NClex Questions

A client who experienced ventricular fibrillation has just been defibrillated. After the defibrillation, which immediate action does the nurse take? 1: Resumes cardiopulmonary resuscitation. 2: Assesses the cardiac rhythm and pulse. 3: Assesses the client's neurological status. 4: Increases the intravenous flow rate.

2: Assesses the cardiac rhythm and pulse.

A nurse is caring for an anxious client who just had a chest tube inserted and an occlusive dressing placed over the insertion site. Which intervention would have the greatest overall immediate benefit to assist the client? 1: Encouraging the client to cough and take deep breaths 2: Staying with the client 3: Reviewing the arterial blood gas report 4: Distracting the client with television

2: Staying with the client

A female client with a history of personality disorder has an appointment for counseling at the mental health clinic. On entering through the clinic door, the client begins to fuss loudly about what the wind has done to her hair, and asks the receptionist if she likes her new lipstick. The nurse interprets that the client likely has which of the following types of personality disorders? 1: Borderline 2: Histrionic 3: Narcissistic 4: Avoidant

2: Histrionic

A 15-year-old female client seeks treatment for a sexually transmitted infection at a local clinic. The nurse should plan to do which of the following to uphold the law regarding informed consent? 1: Immediately telephone the client's parents. 2: Obtain the client's signature on the informed consent form. 3: Withhold treatment pending approval of a court order for treatment. 4: Mail a copy of the consent to the parents by registered mail.

2: Obtain the client's signature on the informed consent form.

An emergency department nurse is caring for an older female client who may have been physically abused by her son. In planning care for the client, the priority nursing action is: 1: Call the police. 2: Tell the son that he cannot visit with his mother. 3: Notify a social worker to investigate the situation. 4: Obtain psychiatric help for the son.

3: Notify a social worker to investigate the situation.

When giving an intramuscular injection to a 4-year-old child, the nurse should take which of the following actions? 1: Use the vastus lateralis muscle only. 2: Allow the child to choose between a lying and a standing position. 3: Obtain assistance to administer the injection. 4: Distract the child with conversation or a toy.

3: Obtain assistance to administer the injection.

Which of the following substances is detected in a home pregnancy test giving a positive result? 1. Estrogen 2. Progesterone 3. Human Chorionic Gonadotropin (hCG) 4. Follicle-stimulating hormone (FSH)

3. Human Chorionic Gonadotropin (hCG)

A client is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. On assessment of the client, the nurse should check which of the following first? 1: Temperature 2: Urine output 3: Respiratory status 4: PCA pump

3: Respiratory status

A nurse is preparing a client for elective cardioversion. The nurse determines that further preparation for the procedure is necessary if which of the following is noted? 1: The client's digoxin (Lanoxin) was withheld for the last 48 hours. 2: The client received a dose of midazolam (Versed) intravenously. 3: The client is wearing a nasal cannula delivering oxygen at 2 L per minute. 4: The defibrillator has the synchronizer turned on and is set at 50 joules.

3: The client is wearing a nasal cannula delivering oxygen at 2 L per minute.

A nurse picks up the chart of a postcraniotomy client and reads a prescription for "dexamethasone (Decadron), 6 mg intravenously now." The nurse prepares the medication and plans to administer the medication over which of the following time periods? 1: 15 seconds 2: 30 seconds 3: 40 seconds 4: 1 minute

4: 1 minute

A nurse is making an initial home visit to a client who was recently discharged from the hospital after coronary artery bypass graft surgery. The nurse should use which type of database to obtain information from the client? 1: An episodic database 2: A follow-up database 3: An emergency database 4: A comprehensive health database

4: A comprehensive health database

A clinic nurse is collecting data on a newly pregnant client. Laboratory results indicate that the client is Rh negative and Coombs antibody negative. The nurse provides the client with education regarding the test results. Which statement by the client indicates an understanding of the information? 1: "I need to receive a shot of RhoGAM today, but it will protect me for life." 2: "I will need a shot of RhoGAM once per month until the baby is born." 3: "I will need a shot of RhoGAM when I am 28 weeks pregnant." 4: "I am glad I won't have to have these RhoGAM shots if I have another child."

3: "I will need a shot of RhoGAM when I am 28 weeks pregnant."

When assisting a client who had a brain attack (stroke) to eat, the nurse can promote independence by taking which of the following actions? 1: Offer only pureed foods. 2: Sit the client in a high-Fowler position. 3: Allow the client to participate as much as possible in eating. 4: Encourage the client to eat with other clients who have also had a brain attack (stroke).

3: Allow the client to participate as much as possible in eating.

A nurse is caring for a hospitalized client with a suspected diagnosis of tuberculosis (TB). Which of the following findings would the nurse expect to note on assessment of the client? 1: Complaints of diarrhea 2: Petechiae on the upper extremities 3: Chills and night sweats 4: High fever

3: Chills and night sweats

Which nutrition instruction is appropriate for the nurse to provide to a mother of a 9-month-old infant? 1: Begin to offer rice cereal mixed with breast milk or formula. 2: Introduce strained vegetables one at a time. 3: Introduce strained fruits one at a time. 4: Begin to initiate self-feeding.

4: Begin to initiate self-feeding.

A nurse is giving dietary instructions to a client to minimize the risk of osteoporosis. The nurse instructs the client to increase dietary intake of which food that is high in calcium? 1: Fish 2: Poultry 3: Pasta products 4: Cheeses

4: Cheeses

A nurse assigned to care for a client with bulimia nervosa notes the presence of inadequate nutritional intake in the client's record. The nurse determines that which of the following would be appropriate to assess based on this assessment? 1: Client's feelings about self and body weight 2: Previous and current coping skills 3: Client's sense of lack of control about the treatment plan 4: Client's eating patterns and food preferences and concerns about eating

4: Client's eating patterns and food preferences and concerns about eating

A client asks the clinic nurse about a natural supplement called elderberry (Sambucus nigra) and what it is used for. The nurse tells the client that this supplement has been used to treat which of the following conditions? 1: Insomnia 2: Nervous disorders 3: Diarrhea 4: Colds

4: Colds

A nurse has noted the presence of body image disturbance for a client who is taking spironolactone (Aldactone). The nurse based this assessment on which of the following side effects of the medication reported by the client? 1: Edema 2: Weight gain 3: Excitability 4: Decreased libido

4: Decreased libido

Which of the following is the priority action before initiating an intermittent enteral feeding? 1: Checking intake and output records 2: Weighing the client 3: Checking the client's vital signs 4: Determining tube placement

4: Determining tube placement

A nurse is delivering care to a client who is receiving tissue-plasminogen activator (Activase). The nurse allows which of the following items to be used at the bedside by the client? 1: Dental floss 2: Firm-bristle toothbrush 3: Small nail-trimming scissors 4: Electric razor

4: Electric razor

A nurse is caring for a client with cardiomyopathy who is scheduled for a heart transplant. The nurse best meets the psychosocial needs of the client by taking which of the following actions" 1: Giving the family time to be alone 2: Making sure the client has seen a member of the clergy 3: Giving the client information about the surgery 4: Exploring with the client the meaning of the surgery

4: Exploring with the client the meaning of the surgery

An emergency department nurse is assigned to care for an older client who has been identified as a victim of physical abuse. In planning care for this client, which of the following is a nursing priority? 1: Referring the abusing family member for treatment 2: Adhering to the mandatory abuse reporting laws 3: Encouraging the client to file charges against the abuser 4: Removing the client from any immediate danger

4: Removing the client from any immediate danger

The school nurse is planning to give a class on testicular self-examination (TSE) at a local high school. The nurse plans to include which instruction on a written handout to be given to the students? 1: Perform the self-examination every other month. 2: Expect the self-examination to be slightly painful. 3: Perform the self-examination after a cold shower. 4: Roll the testicle between the thumb and forefinger.

4: Roll the testicle between the thumb and forefinger.

A nurse working with a chronically mentally ill client can be successful in dealing with a client crisis by taking which of the following actions? 1: Recognizing that rehospitalization is necessary in the event of a crisis 2: Involving the family to support the client whenever crisis occurs 3: Eliminating direct nursing interventions to allow the client to exercise problem-solving skills 4: Identifying strengths and the healthy aspects of functioning that may compensate for the weaknesses

4: Identifying strengths and the healthy aspects of functioning that may compensate for the weaknesses

A nurse is performing an admission assessment on a newborn infant admitted to the nursery with the diagnosis of subdural hematoma following a difficult vaginal delivery. The nurse should do which of the following to assess for major symptoms associated with subdural hematoma? 1: Monitors the urine for blood 2: Monitors the urinary output pattern 3: Tests for contractures of the extremities 4: Tests for equality of extremities when stimulating reflexes

4: Tests for equality of extremities when stimulating reflexes

A nurse is reviewing the findings of a physical examination that are documented in a client's record. The nurse notes which piece of documented objective data? 1: The client's father had diabetes mellitus. 2: The client has an allergy to acetylsalicylic acid (aspirin). 3: The client feels very tired. 4: The client's left eyelid droops.

4: The client's left eyelid droops.

Which of the following activities by the family of an infant with respiratory syncytial virus who is receiving ribavirin (Virazole) would indicate a knowledge deficit regarding management of the disease process? 1: Telling Grandpa who has asthma that he should not visit. 2: The family wears protective items when they visit the infant. 3: Before leaving the infant's room, all family members wash their hands. 4: The infant's pregnant aunt visits while the infant is receiving ribavirin.

4: The infant's pregnant aunt visits while the infant is receiving ribavirin.

The nurse checks for new memory during a neurological assessment by asking the client: 1: To state the date of birth 2: What type of transportation was used to get the hospital 3: What was on last night's supper meal tray 4: To repeat three unrelated words spoken to the client immediately and 5 minutes later

4: To repeat three unrelated words spoken to the client immediately and 5 minutes later

A nurse is performing an assessment of a client with an inner ear disorder. Which of the following assessment questions should the nurse ask the client to elicit information regarding this disorder? 1: "Do you have any hearing loss?" 2: "Do you have any itchiness in your ear?" 3: "Have you ever noticed any swelling around the ear?" 4: "Do you have any burning in the ear?"

1: "Do you have any hearing loss?"

A nurse is examining a client who was seen in the clinic 2 weeks ago for complaints of fatigue. The client now is complaining of a sore throat and sinus congestion. The nurse would proceed with the examination by collecting: 1: Data related to the upper respiratory tract 2: Data related to the treatment for fatigue 3: Data related to follow-up care 4: A comprehensive health database

1: Data related to the upper respiratory tract

A nurse is caring for a client in labor. Immediately after delivering a normal healthy infant, the woman suddenly begins to complain of pain and the nurse notes that the client is bleeding heavily from the vagina. The nurse suspects uterine inversion and immediately takes which of the following actions? 1: Prepares to administer a tocolytic. 2: Places the infant to the mother's breast to breast-feed. 3: Pulls strongly on the umbilical cord. 4: Performs fundal massage.

1: Prepares to administer a tocolytic.

A nurse is assigned to the care of a client who is dying. Which of the following nursing interventions would be least helpful to this client? 1: Provide extremely thorough answers to each question asked by the client or family. 2: Make referrals to other disciplines based on the client's stated needs. 3: Plan to balance the client's need for assistance with the need for independence. 4: Offer to contact clergy to support the spiritual needs of the client.

1: Provide extremely thorough answers to each question asked by the client or family.

A client with quadriplegia complains bitterly about the nurse's slow response to the call bell and the rigidity of the therapy schedule. Which interpretation of this behavior serves as a basis for planning nursing care? 1: The client is reacting to the loss of control. 2: The client's complaints indicate depression. 3: The client must adjust to institutional schedules. 4: Limits must be set on staff response time to call bells.

1: The client is reacting to the loss of control.

A nurse gathers both subjective and objective data during a physical assessment and documents which of the following as subjective data? 1: Apical pulse rate is 78 beats per minute. 2: Client states that he is constipated. 3: Respiratory rate is 18 breaths per minute. 4: Client has peripheral edema.

2: Client states that he is constipated.

A client's preoperative vital signs are temperature 98.6*F orally, apical pulse rate 80 beats per minute with a regular rhythm, respiratory rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which of the following actions should the nurse take first? 1: Report the vital signs immediately to the surgeon. 2: Compare these values with those recorded previously. 3: Recheck the blood pressure in 5 minutes. 4: Report only the apical pulse because it is above the normal range.

2: Compare these values with those recorded previously.

A nurse is working with an obese client and is evaluating a weight-reduction plan designed for the client. Which statement by the client indicates a need for additional teaching? 1: "It is so difficult to find food exchanges that taste good and fill me up." 2: "This diet doesn't let me go out for lunch with my friends at work anymore." 3: "My wife was kidding me the other night about my being a whole new husband." 4: "I wish my mother could have seen me lose the 60 pounds in the last 9 months."

2: "This diet doesn't let me go out for lunch with my friends at work anymore."

A 6-month-old child has a history of severe local reactions to previous diphtheria, tetanus, and pertussis immunizations. When planning for future diphtheria, tetanus, and pertussis immunization administration, what technique should the nurse use that is effective in reducing local irritation? 1: Warm the vaccine to increase the speed of absorption. 2: Use at least a 1-inch needle to deposit the vaccine deep into muscle tissue. 3: Divide the dose, and give it on two separate clinic visits. 4: Apply a topical anesthetic to the injection site for 24 hours.

2: Use at least a 1-inch needle to deposit the vaccine deep into muscle tissue.

