NCLEX prep

What should be the nurse's priority assessment after an epidural anesthetic has been given to a nulligravid client in active labor?

- Blood Pressure

While performing the morning postpartum assessment, the nurse notices that a client's perineal pad is completely saturated with lochia rubra. What is the nurse's best action?

- Ask when the last time she changed her perineal pad

The nurse is taking care of a client with neutropenia. Which nursing action is most important in preventing cross-contamination?

- Changing gloves immediately after use

A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L (5.8 mmol/L). What should be the nurse's first response?

- Notify the anesthesiologist

Which foods should the nurse encourage the mother to offer to her child with iron-deficiency anemia?

- Potatoes, Peas, Chicken

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

- Report Suspicions to Nurse Manager

The student nurse is caring for a client with a suspected respiratory infection. Which statement by the nursing student indicates that the student will facilitate the best time to collect this specimen?

- "I will instruct the client to give the specimen in the morning, as soon as the client awakens." -Sputum accumulates in the lungs during sleep therefore if collected in the morning the specimen will be more concentrated increasing the likelihood of accuracy.

A young school-age girl whose mother and aunt have been diagnosed as having bipolar disorder and whose father is diagnosed with depression is brought to the clinic because of problems with behavior and attention in school and inability to sleep at night. The child says, "My brain does not turn off at night." The child is diagnosed as experiencing attention deficit hyperactivity disorder (ADHD) with a possibility of bipolar disorder as well. What should the nurse say to the father to explain what the provider said? Select all that apply.

- "Your child was diagnosed as having ADHD because of her attention and behavior problems at school." -"ADHD involves difficulty with attention, impulse control, and hyperactivity at school, home, or in both settings." -"Your provider is considering a bipolar diagnosis because of your child's family history of bipolar disorder and her sleep issues."

A 22 lb (10 kg) child is diagnosed with Kawasaki disease and started on gamma globulin therapy. The provider orders an I.V. infusion of gamma globulin, 2 g/kg, to run over 12 hours. What is the correct dose? Record your answer using a whole number.

- 20

A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? Record your answer using a whole number.

- 36% -front and back =18

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction?

- Avoid hot baths and showers

The client with Alzheimer's disease has been prescribed donepezil 5 mg at bedtime. Which instructions should the nurse give to the client's caretaker?

- Avoid suddenly stopping taking the medication

Prior to going to surgery, the client tells the nurse that it is not possible to hear without a hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response?

- Call the surgery unit to explain the client's concern, and ask if the client can wear the hearing aid to surgery.

During a home visit for a client diagnosed with paranoid schizophrenia discharged 1 week ago, the client's mother tearfully states, "I can hardly sleep because I'm so worried about my daughter. I'm afraid to leave her alone in the house. What if something should happen while I am gone?" Which caregiver problem would be the most inclusive one for the nurse to incorporate into the client's plan of care?

- Caregiver Role Strain

The nurse is teaching a pregnant client about injury prevention. Which instruction should the nurse include?

- Change high heel shoes to flats

A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad?

- Clients level of consciousness - A client who has impaired consciousness or altered mental status is at increased risk for injury from a heating pad.

The nurse is caring for a client with a fracture of a long bone. Which symptom is the earliest indication of a fat embolism?

- Confusion

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck their head on the pier railing. According to friends, "The client was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, the client began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first?

- Declining LOC

A nurse implements a teaching plan for a client who's scheduled for discharge. Which client behavior best demonstrates effective teaching?

- Exhibiting a positive change in the patient's behavior

A client with schizophrenia comes to the outpatient mental health clinic 5 days after being discharged from the hospital. The client was given a 1-week supply of clozapine. The client tells the nurse that she has too much saliva and frequently needs to spit. The nurse interprets the client's statement as being consistent with which factor?

- Expected Adverse effect of clozapine

The nurse is assigned to the care of an 89-year-old client who has requested "do not resuscitate" status. The nurse answers a call light and finds the client not breathing. The family member at the bedside demands that the nurse "do something." Which action best demonstrates the nurse's responsibility to the client?

- Explain to the family member the client's wishes regarding "do not resuscitate."

A public health nurse is teaching a community seniors group about the risk of falls. Which aging characteristic increases the risk of falls in elderly individuals?

- Forward-Flexed Position

A client with cancer of the stomach had a total gastrectomy 2 days earlier. Which indicates the client is ready to try a liquid diet?

