cough with copious, foul-smelling secretions. The nurse identifies dyspnea, hemoptysis, and recent weight loss. What should be the priority independent action by the nurse for this client?

Monitor respiratory status and pulse oximetry values.

When assisting to plan nursing care to maintain skin integrity for an adult female bed-bound client, which interventions should the nurse include? Select all that apply. Apply a pleasantly scented dusting powder to the axillae and groin, beneath the breasts, and between the toes. Monitor the skin for breakdown daily during client's bath. Apply deodorant or antiperspirant immediately after shaving under the arms. Keep skin clean and dry to prevent breakdown. Always use alcohol for back rubs. Turn and reposition the client every two hours

Monitor the skin for breakdown daily during client's bath Keep skin clean and dry to prevent breakdown. Turn and reposition the client every two hours

After a person experiences a closure of the epiphyses, which of the following is true?

No further increase in bone length occurs.

A nurse is caring for a client with syndrome of inappropriate antidiuretic hormone secretion (SIADH). The client becomes confused and develops crackles and dyspnea. What is the priority action of the nurse?

Notify the health care provider.

An older adult client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. Based on these signs and symptoms, which intervention should the nurse perform?

Notify the health care provider.

A client with type 2 diabetes hasn't received insulin coverage for his afternoon blood glucose levels for 2 days. After further investigation, a nurse discovers that the afternoon blood glucose levels were phoned in from the laboratory but weren't documented in the client's medical record. What should the nurse do with this information?

Notify the physician and complete an incident report.

A client newly diagnosed with diabetes mellitus is experiencing difficulty with self-administration of insulin. Despite further teaching, the client shows little improvement. What action by the nurse is most appropriate?

Notify the physician of the client's lack of progress and request a diabetes education department consult.

A client is hospitalized for severe preeclampsia and complete placenta previa. The partner tells the nurse that they are frustrated to have been waiting for 3 hours for the physician to discuss the partner's condition and plan of care with them. What is the nurse's most appropriate action? Ask the partner if there is any family support that can come to the hospital. Tell the partner that the physician is very busy and will come when available. Notify the physician that the partner has been waiting to discuss the mother's condition. Reassure the partner that the mother's condition is stable at present.

Notify the physician that the partner has been waiting to discuss the mother's condition.

A nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. Which instruction should the nurse give to the client?

Notify the primary care provider about cloudy or foul-smelling urine.

A nurse is monitoring a client receiving a continuous infusion of lidocaine for ventricular dysrhythmias. During breakfast, the client states, "I am so tired. My vision is so blurry I can't see my food." What is the nurse's best action? Notify the primary registered nurse of the client's symptoms. Cluster activities to allow the client uninterrupted rest time. Administer zolpidem. Ask the client when his or her last eye exam was completed.

Notify the primary registered nurse of the client's symptoms.

The nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms would suggest circulatory impairment? Numbness, cool skin temperature, and pallor Swelling, warm skin temperature, and drainage Numbness, warm skin temperature, and redness Redness, cool skin temperature, and swelling

Numbness, cool skin temperature, and pallor

The quality control nurse is reviewing clients' charts on the medical-surgical unit. When reviewing the nursing staff nursing notes, the quality control nurse expects to find which factors? Select all that apply. Charting errors are erased. Nursing notes follow chronological order. Nursing notes are written with a #2 pencil. Nurses leave one line blank before each new entry. Nurses end each entry with the nurse's signature and title.

Nursing notes follow chronological order. Nurses end each entry with the nurse's signature and title.

A 69-year-old client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?

OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints.

A nurse is caring for a child who has been treated in the emergency department after ingesting drain cleaner. Which nursing interventions would be appropriate in this child care? (Select all that apply.) Observe vital signs for subtle changes. Determine the child's ability to speak. Administer oral antibiotics. Observe for swelling of the tongue. Position the child flat in bed.

Observe vital signs for subtle changes. Determine the child's ability to speak. Observe for swelling of the tongue.

A licensed practical nurse (LPN) who typically works in the nursery is being cross-trained to work with postpartum clients. The charge nurse is busy with a delivery and assigns her to complete hourly rounds on the unit. As she enters a client's room, the LPN notices that a client looks pale and shaky. Which action should she take? Inform the nurse-manager that the client needs to be assessed by a registered nurse. Tell the client to press the call button for a regular staff nurse. Obtain a set of vital signs, check the client's fundus and flow, and compare the findings to baseline data. Find another LPN to help assess the client.

Obtain a set of vital signs, check the client's fundus and flow, and compare the findings to baseline data.

A client who underwent abdominal surgery returns from the postanesthesia care unit with a nasogastric (NG) tube in place. The client complains of nausea. While preparing to attach the client's NG tube to intermittent suction, the nurse notices that the ground on the suction machine's plug is broken. What priority action should the nurse perform first?

Obtain another machine from central supply.

A nurse is caring for a newborn who has developed sepsis. The health care provider has given the following orders. Which order will the nurse implement first? Obtain blood cultures. Start ampicillin 125 mg IV now. Give a 10 mL/kg bolus of fluid. Place a urinary bag for drug screening.

Obtain blood cultures.

The mother of a school-age child reports that her child is having some problems in school. Which of the following would be the priority action?

Obtain more information from the mother and the child.

A client admitted with partial thickness burns to the chest and shoulders 6 hours after a fire has become restless and confused. Which action should the nurse take?

Obtain oxygen saturation using pulse oximetry.

A nurse is monitoring a client who has symptoms of anxiety and dyspnea. The cardiac monitor shows sinus tachycardia with a heart rate of 122. What is the appropriate action of the nurse? Obtain the client's vital signs and oxygen saturation. Administer 100 mg metoprolol. Administer 2.5 mg diazepam. Obtain a stat 12-lead electrocardiogram.

Obtain the client's vital signs and oxygen saturation.

Which intervention is appropriate for the nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine? Assisting with a naloxone challenge test before therapy begins Discontinuing the drug immediately if signs of dependence appear Changing the administration route to by mouth if the client can tolerate fluids Obtaining baseline vital signs before administering the first dose

Obtaining baseline vital signs before administering the first dose

Which intervention is appropriate for the nurse caring for a client in severe pain receiving a continuous I.V. infusion of morphine? Assisting with a naloxone challenge test before therapy begins Discontinuing the drug immediately if signs of dependence appear Changing the administration route to by mouth if the client can tolerate fluids Obtaining baseline vital signs before administering the first dose

Obtaining baseline vital signs before administering the first dose

A client with left hemiparesis is having difficulty handling eating utensils. A nurse asks the physician to request a consult with which discipline?

Occupational therapy

A 52-year-old client admitted with a 3-month history of hemoptysis, shortness of breath, weight loss, and chronic productive cough undergoes testing, which reveals bronchial cancer. After being informed of his diagnosis, the client is tearful and nervous. He tells the nurse he has questions about the type of treatment plan an oncologist might offer. Which action should the nurse take?

Offer emotional support and reassure the client that an oncologist is being consulted to devise a treatment plan.

A client in active labor is sweating profusely and has minimal urine output. Which of the following is how the nurse should intervene? Suggest that the client drink more water Offer the client ice chips and ask the charge nurse to notify the physician of the low urine output Do not intervene because this is a normal finding during active labor Supply the client with beverages that she enjoys drinking

Offer the client ice chips and ask the charge nurse to notify the physician of the low urine output

A neonate of a diabetic mother was born full-term and weighing 10 lb, 1 oz (4.6 kg). While caring for this large-for-gestational age (LGA) neonate, the nurse checks the clavicles for which reason? Neonates of diabetic mothers have brittle bones. Clavicles are commonly absent in neonates of diabetic mothers. One of the neonate's clavicles may have been broken during birth. LGA neonates have glucose deposits on their clavicles.

One of the neonate's clavicles may have been broken during birth.

A nurse is caring for a client newly diagnosed with osteoporosis. Which statements should the nurse include when reinforcing teaching the client about the disease? Select all that apply. Osteoporosis is common in females after menopause. Osteoporosis is a degenerative disease characterized by a decrease in bone density. The disease is congenital, caused by poor dietary intake of milk products. Osteoporosis can cause pain and injury. Passive ROM exercises can promote bone growth. Weight-bearing exercise should be avoided.

Osteoporosis is common in females after menopause. Osteoporosis is a degenerative disease characterized by a decrease in bone density. Osteoporosis can cause pain and injury.

The nurse is caring for a client recovering from an above-the-knee (AKA) amputation. Which interventions should the nurse review with the client to prevent the development of contracture in the residual limb? Select all that apply. Place the residual limb on a pillow when sitting. Hold the residual limb in a flexed position. Perform active range-of-motion exercises to the affected hip joint several times a day. Lie prone for 20 to 30 minutes three times a day. Keep the legs close together. Avoid sitting for long periods of time.

Perform active range-of-motion exercises to the affected hip joint several times a day. Lie prone for 20 to 30 minutes three times a day. Keep the legs close together. Avoid sitting for long periods of time.

A client is experiencing an early postpartum hemorrhage. Which action by the nurse is most appropriate? Inserting an indwelling urinary catheter Performing fundal massage Administering packed red blood cells Performing a pad count

Performing fundal massage

A client who has received an IM injection of ceftriaxone sodium calls the clinic and states "I think I am allergic to this medicine, there is a bump and it hurts at the injection site." What is the nurse's best response?

Place a warm compress on the area for 10 minutes.

The health care provider orders contact precautions for a client with a draining wound. Which action should the nurse take to initiate these precautions?

Place an isolation cart with gloves and gowns outside the room.

The nurse is teaching accident prevention to the parents of a toddler. Which of the following instructions is appropriate for the nurse to tell the parents?

Place locks on cabinets containing toxic substances.

A nurse is caring for a neonate whose mother was abusing drugs. The nurse anticipates that the neonate may experience drug withdrawal. Which intervention would be the priority? Place the Isolette in a quiet area of the nursery. Withhold all medication to help the liver metabolize drugs. Dress the neonate in loose clothing so he won't feel restricted. Place the Isolette near the nurses' station for frequent contact with health care workers.

Place the Isolette in a quiet area of the nursery.

A 69-year-old client comes to the emergency department with a history of productive cough, night sweats, and a 30-lb weight loss over the past 8 months. A diagnosis of tuberculosis is suspected. Which intervention is necessary for this client?

Place the client in a private room with negative air pressure, and implement airborne precautions.

A 6-month-old infant with uncorrected tetralogy of Fallot suddenly becomes increasingly cyanotic and diaphoretic, with weak peripheral pulses and an increased respiratory rate. What is the priority action by the nurse?

Place the infant in a knee-chest position.

A recent abduction of a 2-month-old infant has raised awareness of the need for security plans for hospitals. Which security measure helps ensure the hospitalized infant's security?

Placing an identification bracelet on the infant and the parent immediately on admission

A client is receiving oprelvekin. Which laboratory value will the nurse determine demonstrates the drug is effective for this client?

Platelet of 350,000/µ:l (350 × 109/L)

A neonate born at 32 weeks' gestation is taken to the neonatal intensive care unit (NICU). When caring for this neonate, what are the most important nursing actions to prevent and control infection? Frequently monitor for signs of infection. Use sterile technique for all caregiving. Practice meticulous hand washing. Wear gloves at all times.

Practice meticulous hand washing.

A nurse caring for a client in the first stage of labor notes that the client is irritable, resistant to touch, and withdrawn. Which action should the nurse take next? Prepare for immediate delivery of the baby. Assist the client with ambulation. Teach the client deep breathing and coughing exercise. Give an opioid analgesic.

Prepare for immediate delivery of the baby.