An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. On assessment of the client, which finding would indicate that the client also sustained a respiratory injury as a result of the burn? 1: Clear breath sounds 2: Use of accessory muscles for breathing 3: Fear and anxiety 4: Complaints of pain

2: Use of accessory muscles for breathing

A nurse instructs a mother caring for an infant with acute infectious diarrhea on measures to prevent the spread of pathogens. Which of the following actions by the mother indicates a need for further teaching? 1: Washes hands after changing the diaper. 2: Uses a cloth diaper on the child. 3: Obtains assistance for holding the child's hands when changing the diaper. 4: Places the soiled diaper in a sealed, double plastic bag.

2: Uses a cloth diaper on the child.

A client with Buerger disease asks the nurse what can be done to alleviate the symptoms. The nurse tells the client that: 1: Analgesics are primarily used to control pain 2: Warmth, exercise, and smoking cessation are most helpful. 3: No treatment is currently available 4: Surgery is the most successful therapy

2: Warmth, exercise, and smoking cessation are most helpful.

When educating a newly pregnant woman, the nurse shares that the sex of the fetus can be determined at which gestational age? 1. Weeks 6 to 8 2. Weeks 8 to 10 3. Weeks 13 to 16 4. Weeks 20 to 22

3. Weeks 13 to 16

A nurse is caring for a pregnant client who is receiving an intravenous (IV) infusion of magnesium sulfate. To provide a safe environment, the nurse ensures that which priority item is available? 1: Tongue blade 2: Percussion hammer 3: Calcium chloride injection 4: Potassium chloride injection

3: Calcium chloride injection

A nurse is caring for a pregnant client who is receiving an intravenous (IV) infusion of magnesium sulfate. To provide a safe environment, the nurse ensures that which priority items is available? 1: Tongue blade 2: Percussion hammer 3: Calcium gluconate injection 4: Potassium chloride injection

3: Calcium gluconate injection

An appropriate goal for a client who overeats and is overweight is: 1: Makes a list of food preferences. 2: Weighs self daily with the same scale. 3: Loses 2 pounds each week. 4: Identifies the nutritional value of selected foods.

3: Loses 2 pounds each week.

A nurse is admitting a client with a diagnosis of Addison disease to the hospital. On assessment, the nurse expects to note which of the following findings that is a manifestation of this disorder? (Select all that apply.) 1: Peripheral edema 2: Excessive facial hair 3: Lower-than-normal blood glucose level 4: High blood pressure 5: Signs of dehydration

3: Lower-than-normal blood glucose level 5: Signs of dehydration

A nurse is caring for a client with preeclampsia who suddenly progresses to an eclamptic state. The initial nursing action is to: 1: Check the fetal heart rate. 2: Check the maternal blood pressure. 3: Maintain an open airway. 4: Administer oxygen to the mother by face mask.

3: Maintain an open airway.

A client has a diagnosis of dependent personality disorder. Of the following goal statements, which is appropriate for the nurse to document? 1: Avoids situations that increase anxiety. 2: Adheres to a no self-harm contract. 3: Uses the problem-solving process effectively. 4: Refrains from compulsive behaviors.

3: Uses the problem-solving process effectively.

The nurse is caring for a client in labor. The nurse notes the presence of fetal bradycardia on the fetal monitor and suspects umbilical cord compression. The nurse should immediately place the client in what position? 1: High-Fowler 2: Upright 3: With the hips elevated 4: Semi-Fowler

3: With the hips elevated

A nurse is assessing a family experiencing violence. Which factor does the nurse initially address in the assessment? 1: The family's anger toward the abuse 2: The family's denial of the violent nature of the abuser's behavior 3: The coping style of each family member 4: The family's ability to use community resources

3: The coping style of each family member

A nurse is assessing a client with hypertension being treated with diuretic therapy. The nurse monitors the client for hypokalemia if the client is receiving which of the following diuretics? 1: Triamterene (Dyrenium) 2: Amiloride hydrochloride (Midamor) 3: Spironolactone (Aldactone) 4: Bumetanide (Bumex)

4: Bumetanide (Bumex)

The result of a client's vision test using a Snellen chart is 20/50. The nurse understands this to mean that the client: 1: Is legally blind. 2: Has normal vision. 3: Can read at a distance of 50 feet what a client with normal vision can read at 20 feet. 4: Can read at a distance of 20 feet what a client with normal vision can read at 50 feet.

4: Can read at a distance of 20 feet what a client with normal vision can read at 50 feet.

A nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. What should the nurse do? 1: Hyperoxygenate and hyperventilate the client with an Ambu bag and resuction. 2: Notify the physician as soon as possible. 3: Contact the respiratory department to suction the client. 4: Check the vital signs and discontinue attempts at suctioning until the client is stabilized.

4: Check the vital signs and discontinue attempts at suctioning until the client is stabilized.

A nurse is performing an assessment on a male client with epididymitis. The nurse expects to note which of the following manifestations of this disorder? 1: Diarrhea, groin pain, and scrotal edema 2: Nausea and vomiting and scrotal edema with ecchymosis 3: Fever, diarrhea, groin pain, and ecchymosis 4: Fever, nausea and vomiting, and painful scrotal edema

4: Fever, nausea and vomiting, and painful scrotal edema

The nurse prepares to administer an intravenous (IV) medication when the nurse notes that the medication is incompatible with the IV solution. Which is the best intervention for the nurse to implement for safe medication administration? 1: Ask the provider to prescribe a compatible IV solution. 2: Start a new IV catheter for the incompatible medication. 3: Collaborate with the provider for anew administration route. 4: Flush the tubing with normal saline before and after administering the medication.

4: Flush the tubing with normal saline before and after administering the medication.

A client with Guillain-Barre syndrome has been asking many questions about the condition, and the nursing staff believes that the client is very discouraged about her condition. It is important for the nurse to include which of the following information in discussions with the client? 1: Maximal paralysis occurs within 48 hours after diagnosis. 2: Paralysis occurs proximally to distally. 3: With maximal rehabilitation, function is regained within 3 months. 4: Generally most people recover from this condition.

4: Generally most people recover from this condition.

A nurse in a well-baby clinic is providing safety instructions to a mother of a 1-month-old infant. Which of the following safety instructions is appropriate for an infant of this age? 1: Cover electrical outlets. 2: Remove hazardous objects from low places. 3: Lock all poisons. 4: Never shake the infant's head.

4: Never shake the infant's head.

The nurse is caring for a client with a herniated lumbar intervertebral disk who is experiencing low back pain. The nurse plans to place the client in which position to minimize the pain? 1: Flat with the knees raised 2: High-Fowler position with the foot of the bed flat 3: Semi-Fowler position with the foot of the bed flat 4: Semi-Fowler position with the knees slightly raised

4: Semi-Fowler position with the knees slightly raised

Which of the following should the nurse assess for in a client who has pernicious anemia? 1: Constipation 2: Shortness of breath 3: Dusky lips and gums 4: Smooth, sore, and red tongue

4: Smooth, sore, and red tongue

A client with low back pain asks the nurse which type of exercise will best strengthen the lower back muscles. The nurse tells the client to participate in which beneficial exercise? 1: Tennis 2: Diving 3: Canoeing 4: Swimming

4: Swimming

A nurse is preparing to administer an immunization to an 11-year-old child. Which of the following sites should the nurse select as the best area to administer the intramuscular injection? 1: Posterior lateral aspect of the thigh 2: Anterolateral aspect of the thigh 3: Deltoid muscle 4: Ventral gluteal muscle

4: Ventral gluteal muscle

A client returns from the recovery room after an abdominal surgical procedure. The initial nursing action is to assess which of the following? 1: The abdominal dressing 2: Urinary output in the Foley bag 3: Intravenous solution for accurate flow rate 4: Vital signs

4: Vital signs

Which food should the nurse suggest to the client to increase dietary intake of thiamine? 1: Milk 2: Chicken 3: Broccoli 4: Whole-grain cereals

4: Whole-grain cereals

A nurse prepares to administer which of the following prescribed medications to a newborn within the first hour of life? (Select all that apply.) 1: Hepatitis B vaccine 2: Hepatitis A vaccine 3: Naloxone (Narcan) 4: Surfactant (Infasurf) 5: Erythromycin eye drops 6: Vitamin K (AquaMEPHYTON)

5: Erythromycin eye drops 6: Vitamin K (AquaMEPHYTON)

Hepatitis A vaccine (Harvix) has been prescribed for a client who is planning a trip out of the country. The nurse provides instructions to the client regarding this vaccine. Which of the following statements, if made by the client, indicates a need for further instructions? 1: "This vaccine will protect me against hepatitis B." 2: "This vaccine is given into my muscle." 3: "A booster dose is recommended 6 to 12 months after my initial injection." 4: "This vaccine contains the inactive virus of hepatitis A."

1: "This vaccine will protect me against hepatitis B."

A nurse administers digoxin (Lanoxin) 0.25 mg by mouth rather than the prescribed dose of 0.125 mg to the client. Which should the nurse implement first? 1: Write an incident report. 2: Tell the client about the medication error. 3: Administer digoxin immune fab (Digibind). 4: Tell the client about the adverse effects of digoxin.

1. Write an incident report.

A physician prescribes an intravenous dose of 400,000 units of penicillin G benzathine (Bicillin). The label on the 10-mL ampule sent from the pharmacy reads "penicillin G benzathine (Bacillin), 300,000 units per mL." How many milliliters will the nurse administer? (Round answer to the nearest tenth).

1.3 mL

A physician prescribes levothyroxine (Synthroid) 150 mcg orally daily for a client with hypothyroidism. The medication label states 0.1 mg per tablet. The nurse instructs the client to take how many tablet(s)?

1.5 tablets

The nurse instructs a client at risk for urinary tract infections to drink 3000 mL of fluid daily to decrease the risk. How many 10-ounce glasses of fluid per day should the nurse instruct the client to drink to consume 3000 mL?

10 glasses

Penicillin V potassium 250 mg orally every 8 hours is prescribed for a child with a respiratory infection. The medication label reads "Penicillin V potassium, 125 mg per 5 mL." After determining the dosage is safe, the nurse administers how many mL per dose to the child?

10 mL

A nurse is developing a teaching plan for an older client with hypertension. The client will be discharged to home and must learn to manage diet and medications. To facilitate the client's learning process, the nurse should first: 1: Determine the client's readiness to learn. 2: Plan 30-minute teaching sessions in the evening after visiting hours end. 3: Set priorities for the client. 4: Use one teaching method consistently.

1: Determine the client's readiness to learn.

A client has been diagnosed with pyelonephritis. The nurse interprets that which of the following health problems has placed the client as risk for this disorder? 1: Diabetes mellitus 2: Orthostatic hypotension 3: Hypoglycemia 4: Coronary artery disease

1: Diabetes mellitus

Capecitabine (Xeloda) is prescribed for a client with metastatic breast cancer. In providing information to the client about the medication, the nurse should tell the client that a frequent side effect of the medication is which of the following? 1: Diarrhea 2: Headache 3: Myalgia 4: Dyspepsia

1: Diarrhea

Which of the following early findings would be noted in an infant who is positive for human immunodeficiency virus? 1: Hepatosplenomegaly 2: Sleepiness 3: Lethargy 4: Eye drainage

1: Hepatosplenomegaly

A nurse assessing a female client with Cushing syndrome expects to note which of the following? 1: Hirsutism 2: Hypotension 3: Hypoglycemia 4: Pallor

1: Hirsutism

The nurse provides information about the signs of hypoglycemia to a client with diabetes mellitus who is taking insulin. Which of the following signs should the nurse include in the information? (Select all that apply.) 1: Hunger 2: Sweating 3: Weakness 4: Nervousness 5: Cool, clammy skin 6: Increased urinary output

1: Hunger 2: Sweating 3: Weakness 4: Nervousness 5: Cool, clammy skin

A nurse is assigned to care for a client who is attached to a mechanical ventilator and is receiving propofol (Diprivan). The nurse plans to monitor the client closely for which adverse effect of the medication? 1: Hypotension 2: Facial flushing 3: Tachycardia 4: Increased respiratory rate

1: Hypotension

A client on the psychiatric unit is displaying manipulative behavior. The nurse should use which interventions in working with this client? (Select all that apply.) 1: Identifying the manipulative behaviors exhibited by the client. 2: Communicating to the client the behaviors that are expected. 3: Describing clearly the consequences of not staying within identified limits related to behaviors. 4: Making accusations regarding the client's behaviors. 5: Being prepared to argue with the client to ensure that views of a situation are shared.

1: Identifying the manipulative behaviors exhibited by the client. 2: Communicating to the client the behaviors that are expected. 3: Describing clearly the consequences of not staying within identified limits related to behaviors.

A client with peripheral intravenous (IV) site calls the nurse to the room and tells the nurse that the IV site is swollen. The nurse assesses the IV site and notes that it is also cool and pale and that the IV has stopped running. The nurse documents that which of the following has probably occurred? 1: Infiltration 2: Phlebitis 3: Thrombosis 4: Infection

1: Infiltration

An extremely angry client on a mental health inpatient unit has been placed in restraints because of aggressive behavior. The nurse plans to remove the restraints when the client exhibits which of the following behaviors? 1: Initiates no aggressive acts for an hour after the release of two leg restraints 2: Is under the effects of a sedative that has been administered 3: Divulges all the reasons for the aggressive behavior 4: Apologizes and tells the nurse that it will not happen again

1: Initiates no aggressive acts for an hour after the release of two leg restraints

A client with mania will be placed in seclusion after overturning two tables and throwing a chair against the wall. Before placing the client in seclusion, the nurse would first: 1: Inspect the client for injuries resulting from the incident and initiate appropriate treatment. 2: Document the behavior leading to seclusion. 3: Document the time the client is placed in seclusion. 4: Ensure that a written prescription by the physician allows for the seclusion.