- Frequent Bowel Sounds

A middle-aged female client complains of anxiety, insomnia, weight loss, the inability to concentrate, and eyes feeling "gritty." Thyroid function tests reveal the following: thyroid-stimulating hormone (TSH) 0.02 U/ml, thyroxine 20 g/dl, and triiodothyronine 253 ng/dl. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these assessment findings, the nurse should suspect:

- Graves Disease

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

- Help the client dangle his legs

A client in her first trimester of pregnancy comes to the prenatal clinic and states, "I feel nauseous and I'm vomiting all the time. I can't even keep down water." This client should be evaluated for what condition?

- Hyperemesis Gravidum

A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for which nursing problem?

- Ineffective Breathing Pattern

A client has a reddened area over a bony prominence. The nurse finds an unlicensed nursing personnel (UAP) massaging this area. What should the nurse do?

- Instruct the UAP that massage is contraindicated because it decreases blood flow to the area.

A physician has ordered a wet-to-damp dressing for an infected pressure ulcer. The nurse knows that the primary reason for this treatment is to:

- Keep wound moist

A nurse is reviewing home medications for a client recently admitted to a long-term psychiatric unit. The charge nurse asks why this client has frequent blood draws over the next few weeks. The nurse would be correct to state which home medication dosages vary according to the blood levels of the drug?

- Lithium Carbonate

The nurse is educating the parents of a 2-year-old child with neonatal bronchopulmonary dysplasia (chronic lung disease) who is placed on furosemide. Which statement by the parents best indicates an understanding of this medication?

- Need to make sure my child eats foods rich in potassium

Yankauer suction catheter is used to collect what?

- Oral secretions

Approximately 15 minutes after giving birth to a viable term neonate, a multiparous client has chills. What should the nurse do next?

- Provide Client with warm blanket

The nurse assessment of a 6-month-old infant brought to the outpatient clinic reveals a respiratory rate of 52 breaths/min, retractions, and wheezing. The mother states that her infant was doing fine until yesterday. Which action would be most appropriate?

- Refer Infant to the ER

A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which measure would be most beneficial?

- Regular Exercise

A nurse determines that a client is in false labor. After obtaining discharge orders, the nurse provides discharge teaching to the client. Which instruction is most appropriate at this time?

- Return to the facility if fever occurs

The nurse is providing information to a client who is taking chlorpromazine. What is the most important information for the nurse to provide?

- Schedule Routine Medication Checks

The nurse is monitoring a client receiving a blood transfusion when the client develops a cough with shortness of breath. The client also has a headache and a racing heart. What should the nurse do first?

- Slow the infusion rate down

A 42-year-old client was admitted from a homeless shelter with a diagnosis of tuberculosis and alcoholism. It is essential that which health care team member attends the care conference to discuss discharge planning and community resources?

- Social Worker

A child is diagnosed with pituitary dwarfism. Which pituitary agent will the primary care provider most likely order to treat this condition?

- Somatotropin

A primigravid with severe gestational hypertension has been receiving magnesium sulfate IV for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and a urine output of 20 ml/hour. Which action should the nurse perform next?

- Stop the Magnesium sulfate infusion - Toxicity

The parents of three children ages 4, 7, and 11 years are interested in fostering spiritual development in their children. Then nurse informs the parents that the development of a child's spirituality is best accomplished by:

- Teaching through parental behaviors

A client is experiencing contractions every 3 minutes, right occiput posterior (ROP) position, intact membranes, and a moderate amount of bloody show. The quality of the tracing on the external fetal monitor is poor, and the nurse would like to place an internal fetal scalp electrode (FSE) to assess the baby better. Which of these prevents the nurse from being able to complete this activity?

- The intact membranes

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved?

- The urine output is greater than 35 mL/h.

-The nurse notes bulging and separation of an abdominal incision while assessing a client. What is the purpose of applying a binder?

- To reduce stress on the abdominal incision

Which finding is the best indication that fluid replacement for the client in hypovolemic shock is adequate?

- Urine output is greater than 30ml/hr

A nurse admits an infant diagnosed with pyloric stenosis. What is the nurse's priority intervention?

- Weigh the infant

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?

- Weighing the client each day at the same time

A nurse is assessing a client who is receiving clozapine. The nurse reviews the chart. What should the nurse do next?

- Withhold Clozapine and Call Provider -Medication should be held if HR is over 140

Which client findings require the nurse's attention first?

- a gravida 3, para 2 at 30 weeks' gestation with nausea, vomiting, and epigastric pain

When assessing the client with Parkinson's disease, the nurse should observe the client for:

- a stiff, masklike facial expression.

The nurse needs to pick up a large object that is sitting on the floor in a client's room. Which action *most* increases the nurse's risk of a back injury?

- leaning forward toward the object

surgical asepsis is also known as?