A client comes to the emergency department diagnosed with a ruptured aortic aneurysm. What is the priority action for this client? Administer antihypertensive medication. Transport the client for an aortogram. Administer beta-blocker. Prepare the client for surgery.

Prepare the client for surgery.

A client is admitted to the emergency department with a suspected overdose of an unknown drug. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation.

The nurse is performing wound care on a client. Which task indicates surgical asepsis?

Preparing sterile surgical instruments for the physician to debride the wound

For a child with hemophilia, what is the most important nursing goal?

Preventing bleeding episodes

A client is admitted to the labor and delivery area. How can the nurse most effectively determine the effectiveness of the contractions? Progressive cervical dilatation and descent from station -4 to 0 Sporadic tightening of the uterus in a 5-minute interval Increasing fetal movement Strong uterine contraction with no associated cervical dilation

Progressive cervical dilatation and descent from station -4 to 0

When caring for a client who has had constipation for 4 days, what should be the nurse's primary client care concern?

Promoting defecation

A nurse is caring for a 17-year-old brought to the mental health facility by a family member who is concerned about the client's recent 20-lb (9 kg) weight loss, and weight loss total of 50 lb (22.7 kg) in the last year. What interventions are essential in the treatment of an adolescent diagnosed with an eating disorder? Select all that apply. Provide a highly structured environment. Monitor the clients' weight, vitals, intake and output, caloric intake, and exercise. Provide an isolation environment to monitor all activities. Instruct the client and family that treatment for eating disorders takes a few weeks and the family is not involved in the process. Assist the client in changing the negative perception to a positive one, and assist in setting realistic goals.

Provide a highly structured environment. Monitor the clients' weight, vitals, intake and output, caloric intake, and exercise. Assist the client in changing the negative perception to a positive one, and assist in setting realistic goals.

A 2-year-old with laryngotracheobronchitis is experiencing severe respiratory distress. What nursing action would be a priority?

Provide an atmosphere of cool mist and high humidity.

A nurse is caring for a client in active labor who is crying and asking for something for pain. Her medical record shows that she does not tolerate prescribed opioid analgesics. Which of the following nonpharmacologic interventions might be helpful to this client? Turn on the lights in the room. Administer ibuprofen as ordered. Encourage the client to drink very cold tea. Provide back massage to the client.

Provide back massage to the client.

An older adult client presents at the emergency department (ED) with reports of fatigue and diarrhea. The client reveals areas of ecchymoses and burn marks. Which nursing actions are most appropriate? Select all that apply. Provide explanations and support to the client. Attend to the client's physical needs. Ask the client to leave. Tell the client their secret is safe. Report any signs of abuse to appropriate agencies.

Provide explanations and support to the client. Attend to the client's physical needs. Report any signs of abuse to appropriate agencies.

During rounds, a client who was admitted with gross hematuria asks the nurse about the admitting diagnosis. To facilitate effective communication, what is the nurse's best response?

Provide privacy for the conversation.

A 5-year-old child is brought to the emergency department after being stung multiple times on the face by yellow jackets. Which symptom of anaphylaxis requires priority medical intervention?

Pulse rate of 60 beats/minute

The nurse is caring for a client with Clostridium difficile infection. Prior to entering the room, which step would the nurse take?

Put on a gown.

A nurse is caring for a client with candidiasis. What information should the nurse obtain from the client? Select all that apply. Recent antibiotic use Menopause Use of corticosteroids Use of oral contraceptives Use of over the counter herbal medications

Recent antibiotic use Use of corticosteroids Use of oral contraceptives

A father arrives in a busy emergency department and is upset with his wife for bringing their two-year-old child with epiglottitis in for treatment. Which intervention by the nurse is best?

Recognize the father's behavior as his attempt to cope with the situation.

A registered nurse is caring for a group of clients on a psychiatric unit. Which task can the nurse delegate to the licensed practical/vocational nurse? Redressing lacerations on the wrists of a client who attempted suicide. Preforming a suicide assessment on a client recently admitted with depression. Educating a client on the newly prescribed escitalopram and zolpidem. Assessing a client who is withdrawing from alcohol and methamphetamine.

Redressing lacerations on the wrists of a client who attempted suicide.

A registered nurse (RN) and licensed practical nurse (LPN) are administering medications on the neurologic floor. The LPN prepares to administer phenytoin to a client with a history of seizures. The LPN walks into the room and hands the medication to a nursing assistant. The LPN asks the nursing assistant to give the client the medication after completing the client's morning care. What should the registered nurse do?

Remind the LPN that it is the LPN's duty to administer the medications.

The nurse observes two clients playing basketball during exercise activity. The clients are engaged in aggressive communication and begin to fight. Which nursing intervention is most appropriate?

Remove the clients to separate areas and set limits

The nurse is caring for an infant who has undergone a surgical repair of a cleft lip. The health care provider prescribes elbow restraints. What nursing action should be included in the infant's plan of care?

Remove the restraints every 2 hours.

A nurse is caring for a confused client with a fractured hip who is trying to get out of bed. Which action should the nurse take first?

Reorient the client to the surroundings.

A nurse is assisting with an educational session for a group of women on the topic of urinary tract infection (UTI) prevention. Which information should the nurse expect to be included in this session?

Report any urinary difficulty to the health care provider.

A nurse is reinforcing homecare instructions to a client who is being discharged with a lower leg cast. Which critical information should the nurse reinforce?

Report excessive swelling below the cast immediately.

A nurse suspects an infant may have a tracheoesophageal fistula or esophageal atresia. What is the most important intervention by the nurse?

Report the suspicion to the health care provider.

Because of a staffing shortage, a nurse is reassigned to a cardiovascular unit for a 4-hour shift. The nurse has never worked on a cardiovascular unit and doesn't feel that he or she can safely care for clients in this unit. Which of the following is the most appropriate initial action for the nurse? Report to the unit and do the best he or she can. Call the nursing supervisor. Refuse to go to the cardiovascular unit. Report to the unit and discuss the assignment with the charge nurse to identify tasks that the nurse can perform safely.

Report to the unit and discuss the assignment with the charge nurse to identify tasks that the nurse can perform safely.

The nurse working at a long-term care facility notes an increasing number of clients with pressure ulcer formation and reports this to the facility manager. Which action by the nurse will best address this issue?

Request a quality improvement initiative be implemented.

The licensed practical nurse (LPN) is assigned to care for a 4-year-old child who had a Harrington rod inserted the day before and notices the client is receiving antibiotics by a syringe pump. The nurse is IV certified, but uncomfortable because they are unfamiliar with the equipment. What would be the best course of action?

Request in-service education for use of the syringe pump.

A nurse is providing home care to a client who has failing vision. The nurse is concerned about the client's safety. Which action should the nurse take to help reduce the client's risk of a fall?

Request that the family have handrails installed on the stairs, in hallways, and in bathrooms.

A client is scheduled for a laparoscopic cholecystectomy under general anesthesia. When the nurse asks the client what procedure the client will be having to compare with the informed consent, the client responds, "The doctor is going to take a piece of my liver out." What action should the nurse take at this time?

Request that the health care provider speak with the client before surgery to clarify the surgical procedure.

Just after delivery, the nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do? Rewarm the neonate gradually. Rewarm the neonate rapidly. Observe the neonate at least hourly. Notify the physician when the neonate's temperature is normal.

Rewarm the neonate gradually.

The nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, the nurse should consider which finding significant? Croup Rheumatic fever Severe staphylococcal infection Medullary sponge kidney

Rheumatic fever

Which nursing diagnosis is a priority for a client with a traumatically amputated lower extremity?

Risk for injury related to amputation

Which nursing diagnosis takes highest priority for a client admitted for evaluation for Meniere disease?

Risk for injury related to vertigo

After an upsetting divorce, a client threatens to commit suicide with a handgun and is involuntarily admitted to the psychiatric unit with major depression. Which nursing diagnosis takes highest priority for this client? Hopelessness related to recent divorce Ineffective coping related to inadequate stress management Spiritual distress related to conflicting thoughts about suicide and sin Risk for self-directed violence related to plans to commit suicide by handgun

Risk for self-directed violence related to plans to commit suicide by handgun

Lochia normally progresses in which of the following patterns? Rubra, serosa, alba Serosa, rubra, alba Serosa, alba, rubra Rubra, alba, serosa

Rubra, serosa, alba

A nurse is teaching a client about a newly prescribed drug. What physiological changes does the nurse recognize that could cause a geriatric client to have difficulty learning about prescribed medications?

Sensory deficits

A nurse meets a neighbor and new baby at the local market. The neighbor states that she received outstanding nursing care from one of the nurse's colleagues during her labor and childbirth. What is the best way for the nurse to recognize her nursing colleague's professional efforts? Post accolades to the nurse at the nurses' station. Send the colleague an anonymous card. Share the feedback with the nursing colleague directly. It is a breach of confidentiality to share this information with the colleague

Share the feedback with the nursing colleague directly.

A nurse receives a client assignment and is to care for a client who has terminal lung cancer. The nurse's father died two months ago from the same disease, and the nurse is having difficulty interacting with the client and family due to being overwhelmed with emotion. Which action should the nurse take? Disclose the reason for the behavior to the client and family and have an open discussion. Speak to the nurse in charge about the emotional reaction and explore options. Ask the nurse in charge for permission to go home for personal reasons. Report to another nurse, take a short break, and return to care for the client as assigned.

Speak to the nurse in charge about the emotional reaction and explore options.

A nurse who's assigned the care of six clients is administering a tube feeding to a client when breakfast trays arrive. A client who needs assistance with meals helps herself to her tray and spills hot coffee on her chest and abdomen. How should the nurse intervene?

Stop administering the tube feeding and assist the client with changing her wet clothing, assess the burns, and notify the charge nurse.

A multiparous client with pelvic thrombophlebitis is being treated with bed rest and anticoagulant therapy. The nurse should call for assistance immediately if the client experiences which symptom? Pain in the pelvic area Increased blood pressure Urine retention Sudden onset of shortness of breath

Sudden onset of shortness of breath

A newer nurse is assigned to care for several children with advanced cancer. The nurse finds the assignment extremely challenging due to a lack of experience and is considering requesting a different assignment. What is the best course of action by the nurse to resolve the situation?

Suggest a shared assignment with a senior staff nurse.

The nurse is administering two drugs concomitantly to a client. Which interaction, recognized by the nurse, occurs when two drugs with the same qualitative effects produce a response when given together that is greater than the response either drug produces when given alone?

Synergism

Before eating a meal, a client with obsessive-compulsive disorder (OCD) must wash his or her hands for 18 minutes, comb his or her hair 444 strokes, and switch the bathroom light on and off 44 times. When creating the plan of care, what is the most appropriate goal for this client?

Systematically decrease the number of repetitions of rituals and the amount of time spent performing them.

The nurse is reinforcing education for a client taking tetracycline for severe inflammatory acne. Which instructions are important to reinforce?

Take the drug 1 hour before or 2 hours after meals with large amounts of water.

The parents of a school-age child with asthma express concern about letting the child participate in sports. What should the nurse tell the parents about the relationship between exercise and asthma?

Taking prophylactic drugs before the activity can prevent asthma attacks and enable the child to engage in most sports.

A nurse is caring for a client experiencing a panic attack. Which intervention by the nurse would be most appropriate? Tell the client to take deep breaths. Tell the client to talk about the anxiety. Encourage the client to verbalize feelings. Ask the client about the cause of the attack.

Tell the client to take deep breaths.

A nurse is assisting with a circumcision. After the physician has started the procedure, the nurse reviews the neonate's medical record and notices that an informed consent form hasn't been signed. What should the nurse do? Continue assisting with the circumcision and ask the mother to sign the consent form after the procedure. Tell the physician to stop the procedure immediately because an informed consent form hasn't been signed. Inform the physician and ask the physician to quickly complete the procedure. Notify the medical director of the physician's negligence.