1: Inspect the client for injuries resulting from the incident and initiate appropriate treatment.

The nurse understands that incident reports allow the agency to analyze adverse client events by: 1: Reviewing quality care and determining potential risks for injury to the client 2: Supplying supervisors with objective information for performance reviews 3: Providing a method of reporting injuries to local, state, and federal agencies 4: Determining the effectiveness of nursing interventions in relation to outcomes

1: Reviewing quality care and determining potential risks for injury to the client.

The nurse provides information to a client with gastroesophageal reflux disease (GERD) about the factors that contribute to decreased lower esophageal sphincter (LES) pressure and worsen the condition. The nurse tells the client that which of the following factors contribute to decreased LES pressure? (Select all that apply.) 1: Alcohol 2: Fatty foods 3: Citrus fruits 4: Baked potatoes 5: Caffeinated beverages 6: Tomatoes and tomato products

1: Alcohol 2: Fatty foods 3: Citrus fruits 5: Caffeinated beverages 6: Tomatoes and tomato products

A nurse is preparing a client for skin grafting and notes that the physician has documented that the client is scheduled for a heterograft. The nurse understands that a heterograft used for the burn client is skin from which of the following donors? 1: Another species 2: A cadaver 3: The burned client 4: A skin bank

1: Another species

A nurse performs an assessment on a postpartum client who is beginning to experience respiratory distress. The nurse expects the client to exhibit which early neurological sign? 1: Apprehensiveness 2: Lethargy 3: Excitement 4: Withdrawal

1: Apprehensiveness

A medication nurse is supervising a new nurse who is administering pyridostigmine (Mestinon) orally to a client with myasthenia gravis. Which observation by the medication nurse indicates safe practice by the new nurse before administration of this medication? 1: Asking the client to take sips of water 2: Asking the client to lie down on her right side. 3: Asking the client to look up at the ceiling for 30 seconds. 4: Asking the client to void before taking the medication

1: Asking the client to take sips of water

A nurse witnesses a client going into pulmonary edema. The client exhibits respiratory distress, but the blood pressure is stable at this time. While waiting for help to arrive, the nurse performs the following actions in which order of priority? 1: Rechecks the vital signs 2: Places the client in the high-Fowler position. 3: Calls the respiratory therapy department for a ventilator 4: Places the client on a pulse oximeter and cardiac monitor 5: Begins the client's oxygen at 2 liters by nasal cannula as needed (PRN) 6: Administers the client's morphine sulfate intravenous injections PRN.

2, 5, 4, 1, 6, 3

A nurse is preparing to perform morning care for a client and plans to perform hand hygiene. Number in order of priority the procedures for performing hand hygiene. 1: Rinse the hands. 2: Turn on the water. 3: Wet the hands with warm water. 4: Dry the hands with a paper towel. 5: Turn off the water faucet with the paper towel. 6: Apply soap to the hands and rub them vigorously, keeping them pointed downward.

2,3,6,1,4,5

A nurse is changing the diaper of a 1-day-old term female newborn and notes that the genetalia are red and swollen and that a thick white mucoid vaginal discharge is present. Based on these findings, the nurse determines that the best action is to: 1. Obtain a specimen of the discharge for culture. 2. Document the findings. 3. Notify the physician. 4. Review the mother's record to determine a history of gonorrhea.

2. Document the findings.

Which instruction should the nurse provide to the client to aid in the relief of heartburn for a client in the third trimester of pregnancy? 1. Eat foods high in fat. 2. Drink warm tea. 3. Eat large meals three times a day. 4. Eat less frequently.

2. Drink warm tea.

The nurse is teaching a client about the modifiable risk factors that can reduce the risk for colorectal cancer. The nurse places highest priority on discussing which risk factor? 1. Age older than 30 years 2. High-fat and low-fiber diet 3. Distant relative with colorectal cancer 4. Personal history of ulcerative colitis or gastrointestinal polyps

2. High-fat and low-fiber diet

In planning client education to prevent placental abruption, the nurse should include discussion about the use of: 1. Cocaine 2. Artificial sweeteners 3. Salt 4. Acetylsalicylic acid (aspirin)

1. Cocaine

A community health nurse is conducting an awareness workshop on adolescent suicide. Which of the following should the nurse discuss as a risk factors? (select all that apply.) 1. Family violence 2. Poor impulse control 3. Use of alcohol or drugs 4. Strong peer relationships 5. Family history of depression 6. Adequate school performance

1. Family violence 2. Poor impulse control 3. Use of alcohol or drugs 5. Family history of depression

A delivery room nurse performs an assessment on a mother who has just delivered a healthy newborn infant. The nurse assesses the uterine fundus, expecting to note that it is positioned: 1: At the level of the umbilicus 2: To the left of the abdomen 3: Two fingerbreadths above the symphysis pubis 4: To the right of the abdomen

1: At the level of the umbilicus

A client with chronic renal failure is scheduled to begin hemodialysis. The nurse interprets which of the following neurological or psychological findings exhibited by the client to be atypical? 1: Euphoria 2: Labile emotions 3: Withdrawal 4: Depressions

1: Euphoria

A client is diagnosed with urolithiasis, and laboratory analysis of the stone passed by the client indicates that it is of the uric acid type. The nurse gives the client dietary instructions and tells the client that it is best to avoid consuming which of the following? 1: Sardines 2: Cheese 3: Tea 4: Milk

1: Sardines

A nurse is caring for a client in whom Tourette disorder has been diagnosed and who is experiencing motor tics. Which of the following does the nurse likely expect to note during assessment of the client? 1: Tongue protrusion 2: Grunting sounds 3: Consistent yelping sounds 4: Uttering of obscenitites

1: Tongue protrusion

A nurse prepares to insert an indwelling Foley catheter into a client. To ensure the integrity of the Foley catheter and client safety, the nurse should do which of the following? (Select all that apply.) 1: Use strict aseptic technique 2: Place the drainage bag lower than the bladder level 3: Advance the catheter after urine appears in the tubing 4: Inflate the balloon with 4 mL to 5 mL beyond its capacity 5: Test the balloon for patency before catheter insertion

1: Use strict aseptic technique 2: Place the drainage bag lower than the bladder level 3: Advance the catheter after urine appears in the tubing 5: Test the balloon for patency before catheter insertion

A nurse is assessing a pregnant client with a diagnosis of abruption placentae. The nurse expects to note which manifestations of this condition? (Select all that apply.) 1: Uterine irritability 2: Uterine tenderness 3: Bright red vaginal bleeding 4: Abdominal and low back pain 5: Strong and frequent contractions 6: Nonreassuring fetal heart rate patterns

1: Uterine irritability 2: Uterine tenderness 4: Abdominal and low back pain 6: Nonreassuring fetal heart rate patterns

A nurse working in a pediatric clinic is preparing to administer childhood vaccinations to a 15-month-old child. Which vaccine should be added to the child's routine immunizations at this time since the child is more than 12 months of age? 1: Varicella 2: Hepatitis B 3: Hepatitis A 4: Pneumococcal conjugate vaccine (PCV)

1: Varicella

A nurse is sending an arterial blood gas (ABG) specimen to the laboratory for analysis. Which of the following pieces of information should the nurse write on the laboratory requisition? (Select all that apply.) 1: Ventilator settings 2: List of client allergies 3: Client's temperature 4: Date and time the specimen was drawn 5: Any supplemental oxygen the client is receiving 6: Extremity from which the specimen was obtained

1: Ventilator settings 3: Client's temperature 4: Date and time the specimen was drawn 5: Any supplemental oxygen the client is receiving

A nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform an Allen test on the client. Place in order of priority the actions that the nurse takes to perform this test. 1: Document the findings. 2: Explain the procedure to the client. 3: Release pressure from the radial artery. 4: Apply pressure over the ulnar and radial arteries. 5: Ask the client to open and close his or her hand repeatedly. 6: Assess the color of the extremity distal to the pressure point.

2, 4, 5, 3, 6, 1

A registered nurse is preparing medications for a client. The physician's prescription reads "theophylline, 100 mg orally every 12 hours." The medication label reads theophylline 50-mg capsules. How many capsules should the nurse administer to the client for one dose?

2 capsules

A client has provider instructions to take ibuprofen (Advil) 0.4 g for mild pain. The medication bottle contains ibuprofen (Advil) 200-mg tablets. How many tablets will the nurse instruct the client to take for each dose?

2 tablets

A nurse is caring for a hospitalized adolescent who is on respiratory isolation precautions. Which of the following is an age-appropriate activity the nurse should provide to the adolescent? 1. Drawing materials 2. An MP3 player 3. A puzzle 4. Finger paints

2. An MP3 player

The nurse palpates which anatomical location to assess the popliteal pulse? 1: Inguinal (groin) area 2: Behind the knee 3: Behind the medial malleolus 4: Dorsum of the foot

2: Behind the knee

A mental health nurse reviews the activity schedule for the day and determines that the best activity that a manic client could participate in is which of the following? 1: Brown-bag luncheon and book review. 2: Tetherball. 3: Paint-by-number activity. 4: Deep-breathing and progressive relaxation group.

2: Tetherball.

A client is being evaluated as a potential kidney donor for a family member. The donor asks the nurse why different evaluation teams are needed for donor and recipient. The nurse understands that this is being done for which of the following reasons? 1: To save the client and recipient valuable preoperative time 2: To avoid a conflict of interest by the team evaluating the recipient and the team evaluating the donor 3: To help reduce the cost of the preoperative workup 4: To have a sufficient number of people reviewing the case, so no information is overlooked

2: To avoid a conflict of interest by the team evaluating the recipient and the team evaluating the donor

The nurse is preparing the bedside for a postoperative parathyroidectomy client who is expected to return to the nursing unit from the recovery room in 1 hour. The nurse ensures that which specific piece of medical equipment is at the client's bedside? 1: Cardiac monitor 2: Tracheotomy set 3: Intermittent gastric suction 4: Underwater seal chest drainage system

2: Tracheotomy set

A nurse is testing the function of a client's vestibulocochlear nerve (CN VIII). The nurse would gather which of the following items to perform the test? 1: Flashlight, pupil size chart, or millimeter ruler. 2: Tuning fork and audiometer. 3: Safety pin, hot and cold water in test tubes, and cotton wisp. 4: Snellen chart and ophthalmoscope.

2: Tuning fork and audiometer

A client begins to experience a tonic-clonic seizure. The nurse should take which of the following actions? (Select all that apply.) 1: Restrain the client. 2: Turn the client to the side. 3: Maintain the client's airway. 4: Place a padded tongue blade into the client's mouth. 5: Loosen any restrictive clothing that the client is wearing. 6: Protect the client from injury, and guide the client's movements.

2: Turn the client to the side. 3: Maintain the client's airway. 5: Loosen any restrictive clothing that the client is wearing. 6: Protect the client from injury, and guide the client's movements.

A client was originally prescribed oral sertraline (Zoloft) 25 mg daily for depression. The dose has been gradually increased in an effort to control symptoms. The current dose is 75 mg daily. The medication label reads 25 mg/tablet. To receive the correct dose, the nurse instructs the client to take how many tablets once daily?

3 tablets

Identify the steps in order of priority for inserting a nasogastric tube. 1: Verify tube placement. 2: Anchor the tube to the nose. 3: Position the client in the high-Fowler position. 4: Document the tube length in the client's record. 5: Measure the distance to insert the tube and mark the length of the tube; lubricate the end of the tube with water-soluble lubricating jelly. 6: Insert the tube through the naris and instruct the client to take a sip of water and swallow, continuing to advance the tube until the tape mark is reached.

3, 5, 6, 1, 2, 4

A nurse working in a long-term care facility responds after hearing someone calling, "Help, the bed is on fire!" On entering the room, the nurse finds a client slapping at flames on the bedspread with a pillow. Both hands have been burned. List in order of priority the actions that the nurse should take. 1: Pull the nearest fire alarm. 2: Close the door to the room. 3: Remove the client from the room. 4: Pull the pin on the fire extinguisher. 5: Run to get the nearest fire extinguisher. 6: Aim the extinguisher at the base of the fire and sweep from side to side.

3,1,2,5,4,6

The nurse needs to administer an intravenous infusion of 100 mL of normal saline over a period of 30 minutes. The drop factor is 10 drops (gtt)/mL. The nurse sets the flow rate at how many gtt per minute? (Round answer to the nearest whole number).

33 gtts/min

A client with metastatic bladder cancer is admitted to the hospital for chemotherapy. During the admission assessment the client tells the nurse that a living will was prepared 2 years ago. The client asks the nurse if this document is still effective. The appropriate nursing response is which of the following? 1: "Yes, it is effective until you make the decision to change it." 2: "You will have to discuss the issue with your lawyer." 3: "A living will usually needs to be reviewed annually with your physician." 4: Living will are valid for 6 months."

3: "A living will usually needs to be reviewed annually with your physician."

An adolescent is seen in the clinic and is diagnosed with Epstein-Barr virus (infectious mononucleosis). The adolescent asks the nurse how this virus is transmitted. The nurse informs the adolescent that this virus is transmitted by which of the following routes? 1: Airborne particles 2: Fecal-oral route 3: Saliva 4: Contact with sweat

3: Saliva

The nurse who is caring for a client with Graves disease notes that the client has a problem with taking in adequate nutrition. The nurse develops a plan and should include which positive outcome for this problem? 1: The client verbalizes the need to avoid snacking between meals. 2: The client discusses the relationship between mealtime and the blood glucose level. 3: The client maintains the normal weight or gradually gains weight if it is below normal level. 4: The client demonstrates knowledge regarding the need to consume a diet high in fat and low in protein.