- sterile technique

A nurse is teaching a pregnant client how to distinguish false labor contractions from true labor contractions. Which statement by the client indicates an understanding of this concept?

-"False labor contractions are usually felt in the abdomen."

A nurse assists a student nurse conducting an interview with the family of a preschool 4-year-old boy who is often disruptive in his class, is difficult to engage, and rarely speaks. Which question, if asked by the student, would require intervention by the nurse?

-"Has your child received all his childhood immunizations? You know there is evidence that childhood immunizations play a role in the development of autism."

The nurse is conducting a small-group counseling session on depression. Which client statements would indicate to the nurse that a client is at high risk for suicide?

-"I have a stockpile of pills in the medicine cabinet and gave my stuff away."

The client with mania is irritable and insulting to an unlicensed assistive personnel (UAP). The UAP states, "I cannot believe Mark is so rude. Should he not be overly happy?" Which response by the nurse should help the UAP understand the client's behavior?

-"I know it is difficult, but Mark is a client whose irritable mood is a symptom of his mania."

The nurse is discharging a baby with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they make which statement?

-"I should use a pillow to elevate my child's foot as he sleeps."

Which statement indicates that a client understands the initial treatment for recently diagnosed stage IV ovarian cancer?

-"I will need to have abdominal surgery."

The nurse is caring for a client taking risperidone 2 mg daily. It is most important for the nurse to follow up on which client statement?

-"I'm constantly sick and feel like I always have a fever." -ADE: Agranulocytosis

Which statement by a client receiving carbamazepine would require additional instruction?

-"If I have a seizure, I should take two pills immediately."

Which statement by the client indicates an understanding of teaching regarding use of corticosteroids during preterm labor?

-"The corticosteroids may help my baby's lungs mature."

A client admitted in an acute psychotic state hears terrible voices in the head and thinks a neighbor is upset with the client. What is the nurse's best response?

-"What exactly are these terrible voices saying to you?"

A client is a military soldier who returned home from a 1-month tour of relief duty following a natural disaster. The client is exhibiting symptoms of insomnia, irritability, and anxiety. The client tells the nurse, "I just can't get the sight of those dead bodies out of my head. When I was at the disaster, I tried not to think about what I was doing; now I think about it all the time." Which assessment question would be most relevant for this client?

-"What more can you tell me about what is happening now?"

A family member of a client who is human immunodeficiency virus (HIV) positive is concerned about the possibility of also being HIV positive. What is the best response by the nurse?

-"What's your understanding about how HIV is transmitted?"

A client states, "I feel so sad. I don't think I can go on anymore." Which is the most therapeutic response the nurse can offer the client?

-"You feel like you can't go on anymore?"

Treatment for a child with symptomatic bradycardia includes atropine 0.02 mg/kg/dose. If the child weighs 44.1 lb (20 kg), how much should be given per dose?

-0.4

A physician orders preoperative medications to be administered to a client by the I.M. route: meperidine, 50 mg; hydroxyzine pamoate, 25 mg; and glycopyrrolate, 0.3 mg. The medications are dispensed this way: meperidine, 100 mg/ml; hydroxyzine pamoate, 100 mg/2 ml; and glycopyrrolate, 0.2 mg/ml. How many milliliters in total should the nurse administer?

-2.5

An infant who weighs 17.6 lb (8 kg) is to receive ampicillin 25 mg/kg IV q6h. How many milligrams should the nurse administer per dose? Record your answer using a whole number

-200

A child is receiving I.V. gamma globulin for treatment of Kawasaki disease. The order is for 8 g over 12 hours. The concentration is 8 g in 300 ml of normal saline. How many milliliters per hour will this child receive? Record your answer using a whole number.

-25

A toddler weighing 27.6 lb (12.5 kg) is to receive 4 ml/kg/hr of intravenous normal saline solution. The nurse will administer the fluid using microdrip tubing that delivers 60 gtt/ml. How many milliliters per hour should this client receive? Record your answer using a whole number.

-50 - Ask Pam

A chronically ill school-age child is most vulnerable to which stressor?

-Anxiety over school absences

A client has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure?

-Assess the blood pressure in the supine, sitting, then standing positions.

A nurse is caring for a client on mechanical ventilation who's restless and trying to remove the endotracheal (ET) tube. Which action should the nurse perform next?

-Assess the client for pain and medicate as appropriate.

A nurse is caring for a client in skeletal traction to the left leg. The client reports pain of 8 on the 0- to-10 pain scale while the nurse is in the client's room. Which action would the nurse take first?