Tell the physician to stop the procedure immediately because an informed consent form hasn't been signed.

The nurse tells the student nurse that they will be visiting a family that experienced a stillbirth at 38 weeks gestation. The student nurse begins to cry and says, "I can't possibly participate in the visit. I just found out I am pregnant. I can't deal with the thought of losing a baby in pregnancy." What is the nurse's most appropriate response to the student nurse? Tell the student nurse it is okay to cry and encourage her to talk about the way she is feeling. Tell the student nurse to take the day off and spend time with her other children. Tell the student nurse that her behavior is unprofessional and that the visit is a valuable part of her clinical experience. Tell the student nurse to go home and forget about the experience.

Tell the student nurse it is okay to cry and encourage her to talk about the way she is feeling.

A nurse is caring for a client who has recently been diagnosed with testicular cancer. What information is most important to provide to this client?

Testicular self-examination is still important because there is an increased risk of a second tumor.

The nurse is collecting data from a parent regarding the child's behavior. Which behavior is consistent with the diagnosis of conduct disorder in this child? The child is wetting the bed at night. The child has threatened suicide. The child has purposely hurt animals. The child has a fear of attending school.

The child has purposely hurt animals.

A nurse notes that a 4-year-old child with cerebral palsy has a weight at the 30th percentile and a height at the 60th percentile. Which teaching information is appropriate for this child and parents?

The child's weight and height are within the normal range.

A nurse is caring for a 25-year-old client with end-stage testicular cancer who has been referred to hospice care. Which of the following criteria excludes the client from hospice care? The client's girlfriend prefers not to discuss death around him. The client entered a clinical trial through the National Cancer Institute. The physician prescribes weekly blood transfusions to be given at home. The client explains that he isn't ready to complete his will.

The client entered a clinical trial through the National Cancer Institute.

The nurse is reviewing a client's prenatal history. Which finding would suggest to the nurse that it indicates a genetic risk factor? The client is 25 years old. The client has a child with cystic fibrosis. The client was exposed to rubella at 36 weeks' gestation. The client has a history of preterm labor at 32 weeks' gestation.

The client has a child with cystic fibrosis.

The nurse is preparing to administer chlorpromazine to a client with schizophrenia. Which circumstance, noted in the client's history, would cause the nurse to notify the health care provider for accuracy of the prescription? The client is also receiving labetalol. The client is diagnosed with intractable hiccups. The client had surgery and is restless. The client has a history of nausea and vomiting.

The client is also receiving labetalol.

After having transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded?

The client reports bladder spasms and the urge to void.

The nurse educator is discussing a case regarding a client with obsessive-compulsive disorder who tells the nurse that he or she must check the lock on his or her apartment door 25 times before leaving for an appointment. The nurse educator includes which information about what this behavior represents? The client's attempt to call attention to himself or herself The client's attempt to control his or her thoughts The client's attempt to maintain the safety of his or her home The client's attempt to reduce anxiety

The client's attempt to reduce anxiety

A health care provider has prescribed magnesium sulfate for a client with premature labor. Data collection reveals the client's respiratory rate is 12 breaths/minute, and urine output is 30 mL/hour. The magnesium sulfate serum levels are 7 mg/dL. The client reports feeling warm and flushed. Which action by the nurse is most appropriate? The client is demonstrating early signs of toxicity, and the dosage should be reduced. The client is demonstrating an allergic reaction, and the medication should be discontinued immediately. The client's response is appropriate and within normal limits; therefore, no action is necessary. The client is demonstrating potential complications, and the health care provider should be notified.

The client's response is appropriate and within normal limits; therefore, no action is necessary.

For a client in active labor, the health care provider plans to use an internal electronic fetal monitoring (EFM) device. Which finding from the client's medical record would the nurse interpret as supporting the use of internal EFM? Select all that apply. The membranes have ruptured. Fetus is at -3 station. The cervix is 10 cm dilated. The client has received anesthesia. Fetal head is engaged.

The membranes have ruptured. The cervix is 10 cm dilated. Fetal head is engaged.

Which of the following explanations describes the rationale for administering vitamin K to every neonate? Neonates don't receive the clotting factor in utero. The neonate lacks intestinal flora to make the vitamin. It improves the neonate's nutritional status while feeding patterns are being established The drug prevents the development of phenylketonuria (PKU)

The neonate lacks intestinal flora to make the vitamin.

Two clients arrive at the labor and delivery triage area at the same time. The first client states that her water has been leaking, but that she hasn't had any contractions. The second client says she's having 1-minute contractions every 3 minutes and that she feels like pushing. How should a nurse prioritize these clients? The nurse should assign priority to the first client. Her leaking amniotic fluid indicates that she'll soon go into labor. The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent. Triage observation is appropriate for both clients at this time. It doesn't matter which client receives priority; they're at the same stage of labor.

The nurse should assign priority to the second client. Her signs and symptoms indicate that her baby's birth is imminent.

The nurse is working with a group of adolescents reviewing information regarding the human immunodeficiency virus (HIV). What fact is important for the nurse to include in the review?

The virus can be spread through many routes, including sexual contact.

A nurse instructs a pregnant client about the importance of doing frequent Kegel exercises. Kegel exercises are important for which reason? They promote better breathing by strengthening the diaphragm muscle. They help maintain good perineal muscle tone by tightening the pubococcygeus muscle. They minimize leg cramps by strengthening the calf muscles. They prepare the mother for pushing by strengthening the abdominal muscles.

They help maintain good perineal muscle tone by tightening the pubococcygeus muscle.

A nursing student is gathering information about the client's lung fields. Which statements about crackles would the student expect to review? Select all that apply. Crackles are grating sounds. They are high-pitched, musical squeaks. Crackles are low-pitched noises that sound like snoring. They may be fine, medium, or coarse. Crackles are audible during both expiration and inspiration.

They may be fine, medium, or coarse. Crackles are audible during both expiration and inspiration.

While reading a journal article, a nurse comes across a discussion of the causes of dissociative disorders. Which information would the nurse most likely find in the discussion? They occur as a result of incest. They occur as a result of substance abuse. They occur in more than 40% of all people. They occur as a result of the brain trying to protect the person from severe stress.

They occur as a result of the brain trying to protect the person from severe stress.

The parent of an 8-year-old client tells the nurse that when the child plays with other children, the child does not seem to interact with them, but simply plays alongside. What does the nurse determine about the child?

This is a parallel play typical of toddlers, not school-aged children.

Why are antacids administered regularly, rather than as needed, to treat peptic ulcer disease?

To keep gastric pH at 3.0 to 3.5

Lorazepam is often given along with a neuroleptic agent, such as haloperidol. What is the purpose of administering the drugs together?

To reduce anxiety and potentiate the sedative action of the neuroleptic

What nursing intervention should be provided for a client who is experiencing a seizure?

Turn the client to one side.

A client is scheduled for a laminectomy to repair a herniated intervertebral disk. When developing the postoperative plan of care, the nurse should include which action?

Turning the client from side to side, using the logroll technique

Which situation violates a hospitalized adolescent's right to confidentiality?

Two nurses talk about the adolescent on an elevator on their way to lunch.

Parents of a 6-year-old child tell a physician that the child has been having periods of unawareness with short periods of staring. Based on his history, the child is probably having which type of seizure?

Typical absence

The nurse is interviewing a client on admission to the chemical dependency unit for alcohol detoxification. When asked about alcohol use, the nurse suspects which estimation that this client is most likely to provide? Accurately describe the amount consumed Underestimate the amount consumed Overestimate the amount consumed Deny any consumption of alcohol

Underestimate the amount consumed

A child, age 5, is brought to the pediatrician's office for a routine visit. When inspecting the child's mouth, the nurse expects to find how many teeth?

Up to 20

The nurse is caring for a client with a panic disorder. Which panic attack does the nurse document as uncued?

Upon awaking from a peaceful nap, the client reports shortness of breath.

A client who is homeless is admitted for treatment of a severe infection. The client reports, "I'm allergic to everything." The nurse reviews the client's medical records at that facility and learns that the client has extensive identified medication allergies. What is the best action for the nurse to take?

Use the drug allergy listing in the medical record as a starting point for a full allergy assessment.

A client's neonate was delivered by cesarean. Which management strategy should be implemented regarding breast-feeding after this type of delivery? Delay breast-feeding until 24 hours after delivery. Have the mother breast-feed frequently during the day and every 4 to 6 hours at night. Use the cradle hold position to avoid incisional discomfort. Use the football hold to avoid incisional discomfort.

Use the football hold to avoid incisional discomfort.

The nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care? Using a peri bottle to clean the perineum after each voiding or bowel movement Cleaning the perineum from back to front after a bowel movement Spraying water from peri bottle into the vagina Changing perineal pads every 8 hours

Using a peri bottle to clean the perineum after each voiding or bowel movement

A nurse is assisting with the development of a teaching plan for a client who will undergo a stapedectomy for the treatment of otosclerosis. Which instruction should the plan include?

Vertigo and dizziness are common after surgery.

A client being treated for morbid obesity is 5' 3" tall and weighs 250 lb (113.4 kg). She has lost 60 lb (27 kg) over the past year. A nurse is advising the client about adding an exercise regimen to her diet program. Which exercise is the most appropriate for the nurse to suggest? Aerobics three times per week Jogging for 30 minutes three times per week Walking for 20 minutes per day Weight training for 30 minutes per day

Walking for 20 minutes per day

A nurse is providing care to a neonate. Place the following steps in the order that the nurse should implement them to properly perform ophthalmia neonatorum prophylaxis. All options must be used.

Wash hands and put on gloves. Shield the neonate's eyes from direct light, and tilt the head slightly to the side that will receive the treatment. Gently raise the neonate's upper eyelid with the index finger and pull the lower eyelid down with the thumb. Instill the ointment in the lower conjunctival sac. Close and manipulate the eyelids to spread the medication over the eye. Repeat the procedure for the other eye.

A client is admitted for treatment of chronic renal failure (CRF). The nurse reviews the client's chart to monitor which electrolyte imbalance?

Water and sodium retention

A client received treatment with cytotoxic medications 24 hours ago. Which precautions are necessary when caring for the client? Wear sterile gloves when emptying bedpans or urinals. Use a bleach solution to clean bedpans or urinals after use. Wear personal protective equipment when handling blood, body fluids, and feces. Provide a urinal or bedpan to decrease the likelihood of soiling linens.

Wear personal protective equipment when handling blood, body fluids, and feces.

The nurse is caring for a client with chronic renal failure. Which nursing action should be included when assisting with development of the plan of care?

Weigh the client daily before breakfast.

A client with a history of heart failure is at risk for fluid volume excess. Which nursing intervention would ensure the most accurate monitoring of the client's fluid status?

Weighing the client at the same time each day

A client with a history of type 1 diabetes mellitus recently had an amputation and is in the rehabilitation unit. When the nurse enters the room to administer the client's daily insulin, the client is diaphoretic, reports having a headache, and has slurred speech. What should the nurse do next?

Withhold the client's insulin, check the blood glucose level, bring a glass of orange juice, and report the findings to the charge nurse.

The nurse is reviewing laboratory values on a client with heart failure and atrial fibrillation. The client has a potassium level of 2.8 mEq/L (2.8 mmol/L). The client is scheduled to receive their 0900 dose of digoxin. What is the nurse's best action?

Withhold the dose of digoxin and notify the healthcare provider.