3: The client maintains the normal weight or gradually gains weight if it is below normal level.

A nurse is caring for a client with a precipitate labor. The nurse tells the client that in this type of labor: 1: Induction may be necessary. 2: The onset of contractions is gradual. 3: The labor may last less than 3 hours. 4: A lengthy period of pushing may be necessary.

3: The labor may last less than 3 hours.

A nurse is reviewing the assessment data of a client who has been admitted to the mental health unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. Which of the following circumstances can precipitate a situational crisis? 1: A hurricane that destroyed the client's home 2: An earthquake that destroyed a community 3: The loss of a job 4: Witnessing a fatal automobile accident

3: The loss of a job

An initial goal in the nursing plan of care for a client with schizophrenia newly admitted to the mental health unit would be which of the following? 1: To improve self-care 2: To decrease bizarre behavior 3: To develop a trusting relationship 4: To encourage verbalization of feelings

3: To develop a trusting relationship

A clinic nurse is providing an in-service education program to the nursing staff on immunizations, and the topic of discussion is human immunoglobulin. The nurse tells the staff that this type of vaccine: 1. Has its virulence (potency) diminished so as to not produce a full-blown clinical illness. 2. Contains pathogens made inactive by either chemicals or heat. 3. Is a bacterial toxin that has been made inactive by either chemicals or heat. 4. Has been obtained from the pooled blood of many people and provides antibodies to a variety of diseases.

4. Has been obtained from the pooled blood of many people and provides antibodies to a variety of diseases.

When assessing a client for possibly symptomology of Meniere disease, the nurse should ask which questions? (Select all that apply) 1: "Do you experience ringing in your ears?" 2: "Are you prone to vertigo that can last for days?" 3: "Can you hear better out of one ear than the other?" 4: "Is there a history of Meniere disease in your family?" 5: "Have you ever experienced a head injury in the area of your ears?"

1: "Do you experience ringing in your ears?" 2: "Are you prone to vertigo that can last for days?" 3: "Can you hear better out of one ear than the other?"

The nurse is preparing a client who had a total knee replacement with a metal prosthesis for discharge to home and provides the client with discharge instructions. Which statement by the client indicates a need for further instructions? 1: "I can expect that changes in the shape of the knee will occur." 2: "I need to tell any future caregivers about the metal prosthesis." 3: "I need to report bleeding gums or tarry stools to the physician." 4: "I need to report fever, redness, or increased pain to the physician."

1: "I can expect that changes in the shape of the knee will occur."

The nurse notes old and new ecchymotic areas on an older adult client's arms and buttocks upon admission to the hospital. The client tells the nurse in confidence that her family members frequently hit her. Which statement should the nurse use in response? 1: "I have a legal obligation to report this type of abuse." 2: "Let's get these treated, and I will maintain the confidence." 3: "Let's talk about ways to prevent someone from hitting you." 4: "If this happens again, you must call the emergency department."

1: "I have a legal obligation to report this type of abuse."

A nurse is collecting data from a client with a history of hypertension. The nurse interprets that the client would benefit from biofeedback as an adjunctive therapy if the client made which of the following statements? 1: "I have such a stressful job, you wouldn't believe it." 2: "It is so hard giving up all the salty foods that I enjoy." 3: "I don't have the money to pay for the pills that I take every day." 4: "It is hard for me to get to the bus to come in to the clinic for my blood pressure checks."

1: "I have such a stressful job, you wouldn't believe it."

A nurse has provided discharge instructions regarding home care to a client after a prostatectomy for cancer of the prostate. Which client statement indicates an understanding of the instructions? 1: "I should not lift anything over 20 pounds." 2: "To prevent dribbling of urine, I need to limit my fluid intake to four glasses daily." 3: "If I see any clots in my urine, I need to call the physician immediately." 4: "I can begin to drive my car in 1 week."

1: "I should not lift anything over 20 pounds."

A nurse has taught a 64-year-old woman at risk for breast cancer how to do breast self-examination (BSE). The nurse determines that the client understands the procedure if the client states which of the following? (Select all that apply) 1: "I will inspect my breasts while standing in front of the mirror." 2: "I will do the examination on any day of each month." 3: "I will use the pads of my fingers and press deeply to feel lumps." 4: "I will examine my right breast with my right hand, and vice verse." 5: "I will palpate my breasts when I am in a lying position."

1: "I will inspect my breasts while standing in front of the mirror." 3: "I will use the pads of my fingers and press deeply to feel lumps." 5: "I will palpate my breasts when I am in a lying position."

A physician prescribes warfarin (Coumadin) for a client. The home care nurse visits the client at home and teaches the client about the medication and its administration. Which statement by the client indicates the need for further instructions? 1: "My urine will change to reddish orange." 2: "This medication will frequently require blood work to monitor its effects." 3: "This medicine will still be working 4 to 5 days after it is discontinued." 4: "Aspirin or any aspirin-containing medications cannot be taken while taking this medication."

1: "My urine will change to reddish orange."

A nurse conducts a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which statement by the client indicates an understanding of the purpose of and need for iron supplementation? 1: "The iron is needed to make red blood cells to supply my baby with food." 2: "Meat does not provide iron and should be avoided." 3: "Iron supplements will give me diarrhea." 4: "My body has all the iron it needs, and I don't need to take supplements."

1: "The iron is needed to make red blood cells to supply my baby with food."

A nurse provides instructions to a client with mild preeclampsia regarding care at home. Which statement by the client indicates the need for further instructions? 1: "The purpose of having the home care nurse visiting is that I will not have to struggle to make it to the physician's office." 2: "My blood pressure needs to be checked each morning, and I will be taught how to take it." 3: "I need to check my weight every day at the same time of day." 4: "I need to check my urine every day for protein and call the physician if it is 2+ or more."

1: "The purpose of having the home care nurse visiting is that I will not have to struggle to make it to the physician's office."

A nurse is caring for a client with delirium who has become physically abusive. Of the following statements, which initial nursing response should be made to the client? 1: "You are not to hit me or anyone else. Tell me how you feel." 2: "If you hit me, I am putting you into restraints." 3: "The seclusion room is empty and that's where you will need to be if you threaten to hit me or anyone else." 4: "I will call the physician for a prescription for a shot for you if you continue to threaten to hit me or anyone else."

1: "You are not to hit me or anyone else. Tell me how you feel."

A nurse performs an assessment on a 9-month-old infant. Which finding indicates a physiological problem? 1. Head lag is noted when pulled to sitting. 2. Inability to stand without support. 3. Creeping or crawling along the floor. 4. Absence of rooting reflex.

1. Head lag is noted when pulled to sitting.

The nurse is doing an initial assessment at the beginning of the work shift on a shift on a client who has a spinal cord injury. The nurse assesses the client's sensory ability by asking the client to: 1. Tell whether a cotton wisp or pin is touching the skin. 2. Touch the thumb to each finger in sequence. 3. Fan the fingers as widely as possible. 4. Squeeze a tennis ball as hard as possible.

1. Tell whether a cotton wisp or pin is touching the skin.

A female prison client, who killed her abusive husband by shooting him six times, is eligible for parole and asks the nurse, "Do you think I have a chance of being paroled?" Which nursing response is a therapeutic response? 1: "You have promises of obtaining employment and regaining your children already lined up. I believe that the parole board will view your problem solving as a positive criterion." 2: "Let me respond by telling you that most parole applications are denied the first time. Nevertheless, I have learned that your good conduct record will be seriously considered." 3: "If I were you, I would not build up too much hope. Simply having a firm plan in place will not help your case." 4: "Do you think you do?"

1: "You have promises of obtaining employment and regaining your children already lined up. I believe that the parole board will view your problem solving as a positive criterion."

A nurse is checking a baseline serum creatinine level in an adult client who will be receiving an intravenous antibiotic that is nephrotoxic. The nurse determines that it is safe to administer the medication if the client's serum creatinine is which of the following levels? 1: 1.3 mg/dL 2: 1.8 mg/dL 3: 2.3 mg/dL 4: 2.8 mg/dL

1: 1.3 mg/dL

A nurse is preparing to suction a tracheostomy on a preterm infant. The nurse prepares the equipment for the procedure and should turn the suction to which of the following settings? 1: 40 mm Hg 2: 80 mm Hg 3: 100 mm Hg 4: 120 mm Hg

1: 40 mm Hg

A client with diabetes mellitus receives Humulin Regular insulin 8 units subcutaneously at 7:30 am. The nurse would be most alert to signs of hypoglycemia at what time during the day? 1: 9:30 am to 11:30 am 2: 11:30 am to 1:30 pm 3: 1:30 pm to 3:30 pm 4: 3:30 pm to 5:30 pm

1: 9:30 am to 11:30 am

Vasopressin (Pitressin) therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse who is preparing to administer the medication to the client obtains which of the following items that is essential for use during administration of this medication? 1: A cardiac monitor 2: An artificial airway 3: A suction setup 4: A tracheotomy set

1: A cardiac monitor

Which of the following clients with renal failure is best suited for peritoneal dialysis as a treatment option? 1: A client with severe congestive heart failure 2: A client with a history of ruptured diverticula 3: A client with a history of herniated lumbar disk 4: A client with a history of three previous abdominal surgeries

1: A client with severe congestive heart failure

A nurse is assigned to care for a client with paranoid personality disorder who is experiencing difficulty with diversional activity. The nurse plans care, knowing that which of the following activities is appropriate for this client? 1: A crossword puzzle 2: Playing bridge 3: Playing chess 4: Playing cards with another client

1: A crossword puzzle

A client becomes restless and agitated and complains of shortness of breath and palpitations. The nurse identifies on the cardiac monitor that the client is experiencing an atrial fibrillation with a rapid ventricular response. The nurse determines that which priority problem is most likely to occur in the client? 1: A decrease in cardiac output 2: A breathing pattern that is not effective 3: Anxiety 4: A disruption in gas exchange in the alveoli

1: A decrease in cardiac output

A client is admitted to the hospital with a myocardial infarction and is not experiencing chest pain at this time. The nurse reviews the electrocardiogram rhythm strip and notes that the PR intervals are 0.16 seconds. The nurse understands that a PR interval of 0.16 seconds found on an electrocardiogram rhythm strip indicates which of the following? 1: A normal finding 2: An abnormal finding 3: First-degree atrioventricular block 4: An impending reinfarction

1: A normal finding

The emergency service team brings a client to the emergency department. The client was found lying in an alley near a dumpster by a policeman, who reports that the client is a homeless victim. An assessment is performed, and the client is suspected of having frostbite of the hands. Which of the following findings would the nurse note in this condition? 1: A white appearance to the skin that is insensitive to touch 2: A pink edematous hand 3: Black fingertips surrounded by an erythematous rash 4: Red skin with edema in the nail beds

1: A white appearance to the skin that is insensitive to touch

A nurse is preparing to administer diphtheria, pertussis, tetanus (DOT), Haemophilus influenza type b (Hib), and hepatitis B vaccines simultaneously. The nurse should: 1: Administer DPT in one leg and Hib and hepatitis B in the other leg. 2: Administer Hib in one leg and DPT and hepatitis B in the other leg. 3: Administer hepatitis B in one leg and DPT and Hib in the other leg. 4: Administer DPT and Hib in the gluteal muscle and hepatitis B in the leg.

1: Administer DPT in one leg and Hib and hepatitis B in the other leg.

A clinic nurse is caring for a child who was diagnosed with erythema infectiosum (fifth disease), and the mother asks the nurse how this disease is transmitted. The nurse informs the mother that fifth disease is transmitted by which of the following routes? 1: Airborne particles 2: Fecal-oral route 3: Saliva 4: Contact with sweat

1: Airborne particles

A nurse instructs a client with tuberculosis about personal hygiene and the proper handling and disposal of respiratory secretions. The nurse tells the client to take which of the following actions? 1: Discard used tissues in a plastic bag. 2: Brush the teeth and rinse the mouth once a day. 3: Wash hands at least four times a day. 4: Turn the head to the side if coughing or sneezing.

1: Discard used tissues in a plastic bag.

A nurse sees another nurse administer an incorrect medication to a client. The nurse who administered the incorrect medication does not report the error. The initial action by the nurse who observed the error is which of the following? 1: Ask the nurse whether he or she intends to report the error. 2: Contact the supervisor. 3: Document the error in the client's record. 4: Complete an incident report.

1: Ask the nurse whether he or she intends to report the error.

The nurse is developing a plan of care for a client with a dissecting abdominal aortic aneurysm. Which interventions should be included in the plan? (Select all that apply). 1: Assess peripheral circulation. 2: Monitor for abdominal distension. 3: Tell the client that abdominal pain is expected. 4: Turn the client to the side to look for ecchymoses on the lower back. 5: Perform deep palpitation of the abdomen to assess the size of the aneurysm.

1: Assess peripheral circulation. 2: Monitor for abdominal distension. 4: Turn the client to the side to look for ecchymoses on the lower back.

A nurse is assessing a 36-month-old child during a wellness visit to the pediatrician. The child weighs 43 pounds and is 41 inches tall. After plotting the measurements on the standardized growth charts for a 36-month-old, what should the nurse do next? 1: Assess the parents' body shape and stature. 2: Document these as expected findings for a 3-year-old child. 3: Counsel the parent on appropriate physical activities and exercises. 4: Refer the child and the parents for nutritional counseling related to obesity.

1: Assess the parents' body shape and stature.