-Assess the client's alignment in bed

Assessment of a client in active labor reveals the following: moderate discomfort; cervix dilated 3 cm, 0 station and completely effaced; and fetal heart rate of 136 bpm. Which should the nurse plan to do next?

-Assist the client with comfort measures and breathing techniques.

A 9-month-old, well-nourished boy who lives with his extensive extended family tests positive for tuberculosis. What is a risk factor for tuberculosis in this child?

-Being an infant

The nurse reviews the laboratory report of a child with leukemia (see exhibit). What does the nurse determine is the priority problem for this client?

-Bleeding

A client with a long history of experiencing dissociative identity disorder is admitted to the unit after the cuts on her legs were sutured in the emergency department. During the admission interview, the client tearfully states that she does not know what happened to her legs. Then a stronger, alter personality states that the client is useless, weak, and needs to be eliminated completely. The nurse should do which action first?

-Contract with the alter personality to tell the nurse when he has the urge to harm the client and the body they both share.

A nurse is reviewing a client's medical history. Which factor indicates the client is at risk for candidiasis?

-Corticosteroid use

A client has several patches of vesicles over both arms. Which care should the nurse provide to this client?

-Cover the draining areas with sterile gauze.

What is an expected assessment finding when caring for a client with a percutaneous feeding tube?

-Dark pink stoma without drainage

A client enters the crisis unit complaining of increased stress from studies as a medical student. The client reports increasing anxiety for the past month. The physician orders alprazolam, 0.25 mg by mouth three times per day, along with professional counseling. Before administering alprazolam, the nurse reviews the client's medication history. Which drug can produce additive effects when taken concomitantly with alprazolam?

-Diphenhydramine

A depressed client on a psychiatric unit asks the nurse to call the hospital lawyer to discuss writing out a will. What is the nurse's priority intervention?

-Discuss thoughts and explore intent for suicide with the client.

A client arrives at the emergency department with chest and stomach pain and a report of black, tarry stools for several months. Which diagnostic testing would the nurse anticipate?

-ECG (electrocardiogram), complete blood count, testing for occult blood, and comprehensive serum metabolic panel

Immediately after the first oral feeding after corrective surgery for pyloric stenosis, a 4-week-old infant is fussy and restless. What action would be most appropriate at this time?

-Give the infant a pacifier to suck on.

The client sustained an open fracture of the femur from an automobile accident. The nurse should assess the client for which type of shock?

-Hypovolemic

A primigravid client with class II heart disease who is visiting the clinic at 8 weeks' gestation tells the nurse that she has been maintaining a low-sodium, 1,800-calorie diet. Which instruction should the nurse give the client?

-Increase caloric intake to 2,200 calories daily to promote fetal growth.

A 12-year-old child is scheduled for surgery to repair a fractured tibia. One hour prior to surgery, the nurse assesses that the child is febrile. What is the best action for the nurse to take

-Inform the surgeon

A child has ingested poisonous hydrocarbons. What is the most important nursing intervention?

-Keep child calm and relaxed

A client who had an open appendectomy for a perforated appendix has an incision secured with adhesive strips. What instruction should the nurse give the client about caring for the incision?

-Leave the adhesive strips in place until they fall off.

A nurse is caring for a client recently diagnosed with cancer and experiencing moderate situational anxiety. Which interventions would the nurse include in the care plan? Select all that apply.

-Maintain a calm, nonthreatening environment. -Encourage the client to verbalize concerns regarding the diagnosis. -Encourage the client to use deep-breathing exercises and other relaxation techniques during periods of increased stress.

When teaching a primigravid client with diabetes about common causes of hyperglycemia during pregnancy, the nurse would include which information?

-Maternal Infection

A nurse is teaching the families of clients with chronic mental illnesses about causes of relapse and rehospitalization. What should the nurse include as the primary cause?

-Non compliance with medication

Which action would be most appropriate after assessing a neonate's cry as infrequent, weak, and very high pitched?

-Notify the primary care provider because this may indicate a neurologic problem.

A client recovering from an acute illness is extremely weak and unable to assist with transferring from the bed to a chair. Which action should the nurse take to ensure safety for both the client and nurse?

-Obtain an assistive device to help with the transfer.

The nurse has just completed a client's home visit and has scheduled another client's visit immediately after. Which measures should the nurse take to minimize risks of infection during home visits? Select all that apply.

-Perform hand hygiene before and after client contact. -Implement standard precautions during home visits.

A 4-year-old child is admitted for an appendectomy. What is the most appropriate way for the nurse to prepare the child for surgery?

-Permit the child to play with the blood pressure cuff, electrocardiogram (ECG) pads, and a face mask.