A client who has been prescribed nitroglycerin, metoprolol, and furosemide is dizzy and has a blood pressure of 84/50 mm Hg. Which action should the nurse take when the medications are scheduled to be provided? Withhold the medications, and notify the health care provider. Administer the furosemide and metoprolol, and withhold the nitroglycerin. Ensure the client takes medications while lying in bed. Administer the nitroglycerin and metoprolol, and withhold the furosemide.

Withhold the medications, and notify the health care provider.

For several years, a client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride by mouth four times per day. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client also is confused and incontinent, the nurse suspects malignant neuroleptic syndrome. What steps should the nurse take? Give the next dose of fluphenazine, call the physician, and monitor vital signs. Withhold the next dose of fluphenazine, call the physician, and monitor vital signs. Give the next dose of fluphenazine and restrict the client to his room to decrease stimulation. Withhold the next dose of fluphenazine, administer an antipyretic agent, and increase the client's fluid intake.

Withhold the next dose of fluphenazine, call the physician, and monitor vital signs.

A nurse working in a walk-in clinic has been alerted that there's an outbreak of tuberculosis (TB). Which client does the nurse identify as having the highest risk for developing TB?

a 43-year-old homeless man with a history of alcoholism

Which client is most at risk for developing deep vein thrombosis (DVT)? a 62-year-old female recovering from a total hip replacement a 35-year-old female 2 days postpartum a 33-year-old male runner with Achilles tendonitis an ambulatory 70-year-old male who's recovering from pneumonia

a 62-year-old female recovering from a total hip replacement

The nurse is assigned to care for a group of clients on the medical-surgical unit. Following report, which client should the nurse see first?

a client that a family member states is having a new onset of slurred speech and left facial drooping

Which adolescent client would the school nurse consider at greatest risk for developing acquired immunodeficiency syndrome (AIDS)?

a client who states they have multiple sexual partners

Which client on the rehabilitation unit is most likely to develop autonomic dysreflexia?

a client with a high cervical spine injury

A nurse is assigned to care for a group of clients following a motor vehicle collision. Which client should the nurse attend to first?

a client with a respiratory rate of 39 breaths/minute, restlessness, and bruising on the chest wall

A nurse is reviewing data for multiple clients in the first stage of labor. Which client should receive priority attention? a client with blood pressure of 160/90, pulse 92, respiration 22, temperature 99.1, and positive proteinuria a client with blood pressure of 110/60, pulse 72, respiration 20, temperature 98.1, and positive proteinuria a client with blood pressure of 150/90, pulse 102, respiration 18, temperature 97.1, and negative protein in urine a client with blood pressure of 120/90, pulse 82, respiration 20, temperature 97.2, and negative proteinuria++

a client with blood pressure of 160/90, pulse 92, respiration 22, temperature 99.1, and positive proteinuria

A client has been placed in an isolation room and family members have stated that access to the client seems restricted. Which actions would be appropriate for the nurse to take to address this situation? Select all that apply. a communication plan for the family and client free access to the client for immediate family a thorough explanation of the isolation procedures acknowledgement of the family's concerns discontinued isolation procedures at the family's request

a communication plan for the family and client a thorough explanation of the isolation procedures acknowledgement of the family's concerns

The nurse is reinforcing education on cast care for a client with a cast on the arm. How should the nurse instruct the client to place the casted limb, if there is swelling?

above the level of the heart

A client is receiving emergency care following a motor vehicle collision. The health care provider has diagnosed a left pneumothorax. Which sign would typically be present upon auscultation of the client's lungs?

absence of breath sounds over the left lung field

The nurse is caring for a client with alcohol-related acute pancreatitis. Which intervention is most appropriate to reduce the exacerbation of pain? lying supine taking aspirin eating low-fat foods abstaining from alcohol

abstaining from alcohol

On her second visit to the prenatal facility, a client states, "I guess I really am pregnant. I've missed two periods now." Based on this statement, the nurse determines that the client has accomplished which psychological task of pregnancy? facing reality bonding with the fetus accepting the baby accepting the pregnancy

accepting the pregnancy

The nurse prepares to administer morning medications to a client with hepatitis. The client's medications are listed below. Which medication should the nurse withhold?

acetaminophen 650 mg orally every day

A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should anticipate which measure?

administering large doses of I.V. antibiotics as ordered

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for:

adult respiratory distress syndrome (ARDS).

A nurse is collecting data on a client with possible osteoarthritis. What factor places this client at the greatest risk for osteoarthritis?

age

A nurse is reinforcing education provided to a client about reducing risk factors for coronary artery disease. Which risk factor does the nurse inform the client is nonmodifiable? age hypertension personality smoking

age

The nurse is admitting a preschooler diagnosed with varicella (chickenpox). Which infection-control precautions should the nurse anticipate? isolation airborne droplet neutropenic

airborne

A nurse is orienting a new nurse to the labor and delivery unit. Which action by the new nurse regarding a neonate's security requires intervention by the preceptor? affixing matching identification bands to the parents and neonate at birth positioning a rooming-in neonate's bassinet toward the center of room rather than near the door to the hallway affixing a security bracelet that monitors movement to a neonate allowing volunteers to return neonates to the nursery

allowing volunteers to return neonates to the nursery

Following a precipitous birth, examination of the client's vagina reveals a fourth-degree laceration. Which of the following nursing interventions should the nurse implement to promote healing? Select all that apply. applying cold to limit edema during the first 12 to 24 hours instructing the client to use two or more peripads to cushion the area instructing the client on the use of sitz baths instructing the client about the importance of perineal (Kegel) exercises increasing fiber in the diet to prevent constipation

applying cold to limit edema during the first 12 to 24 hours instructing the client on the use of sitz baths instructing the client about the importance of perineal (Kegel) exercises increasing fiber in the diet to prevent constipation

The nurse correctly instructs a client with peripheral vascular disease that stress-reduction techniques: are helpful only because they assist in smoking cessation. are helpful because stress stimulates the release of vasoconstricting catecholamines. are helpful because they distract the client from focusing on claudication pain. haven't proved useful in clients with peripheral vascular disease

are helpful because stress stimulates the release of vasoconstricting catecholamines.

A 4-year-old child is experiencing separation anxiety when the parents leave the hospital. What is the most appropriate complementary therapy for the nurse to utilize to calm the child?

aromatherapy

A clinical nurse specialist developed clinical pathways for common orthopedic conditions. In which way should the interdisciplinary team use these pathways?

as guidelines to ensure continuity of care

A mother brings her 2-month-old infant to the clinic for a well-baby checkup. To best assess the interaction between the mother and infant, the nurse should observe them:

as the mother feeds the infant.

The nurse is gathering data from an adolescent client. What technique is best to use when developing rapport?

asking open-ended questions

A client with end-stage pulmonary hypertension tells the physician they don't want any heroic measures should their heart stop, and doesn't want to be placed on a ventilator. The physician enters a do-not-resuscitate order into the hospital's computer system. Which ethical principle is the nurse upholding by supporting the client's decision?

autonomy

A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the physician recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering her response to the client, the nurse must depend on the ethical principle of:

autonomy.

A nurse is caring for a client with multiple myeloma. Which finding indicates that the client is not coping well with the prognosis?

avoids conversations concerning his or her health

A nurse is reinforcing education for a client entering the third trimester of pregnancy. The nurse determines that the client understands the education when the client states which symptom will be immediately reported? hemorrhoids blurred vision dyspnea on exertion increased vaginal mucus

blurred vision

A client with multiple sclerosis (MS) is admitted to the hospital reporting weakness, incoordination, dizziness, and loss of balance. Which additional signs and symptoms would the nurse question the client about?

blurred vision, intention tremor, and urinary hesitancy

The nurse auscultates inspiratory and expiratory wheezes with a decreased forced expiratory volume in a client with asthma. Which class of medication would the nurse expect to administer immediately?

bronchodilators

The nurse is teaching the parents of a young child how to handle suspected poisoning. If the child ingests poison, the parents should first:

call the poison control center.

In the emergency department, a client with facial lacerations states that the spouse beat the client with a shoe. After the lacerations are repaired, the client waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence the spouse represents. Suddenly the client's spouse arrives, shouting a desire to "finish the job." What is the first priority of the nurse who witnesses this scene? remaining with the client and staying calm calling a security guard and another staff member for assistance saying that the client's spouse must leave at once determining why the spouse feels so angry

calling a security guard and another staff member for assistance

A client arrives in the emergency department with tachycardia, decreased urination, restlessness, and confusion. Auscultation reveals a fourth heart sound. What does the nurse suspect is occurring? myocardial infarction (MI) cardiogenic shock peripheral vascular disease abdominal aortic aneurysm (AAA)

cardiogenic shock

A male with heart failure is experiencing tachycardia, decreased blood pressure, and decreased peripheral pulses. The nurse interprets these symptoms as indicating which condition? anaphylactic shock cardiogenic shock distributive shock myocardial infarction (MI)

cardiogenic shock

Which information is the priority to include in the discharge plan for a client leaving the hospital in a leg cast?

cast care, neurovascular checks, and hygiene measures

Which potential side effects should the nurse include when assisting in discharge teaching of a male client who was started on atenolol? causes and treatments for erectile dysfunction control of excessive flatus management of incontinence prevention of constipation

causes and treatments for erectile dysfunction

A client with active genital herpes is admitted to the labor and birth area during the first stage of labor. What intervention specific to the client's condition should the nurse anticipate? continuous monitoring of fetal heart rate administration of IV antibiotic induction of labor cesarean delivery

cesarean delivery

An 8-year-old child, diagnosed with obsessive-compulsive disorder, is admitted by the nurse to a psychiatric facility. When gathering data from the client, which behaviors would be characterized as compulsions? Select all that apply. checking and rechecking that the television is turned off before going to school repeatedly washing the hands brushing teeth three times per day routinely climbing up and down a flight of stairs three times before leaving the house feeding the dog the same meal every day Wanting to play the same video game each night

checking and rechecking that the television is turned off before going to school repeatedly washing the hands routinely climbing up and down a flight of stairs three times before leaving the house

The student nurse is studying about a child with acute glomerulonephritis. Which child would be most likely to develop the disease?

child who had a streptococcal infection 2 weeks ago

A nurse is working in a gastroenterologist's office. With which client would the nurse instruct on signs of rectal cancer? client with adenomatous polyps client with diverticulitis client with hemorrhoids client with peptic ulcer disease

client with adenomatous polyps

In which group is it most important for the client to understand the importance of an annual Papanicolaou (Pap) test?

clients infected with the human papillomavirus (HPV)

The nurse is gathering data from a child suspected of being a victim of abuse. What observation by the nurse would lead to this suspicion?

contusions of the back and buttocks

The nurse is assisting with the development of a care plan for a client with anorexia nervosa. Which information should the nurse ensure is included? coping mechanisms used in the past concerns about changes in lifestyle and daily activities rejection of feedback from family and significant others appropriate social behaviors centering on drinking alcohol

coping mechanisms used in the past

The nurse is caring for a teenage client involved in a motor vehicle accident. The client has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:

cover the opening with sterile petroleum gauze.

The nurse is caring for a child with an upper respiratory tract infection experiencing difficulty breathing. The health care provider has prescribed a mist tent with a nebulizer for the child. What does the nurse identify is the purpose of the mist tent and nebulizer?

creates a cool, moist environment that decreases respiratory tract edema

The nurse is monitoring laboratory studies for a client who had a myocardial infarction. Which test will the nurse monitor that is most indicative of cardiac damage? arterial blood gas (ABG) levels complete blood count (CBC) complete chemistry creatine kinase isoenzymes (CK-MB)

creatine kinase isoenzymes (CK-MB)

The nurse is reviewing the laboratory tests of a child diagnosed with muscular dystrophy. Which laboratory test does the nurse observe that would help diagnose this condition?

creatinine

The nurse is collecting data for a client diagnosed with a dementia disorder. Which factor is most important for the nurse to determine when collecting data for this diagnosis? prognosis genetic information degree of impairment implications for treatment

degree of impairment

A client's membranes rupture during the 36th week of pregnancy. Eighteen hours later, the nurse measures the client's temperature at 101.8° F (38.8° C). After initiating prescribed antibiotic therapy, the nurse should prepare amniocentesis. delivery. sonography. tocolytic drug therapy.

delivery.