A home care nurse visits a client who has recently been told that she is positive for human immunodeficiency virus (HIV) infection. The client is having difficulty accepting the diagnosis. The home care nurse analyzes the client's behavior and responds in which of the following ways? 1: Assesses the client's coping skills and knowledge deficit regarding HIV. 2: Acknowledges that psychosocial problems are related to ineffective coping skills. 3: Recognizes that persons who are HIV positive have less than 1 year to live. 4: Ignores the problem, knowing that over time the client will accept the diagnosis.

1: Assesses the client's coping skills and knowledge deficit regarding HIV.

An emergency department nurse is performing an assessment on a client who has sustained circumferential burns of both legs. Which assessment would be the priority in caring for this client? 1: Assessing peripheral pulses 2: Assessing neurological status 3: Assessing urine output 4: Assessing blood pressure (BP)

1: Assessing peripheral pulses

A client sustained a penetrating eye injury from a piece of glass when a mirror with a metal backing in the client's bathroom fell and broke. On visual assessment of the injured eye, the nurse can see a piece of glass protruding from the eye. The nurse prepares the client for which interventions? (Select all that apply.) 1: Assessment of visual acuity 2: X-rays studies of the eye orbit 3: Administration of a tetanus booster 4: Immediate removal of the glass with forceps 5: Computed tomography (CT) scans of the orbit 6: Magnetic resonance imaging (MRI) of the eye orbit

1: Assessment of visual acuity 2: X-rays studies of the eye orbit 3: Administration of a tetanus booster 5: Computed tomography (CT) scans of the orbit

A nurse is planning client assignments. Which of the following is the least appropriate assignment for the nursing assistant? 1: Assisting a developmentally disabled child to eat lunch. 2: Obtaining frequent oral temperatures on a client. 3: Accompanying a 51-year-old man who is being discharged to home after a bowel resection 8 days ago to his transportation. 4: Collecting a urine specimen from a 70-year-old woman admitted 3 days ago.

1: Assisting a developmentally disabled child to eat lunch.

It has been 12 hours since the client's delivery of a newborn. The nurse assesses the client for the process of involution and documents that it is progressing normally when palpation of the client's fundus is noted at which level? 1: At the umbilicus 2: One fingerbreadth below the umbilicus 3: Two fingerbreadths above the umbilicus 4: Two fingerbreadths below the umbilicus

1: At the umbilicus

A mother tells the nurse that her 2-year-old child does not want anything to do with toilet training and yells "No!" consistently when she tries to toilet train. According to Erikson, the nurse interprets that the child is experiencing which psychosocial crisis? 1: Autonomy vs Shame and Doubt 2: Initiative vs Guilt 3: Industry vs Inferiority 4: Trust vs Mistrust

1: Autonomy vs Shame and Doubt

The nurse develops a discharge plan for a client who had a total abdominal hysterectomy. The nurse should include which activity instructions in the plan? (Select all that apply.) 1: Avoid heavy lifting. 2: Sit as much as possible. 3: Take baths rather than showers. 4: Limit stair climbing to five times a day. 5: Gradually increase walking as exercise but stop before becoming fatigued. 6: Avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks.

1: Avoid heavy lifting. 4: Limit stair climbing to five times a day. 5: Gradually increase walking as exercise but stop before becoming fatigued. 6: Avoid jogging, aerobic exercises, sports, or any strenuous exercise for 6 weeks.

A nurse is attempting to deescalate aggressive behavior exhibited by a client with schizophrenia. Which actions should the nurse take? (Select all that apply.) 1: Be assertive with the client. 2: Negotiate options with the client. 3: Demonstrate control and aggressiveness with the client. 4: Give the client lengthy instructions to distract the client. 5: Persuade the client to move to another area of the nursing unit. 6: Stand close to the client, and tell the client that the behavior is unacceptable.

1: Be assertive with the client. 2: Negotiate options with the client. 5: Persuade the client to move to another area of the nursing unit.

A nurse is caring for a client with a suspected diagnosis of aplastic anemia. Which of the following tests would the nurse anticipate would be prescribed to confirm the diagnosis? 1: Bone marrow aspiration 2: Complete blood count 3: Sickle cell screen 4: Schilling test

1: Bone marrow aspiration

The nurse should assess which area in a dark-skinned client for the presence of pallor? 1: Buccal mucosa 2: Nail beds 3: Over the palms of the hands 4: In the fingertips

1: Buccal mucosa

Which of the following laboratory results indicate a therapeutic drug level? (Select all that apply.) 1: Carbamazepine (Tegretol) 10 mcg/mL 2: Digoxin (Lanoxin) 3 ng/mL 3: Gentamicin 8 mcg/mL 4: Phenytoin (Dilantin) 28 mcg/mL 5: Theophylline 10 mcg/mL 6: Tobramycin (Nebcin) 20 mcg/mL

1: Carbamazepine (Tegretol) 10 mcg/mL 3: Gentamicin 8 mcg/mL 5: Theophylline 10 mcg/mL

A client has a diagnosis of hypothyroidism. The nurse assesses that the client has a positive Trousseau sign if the client has which of the following responses when tested? 1: Carpopedal spasm when a blood pressure cuff is inflated on the arm for 3 minutes 2: Spasm of the facial muscle when tapped below the temple 3: Pulling up of the knees when the head is bent onto the chest 4: Fanning and spreading of the toes when the sole of the foot is stroked

1: Carpopedal spasm when a blood pressure cuff is inflated on the arm for 3 minutes

A nurse employed in a long-term care facility is observing for signs of depression in an older client. The nurse monitors for which of the following? 1: Change in appetite and social withdrawal 2: Change in appetite and gait disturbances 3: Change in behavior and impaired judgment 4: Delusions and disorganized thought processes.

1: Change in appetite and social withdrawal

A nurse is caring for the client who has just had a precipitate delivery. Before attempting to deliver the placenta, the nurse waits for which of the following signs as an indication of placental separation? 1: Change in uterine shape 2: Sudden abdominal pain 3: Shortened umbilical cord 4: Decreased blood flow from the introitus

1: Change in uterine shape

A nurse is caring for a client who is receiving an intermittent feeding via a nasogastric tube. Before feeding the client via the nasogastric tube, the nurse should take which of the following actions? 1: Check the placement of the tube. 2: Check the last time that medications were given. 3: Check the client's temperature. 4: Warm the feeding to 103*F.

1: Check the placement of the tube.

A nurse is monitoring a client who is receiving a blood transfusion. The client begins to complain of a sweaty and warm feeling and a backache. The nurse notes that the client's skin is flushed and suspects that the client is having a transfusion reaction. The nurse immediately stops the blood transfusion, hangs an intravenous (IV) bag of normal saline, infuses it at a keep-vein-open rate, and then: 1: Contacts the physician. 2: Inserts a Foley catheter into the client. 3: Monitors the client closely for the next hour. 4: Administers diphenhydramine (Benadryl) as needed (PRN), which was previously prescribed to treat pruritus caused by eczema.

1: Contacts the physician.

A nurse is assigned to care for a client who is Asian (Chinese). The nurse enters the room and, following a greeting and introduction to the client, begins to discuss the plan of care for the day. During the discussion, the client turns away from the nurse. The nurse should take which of the following actions? 1: Continue with the discussion. 2: Ask the client if she can hear the nurse. 3: Return later to continue with the discussion. 4: Leave the room and ask for another nurse to be assigned to the client.

1: Continue with the discussion.

The nurse instructs a client with a diagnosis of atrial fibrillation to use an electric razor for shaving. The nurse should tell the client that the importance of its use is that: 1: Cuts need to be avoided. 2: Any cut may cause infection. 3: Electric razors can be disinfected. 4: All straight razors contain bacteria.

1: Cuts need to be avoided.

A nurse is planning client and unit activities for the day. Select the activities that the nurse should delegate to the nursing assistant. (Select all that apply.) 1: Deliver fresh water to the clients. 2: Empty urine out of Foley bags. 3: Take temperatures, pulses, respirations, and blood pressures. 4: Count the substance control medications in the opioid medication supply. 5: Check the crash cart (cardiopulmonary resuscitation cart) for necessary supplies using a checklist. 6: Check all intravenous (IV) solution bags on clients receiving IV therapy for the remaining amounts of solution in the bags.

1: Deliver fresh water to the clients. 2: Empty urine out of Foley bags. 3: Take temperatures, pulses, respirations, and blood pressures.

As a nurse approaches a client who was recently admitted to the inpatient unit of a psychiatric hospital, the client says, "Quit following me. You're with the FBI; I can tell by the way you are walking." This is an example of which of the following alterations in thinking? 1: Delusion 2: Hallucination 3: Circumstantiality 4: Loose association

1: Delusion

A client is admitted to the hospital with chest pain, and myocardial infarction is suspected. The nurse informs the client about the importance of notifying a staff member immediately if chest pain occurs, knowing that the common initial reaction exhibited by clients with chest pain is which of the following? 1: Denial 2: Anger 3: Depression 4: Hostility

1: Denial

Which clinical manifestation would a nurse assess for when caring for a schizophrenic client who has a disintegrated sense of self? 1: Depersonalization 2: Flat affect 3: Magical thinking 4: Word salad

1: Depersonalization

A community health nurse working in a school setting is concerned because parents are not participating in health activities designed to promote child safety. The nurse's initial action is to: 1: Determine the appropriateness of the planned health activity. 2: Perform an analysis of health problems related to child safety. 3: Develop a focused child safety program. 4: Implement the child safety program.

1: Determine the appropriateness of the planned health activity.

A nurse prepares to administer potassium chloride through a central intravenous line for a client with hypokalemia. The nurse should plan to do which of the following when preparing and administering this medication? (Select all that apply.) 1: Diluting the medication in the appropriate amount of normal saline 2: Monitoring urine output during administration 3: Checking the physician's prescription for the potassium chloride 4: Giving the medication using a macrodrip intravenous tubing 5: Administering via bolus injection over 1 to 3 minutes

1: Diluting the medication in the appropriate amount of normal saline 2: Monitoring urine output during administration 3: Checking the physician's prescription for the potassium chloride

A nurse is monitoring the vital signs of a client after delivery of a healthy newborn and notes that the mother's apical pulse is 50 beats per minute. Which of the following nursing actions is appropriate? 1: Document the finding. 2: Notify the physician. 3: Encourage the mother to ambulate, and then reassess the apical pulse. 4: Increase oral fluids.

1: Document the finding.

A pediatric nurse is caring for a hospitalized preschooler who is in traction. The nurse determines that the appropriate play activity for the child is which of the following? 1: Drawing and coloring pictures 2: Reading from a large picture book 3: Hand sewing a picture 4: Listening to music

1: Drawing and coloring pictures

A client is diagnosed with Haemophilus influenza pneumonia. In addition to standard precautions, which of the following should the nurse implement immediately? 1: Droplet precautions 2: Contact precautions 3: Airborne precautions 4: Neutropenic precautions

1: Droplet precautions

A nurse is collecting data from a client who has recently started on an antipsychotic medication. The nurse assesses the client for which common side effect of antipsychotics? 1: Dry mouth 2: Weight loss 3: Muscle weakness 4: Headaches

1: Dry mouth

The nurse monitors a client with a pelvic fracture sustained in an automobile crash for signs of fat embolism syndrome. Which of the following manifestations are indicative of this complication? (Select all that apply.) 1: Dyspnea 2: Chest pain 3: Bradypnea 4: Bradycardia 5: Lung crackles 6: Altered mental status

1: Dyspnea 2: Chest pain 5: Lung crackles 6: Altered mental status

A family of a client with Parkinson disease tells the nurse that the client is having difficulty adjusting to the disorder and that they do not know what to do to help. The nurse advises the family that which of the following is most therapeutic in assisting the client to cope with the disease? 1: Encourage and praise client efforts to exercise and perform activities of daily living (ADLs). 2: Cluster activities at the end of the day when the client is restless and bored. 3: Plan only a few activities for the client during the day. 4: Assist the client with ADLs as much as possible.

1: Encourage and praise client efforts to exercise and perform activities of daily living (ADLs).

A nurse is reviewing general injury prevention information with the staff of the pediatric department in the hospital. Identify the interventions that the nurse should review to promote safety specifically for infants and toddlers. (Select all that apply.) 1: Ensure that crib sides are up. 2: Place large, soft pillows in the crib. 3: Use large, soft toys without small parts. 4: Attach a pacifier to a stretchable piece of ribbon and pin to the infant's clothing. 5: Ensure that an infant or toddler is never left unattended while lying on a changing table. 6: Allow a toddler who is toilet training to stay in the bathroom alone to provide privacy.

1: Ensure that crib sides are up. 3: Use large, soft toys without small parts. 5: Ensure that an infant or toddler is never left unattended while lying on a changing table.

A nurse is performing an admission assessment on a client who has been admitted to the hospital with a diagnosis of fever of unknown origin. The nurse performs interventions based on the nurse practice act when the nurse takes which of the following actions? 1: Enters the assessment findings on the client's record. 2: Writes the assessment findings on a worksheet. 3: Informs the supervisor of the client's vital signs. 4: Tells another nurse that the client has a high fever.

1: Enters the assessment findings on the client's record.

A nurse is caring for a client who has hand restraints. The nurse should check the client's skin and circulation under the restraints how often? 1: Every 30 minutes. 2: Every 2 hours. 3: Every 3 hours. 4: Every 4 hours.