The nurse is caring for a child following the insertion of a shunt on the right side of the head to relieve hydrocephalus. Which priority intervention should the nurse include in the plan of care?

-Place the child flat in bed on the left side.

Which goal is most important when developing a long-term care plan for a child with hemophilia?

-Prevent injury during each stage of development.

A client with obsessive-compulsive disorder reveals that he was late for his appointment "because of my dumb habit. I have to take off my socks and put them back on 41 times! I can't stop until I do it just right." The nurse interprets the client's behavior as most likely representing which factor?

-Relief From Anxiety

Which statement about religion and spirituality is most accurate?

-Religion is an organized system of spiritual beliefs.

A client with chronic renal failure is receiving hemodialysis three times a week. What should the nurse do to protect the fistula?

-Report the loss of a thrill or bruit on the arm with the fistula.

A client is being seen in the emergency department and starts speaking in language not spoken by nursing staff. What is the nurse's first intervention?

-Seek out a facility-approved translator.

A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important?

-Stop the transfusion, infuse normal saline solution, and call the physician.

A client has been diagnosed with avoidant personality disorder. The client reports loneliness, but has fears about making friends. The client also reports anxiety about being rejected by others. In a long-term treatment plan, in what order, from first to last, should the nurse list interventions for the client? All options must be used.

-Talk with the client about self-esteem and fears. -Teach the client anxiety management and social skills. -Help the client make a list of small group activities at the center that the client would find interesting. -Ask the client to join in a chosen activity with the nurse and two other clients.

A client with bipolar disorder, mania, has flight of ideas and grandiosity and becomes easily agitated. To prevent harmful behaviors, which of the following should the nurse do initially?

-Tell the client to seek out staff when feeling agitated.

A nurse is developing a plan of care with the parents of a school-age client diagnosed with a seizure disorder. What instructions should the nurse give the parents to promote the client's growth and development?

-The child will likely have normal intelligence and be able to attend regular school.

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which assessment best indicates that the disease is under control?

-The client exhibits signs of adequate GI perfusion with normal bowel sounds.

A nurse selects a priority nursing diagnosis of Fear related to being embarrassed in the presence of others for a client who exhibits symptoms of social phobia. Which outcomes, if met, would demonstrate improvement in client's symptoms? Select all that apply.

-The client manages fear in group situations. -The client verbalizes feelings that occur in stressful situations. -The client develops a plan for responding to stressful situations.

A nurse is helping a client ambulate for the first time after 3 days of bed rest. Which observation by the nurse suggests that the client tolerated the activity without distress?

-The client's pulse and respiratory rates increased moderately during ambulation.

A client experiencing alcohol withdrawal is prescribed lorazepam. The client's family asks the nurse about the purpose of the medication. What is the nurse's best response?

-The lorazepam will reduce the your family member's symptoms of withdrawal.

The nurse is planning care for a client with a spinal injury who is to remain on complete bed-rest. What should the nurse do to prevent the development of pressure ulcers? Select all that apply.

-Turn the client every 2 hours. -Monitor the serum albumin. -Request a prescription for a pressure mattress. -Inspect the skin for redness.

What is a priority nursing assessment for an infant receiving phototherapy?

-Urine Output

The parents of a 6-year-old child tell the nurse that they are concerned about the child's tonsils. On inspection, the nurse notes that the tonsils are large but not reddened or inflamed. How does the nurse interpret this finding?

-a normal increase in lymphoid tissue

When the client who has had a hip replacement is lying on the side, the nurse should place pillows or an abductor splint between the legs to prevent

-adduction of the hip joint.

A client in the hospital for gout reports an excruciating migraine but declines analgesic medications when offered. Later the nurse observes a visitor performing what appears to be a type of physical manipulation of the client's head and neck. The client reports that the visitor is a therapist. The best action for the nurse to take is to:

-advise the client how the client might receive adjunct services.

A client with newly diagnosed type 1 diabetes is scheduled to receive regular insulin 10 units and NPH insulin 20 units every morning. When should the nurse schedule the administration of these medications?

-both insulins 0.5 hours before breakfast

When reviewing an older adult client's care and treatment plan, which physiological changes does the nurse evaluate as a concern for medication management due to a prolonged drug half-life? Select all that apply.

-decreased liver mass -increased fat layer -decreased kidney function -decreased liver perfusion

A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find

-deposits of adipose tissue in the trunk and dorsocervical area.

A nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates an emergency cesarean birth may be necessary at this time?

-fetal heart rate of 80 beats/minute

Which findings are considered positive signs of pregnancy?

-fetal heartbeat and fetal movement on palpation

The nurse is admitting a client with a history of bipolar mania. Which assessment finding is the priority when developing a plan of care?