A client is referred to a mental health clinic by the court for harassing a couple next door and claiming that the husband was in love with her. She wrote love notes and called him on the telephone throughout the night. The client is employed and has had no problems with her job. The nurse interprets these findings as suggesting which condition? major depression schizophrenia delusional disorder bipolar affective disorder

delusional disorder

The nurse is reviewing the teaching provided to the family of a client with a psychiatric disorder about traditional antipsychotic drugs and their effect on symptoms. The nurse understands that which symptom would be most responsive to these types of drugs? apathy delusions social withdrawal attention impairment

delusions

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should:

demonstrate eyedrop instillation.

Which would the nurse incorporate when reinforcing education for the parents of a neonate diagnosed with sickle cell anemia?

demonstrate how to take an accurate temperature

A client is admitted to the inpatient treatment unit for detoxification after a cocaine overdose. The client tells the nurse. "Even though I frequently use cocaine, I can control my use if I want to." The nurse interprets this statement as indicating which defense mechanism? withdrawal logical thinking repression denial

denial

An older adult client is admitted to an acute care floor with the diagnosis of heart failure. Upon further workup, the health care provider informs the nurse that the client has right-sided heart failure. Which symptom should the nurse expect to find in this client? Select all that apply. dependent edema jugular vein distention weight loss crackles weight gain

dependent edema jugular vein distention weight gain

A client with bipolar disorder is having difficulty sleeping. Which behavior modification technique should the nurse reinforce with the client? use a sleep medication work on solving a problem exercise before bedtime develop a sleep ritual

develop a sleep ritual

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?

developing a list of people with whom the client has had contact

Root cause analysis has revealed the source of medication errors in the neonatal intensive care unit. Completion of the performance improvement process requires developing an action plan to resolve the root causes. duplicating the investigation in adult intensive care units. educating unlicensed (unregulated) staff regarding the action plan. approval of interventions by the state board of nursing.

developing an action plan to resolve the root causes.

A plan of care for a client with osteoporosis includes active and passive exercises, calcium supplements, and daily vitamins. What documentation by the nurse would demonstrate that effective therapy is being maintained?

development of an increase in mobility

A 14-month-old child with acquired immunodeficiency syndrome (AIDS) is admitted to the facility with an infection. When assisting in developing a plan of care, the nurse must keep in mind that AIDS in children commonly is associated with:

developmental delays.

A nurse is reinforcing teaching with a client at 24 weeks of gestation regarding a glucose tolerance test to screen for gestational diabetes. The client asks, "What will be done if I have this disorder?" The nurse is correct to state that gestational diabetes is managed by which therapy? dietary control of carbohydrates, fats, and proteins metformin ultralente (long-acting) insulin metformin and ultralente (long-acting) insulin

dietary control of carbohydrates, fats, and proteins

A client tells the nurse that she doesn't want to sign the hepatitis B vaccination consent form because she heard that, "vaccinations can cause autism." What's the most appropriate nursing interaction? telling the client that such information hasn't been substantiated supporting the client's decision because all vaccines have associated risks encouraging the client to discuss the issue with the pediatrician at the infant's 2-week check-up discussing the purpose of the vaccine and providing the client with written information

discussing the purpose of the vaccine and providing the client with written information

The nurse is providing care to a client. The history reveals that the client was reported missing after being the victim of a violent crime. Two months later, a family member found the client working in a city 100 miles from home. The client was not able to recognize the family member or recall being the victim of a crime. The nurse would suspect which condition? depersonalization/derealization disorder dissociative amnesia dissociative fugue dissociative identity disorder (DID)

dissociative fugue

The nurse is obtaining data when the postpartum client comes for follow-up visits at 2, 4, and 6 weeks. When would be the best time for the client to have postpartum depression screenings? during each of the three visits using the Edinburgh Postnatal Depression Scale through general conversation and observation beginning 4 weeks after birth beginning 6 weeks after birth using the Beck Depression Inventory by interviewing the father of the child during each of the three visits

during each of the three visits using the Edinburgh Postnatal Depression Scale

A nurse is caring for a client with a fractured left femur. Which finding would require the nurse to contact the health care provider immediately?

dyspnea and increasing restlessness

Which aspect is most important for successful management of the child with Reye syndrome?

early diagnosis

Which short-term goal is appropriate for a client with an antisocial personality disorder who acts out when distressed? identifying personal improvement techniques identifying situations that are out of the client's control encouraging the client to identify traumatic life events educating the client about expressing feelings in a nondestructive manner

educating the client about expressing feelings in a nondestructive manner

A nurse is caring for a client with anorexia nervosa who requires a high-protein, high-calorie diet. When offering appropriate choices for snacks, which snack would be best for this client? chicken soup and crackers a doughnut and orange juice egg salad and peanuts cashews and strawberries

egg salad and peanuts

A 74-year-old client has three grown children who each have families of their own. The client is retired and looks back on life with satisfaction. According to Erickson, which stage is this client currently experiencing?

ego integrity.

A client with major depression hasn't responded to antidepressants. Which intervention should the nurse prepare the client for? electroconvulsive therapy (ECT) electroencephalography (EEG) electromyography (EMG) tranquilizers

electroconvulsive therapy (ECT)

A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:

electromyography (EMG).

A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse's first priority is to:

ensure safety by initiating suicide precautions.

A 3-month-old infant is admitted to the hospital to rule out nonaccidental trauma. X-ray findings indicate a fractured right humerus, fractured ribs, and a fractured left scapula. In this situation, a nurse is responsible for:

ensuring that the suspected child abuse is reported to local authorities.

A client with chronic renal failure who receives hemodialysis three times weekly has a hemoglobin (Hb) level of 7 g/dl. The most therapeutic pharmacologic intervention would be to administer:

epoetin alfa.

Which short-term goal is appropriate for a client with borderline personality disorder who displays low self-esteem? write in a journal daily express fears and feelings stop obsessive-compulsive behaviors decrease dysfunctional family conflicts

express fears and feelings

Which action is the best precaution against transmission of infection? eye prophylaxis with antibiotics for a neonate whose mother has hepatitis B infection strict isolation for a neonate whose mother has cytomegalovirus (CMV) infection eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection strict isolation for a neonate whose mother has human immunodeficiency virus (HIV)

eye prophylaxis with antibiotics for a neonate whose mother has gonorrhea infection

When caring for a child diagnosed with a ventricular septal defect, how would the nurse describe this condition when talking with the parents? narrowing of the aortic arch failure of a septum to develop completely between the atria narrowing of the valves at the entrance of the pulmonary artery failure of a septum to develop completely between the ventricle

failure of a septum to develop completely between the ventricles

The nurse cares for an infant receiving inadequate treatment for congenital hypothyroidism. Which signs or symptoms should the nurse expect to observe?

fatigue and sleepiness

The nurse is caring for a client with hypothyroidism. Which client data would the nurse expect to collect?

fatigue, cold intolerance, weight gain, and constipation

A nurse is planning care for a client diagnosed with acute hepatitis A. What is the primary mode of transmission for hepatitis A? fecal contamination and oral ingestion exposure to contaminated blood sexual activity with an infected partner sharing a contaminated needle or syringe

fecal contamination and oral ingestion

Which nurse should be assigned to a client receiving brachytherapy for the treatment of cervical cancer? female nurse with 3 years' experience working in oncology male nurse who has floated to this unit from the operating room female nurse with 10 years' experience who suspects she may be pregnant male nurse who is also assigned to another client receiving brachytherapy

female nurse with 3 years' experience working in oncology

A nurse is assisting with the care of a pregnant client experiencing mild active bleeding from placenta previa. The nurse suspects that an emergency cesarean birth may be necessary based on which finding? maternal blood pressure of 130/82 mm Hg absence of pooling of vaginal bleeding under the client fetal heart rate of 80 beats/minute maternal heart rate of 78 beats/minute

fetal heart rate of 80 beats/minute

Which findings would be considered positive signs of pregnancy? fatigue and skin changes quickening and breast enlargement fetal heartbeat and fetal movement on palpation abdominal enlargement and Braxton Hicks contractions

fetal heartbeat and fetal movement on palpation

When collecting data on a child with cellulitis, which symptoms would the nurse expect to find?

fever, edema, tenderness, and warmth at the site

A client is admitted with retinal detachment. Which sign or symptom would the nurse anticipate during data collection?

flashing lights and floaters

A nurse receiving morning report is told that the family members of a terminally ill client require a lot of attention. Which intervention should the nurse implement to meet the psychosocial needs of the family?

flexible visitation, allowing participation in client care, and rest breaks for the family and client

Which communication guideline should the nurse use when talking with a client experiencing mania? address the client in a light and joking manner focus and redirect the conversation as necessary allow the client to talk about several different topics ask open-ended questions to facilitate conversation

focus and redirect the conversation as necessary

A nurse is gathering data to determine fall risk for a client. What information is most important for the nurse collect? Select all that apply. functional level muscular strength social history dietary preferences gait and balance visual acuity

functional level muscular strength gait and balance visual acuity

The nurse is assigned to care for a client with early-stage Alzheimer's disease (AD). Which nursing interventions should be included in the client's care plan? Select all that apply. change the client's routine often engage the client in complex discussions to improve memory furnish the client's environment with familiar possessions assist the client with activities of daily living (ADLs) as necessary assign tasks in simple steps

furnish the client's environment with familiar possessions assist the client with activities of daily living (ADLs) as necessary assign tasks in simple steps

A 3-year-old child is receiving ampicillin for acute epiglottitis. Which sign would lead the nurse to suspect that the child is experiencing a common adverse effect of this drug?

generalized rash

A nurse is collecting data from a client diagnosed with schizophrenia. Which symptoms would the nurse identify as supporting the client's diagnosis? persistent, intrusive thoughts leading to repetitive, ritualistic behaviors feelings of helplessness and hopelessness unstable moods and delusions of grandeur hallucinations or delusions and decreased ability to function in society

hallucinations or delusions and decreased ability to function in society

Several children at a day care center have been infected with hepatitis A virus. Which instruction reinforced by the nurse would reduce the risk of spreading hepatitis A to other children and staff members? hand washing after diaper changes isolation of the sick children using masks during contact with children sterilization of all eating utensils

hand washing after diaper changes

The nurse is preparing a client for magnetic resonance imaging (MRI). What does the nurse recognize as conditions that would exclude the client from MRI?

having a cardiac pacemaker/defibrillator

A nurse, driving on a highway, is the first on the scene after a multivehicle collision. Which assessment data for the accident victims would require immediate care?

head injuries

A nurse is assigned to care for a client with peptic ulcer disease. Which finding will the nurse report immediately to the health care provider? blood pressure 140/84 mm Hg abdominal pain loss of appetite heart rate 126 bpm

heart rate 126 bpm

A 29-week gestation client arrives in the labor and delivery suite for an emergency cesarean section. The neonate is born and exogenous surfactant is administered. Which action best explains the main function and goal of surfactant use? assists with ciliary body maturation in the upper airways eliminating mucus helps maintain a rhythmic breathing pattern reducing tachypnea promotes mucus production lubricating the respiratory tract helps lungs remain expanded after the initiation of breathing improving oxygenation

helps lungs remain expanded after the initiation of breathing improving oxygenation

The health care provider has ordered diagnostic testing for a client suspected of having thalassemia. When reviewing labs from this client, which findings does the nurse determine are consistent with the disorder? Select all that apply. hemoglobin 8.8 g/dL (88g/L) hemoglobin 13.4 g/dL (134g/L) hematocrit 36% (0.36) red blood cells 2.9 red blood cells 5.2

hemoglobin 8.8 g/dL (88g/L) red blood cells 2.9

The nurse obtains the antepartum history of a client who's 6 weeks pregnant. Which finding should the nurse discuss with the client first? her participation in low-impact aerobics three times per week her consumption of six to eight cans of beer on weekends her consumption of four to six small meals daily her practice of taking a multivitamin supplement daily

her consumption of six to eight cans of beer on weekends

A nurse is assisting in monitoring a client who's receiving oxytocin to induce labor. The nurse would be alert for which maternal adverse reactions? Select all that apply. hypertension jaundice dehydration fluid overload uterine tetany Bradycardia

hypertension fluid overload uterine tetany

The nurse is performing an assessment on a client who has developed a paralytic ileus. The nurse expects the client's bowel sounds will be:

hypoactive.