1: Every 30 minutes

A nurse is caring for a child following an appendectomy. The nurse plans care, knowing that in children, pain is experienced as which of the following? 1: Expressed differently according to the developmental stage 2: Diminished because of the immaturity of the nervous system 3: Easily forgotten 4: Unmeasurable

1: Expressed differently according to the developmental stage

Decerebrate posturing is characterized by which of the following? 1: Extension of the extremities and pronation of the arms 2: Flexion of the extremities and pronation of the arms 3: Upper extremity flexion with lower extremity extension 4: Upper extremity extension with lower extremity flexion

1: Extension of the extremities and pronation of the arms

The nurse performs an assessment on a client newly diagnosed with rheumatoid arthritis. The nurse expects to note which early manifestations of the disease? (Select all that apply.) 1: Fatigue 2: Anorexia 3: Weakness 4: Low-grade fever 5: Joint deformities 6: Joint inflammation

1: Fatigue 2: Anorexia 3: Weakness 4: Low-grade fever 6: Joint inflammation

On assessment, which of the following clinical manifestations would lead a nurse to suspect that a client was experiencing a disulfiram-alcohol reaction? 1: Flushing, throbbing in the head and neck, difficulty breathing, nausea, vomiting, sweating, dizziness, and weakness 2: Dry skin, vomiting, diarrhea, tremors, ataxia, and muscle stiffness 3: Dry skin, tachycardia, vomiting, diarrhea, tremors, ataxia, and muscle stiffness 4: Nausea, vomiting, diarrhea, dizziness on changing position, and muscle cramping

1: Flushing, throbbing in the head and neck, difficulty breathing, nausea, vomiting, sweating, dizziness, and weakness

A client had a sputum specimen sent to the laboratory for Gram stain, culture, and sensitivity. The nurse expects to be able to obtain results of which test shortly after sending it to the laboratory? 1: Gram stain 2: Culture 3: Sensitivity 4: Culture and sensitivity

1: Gram stain

A client has glaucoma. The nurse reviews the client's medical record, expecting to note which of the following manifestations of this eye condition? (Select all that apply.) 1: Halos around lights 2: Headache or eye pain 3: Decreased visual acuity 4: Loss of peripheral vision 5: Increased accommodation 6: Tonometry reading of 24 mm Hg

1: Halos around lights 2: Headache or eye pain 3: Decreased visual acuity 4: Loss of peripheral vision 6: Tonometry reading of 24 mm Hg

A nurse is performing an assessment on a preschool child. To facilitate the cooperation of the child, the nurse should: 1: Have the child pretend to be a nurse. 2: Have the parent leave the room. 3: Offer information and answer questions. 4: Explain in detail each part of the examination before doing it.

1: Have the child pretend to be a nurse.

A nurse is caring for a client who is receiving blood transfusion therapy. Which clinical manifestations would alert the nurse to a hemolytic transfusion reaction? (Select all that apply.) 1: Headache 2: Tachycardia 3: Hypertension 4: Apprehension 5: Distended neck veins 6: A sense of impending doom

1: Headache 2: Tachycardia 3: Hypertension 4: Apprehension 6: A sense of impending doom

The nurse monitors a client who experienced a head injury. Which of the following are manifestations of an increase in intracranial pressure (ICP)? (Select all that apply) 1: Headache 2: Tachycardia 3: Hypotension 4: Pupillary changes 5: Abnormal posturing 6: Widened pulse pressure

1: Headache 4: Pupillary changes 5: Abnormal posturing 6: Widened pulse pressure

A nurse is caring for a client with a diagnosis of retinal detachment. The client suddenly complains of a burst of black spots in the eye. The nurse interprets this symptom as indicating which of the following? 1: Hemorrhage as a result of the detachment 2: An expected finding 3: The need to restrict fluids 4: The need to patch the affected eye

1: Hemorrhage as a result of the detachment

A hospital employee is removing trash from a nursing unit and accidentally pricks a finger with a needle that was discarded in the trash. The nurse reviews the employee's record and notes that the hepatitis B vaccine has never been administered to this employee. The nurse prepares to administer which of the following to the hospital employee? 1: Hepatitis B immunoglobulin and hepatitis B vaccine 2: Hepatitis B immunoglobulin 3: Immunoglobulin 4: Hepatitis B vaccine

1: Hepatitis B immunoglobulin and hepatitis B vaccine

A nurse is doing discharge teaching with a client who has sickle cell disease. The nurse should tell the client that which of the following factors might precipitate a sickle cell crisis? 1: Infection 2: Mild exercise 3: Fluid overload 4: Warm weather

1: Infection

A nurse is preparing a list of instructions for a client who had a creation of an ileal conduit and will be caring for the conduit at home. Which of the following should the nurse include in the instructions? (Select all that apply.) 1: Inspect the skin surrounding the stoma. 2: Inspect the stoma for color, moisture, and protrusion. 3: Contact the physician if the stoma color changes from pink to purple. 4: Cut an opening in the faceplate of the appliance that is slightly smaller than the stoma. 5: Limit fluids to minimize appliance odor from urine breakdown to ammonia. 6: Cleanse the skin around the stoma by using mild soap and water, and then rinse and dry it well.

1: Inspect the skin surrounding the stoma. 2: Inspect the stoma for color, moisture, and protrusion. 3: Contact the physician if the stoma color changes from pink to purple. 6: Cleanse the skin around the stoma by using mild soap and water, and then rinse and dry it well.

A nurse is caring for a client with a phobia who is being treated for the condition with systematic desensitization. The nurse understands that this form of behavior modification is implemented by which of the following interventions? 1: Introducing the client to short periods of exposure to the phobic object while in a relaxed state. 2: Encouraging self-control in the client 3: Using medication 4: Using a positive stimulus to avoid the negative stimulus

1: Introducing the client to short periods of exposure to the phobic object while in a relaxed state.

The nurse working at a health screening clinic gathers data from a client to identify the client's modifiable risk factors associated with coronary heart disease. Which risk factors are modifiable? (Select all that apply.) 1: Is a cigarette smoker 2: Is physically inactive 3: Is female, age 45 years 4: Is an African American 5: Has a family history of heart disease 6: Has a personal history of diabetes mellitus

1: Is a cigarette smoker 2: Is physically inactive 6: Has a personal history of diabetes mellitus

A nurse enters a client's room with a pulse oximetry machine and tells the client that the physician has prescribed continuous continuous oxygen saturation readings. The client's face changes to one of apprehension. The nurse should quickly and effectively alleviate the client's anxiety by stating that pulse oximetry: 1: Is painless and safe. 2: Causes only mild discomfort at the site. 3: Requires insertion of only a very small catheter. 4: Has an alarm to signal dangerous drops in oxygen saturation levels.

1: Is painless and safe.

A nurse is collecting data from a client with the diagnosis of Brown-Sequard syndrome. Which of the following findings does the nurse expect to note? 1: Ispilateral paralysis and loss of touch and vibration sensation 2: Bilateral loss of pain and temperature sensation 3: Contralateral paralysis and loss of touch and vibration sensation 4: Complete paraplegia or quadriplegia, depending on the level of injury

1: Ispilateral paralysis and loss of touch and vibration sensation

A client is diagnosed with macular degeneration and asks the nurse to describe this condition. The nurse should include which information in response to the client? (Select all that apply.) 1: It can be an age-related problem. 2: Mild blurring and distortion occur. 3: It is caused by gradual blockage of retinal capillaries. 4: It is a deterioration of the area that controls peripheral vision. 5: Treatment aims to help the client maximize remaining vision. 6: Two types, atropic (age related or dry) or exudative (wet), exist.

1: It can be an age-related problem. 2: Mild blurring and distortion occur. 3: It is caused by gradual blockage of retinal capillaries. 5: Treatment aims to help the client maximize remaining vision. 6: Two types, atropic (age related or dry) or exudative (wet), exist.

A nurse manager provides an educational session to nursing staff about client confidentiality. The nurse manager explains that which of the following indicates a breach in client confidentiality? (Select all that apply.) 1: Leaving a client's medical record in a conference room unattended 2: Providing the client's wife with information about the results of a diagnostic study 3: Placing only a hospital room number on the cover of a hospitalized client's medical record 4: Asking the client for written permission for a research team to review his or her medical record 5: Allowing a student nurse to review diagnostic test results in a client's medical record if the client provides permission to do so 6: Allowing another staff member to use one's computer access code to document vital signs and intake and output amounts

1: Leaving a client's medical record in a conference room unattended 2: Providing the client's wife with information about the results of a diagnostic study 6: Allowing another staff member to use one's computer access code to document vital signs and intake and output amounts

A client with severe psoriasis is experiencing chronic low self-esteem. The nurse should use which of the following therapeutic strategies when working with this client? 1: Listening attentively 2: Pretending not to notice affected skin areas 3: Keeping communications brief 4: Approaching the client in a formal manner

1: Listening attentively

The nurse prepares to implement suicide precautions for a suicidal client. Select the nursing interventions with regard to these precautions. (Select all that apply.) 1: Maintain arm's length distance with the client at all times. 2: Ensure that meal trays contain no glass or metal silverware. 3: Carefully watch the client swallow each dose of medication. 4: Conduct one-on-one nursing observation and interaction 24 hours a day. 5: Document client's mood, verbatim statements, and behaviors every 15 to 30 minutes per protocol. 6: Allow the client to totally cover self with the bedcovers during sleep at night as long as the nurse is present.

1: Maintain arm's length distance with the client at all times. 2: Ensure that meal trays contain no glass or metal silverware. 3: Carefully watch the client swallow each dose of medication. 4: Conduct one-on-one nursing observation and interaction 24 hours a day. 5: Document client's mood, verbatim statements, and behaviors every 15 to 30 minutes per protocol.

A nurse is providing dietary instructions to a client with tuberculosis (TB). The nurse should specifically instruct the client to increase intake of which of the following food items in the daily diet? 1: Meats and citrus fruits 2: Cereals and broccoli 3: Eggs and bacon 4: Rice and fish

1: Meats and citrus fruits

Which of the following describes the positive outcome for a client discharged from the mental health unit after an episode of severe depression? 1: Meets self-care needs and interacts socially 2: Attends outpatient group therapy 3: Starts a new hobby 4: Complies with medication regimen

1: Meets self-care needs and interacts socially

A client underwent creation of an ileostomy 2 days ago. The nurse assesses the client for signs of which acid-base disorder that can occur in a client with an ileostomy? 1: Metabolic acidosis 2: Metabolic alkalosis 3: Respiratory acidosis 4: Respiratory alkalosis

1: Metabolic acidosis

A client who is intubated and receiving mechanical ventilation is at risk for infection. The nurse should include which of the following in the care of this client? (Select all that apply.) 1: Monitor sputum characteristics and amounts. 2: Use the closed system method for suctioning. 3: Monitor the client's temperature at least twice per shift. 4: Maintain strict aseptic technique when suctioning. 5: Drain water from the ventilator tubing into the humidifier bottle.

1: Monitor sputum characteristics and amounts. 2: Use the closed system method for suctioning. 3: Monitor the client's temperature at least twice per shift. 4: Maintain strict aseptic technique when suctioning.

The nurse is caring for a client with heart failure who has a magnesium level of 1.4 mg/dL. The nurse should: 1: Monitor the client for irregular heart rhythms. 2: Encourage the intake of antacids with phosphate. 3: Teach the client to avoid foods high in magnesium. 4: Provide a diet of ground beef, eggs, and chicken breast.

1: Monitor the client for irregular heart rhythms.

Which of the following parameters does the nurse monitor to determine the effectiveness of filgrastim (Neupogen)? 1: Neutrophil count 2: Platelet count 3: Blood urea nitrogen 4: Creatinine level

1: Neutrophil count

A nurse is reviewing the arterial blood gas (ABG) results of a client in the respiratory care unit and notes that pH is 7.38, PCO2 is 38 mm Hg, PO2, is 86 mm Hg, and HCO3- is 23 mEq/L. The nurse interprets that the client's blood gases indicate which of the following? 1: Normal results 2: Metabolic alkalosis 3: Metabolic acidosis 4: Respiratory acidosis

1: Normal results

A client with chronic renal failure is prescribed a protein-restricted diet. Which of the following sources of incomplete protein does the nurse instruct the client to avoid? 1: Nuts 2: Eggs 3: Milk 4: Fish

1: Nuts

Which of the following should the nurse include in the plan of care for a client with depression whose nutritional intake is poor? (Select all that apply.) 1: Offer small, high-calorie, high-protein snacks frequently throughout the day and evening. 2: Offer high-protein, high-calorie fluids frequently throughout the day and evening. 3: Remain with the client during meals. 4: Complete the food menu for the client. 5: Obtain a consult from a dietician.

1: Offer small, high-calorie, high-protein snacks frequently throughout the day and evening. 2: Offer high-protein, high-calorie fluids frequently throughout the day and evening. 3: Remain with the client during meals. 5: Obtain a consult from a dietician.

A nurse is assessing a client who is diagnosed with agoraphobia. Which of the following information would the nurse expect to obtain during the assessment? 1: Palpitations, fear of losing control or dying when driving in a car and traveling over bridges 2: Complaints of palpitations, sweating, trembling or shaking, nausea, dizziness, and chills or hot flashes 3: A rapid pulse, fear of apprehension, derealization, and psychomotor hyperactivity 4: Persistent, obsessive worries about real-life problems accompanied by the client's attempts to neutralize them

1: Palpitations, fear of losing control or dying when driving in a car and traveling over bridges

A nurse is caring for a 5-year-old child with tetralogy of Fallot. The nurse notes that the child has clubbed fingers and understands that the clubbing most likely results from which of the following: 1: Peripheral hypoxia 2: Delayed physical growth 3: Chronic hypertension 4: Destruction of bone marrow

1: Peripheral hypoxia

A home care nurse visits a 3-year-old child with chickenpox. The child's mother tells the nurse that the child keeps scratching the skin at night and asks the nurse what to do. The nurse tells the mother to: 1: Place soft cotton gloves on the child's hands at night. 2: Apply generous amounts of a cortisone cream to prevent itching. 3: Give the child a glass of warm milk at bedtime to help the child to sleep. 4: Keep the child in a warm room at night so blankets will not cause the child to scratch.