-hyperactivity, ignoring eating, and sleeping

The nurse is conducting health assessments for school-age children. Which play preferences would the nurse anticipate finding in a 7-year-old girl?

-likes to play only with other girls - They like to only play with kids of their same-sex during the stage

A nurse is working with an unlicensed assistive personnel (UAP). Which clients should the nurse assign to the UAP? Select all that apply.

-older adult client who had hip replacement surgery and needs to walk in the hall with a walker -adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours

A nurse is caring for a client with agoraphobia. Which signs and symptoms would the nurse anticipate? Select all that apply.

-panic attacks. -inability to leave home.

The lab results show that a mother has a blood type of O positive and her infant has the blood type of A negative. As part of the plan of care, the nurse should assess the infant for which condition?

-pathologic hyperbilirubinemia

A nurse is performing a sterile dressing change. Which action contaminates the sterile field?

-pouring solution onto a sterile field cloth -Explanation: Pouring solution onto a sterile field cloth contaminates the sterile field because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action.

When developing the preoperative plan of care for an infant with Hirschsprung's disease, the nurse should include which intervention?

-restricting oral intake to clear liquids

A nurse is assessing a client who has just been admitted to the emergency department. Which signs suggest an overdose of an antianxiety agent?

-slurred speech, dyspnea, and impaired coordination

A healthcare provider (HCP) placed a direct fetal scalp electrode on the fetus. What information should a nurse include when documenting direct fetal scalp electrode placement?

-time of fetal scalp electrode placement, -name of the HCP who applied the electrode -the fetal heart rate (FHR)

A triage nurse in a large urban hospital has received five clients in the emergency department at the same time. Place the clients in the order in which the nurse should attend them. All options must be used.

1. 45-year-old client with chest pain who collapses and is pulseless 2. 80-year-old client with a respiratory rate of 8 breaths/min, blood pressure 80/50 mm Hg, and cyanosis 3. 50-year-old client with history of type 2 diabetes and an open fracture of the left lower leg 4. 60-year-old client with chest discomfort who was not wearing a seat belt in motor vehicle collision 5. 35-year-old client with a dry, hacking cough and fever for the past 3 days

The parent of an Indian immigrant has recently come to live with the children in the United States. The child expresses concern because her parent will not take the medication that their physician has prescribed for hypertension. The parent insists on using a topical cream from India, but the supply has run out and they are unsure if it can be obtained in the United States. What steps should the client's nurse take (in order of priority)? All options must be used.

1. Establish the baseline and trending blood pressure measurements to determine how critical the hypertension is. 2. Determine the family's willingness and capacity to regularly monitor and record the client's blood pressure changes. 3. Identify the topical cream the mother desires through research and coordination with friends and family in India. 4. Conduct illness and treatment education with the client and family, attempting to negotiate at least an interim treatment.

A nurse is completing a health screening activity to identify at which point in the menstrual cycle a client's problem occurs. Place the pathophysiologic steps of the menstrual cycle listed below in the correct sequential order. All options must be used.

1. The top layer of the endometrium breaks down and sloughs. 2. The endometrium begins thickening. 3. The level of estrogen in the blood peaks. 4. A follicle matures and ovulation occurs. 5. Peak endometrial thickening occurs. 6. Increased estrogen and progesterone levels inhibit luteinizing hormone.

A nurse is caring for a client diagnosed with herpes zoster. Place in chronological order the pathophysiological changes that the nurse would anticipate in assessing the progression of the disease. All options must be used.

1. Varicella-zoster virus is reactivated. 2. Residual antibodies from the initial infection mobilize but are ineffective. 3. The virus multiplies in the ganglia, causing deep pain, itching, and paresthesia or hyperesthesia. 4. Vesicles appear, filled with either clear fluid or pus. 5. Vesicles crust and scab. 6. Client experiences post-herpetic neuralgia.

A patient has just been admitted to the hospital for observation. Based on the laboratory results, what is the patient's primary problem? Hematocrit 45%, Hemoglobin 15g/dl (150g/L), Platelets 50 x 10^9/L

A. DVT B. Recurrent Nosebleeds C. Productive Cough D. RUQ pain

A 75-year-old woman was brought to the crisis center by her husband. The husband reports that his wife has been in shock and anxious since her purse was stolen outside of their home. The woman blames herself for being robbed, is worried about her stolen wallet and credit cards, and is afraid to go home. What nursing actions are indicated? Select all that apply.

Encourage her to talk about the robbery and her feelings. Discuss what changes at home would help her feel safe. Investigate if she has physical injuries from the robbery.