A nurse is instructing a premenopausal client about breast self-examination. When should the nurse recommend is the best time for the client to perform self-examination?

immediately after menses

A nurse is caring for a neonate and is using measures to help maintain the neonate's temperature. Which intervention would be most effective in helping to prevent evaporative heat loss? administering warm oxygen controlling the drafts in the room immediately drying the neonate placing the neonate on a warm, dry towel

immediately drying the neonate

Which nursing diagnosis would be the priority for a client who has just been admitted to the hospital with burns?

impaired skin integrity

A client continues to improve after a left hemisphere cerebrovascular accident (CVA). The interprofessional team is planning a transfer to a rehabilitation unit for follow-up care. Which nursing diagnosis is the priority?

impaired swallowing

A client is diagnosed with dependent personality disorder. When gather data from the client, which behavior would the nurse suspect as being most likely indicative of ineffective coping? inability to make choices and decisions without advice demonstration of interest solely in solitary activities avoidance in developing relationships recurrent self-destructive behavior with history of depression

inability to make choices and decisions without advice

A client with a recent fracture is suspected of having compartment syndrome. Which findings does the nurse recognize correlate with this diagnosis?

inability to perform active movement; pain with passive movement

A physician enters a computer order for a nurse to irrigate a client's nephrostomy tube every 4 hours to maintain patency. The nurse irrigates the tube using sterile technique. After irrigating the tube, the nurse decides that she can safely use the same irrigation set for her 8-hour shift if she covers the set with a paper, sterile drape. This action by the nurse is

inappropriate because irrigation requires strict sterile technique.

A nurse is providing fluid replacement for a client with burns on 35% of the body that occurred 12 hours previously. The client's blood pressure is 85/60 mm Hg, pulse is 124 beats/minute, and urine output was 25 mL during the past hour. What prescription should the nurse expect to receive from the health care provider?

increase the IV fluid infusion rate

A client with hyperparathyroidism develops renal calculi. The nurse should expect to see which electrolyte levels?

increased calcium levels

A new mother is discharged 16 hours after a vaginal birth. After reviewing the client's discharge instructions, the nurse determines that the teaching was successful when the client states that she will contact her health care provider if she develops which symptom? vaginal tenderness and dryness during sexual activity uterus that is no longer palpable abdominally after 2 weeks increased flow of bright red lochia fatigue with weight loss

increased flow of bright red lochia

The nurse is caring for a child with increased laryngotracheal edema and early signs of impending airways obstruction. The nurse should observe for which warning sign?

increased heart and respiratory rates, retractions, and restlessness

A nurse is caring for a client with acute pyelonephritis. Which nursing intervention is the most important?

increasing fluid intake to 3 L/day

Which nursing action is most important to decrease the risk of postoperative complications in a child with sickle cell anemia?

increasing fluids

A client is scheduled to undergo an exploratory laparoscopy. The registered nurse (RN) asks the licensed practical nurse (LPN) to prepare the client for surgery. The RN must confirm that the LPN has specialized training before delegating which task?

initiating I.V. therapy, as ordered

The nurse is working with a client with rule-out abdominal aortic aneurysm (AAA) that reports severe, worsening back pain. The following have been ordered by the healthcare provider. Which action should the nurse delegate to the licensed practical/vocational nurse (LPN/VN)? inserting a urinary catheter administering pain medication by IV push placing a second IV line measuring vital signs

inserting a urinary catheter

A 13-year-old boy visits the school nurse because he's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the child may have scoliosis. The nurse should first:

inspect the child for uneven shoulder height or uneven hip height.

A home health care nurse is working with the family of a client who has Alzheimer's disease. The client's spouse is too exhausted to continue providing care alone and the client's adult children live too far away to provide relief on a weekly basis. Which nursing intervention would be most helpful? request to meet with the children to explain that their participation in the client's care is needed suggest that the spouse seek psychological counseling to help with coping investigate community resources for adult day care and other services insist that the client be placed in a long-term-care facility for the good of the family

investigate community resources for adult day care and other services

A female client who recently had a colostomy expresses concerns about her sexual relationship with her husband. Which intervention is the most appropriate?

inviting a client with a similar experience to speak with the client

While providing care to a client receiving antipsychotic therapy, the nurse suspects that the client is experiencing tardive dyskinesia based on which finding? involuntary movements blurred vision restlessness sudden fever

involuntary movements

A nurse is caring for a client with a history of falls. What is the first priority when caring for a client at risk for falls?

keep the bed in the lowest possible position

The nurse is caring for an 11-year-old child with cerebral palsy who has a pressure ulcer on the sacrum. When reinforcing education for the parent about dietary intake, which foods should the nurse plan to emphasize?

lean meats and low-fat milk

The nurse is preparing to reinforce discharge instructions for a client who was diagnosed with osteoarthritis. Which discharge instruction about home activity should be given to this client?

learn to pace activity

A client addicted to alcohol begins individual therapy with a nurse. Which goal should be a priority for the client? learning to express feelings establishing new roles in the family determining new strategies for socializing decreasing preoccupation with physical health

learning to express feelings

A nurse is providing care to a client diagnosed with bipolar disorder, currently experiencing mania. When reviewing the plan of care for the client, which intervention would the nurse most likely implement at this time? urging the client to finish all of the high-calorie food provided at meals insisting that the client remain as active as possible throughout daytime hours allowing the client to exhibit hyperactive, demanding, manipulative behavior without limits listening attentively with a neutral attitude, avoiding situations involving increased stimulation

listening attentively with a neutral attitude, avoiding situations involving increased stimulation

A nurse observes a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown). Which term best identifies the discharge? lochia alba lochia lochia serosa lochia rubra

lochia rubra

While administering medications to a group of clients admitted with anxiety, a nurse hears someone call for help. The nurse should respond by:

locking the medication cart and responding to the call for help.

An older adult client admitted to the hospital with chest pain has difficulty hearing. Which method should the nurse use when collecting data from this client?

lower voice pitch while facing the client

A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the client's right arm, and the left arm and hand should be elevated as much as possible to prevent which condition? lymphedema Trousseau sign intravenous infusion infiltration muscle atrophy related to immobility

lymphedema

A nurse is caring for a client at 30 weeks' gestation who has tested positive for the human immunodeficiency virus (HIV). Which information would be most appropriate for the nurse to emphasize when reinforcing instruction about prenatal care? Select all that apply. maintaining compliance with medication therapy increasing fluid intake to 2 liters per day limiting her intake of protein-rich foods maintaining breast skin integrity to help with breastfeeding ensuring periodic rest periods throughout the day

maintaining compliance with medication therapy increasing fluid intake to 2 liters per day ensuring periodic rest periods throughout the day

A nurse is carrying out the plan of care developed for a client diagnosed with dissociative identity disorder (DID). Which intervention would be the priority for this client? giving antipsychotic medications as prescribed maintaining consistency when interacting with the client confronting the client about the use of alter personalities preventing client interaction with others when one of the alter personalities is in control

maintaining consistency when interacting with the client

When caring for a child with sickle cell anemia in vaso-occlusive crisis, what does the nurse identify as the priority nursing intervention?

manage pain

A neonate was diagnosed as having cystic fibrosis. When reviewing a neonate's medical record, the nurse would most likely find which condition? duodenal obstruction jejunal atresia malrotation meconium ileus

meconium ileus

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances? metabolic acidosis respiratory acidosis metabolic alkalosis respiratory alkalosis

metabolic acidosis

The nurse is assisting with the admission of a client with an amnestic disorder. Which evaluation would the nurse anticipate preparing to help identify the cause of the disorder? angiography cardiac catheterization electrocardiography metabolic and endocrine tests

metabolic and endocrine tests

A pregnant client at term is in the first stage of labor and has an electronic fetal monitoring (EFM) device in place. Which EFM pattern suggests adequate uteroplacental-fetal perfusion? persistent fetal bradycardia variable decelerations moderate variability late decelerations

moderate variability

A client is hospitalized with obsessive-compulsive disorder. On admission, the client becomes nervous and asks to go to the bathroom to brush teeth. The client states, "I brush my teeth 25 times a day." The nurse notes that the client's gums are inflamed and bleeding. Based on this observation, what intervention would be most appropriate?

monitoring the client's dental care and setting limits on the amount of daily brushing

In caring for a client with insulin-dependent diabetes mellitus, the nurse identifies that the client may require which change to their daily routine during periods of infection?

more insulin

The nurse has conducted a vision assessment for an adolescent client. Which term will the nurse use to document the finding of the client's nearsightedness?

myopia

The nurse is gathering data from a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion. Which signs suggest that the client is experiencing complications? Select all that apply. tetanic contractions neck vein distention pulmonary congestion weight loss polyuria

neck vein distention pulmonary congestion

The nurse is working as part of multidisciplinary team in developing the plan of care for a premature neonate. Breast milk is being encouraged as part of the plan. The nurse understands that the use of breast milk for this neonate would help prevent which condition? Down syndrome hyaline membrane disease necrotizing enterocolitis Turner syndrome

necrotizing enterocolitis

A nurse presents a client with the informed consent form for an abdominal paracentesis. The client asks the nurse what the procedure involves. The nurse should have the client sign the form and ask the physician explain the procedure again. explain the form and have the client's healthcare power of attorney sign it. explain the procedure and the benefits and risks associated with it, then have the client sign the form. notify the physician that the client doesn't understand the procedure.

notify the physician that the client doesn't understand the procedure.