1: Place soft cotton gloves on the child's hands at night.

A nurse is caring for a client who is experiencing psychomotor agitation. Which of the following activities would be appropriate for the nurse to plan for the client? 1: Playing Ping-Pong 2: Playing chess 3: Playing simple card games 4: Reading magazines

1: Playing Ping-Pong

A nurse is monitoring the results of periodic serum laboratory studies drawn on a client with diabetic ketoacidosis who is receiving an intravenous insulin infusion. The nurse alerts the physician for which of the following values? 1: Potassium 3.1 mEq/L 2: Calcium 9.2 mg/dL 3: Sodium 137 mEq/L 4: Serum osmolality 288 mOsm/kg H2O

1: Potassium 3.1 mEq/L

A nurse is caring for a client receiving fludrocortisone acetate (Florinef) for the treatment of Addison disease. The nurse monitors the client, knowing that the anticipated therapeutic effect of fludrocortisone (acetate (Florinef) is which of the following? 1: Promotes electrolyte balance. 2: Stimulates thyroid production. 3: Stimulates the immune response. 4: Stimulates thyrotropin production.

1: Promotes electrolyte balance.

A female client who is in a manic state emerges from her room topless while making sexual remarks and lewd gestures toward the staff and her peers. The nurse should initiate which intervention first? 1: Quietly approach the client, escort her to her room, and help her to get dressed. 2: Confront the client on the inappropriateness of her behavior and offer her a time out. 3: Approach the client in the hallway and insist that she go to her own room immediately. 4: Ask the other clients to ignore her behavior; eventually she will return to her own room.

1: Quietly approach the client, escort her to her room, and help her to get dressed.

A client experienced an open pneumothorax and has a sucking chest wound, which has been covered with an occlusive dressing. The client suddenly begins to experience severe dyspnea, and the nurse notes tracheal deviation to the unaffected side. The nurse should immediately: 1: Remove the dressing. 2: Reinforce the dressing. 3: Check the apical heart rate. 4: Measure oxygen saturation by oximetry.

1: Remove the dressing.

A nurse is caring for a client receiving chemotherapy. On review of the morning laboratory results, the nurse notes that the white blood cell count is extremely low, and the client is immediately placed on neutropenic precautions. When the client's breakfast tray arrives, the nurse inspects the meal and prepares to bring the tray into the client's room. Which of the following actions should the nurse take before bringing the meal to the client? 1: Remove the fresh apple from the breakfast tray. 2: Remove the coffee from the breakfast tray. 3: Call the dietary department and ask for disposable utensils. 4: Ask the client if she feels like eating at this time.

1: Remove the fresh apple from the breakfast tray.

The nurse sends a sputum specimen to the laboratory for culture from a client with suspected active tuberculosis (TB). The results report that Mycobacterium tuberculosis is cultured. How would the nurse correctly analyze these results? 1: Results are positive for active tuberculosis. 2: Results indicate a less virulent strain of tuberculosis. 3: Results are inconclusive until a repeat sputum is sent. 4: Results are unreliable unless the client has also had a positive Mantoux test.

1: Results are positive for active tuberculosis.

A client is diagnosed with Meniere disease and asks the nurse to describe the disorder. The nurse provides the client with which information? (Select all that apply.) 1: Ringing in the ears occurs. 2: It is characterized by vertigo 3: Bilateral sensorineural hearing loss occurs. 4: Permanent hearing loss develops as the attacks increase. 5: Cigarette smoking needs to be avoided because of the blood vessel-constricting effect. 6: Salt and fluid restrictions that reduce the amount of fluid in the ear may be helpful.

1: Ringing in the ears occurs. 2: It is characterized by vertigo 4: Permanent hearing loss develops as the attacks increase. 5: Cigarette smoking needs to be avoided because of the blood vessel-constricting effect. 6: Salt and fluid restrictions that reduce the amount of fluid in the ear may be helpful.

A school nurse is planning to give a class on testicular self-examination (TSE) at the local high school. The nurse should include which of the following information on a written handout to be given to the students? 1: Roll the testicle between the thumb and forefinger. 2: Perform the examination every other month. 3: Perform the examination after a cold shower. 4: Expect the examination to be slightly painful.

1: Roll the testicle between the thumb and forefinger.

A nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula. To provide a safe and effective delivery of the oxygen, the nurse should avoid which of the following actions? 1: Securing the oxygen tubing to the client's bottom sheet. 2: Keeping the humidification jar filled with distilled water. 3: Observing the client's nares frequently for skin breakdown. 4: Checking the oxygen flow rate and physician's prescriptions every shift.

1: Securing the oxygen tubing to the client's bottom sheet.

The nurse caring for a client receiving intravenous (IV) therapy should monitor for which signs of infiltration at the catheter site of an IV infusion? (Select all that apply.) 1: Slowing of the IV rate 2: Tenderness at the insertion site 3: Edema around the insertion site 4: Skin tightness at the insertion site 5: Warmth of skin at the insertion site 6: Fluid leaking from the insertion site

1: Slowing of the IV rate 2: Tenderness at the insertion site 3: Edema around the insertion site 4: Skin tightness at the insertion site 6: Fluid leaking from the insertion site

A family is trying to communicate with a brain attack (stroke) client with aphasia, and the nurse provides a list of interventions to the family to promote effective communication. Which interventions should the nurse place on the list? (Select all that apply.) 1: Speak to the client at a slow rate 2: Look directly at the client while listening 3: Allow sufficient time for the client to respond 4: Complete the sentences that the client cannot finish 5: Raise the volume of the voice when talking to the client 6: Allow family members to give all the responses for the client when someone is asking the client questions

1: Speak to the client at a slow rate 2: Look directly at the client while listening 3: Allow sufficient time for the client to respond

A nurse is conducting a group therapy session, and a female client with a manic disorder is monopolizing the group. The nurse should tell the client which of the following? 1: To stop talking and try listening to others 2: To leave the room 3: To understand that group therapy will be eliminated from her treatment plan 4: To sit at the nurses' station until the group therapy session has finished

1: To stop talking and try listening to others

The nurse is assessing a client with a diagnosis of acute pulmonary edema who is receiving mechanical ventilation. The nurse determines that the client is experiencing anxiety if the client exhibits which of the following signs and symptoms? 1: Tachycardia, clinging to family members, and pupil dilation 2: Bradycardia, hand clenching, and startling behaviors 3: Hypotension, confusion, and combative behaviors 4: Tachypnea, decreased level of consciousness, and palpitations

1: Tachycardia, clinging to family members, and pupil dilation

A nurse has provided instructions to a female client with cystitis about measures to prevent recurrence. The nurse determines that the client needs further instruction if the client verbalizes to: 1: Take bubble baths for more effective hygiene. 2: Wear underwear made of cotton or with cotton panels. 3: Drink a glass of water and void after intercourse. 4: Avoid wearing pantyhose while wearing slacks.

1: Take bubble baths for more effective hygiene.

A client taking warfarin sodium (Coumadin) has been instructed to limit the intake of foods high in vitamin K. The nurse determines that the client understands the instructions if the client indicates that which food items need to be avoided? (Select all that apply.) 1: Tea 2: Turnips 3: Oranges 4: Cabbage 5: Broccoli 6: Strawberries

1: Tea 2: Turnips 4: Cabbage 5: Broccoli

A nurse is caring for a client with schizophrenia and documents that the client has an inappropriate affect. Which of the following best describes this type of behavioral response? 1: The client's emotional response to a situation is not congruent with the tone of the situation. 2: The client has an immobile facial expression or blank look. 3: The client displays minimal emotional responses. 4: The client is mumbling to himself.

1: The client's emotional response to a situation is not congruent with the tone of the situation.

Which of the following are accurate principles of sterile technique? (Select all that apply.) 1: The edge of a sterile field and 1 inch inward is unsterile. 2: If a package is not labeled sterile, it should be considered an unsterile item. 3: Sterile objects that come in contact with unsterile objects are considered contaminated. 4: Any part of a sterile field that hangs below the top of the table is sterile as long as it is not touched. 5: When a sterile field becomes wet, it remains sterile as long as the items on the field are not contaminated. 6: Items in a sterile package must be used immediately once the package has been opened; otherwise it is considered contaminated.

1: The edge of a sterile field and 1 inch inward is unsterile. 2: If a package is not labeled sterile, it should be considered an unsterile item. 3: Sterile objects that come in contact with unsterile objects are considered contaminated. 6: Items in a sterile package must be used immediately once the package has been opened; otherwise it is considered contaminated.

A registered nurse (RN) assigns a new nursing graduate to care for a client with a diagnosis of active tuberculosis. The registered nurse explains how to use a particulate respirator to the new graduate. Which observation by the RN indicates that the new graduate understands proper use and maintenance of this type of respirator? 1: The new graduate states that the nosepiece is readjusted if air is detected escaping around the nose. 2: The new graduate states that another particulate respirator is obtained if air is escaping around the nose. 3: The new graduate states that a fit check is not needed after the initial fit. 4: The new graduate states that a fit check is necessary only when putting on the respirator for the first time.

1: The new graduate states that the nosepiece is readjusted if air is detected escaping around the nose.

A nurse is developing a hospital policy on guidelines for telephone and verbal prescriptions. Which of the following guidelines should the nurse include in the policy? (Select all that apply). 1: The nurse should clarify questions with the physician. 2: The nurse should repeat the prescribed prescriptions back to the physician. 3: The use of abbreviations such as TO (telephone order) is never acceptable. 4: Verbal prescriptions are never acceptable; the physician must document the prescription. 5: Co-signing the prescription by the physician is not necessary if the nurse repeats the prescription for verification. 6: The name of the physician giving the prescription does not need to be documented if the physician is the client's primary physician.

1: The nurse should clarify questions with the physician. 2: The nurse should repeat the prescribed prescriptions back to the physician.

A 9-month-old infant is admitted to a pediatric unit with a diagnosis of dehydration and malnutrition and suspected failure to thrive. Child neglect is suspected. Which of the following would be important for the nurse to observe when the parents visit the infant? 1: The parents level of concern about the child 2: The parents' patterns of visitation 3: The parents' interactions with one another 4: Clues regarding the nutritional patterns of the other children in the family

1: The parents level of concern about the child

When collecting data during the psychosocial assessment of a human immunodeficiency virus-infected client, the nurse should first determine which of the following? 1: The presence of any concerns or fears 2: What type of career the client would like to pursue 3: Why the client waited so long to seek treatment 4: Which family member will assume the client's care after discharge

1: The presence of any concerns or fears

A child with beta thalassemia is receiving chronic transfusion therapy for the treatment of this disorder. Deferoxamine (Desferal) is prescribed to be administered to this child. The nurse determines that this medication has been prescribed to have which of the following effects? 1: To prevent organ damage from too much iron in the blood 2: To increase absorption of iron in the blood 3: To prevent a blood transfusion reaction 4: To produce a mild sedation in the child during transfusion

1: To prevent organ damage from too much iron in the blood

A client with angina pectoris has received instructions on lifestyle changes to control the disease process. The nurse would determine that further teaching is needed if the client states to: 1: Try to exercise at least once a week for 30 minutes. 2: Avoid using table salt with meals. 3: Use muscle relaxation to cope with stressful situations. 4: Take nitroglycerin at the first sign of chest discomfort.

1: Try to exercise at least once a week for 30 minutes.

The community health nurse is providing teaching regarding prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which of the following points should the nurse include in the session? (Select all that apply.) 1: Tuck pants legs into socks. 2: Wear closed shoes when hiking. 3: Apply insect repellent containing DEET. 4: Cover ground area with a blanket when sitting. 5: Remove attached ticks by grasping with the thumb and forefinger. 6: Wear long sleeves and long pants in dark colors when in high-risk areas.

1: Tuck pants legs into socks. 2: Wear closed shoes when hiking. 3: Apply insect repellent containing DEET. 4: Cover ground area with a blanket when sitting.

A client has had a left mastectomy with axillary lymph node dissection. The nurse determines that the client understands postoperative restrictions and arm care if the client states to: 1: Use gloves when working in the garden. 2: Use a straight razor to shave under the arms. 3: Carry a handbag and heavy objects on the left arm. 4: Allow blood pressures to be taken only on the left arm.

1: Use gloves when working in the garden.

A clinic nurse is assessing a client who had a total gastrectomy 2 months ago. The nurse checks which of the following that would indicate a specific complication of this surgical procedure? 1: Vitamin B12 and folic acid levels 2: Blood urea nitrogen levels 3: Pupillary response to light 4: Calcium levels

1: Vitamin B12 and folic acid levels

The nurse develops a discharge plan for a client with peripheral neuropathy of the lower extremities. The nurse should include which instructions in the plan? (Select all that apply.) 1: Wear support or elastic stockings. 2: Wear well-fitted shoes, and walk barefoot only when at home. 3: Wear dark-colored stockings or socks, and change them daily. 4: Use a heating pad set at the low setting on the feet if they feel cold. 5: Apply lanolin or lubricating lotion to the legs and feet once or twice daily. 6: Wash the feet and legs with mild soap and water and rinse and dry them well.