A client commonly jumps when spoken to and reports feeling uneasy. The client says, "It's as though something bad is going to happen." In which order, from first to last, should the nursing actions be done? All options must be used.

Reduce environmental stimuli. Ask the client to deep breathe for 2 minutes. Discuss the client's feelings in more depth. Teach problem-solving strategies.

Which nursing action would be therapeutic for the client being admitted to the unit with panic disorder? Select all that apply.

Support the client's attempts to discuss feelings. Respect the client's personal space. Reassure the client of safety.

The nurse is recording a client's intake and output at the end of an 8-hour shift. The client had 300 ml in nasogastric suction container and 200 ml of urine in the foley bag.There was 300 ml of D5W infused from a 1000-ml bag during the shift, and the client was documented to have consumed 500 ml of liquids. What conclusion should the nurse reach regarding the client's intake and output?

The client's intake was 300 ml greater than output. -800-500=300

The nurse is providing care for a client who is a recent immigrant. What principle should the nurse apply to the client's care?

The client's preferences around touch and personal space may differ from the nurse's.

How much urine output indicates adequate fluid replacement for a person with burns?

- 30 to 50 mL/hr

A 7-month old infant weighing 16 pounds (7.25 kg) will have a normal urine output of

2ml/kg/hr

During the health history, a client bluntly states, "I think I'm better off dead." What is the best response by the nurse?

- Are you thinking of suicide?

A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) who is being discharged after treatment for an acute exacerbation. Which statement by the client indicates proper understanding of the discharge instructions?

"I should try to eat several small meals during the day."

Which intervention can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) working on a medical-surgical unit?

- Administer zolpidem 5 mg as needed for sleep.

A client with major depression states, "Life is not worth living anymore. Nothing matters." Which response by the nurse is best?

- Are you thinking of killing yourself?

The parents of an infant with myelomeningocele ask the nurse about their child's future mental ability. What is the nurse's best response?

- "About one-third have an intellectual disability, but it is too early to tell about your child."

A client is diagnosed with agoraphobia without panic disorder. Which type of therapy would most the nurse expect to see included in the plan of care?

- Behavior Therapy

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?

- Check Equipment

When assessing a client's pain, which is the most reliable indicator of the existence and intensity of acute pain?

- Client's self-report

An older adult is having abdominal surgery. The nurse should assess the client for which postoperative concern related to normal changes in the integumentary system of an older adult?

- Decreased Healing

Which nursing intervention is most important in preventing postoperative complications?

- Early Ambulation

A nurse is caring for a client in labor. Which assessment finding indicates fetal distress?

- Fetal pH of less than 7.2

A client has severe anxiety after hearing about a death in the immediate family. She is not able to focus on the questions asked of her. She will not eat, drink any fluids or attend to her personal care. At night, she is found outdoors without a coat in winter looking for answers to what she could have done differently for the deceased individual. Which instruction by the nurse is best?

- Here, drink this glass of milk

After 2 days on a psychiatric unit, a client is still isolating himself in his room, except for meals. The client says he is uncomfortable around crowds of people. Which nursing intervention is the most appropriate initially?

- Invite the client to go for a walk with the nurse and one other client.

A menopausal woman is taking hormone replacement therapy. What warning sign of endometrial cancer should the nurse instruct the client to report to her health care provider?

- Irregular Vaginal Bleeding

A nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction?

- Shallow Chest Breathing

A nurse is teaching parents how to reduce the spread of impetigo. The nurse should encourage parents to:

- Teach children the importance of proper hand washing.

A primipara who is Rho(D) negative has just given birth to a Rh-positive baby. The nurse is developing a plan of care. How should Rho(D) immune globulin be administered?

- To the client in 3 days

T/F: LPN's can administer oral medications

- True

A nurse is obtaining a sterile urine specimen from a client's indwelling urinary catheter. During the procedure, the nurse should

- aspirate urine from the tubing port, using a sterile syringe and needle.

A parent brings a child to the clinic with symptoms of weight loss, paleness, fatigue, and not growing. What question about the child's environment should the nurse ask the parent based on these symptoms?

-"How old is the house that you live in?"

The nurse has completed client instruction about lorazepam. Which of the following client statements indicate that the client understands the teaching?

-"I can develop a dependency on this medication."

When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching?

-"I will administer the enema while lying on my left side with my right knee flexed."

The supervisor is performing a chart review. The nurse can be held legally liable for which documentation?