A 4-year-old child is admitted to the burn unit with a circumferential burn to the left forearm. Which finding would alert the nurse to a potential complication that should be reported to the health care provider?

numbness of fingers

A client is experiencing a manic episode while the nurse is attempting to obtain subjective data. What is the best method for the nurse to obtain the necessary information to care for the client? Select all that apply. obtain the data in short sessions give the client medication so that he or she will sit quietly obtain the data by watching and listening apply restraints while the client is in the manic phase talk with family members to obtain information

obtain the data in short sessions obtain the data by watching and listening talk with family members to obtain information

Which action may a nurse on the orthopedic unit safely delegate to a licensed practical nurse (LPN)?

obtaining vital signs during blood administration

A nurse is working with the multidisciplinary team providing care to a pregnant client with hyperemesis gravidarum who will need close monitoring at home. The nurse as part of the team would expect to assist in beginning discharge planning at which time? on the day of discharge when the client expresses readiness to learn when the client's vomiting has stopped on admission to the facility

on admission to the facility

A 2-year-old child is being treated with rifampin for tuberculosis. Which expected finding does the nurse anticipate?

orange body secretions

The nurse attempts to establish a therapeutic relationship with a client in the behavioral health unit. The nurse is reading the client's chart, becomes familiar with the medications the client is taking, and arranges for a meeting. What phase of the nurse-client relationship is the nurse demonstrating?

orientation phase

When reading the history and physical of a client diagnosed with emphysema, the nurse notes that the client has decreased breath sounds in the bases bilaterally. The nurse determines that this is most likely due to which finding?

over-inflation of the lungs

A client underwent a bowel resection and has been using an incentive spirometer postoperatively. Which finding indicates to the nurse that the client's use of incentive spirometry is effective?

oxygen saturation level 96% on room air

The nurse, who is providing care for four clients, receives a report on the clients. Which report is an outcome indicator?

pain level 3/10 one hour after administration of pain medication

A client has been admitted to the emergency department with severe right upper quadrant pain. Based on the signs and symptoms and laboratory data documented in the chart shown, the nurse would expect the client to have which diagnosis?

pancreatitis

A client tells a nurse, "I feel that I'm losing my mind!" The nurse interprets this statement as most commonly associated with which disorder?

panic disorder

The nurse is caring for a client who complains of a choking sensation, racing heart, dizziness and fearfulness. Which term would the nurse use to document these symptoms?

panic disorder

A nurse is talking to the family of a client with anorexia nervosa. Which family behavior is most likely to be seen during the family's interaction? sibling rivalry rage reactions parental disagreement excessive independence

parental disagreement

A parent of a 9-year-old-child scheduled to have surgery expresses concern about the potential for postoperative infection. A nurse provides the parent with information about the measures taken to maintain surgical asepsis. Typical surgical asepsis involves:

performing a preoperative surgical scrub for at least 3 to 5 minutes.

A novice nurse is caring for a client who requires a cesarean section for labor dystocia. The client's partner signs the consent form for cesarean section. Which of the following individuals is responsible for obtaining the informed consent prior to a cesarean section? physician admitting nurse the nurse assigned to the client senior staff nurse

physician

The parents of a 4-year-old report that their child has been scratching the rectum recently. About which infestation or condition will the nurse reinforce education?

pinworms

A nurse is obtaining data on a 3-year-old child with nuchal rigidity. Which sign would be documented on the chart to support this condition?

positive Kernig's sign

A client, diagnosed with active tuberculosis (TB), asks the nurse if they will be admitted to the hospital. The nurse responds that hospitalization would most likely occur to

prevent the spread of the disease.

Which nursing intervention is most appropriate for a client with multiple myeloma? monitoring respiratory status balancing rest and activity restricting fluid intake preventing bone injury

preventing bone injury

Which factor does the nurse inform the parents will place a child at increased risk for an asthma-related death?

prior admission to an intensive care unit for asthma

The parent of a neonate born with a cleft lip and palate prepares to feed the child for the first time. Which parent education should the nurse reinforce as a priority of care before the parent attempts the first feeding?

proper positioning of the neonate

When making ethical decisions about caring for preschoolers, a nurse should remember to

provide beneficial care and avoid harming the child.

The nurse is obtaining data from a child who is suspected of having a scabies infestation. What finding by the nurse would correlate with this diagnosis?

pruritic papules, pustules, and linear burrows of the finger and toe webs

An agitated and incoherent client, age 29, comes to the emergency department and reports having visual and auditory hallucinations. The history reveals that the client was hospitalized for schizophrenia from ages 20 to 21. The physician prescribes haloperidol, 5 mg I.M. The nurse understands that this drug is used in this client to treat: dyskinesia. dementia. psychosis. tardive dyskinesia.

psychosis.

The nurse is gathering data from a client with an abdominal incision and suspects there is a potential for delayed wound healing. Which observation most likely supports this finding?

purulent drainage on a soiled wound dressing

A nurse is attempting to interact with a neonate experiencing drug withdrawal. The nurse determines that the neonate is willing to interact based on which behavior? gaze aversion hiccups quiet, alert state yawning

quiet, alert state

A client in a nursing home is receiving continuous nasogastric (NG) feedings. At the start of the shift, a nurse finds the client turned on the side with the bed flat. The feeding is running with a volumetric pump at 75 mL/hour, as prescribed. The formula container is filled with 150 mL of fluid. Based on this information, which action should the nurse take?

raise the head of the bed (HOB) at least 30 degrees

The nurse is caring for a client with esophageal varices. What is a priority intervention when caring for this client? recognizing hemorrhage controlling blood pressure encouraging nutritional intake reinforcing education to the client about varices

recognizing hemorrhage

A rape victim is being prepared for discharge. The nurse is aware that the client is at risk for posttraumatic stress disorder (PTSD) and instructs the client that it's important to report which symptoms associated with PTSD? Select all that apply. recurrent, intrusive recollections or nightmares gingival and dental problems sleep disturbances flight of ideas unusual talkativeness Difficulty concentrating

recurrent, intrusive recollections or nightmares sleep disturbances Difficulty concentrating

As part of routine screening for colorectal cancer, a client must undergo fecal occult blood testing. Which foods should the nurse instruct the client to avoid 48 to 72 hours before the test and throughout the collection period? Select all that apply. high-fiber foods red meat turnips horseradish tomatoes Apples

red meat turnips horseradish

A client with depression doesn't respond to drug therapy. At a team conference, staff members recommend electroconvulsive therapy (ECT). The nurse knows that most people respond negatively to the thought of an electric current passing through the brain. Therefore, when discussing ECT with the client, the nurse should: use the term "shock" in a neutral, calm manner. refer to the procedure as a "treatment" instead of "shock therapy." refer to the procedure as ECT. explain how the convulsions are artificially induced.

refer to the procedure as a "treatment" instead of "shock therapy."

While caring for a hospitalized client diagnosed with schizophrenia, a nurse observes the client watching television. The client states, "The television is speaking directly to me." The nurse interprets the client's statement as indicating which type of thinking? autistic concrete hallucination referential

referential

Which interventions should the nurse perform when caring for a client who is an organ donor and considered brain dead? Select all that apply. notifying the immediate family that the client is deceased reinforcing information that has been provided to the family providing an area where the family can have some privacy obtaining informed consent for organ procurement from the next of kin allowing flexible times for the family to visit with the loved one maintaining the client's dignity while providing compassionate care

reinforcing information that has been provided to the family providing an area where the family can have some privacy allowing flexible times for the family to visit with the loved one maintaining the client's dignity while providing compassionate care

Which therapeutic strategy is used to reduce anxiety in a client diagnosed with illness anxiety disorder?

relaxation exercises

A community nurse makes their introduction to the family and outlines the purpose of the home visit. The nurse asks permission before sitting on the mattress beside the postpartum mother in the bedroom. Which element of the therapeutic relationship do these behaviors demonstrate? accountability choice respect genuineness

respect

A client gives birth to a neonate prematurely, at 28 weeks' gestation. To obtain the neonate's Apgar score, the nurse assesses the neonate's: temperature. respiration. blood pressure. weight.

respiration.

A client with placenta previa is hospitalized, and a cesarean birth is planned. When gathering data, what condition should the nurse closely monitor for? prematurity congenital anomalies respiratory distress aspiration pneumonia

respiratory distress

The nurse is teaching a client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:

rest in a room set at a comfortable temperature.

The nurse is monitoring a client with a symptom of increased intracranial pressure (ICP) after head trauma. What observation does the nurse recognize as an early sign?

restlessness and confusion

The nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity: develops rapidly and is temporary. occurs by antibody transmission. results from exposure of an antigen through immunization or disease contact. may be transferred by mother to neonate.

results from exposure of an antigen through immunization or disease contact.

The nurse is planning to administer a sodium polystyrene sulfonate enema to a client with a potassium level of 5.9 mEq/L. Correct administration and the effects of this enema would include having the client:

retain the enema for 30 minutes to allow for sodium exchange; afterward, the client should have diarrhea.

A client admitted with a diagnosis of pneumonia is known to be a "blue bloater." What would be the nurse's best explanation to the client for using this term?

retaining more carbon dioxide

A client with diabetes is being taught about possible complications. The nurse should include which conditions in the discussion with the client?

retinopathy, neuropathy, and coronary artery disease

A new nurse is asked to start an I.V. on an antepartum client. The new nurse has performed the procedure only once and isn't familiar with the I.V. pumps used in this facility. The new nurse should: ask another new nurse to assist her. attempt the procedure without assistance. review the unit's procedure manual. tell the client that she isn't experienced enough to start the I.V.

review the unit's procedure manual.

The nurse is obtaining a client's apical pulse rate. Which pulse features should the nurse document? Select all that apply. rhythm timing in the cycle amplitude pitch intensity

rhythm amplitude intensity

An adolescent client with anorexia nervosa tells a nurse about their outstanding academic achievements and thoughts about suicide. Which factor must the nurse consider when contributing to the care plan for this client? self-esteem physical illnesses paranoid delusions relationship avoidance

self-esteem

A nurse is caring for a client suspected of having posttraumatic stress disorder (PTSD). The nurse is aware that the client is also commonly at high risk for developing which condition?

self-harm and violent behavior

A nurse is evaluating the effectiveness of therapy with acetylcysteine in a child with acetaminophen poisoning. Which laboratory values would be most important for the nurse to monitor? serum alanine aminotransferase (ALT) serum calcium levels prothrombin time (PT) serum glucose levels

serum alanine aminotransferase (ALT)

A client with diabetes insipidus has had limited fluid intake over the past 12 hours. For which complications should the nurse monitor the client?

severe dehydration and hypernatremia

A client is brought to the emergency department by a friend because the client "won't wake up." The friend reports that the client "took some pills and had a few beers." What reaction would the nurse most likely find when assessing the client?

shallow respirations

A nurse is caring for a client newly diagnosed with Human Immunodeficiency Virus (HIV). Which action by the nurse violates the client's confidentiality?

sharing the client's information with the clergy who is visiting with the client

The client is scheduled for extracorporeal shock wave lithotripsy (ESWL). The nurse should reinforce that the stones will be what?

shattered

A nurse is reinforcing education for the parents of a child with a urinary tract infection. Which factor should the nurse indicate contributes to urinary tract infection?

short urethra

The clinic nurse is reinforcing teaching about symptoms of cardiovascular disease (CVD) with the client. What are common symptoms associated with cardiovascular disease? shortness of breath, chest discomfort/pain, palpitations dyspnea, headache, sputum production fatigue, weight changes, edema mood swings, vomiting, fainting

shortness of breath, chest discomfort/pain, palpitations

The nurse is caring for a female client with osteoarthritis who is being discharge to home. Which items would the nurse reinforce the use of in order to assist the client to dress independently at home? Select all that apply. tennis shoes that tie skirts with elastic waists blouse with rear buttons jackets with Velcro closures bras with front closure

skirts with elastic waists jackets with Velcro closures bras with front closure

When caring for an older adult client, the nurse should expect to find which normal age-related changes that may affect client education?

slowed reaction time

A client with schizophrenia tells the nurse, "My intestines are rotted from the worms chewing on them." This statement indicates a: delusion of persecution. delusion of grandeur. somatic delusion. jealous delusion.

somatic delusion.

The nurse is caring for a client after abdominal surgery. When reinforcing education for coughing and deep breathing, what should the nurse include?

splint the incision, take a deep breath, and then cough

The nurse is caring for a client with posttraumatic stress disorder (PTSD) experiencing a frightening flashback. The nurse can best offer reassurance of safety and security through which nursing action? encouraging the client to talk about the traumatic event assessing for maladaptive and coping strategies staying with the client acknowledging feelings of guilt or self-blame

staying with the client

The nurse is discussing cocaine, amphetamines, and caffeine with a client. How would the nurse classify these substances? analgesics opiates stimulants anticholinergics

stimulants

The nurse is planning a health teaching session for parents of a toddler. When describing a toddler's typical eating pattern, the nurse should mention that many children of this age exhibit:

strong food preferences.