-1200 Administered cephalosporin. The client has an allergy to penicillin -BSmith, RN

The nurse is caring for a 10-year-old child who weighs 82.2 lb (37.3 kg) and is to receive 2.5 ml/kg/hr of 0.45% NaCl solution. How many milliliters per hour should this child receive? Record your answer using a whole number.

-93

The nurse is performing an admission assessment of a new client. When asked about the use of herbs and supplements, the client states, "Just valerian for the past few weeks." What nursing actions are appropriate? Select all that apply.

-Assess the client for recent anxiety or insomnia. -Ensure that the care provider is made aware of the client's use of valerian.

The parents of a child on sulfamethoxazole and trimethoprim for a urinary tract infection report that the child has a red, blistery rash. What instructions should the nurse give the parents?

-Discontinue the medicine and come for immediate further evaluation.

A neonate is 4 hours of age. Nursing assessment reveals a heart murmur. What should the nurse do?

-Further assess for signs of distress.

The client is shaking and is reporting a high degree of stress about hospitalization. Which nursing intervention is most appropriate?

-Instruct the client to inhale and exhale slowly.

In a mental health interview, a client who has returned from military service reports feeling ashamed of being "weak" and of letting past experiences control thoughts and actions in the present. What is the nurse's best response?

-Many people who've been in your situation experience similar emotions and behaviors.

A nurse is assessing a client who reports abdominal pain, nausea, and diarrhea. What does the nurse consider first when palpating the abdomen?

-Palpation alters abdominal sounds from baseline.

Four hours after supratentorial surgery, the client is receiving IV fluid at 80 mL per hour, and the nurse is monitoring the client's neurological status using the Glasgow Coma Scale. At 1015, the client has turned to the left side and is lying flat. At 1030 the nurse notes the changes in the client's status (see chart.) What should the nurse do next?

-Position the client supine with the head of the bed at elevated at 30 degrees.

A nurse is caring for a client diagnosed with panic disorder. The client begins to hyperventilate. How should the nurse respond initially?

-Stay with the client during the anxiety attack.

The nurse is offering further education to a client about the management of COPD. Which outcomes would indicate the teaching has been effective? Select all that apply.

-The client demonstrates pursed-lip breathing and coughing exercises. -The client maintains smoking cessation. -The client schedules follow-up physician appointments.

The nurse has observed that a client who identifies as a Mormon has drunk the coffee that was on the breakfast tray. How should the nurse best interpret this observation?

-The client's personal religious practices may differ from those of the larger religious group

A Muslim couple is in the labor process. The male healthcare provider recommends that the membranes be ruptured because contractions have not been effective in causing dilation. The Muslim couple expresses to the nurse that this is unacceptable because the provider is male. What action does the nurse take?

-Work with the healthcare provider to locate a female healthcare provider for the procedure.

Four days after surgery for internal fixation of a C3-C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which features of the wheelchair are appropriate for the needs of this client? Select all that apply.

-back and head that are high -seat that is lower than normal -chair controlled by the client's breath

A student nurse is reviewing physician orders written on a client's chart. Which entry is written incorrectly because it contains material from the "do not use" list of the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission)?

-epoetin alfa 6500 U SQ daily.

The nurse assesses the neurologic system of a newborn. Which behavior would the nurse interpret as a normal reflex response?

-makes a walking movement when held upright with one foot touching the table

A client is admitted to the emergency department having just used cocaine. The nurse should assess this client for which factors? Select all that apply.

-mood swings -feeling of euphoria -increased blood pressure -tachycardia

The nurse is observing the unlicensed assistive personnel (UAP) give mouth care to a client who has had a stroke and is unconscious. The nurse should intervene if the UAP does which?

-positions the client on the back with a small pillow under the head

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

Which client will the community health nurse visit first?

-the client with type 1 diabetes mellitus with acute visual changes

The family of a client diagnosed with Alzheimer's disease wants to keep the client at home. They say that they have the most difficulty in managing his wandering. What should the nurse instruct the family to do? Select all that apply.

1. Install motion and sound detectors. 2. Have the client wear a medical alert bracelet. 3. Install door alarms and high door locks.

A nurse working on the postpartum unit is asked to participate in the unit Client Safety Committee. What type of projects would the committee conduct for the unit? Select all that apply.

1. prevention of infant abduction 2. safe medication administration 3. proper restraints during procedures 4. maternal/infant identification system

Which of the following client behaviors indicates the nurse-client relationship is in the working phase?

The client makes an effort to describe his or her problems in detail.

When developing a teaching plan for the parents of a neonate who is to receive phototherapy, the nurse should give the parents which information? Select all that apply.

Their baby's eyes will be covered. The vital signs will need to be monitored frequently. They will be able to visit and care for their baby.