A client is admitted to the hospital with a diagnosis of respiratory failure. The client is intubated, placed on 100% FiO2, and is coughing up copious secretions. Which intervention has priority?

suctioning the client

A client with dissociative disorder is hospitalized. The client has threatened to commit suicide. When gathering data from the client, which set of circumstances would the nurse identify as indicating the highest risk of suicide? suicide plan, handy means of carrying out plan, and history of previous attempt preoccupation with morbid thoughts and limited support system suicidal ideation, active suicide planning, and family history of suicide threats of suicide, recent job loss, and intact support system

suicide plan, handy means of carrying out plan, and history of previous attempt

An adolescent becomes increasingly withdrawn, is irritable with family members, and has been getting lower grades in school. After giving away a stereo and some favorite clothes, the adolescent is brought to the community mental health agency for evaluation. This adolescent is at risk for: suicide. anorexia nervosa. school phobia. psychotic break.

suicide.

A primigravida client in the fifth month of pregnancy has been receiving regular prenatal care since week 8. During a routine visit, the client reports feeling dizzy, breathless, and clammy when arising from bed in the morning. The nurse should obtain data relevant to which condition? shock hemorrhage supine hypotension fainting

supine hypotension

A client with severe acute respiratory syndrome privately informs a nurse that he doesn't want to be placed on a ventilator if his condition worsens. The client's wife and children have repeatedly expressed their desire that everything be done for the client. The most appropriate action by the nurse would be to:

support the client's decision.

A client arrives in the local clinic and reports a chronic cough and fatigue. The client admits to smoking two packs of cigarettes daily for 10 years and also informs the nurse of a 9 kg weight loss over the last 2 months. Which test, required for a definitive diagnosis of cancer, does the nurse prepare the client for?

surgical biopsy

Which symptom is the most common manifestation of severe combined immunodeficiency disease (SCID)?

susceptibility to infection

Which leisure activity does the nurse include in the care plan for a school-age child with hemophilia?

swimming

A client is admitted with hemophilia. Which sports should the nurse recommend for this client? Select all that apply. basketball swimming baseball golf soccer

swimming golf soccer

A client presents with pain and warmth in his big toe and reduced urine output. The health care provider suspects gouty arthritis. The nurse can expect the health care provider to confirm this diagnosis by ordering which diagnostic tests?

synovial fluid analysis and serum uric acid level

A client is diagnosed with a fat emboli. Which signs and symptoms would the nurse expect to find when gathering data from this client?

tachypnea, tachycardia, shortness of breath, petechial rash on chest and neck

The nurse-manager asks hospital staff to decrease costs on the unit. Which practice would be the most beneficial in reducing costs?

taking only necessary supplies into the clients' rooms

On the first postpartum night, a client requests that her neonate be sent back to the nursery so she can get some sleep. The nurse identifies that the client is most likely in which phase? depression phase letting-go phase taking-hold phase taking-in phase

taking-in phase

An obese client is admitted to the facility for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client?

teaching the client alternative ways to lose weight

Several children in a kindergarten class have been treated for pinworm. To prevent the spread of pinworm, the school nurse meets with the parents and explains that they should:

tell the children not to bite their fingernails.

When a nurse attempts to make sure the health care provider obtained informed consent for a thyroidectomy, the nurse realizes the client doesn't fully understand the surgery. The nurse approaches the physician, who curtly says, "I've told this client all about it. Just get the consent." The nurse should

tell the health care provider the client isn't comfortable consenting to surgery at this point.

A school-age child reveals to the nurse that a parent has been abusive. What constitutes a breach of the child's right to confidentiality?

telling the child in the next room, who also suffered abuse, so the two children can talk to each other

A client with a fractured femur is in Russell's traction and asks the nurse to help with back care. Which nursing action is most appropriate?

telling the client to use the trapeze to lift his back off the bed

A registered nurse (RN) has been "care-paired" with a licensed practical nurse (LPN) during the evening shift. Whose care should the RN assign to the LPN?

the 2-year-old child who has started eating soft, solid foods following a tonsillectomy

The nurse is gathering data from a client with Meniere disease. Which symptom does the nurse relate to the disease process?

tinnitus

A nurse is examining the progress record of a client with femur fractures who has had bilateral leg skeletal traction applied. The nurse reinforces education of the child on performing Kegel exercises. What is the most important purpose of these exercises?

to maintain good perineal muscle tone by tightening the pubococcygeus muscle

A nurse is providing care to a postpartum client. As part of the client's plan of care, the nurse reinforces the need to perform Kegel exercises based on which reason? to assist with lochia removal to promote the return of normal bowel function to promote blood flow, enabling healing and muscle strengthening to assist the client in burning calories for rapid, postpartum weight loss

to promote blood flow, enabling healing and muscle strengthening

Professional regulations and laws that govern nursing practice are in place for what reason?

to protect the safety of the public

Discharge instructions for a child with atopic dermatitis include keeping the fingernails cut short. Which rationale should the nurse give for this intervention?

to reduce breaks in skin from scratching that may lead to secondary bacterial infections

A health care provider prescribes diet, exercise, and oral antidiabetic agents for a client with diabetes. Which type of diabetes will the nurse reinforce educating the client about?

type 2 diabetes

A child has been sent to the school nurse for wetting her pants three times in the past 2 days. The nurse should recommend that this child be evaluated for which complication?

urinary tract infection

The nurse is collecting data on a 6-year old child. The child reports dysuria and urgency. The parent reports that the child has recently had some enuresis. The nurse recognizes these as signs and symptoms of which condition?

urinary tract infection

A nurse is caring for a client with reports of abdominal pain. Which differential diagnosis should the nurse anticipate for this client? Select all that apply. urinary tract infection internal hemorrhoids appendicitis renal calculi bronchitis

urinary tract infection appendicitis renal calculi

The nurse is caring for a child with a Harrington rod placement. Which data gathered by the nurse would be of greatest concern 2 days postoperatively?

urine output less than 30 mL/hr

A client returns to the acute care unit after abdominal surgery. Which measure should the nurse perform first that will help reduce or prevent the incidence of atelectasis?

use of an incentive spirometer

The nurse is assigned to care for a client with amnesia. When preparing to deliver care, which action will best meet the needs of this client? provide the client with lots of space to test his or her independence promote activities to keep the client busy on the care unit with group meetings use short, simple commands when providing instruction spend time with the client, asking questions about recent life

use short, simple commands when providing instruction

A nurse is caring for a client who had a transurethral resection of the prostate 1 day prior and is on continuous bladder irrigation. The nurse suspects the catheter is blocked. Which nursing intervention is appropriate?

use sterile technique to irrigate the catheter gently

A nurse is assisting with the care of neonate immediately after birth. The neonate is to receive vitamin K intramuscularly. The new parents asks the nurse, "Where are you going to give it?" Which site would the nurse include in the response to the parents? deltoid ventrogluteal abdomen vastus lateralis

vastus lateralis

The primary health care provider prescribes penicillin G, 300,000 units IM, for a child who is 18 months old. Which site does the nurse select to administer this injection?

vastus lateralis muscle

A client has sudden cardiac death. Which arrhythmia commonly associated with sudden cardiac death does the nurse suspect this client may have experienced? atrial fibrillation ventricular fibrillation atrial tachycardia ventricular bigeminy

ventricular fibrillation

Which outcome developed by the health care team is appropriate for a client diagnosed with pedophilia?

verbalizing appropriate methods to meet sexual needs upon discharge

The nurse correctly identifies which as belonging to the dorsal cavity?

vertebral canal

A school nurse is obtaining data from a student at an elementary school. Which finding would lead the nurse to suspect impetigo?

vesicular lesions that ooze, forming crusts on the face and extremities

What should the nurse monitor the client for when the client is using phencyclidine (PCP)? cardiac arrest seizure disorder violent behavior delirium reaction

violent behavior

The nurse is assessing an 11-year-old female client. Which assessment finding must be reported to the health care provider?

visible decay of the two front teeth

A client is 2 weeks post op from knee replacement surgery and has been on warfarin therapy. The client's most recent INR blood level was 5.6. What should the nurse prepare to administer to the client?

vitamin K

A nurse is caring for an infant after surgical repair of pyloric stenosis. Which common symptom would the nurse expect to see 48 hours after surgical repair?

vomiting

The nurse is talking to an adolescent about preventing sport-related injuries. Which is the best strategy for the nurse to reinforce teaching about this subject?

warming up

A school-age child is admitted to the medical facility with a diagnosis of acute lymphocytic leukemia (ALL). Which nursing interventions are most appropriate?

washing hands before/upon entering room

While reviewing a client record, the nurse sees that the client has a documented history of microphobia. What behavior does the nurse anticipate the client exhibiting?

washing the hands repetitively

A client with peptic ulcer disease is prescribed aluminum-magnesium complex. When teaching about this antacid preparation, the nurse should instruct the client to take it with: fruit juice. water. a food rich in vitamin C. a food rich in vitamin D.

water.

During data collection, a client with schizophrenia leaves his arm in the air after the nurse has taken his blood pressure. His action shows evidence of: somatic delusions. waxy flexibility. neologisms. nihilistic delusions.

waxy flexibility.

A nurse is caring for a client who underwent a nephrectomy. While gathering data about client's response to the surgery, the nurse should stay alert for which signs and symptoms of hemorrhage?

weak, irregular pulse; cool, moist skin; and hypotension

The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). To adhere to standard precautions, the nurse should:

wear gloves when providing mouth care.

A nurse is caring for a client with tuberculosis. Which infection-control technique is the priority when caring for this client?

wearing an N95 respirator when caring for the client

A 2-year-old child has been diagnosed with asthma. The parents ask about the most common asthma triggers. What is the nurse's response?

weather

The nurse is preparing to calculate the safe dose range of a chemotherapy drug for a child with Wilms tumor. The drug is ordered in mg/m2. What information does the nurse need in order to calculate the body surface area (m2) of the child? Select all that apply. blood type weight height white blood cell count (WBC) birth weight

weight height

A 5-month-old infant is brought to the pediatric clinic by the parent. The child has had recurrent middle-ear infections since 3 months of age. Which information is most important for the nurse to collect at today's visit?

whether the child received all the prescribed antibiotic at the time of the last infection

A client is preparing for discharge from the emergency department after sustaining an ankle sprain. The client is instructed to avoid weight bearing on the affected leg and is given crutches. After instruction, the client demonstrates proper crutch use in the hallway. What additional information is most important to know before discharging the client?

whether the client needs to navigate stairs routinely at home

An adolescent with diabetes is learning to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the teen, would indicate the need for further instruction?

withdraws the NPH insulin first

Before a transesophageal echocardiogram, a client is given an oral topical anesthetic spray. Upon return from the procedure, the nurse observes that the client has no active gag reflex. In response, the nurse should:

withhold food and fluids.

The nurse is to give a client a 325-mg aspirin suppository. The client has diarrhea and is in the bathroom. The best nursing approach at this time would be to:

withhold the suppository and notify the client's physician.

A client comes to the emergency department with symptoms of a myocardial infarction (MI). The health care provider prescribes reteplase. The nurse is aware that this medication will be most effective when given at which time? within 1 to 3 hours of onset of symptoms within 6 hours of onset of symptoms within 12 hours of onset of symptoms within 6 to 8 hours of onset of symptom

within 1 to 3 hours of onset of symptoms