1: Wear support or elastic stockings. 5: Apply lanolin or lubricating lotion to the legs and feet once or twice daily. 6: Wash the feet and legs with mild soap and water and rinse and dry them well.

A nurse administers digoxin (Lanoxin) 0.25 mg by mouth rather than the prescribed dose of 0.125 mg to the client. Which should the nurse implement first? 1: Write an incident report. 2: Tell the client about the medication error. 3: Administer digoxin immune fab (Digibind). 4: Tell the client about the adverse effects of digoxin.

1: Write an incident report.

A nurse is assigned to care for a client admitted to the mental health unit with a diagnosis of mania. Which activity should the nurse provide for the client initially? 1: Writing 2: Playing cards with staff members 3: Playing checkers with other clients on the unit 4: Playing a board game with family members

1: Writing

A nurse is collecting data regarding a client's cigarette smoking one and one half packs per day for the past 15 years. The nurse would determine that the client has a smoking history of how many packs per year?

22.5 pack years

Following assessment and diagnostic evaluation, it has been determined that a client has stage II of Lyme disease. The nurse expects to note which assessment finding that is indicative of this stage? 1: Erythematous rash 2: Cardiac conduction defects 3: Arthralgias 4: Enlargement of joints

2: Cardiac conduction defects

The parents of a male newborn who is uncircumcised request information on how to clean the newborn's penis. The nurse should make which statement to the parents? 1: "Retract the foreskin and cleanse the glans when bathing the newborn." 2: "Avoid retracting the foreskin when cleaning the penis because this may cause adhesions." 3: "Retract the foreskin no farther than it will easily go and replace it over the glans after cleaning the penis." 4: "Retract the foreskin and cleanse the penis with every diaper change."

2: "Avoid retracting the foreskin when cleaning the penis because this may cause adhesions."

During a clinical conference, a nursing instructor asks a nursing student to explain the purpose of effleurage for a client in early labor. Which statement by the student indicates an understanding of the procedure? 1: "Effleurage is a form of biofeedback to enhance bearing-down efforts during delivery." 2: "Effleurage is light stroking of the abdomen to facilitate relaxation during labor." 3: Effleurage is the application of pressure to the sacrum to relieve a backache." 4: Effleurage stimulates uterine activity by contracting a specific muscle group while other parts of the body rest."

2: "Effleurage is light stroking of the abdomen to facilitate relaxation during labor."

A nurse is working with a client during crisis intervention. Which statement by the client indicates a successful outcome of crisis intervention? 1: "I still cannot return to work, but my concentration is better." 2: "I have learned that my old ways of coping did not work. I have learned new ways of dealing with things." 3: "I am sleeping better now." 4: I am going to have to work on repairing my relationship with my family."

2: "I have learned that my old ways of coping did not work. I have learned new ways of dealing with things."

A perinatal client with a history of heart disease has been instructed on care at home. Which statement by the client would indicate that the client understands her needs? 1: "There is no restriction on people who visit me." 2: "I should avoid stressful situation." 3: "My weight gain is not important." 4: "I should rest on my back."

2: "I should avoid stressful situation."

A nurse provides instructions to a pregnant woman regarding measures to relieve low back pain. Which statement by the client indicates an understanding of these measures? 1: "I will wear an abdominal support." 2: "I will do the pelvic tilt exercises." 3: "I need to work on relaxing my abdominal muscles when I stand." 4: "I need to wear shoes with a higher heel of at least 2 inches."

2: "I will do the pelvic tilt exercises."

The nurse encourages a client with Raynaud disease to engage in measures that will minimize effects of the disorder. Which statement by the client indicates an understanding of these measures? 1: "I will take daily cool baths." 2: "I will keep my hands and feet warm and dry." 3: "I will cut down on smoking." 4: "I will eat a high-protein diet."

2: "I will keep my hands and feet warm and dry."

A nurse provides instructions to a client beginning oral contraceptives. Which statement by the client indicates the need for further instructions? 1: "I will take one pill daily at the same time every day." 2: "I will not need to use an additional birth control method once I start these pills." 3: "If I miss a pill, I need to take it as soon as I remember." 4: "If I miss two pills, I will take them both as soon as I remember and I will take two pills the next day also."

2: "I will not need to use an additional birth control method once I start these pills."

A nurse is providing medication instructions to a client who is taking imipramine (Tofranil) daily. Which of the following statements by the client indicates a need for further instructions? 1: "I need to avoid alcohol while taking the medication." 2: "It is best to take the medication in the morning before breakfast." 3: "The effects of the medication may not be noticed for at least 2 weeks." 4: "If I miss a dose, I need to take it as soon as possible unless it is almost time for the next dose."

2: "It is best to take the medication in the morning before breakfast."

A camp nurse provides instructions regarding skin protection from the sun to the parents who are preparing their children for a camping adventure. Which statement by a parent indicates a need for further instructions? 1: "A protective sunscreen is best to prevent sunburn." 2: "My child won't need the sunscreen on cloudy, hazy days." 3: "I need to pack a hat, long-sleeved shirts, and long pants for my child to wear." 4: "My child should wear clothes that have a tightly woven material for greater protection from the sun's rays."

2: "My child won't need the sunscreen on cloudy, hazy days."

A nurse has provided instructions to a pregnant woman about food items to consume that contain folic acid. Which statement by the client indicates adequate understanding of the food items that contain folic acid? 1: "I will eat a banana every day." 2: "Peanuts, sunflower seeds, and raisins are high in folic acid." 3: "A glass of milk a day will be sufficient." 4: "I'll eat yogurt every day."

2: "Peanuts, sunflower seeds, and raisins are high in folic acid."

A client who is experiencing suicidal thoughts greets the nurse with the following statement, "It just doesn't seem worth it anymore. Why not just end it all?" The nurse should further assess the client by making which of the following responses? 1: "Did you sleep at all last night?" 2: "Tell me what you mean by that." 3: "I know you have had a stressful night." 4: "I'm sure that your family is worried about you."

2: "Tell me what you mean by that."

A nurse is caring for a client who is scheduled for radiation therapy. Which statement by the client indicates a common concern of clients receiving this therapy? 1: "I'm certain that this will do the trick." 2: "Will I be radioactive afterward?" 3: "This is just one of several options I have for treatment." 4: "This treatment is great because it is invisible and very effective."

2: "Will I be radioactive afterward?"

A 4-year-old child with cancer is admitted to the hospital for radiation therapy and surgery. To assess adequacy of support for the child's psychosocial needs, the nurse should ask the parents which of the following questions? 1: "What signs and symptoms has your child been having?" 2: "Will a family member be able to stay with the child most of the time?" 3: "How long have you known your child's diagnosis?" 4: "What are your child's favorite books, activities, and toys?"

2: "Will a family member be able to stay with the child most of the time?"

A nurse is caring for a client admitted to the hospital with acute myocardial infarction (MI). The nurse should monitor the client for which most common complication of MI? 1: Cardiogenic shock 2: Cardiac dysrhythmias 3: Congestive heart failure 4: Recurrent myocardial infarction

2: Cardiac dysrhythmias

A nurse is preparing to administer an intramuscular injection to a 10-year-old child in the vastus lateralis muscle. Which of the following indicates the maximum volume of medication that can be safely administered into this muscle? 1: 0.5 mL 2: 2.0 mL 3: 2.5 mL 4: 3 mL

2: 2.0 mL

A physician prescribes a diltiazem hydrochloride (Cardizem) intravenous bolus followed by an intravenous infusion of the same medication to control a rapid atrial fibrillation. In preparing the medication, the nurse is aware of which of the following? 1: A diltiazem hydrochloride bolus must be pushed very rapidly over a period of 2 to 3 seconds. 2: A diltiazem hydrochloride infusion should not infuse for more than 24 hours. 3: Diltiazem hydrochloride is the only effective beta-blocker for treating dysrhythmias. 4: Diltiazem hydrochloride increases myocardial contractility and thus increases oxygen demand.

2: A diltiazem hydrochloride infusion should not infuse for more than 24 hours.

The results of a nonstress test are documented in the chart as "no accelerations during a 40-minute observation." The nurse interprets these findings as which of the following? 1: A reactive nonstress test 2: A nonreactive nonstress test 3: Equivocal 4: Unsatisfactory

2: A nonreactive nonstress test

A nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following indicates the need for further action and analysis? 1: The need is clear breath sounds in a client with congestive heart failure 2: A postoperative client who develops a cough and a fever 3: The absence of a wound infection in a client who had a coronary artery bypass graft 4: A client with diabetes mellitus demonstrating accurate use of a glucometer following teaching

2: A postoperative client who develops a cough and a fever

A nurse is caring for a hospitalized client with a mechanical heart valve who is receiving maintenance therapy of warfarin sodium (Coumadin). The client's international normalized ratio is 3. The nurse anticipates which of the following prescriptions? 1: Holding the next dose of warfarin sodium 2: Administering the next dose of warfarin sodium 3: Increasing the next dose of warfarin sodium 4: Adding a dose of heparin

2: Administering the next dose of warfarin sodium

A client is due in hydrotherapy for a burn dressing change. To ensure that the procedure is most tolerable for the client, the nurse takes which of the following actions? 1: Ensures that the client has a robe and slippers. 2: Administers an analgesic 20 minutes before therapy. 3: Sends dressing supplies with the client to hydrotherapy. 4: Administers the intravenous antibiotic 30 minutes before therapy.

2: Administers an analgesic 20 minutes before therapy.

Which of the following school-aged children are at the greatest risk for developing Osgood-Schlatter disease? 1: A 6-year-old in which epiphyseal closure has not occurred 2: An active adolescent boy involved in sports activities 3: A child who is on the school swim team 4: A child with a history of multiple streptococcal throat infections

2: An active adolescent boy involved in sports activities

A nurse is caring for a client with schizophrenia and documents in the client's record that the client has a flat affect. Which of the following appropriately describes this behavior observed by the nurse? 1: A minimal emotional response 2: An immobile facial expression or blank look 3: An emotional response that is incongruent with the tone of the situation 4: Grimacing, giggling, or mumbling to oneself

2: An immobile facial expression or blank look

A home care nurse assigned to a client with cognitive-perceptual difficulties and fine motor coordination would request consultation with which of the following professionals? 1: A physical therapist 2: An occupational therapist 3: A speech pathologist 4: A recreational therapist

2: An occupational therapist

A clinic nurse is providing home care instructions to a client with a diagnosis of hordeolum. Which of the following instructions should the nurse provide to the client? 1: Apply a cool compress to the eye twice daily. 2: Apply a warm compress to the eye for 15 minutes four times daily. 3: Press on the hordeolum after using a warm compress to induce rupture. 4: Use over-the-counter antibiotic ointment for faster healing.

2: Apply a warm compress to the eye for 15 minutes four times daily.

A 3-year-old child is admitted to the hospital with a diagnosis of acute lymphocytic leukemia. The nurse assigned to care for the child is concerned because the child is crying and stating, "My knees hurt." Which of the following interventions should the nurse take? 1: Administer acetylsalicylic acid (aspirin). 2: Apply cold packs to the knees. 3: Apply a heating pad on low setting to the knees. 4: Attempt to involve the child in diversional activities to forget the discomfort.

2: Apply cold packs to the knees.

A client needs to receive a medication by intramuscular injection. Because this client is also on anticoagulant therapy, the nurse understands that safety measures for this client include which of the following protocols? 1: Applying a pressure bandage to the intramuscular site after the injection 2: Applying prolonged pressure to the intramuscular site after the injection 3: Decreasing the intramuscular needle size 4: Doubling the dose of the anticoagulant

2: Applying prolonged pressure to the intramuscular site after the injection

A nurse plans to change the dressing of the client who has had arterial bypass surgery. Which of the following techniques is most important for the nurse to follow? 1: Standard precautions 2: Aseptic technique 3: Clean technique 4: Reverse isolation technique

2: Aseptic technique

The registered nurse determines that the nursing student is performing the breath-auscultation procedure correctly if which observations are made? (Select all that apply.) 1: Uses the bell of the stethoscope. 2: Asks the client to sit up. 3: Places the stethoscope over the client's gown. 4: Has the client breathe slowly and deeply through the mouth. 5: Warms the diaphragm of the stethoscope before placing it on the client.

2: Asks the client to sit up. 4: Has the client breathe slowly and deeply through the mouth. 5: Warms the diaphragm of the stethoscope before placing it on the client.

A hospitalized client goes into respiratory distress and requires emergency intubation. After intubation, the nurse should take which of the following actions first to evaluate proper endotracheal tube placement? 1: Ask the client to take a deep breath. 2: Auscultate for bilateral breath sounds. 3: Check the endotracheal tube centimeter marking at the lip line. 4: Call for a stat chest radiograph

2: Auscultate for bilateral breath sounds.

Benztropine mesylate (Cogentin) is prescribed for a client with a diagnosis of Parkinson disease. The clinic nurse tells the client which of the following? 1: Sit in the sun for 30 minutes daily. 2: Avoid driving if drowsiness or dizziness occurs. 3: Expect difficulty swallowing while taking this medication. 4: Expect episodes of vomiting and constipation while taking this medication.

2: Avoid driving if drowsiness or dizziness occurs.

The nurse is developing a discharge-teaching plan for a client with chronic arterial insufficiency. Which of the following should the nurse include during the instruction? (Select all that apply) 1: Cross the legs at the ankles only. 2: Avoid the use of tobacco products. 3: Wear rounded toe shoes with soft insoles. 4: Wash feet daily with warm water and mild soap and dry well. 5: Use a mirror to visualize hard-to-access places of the feel weekly. 6: Seek assistance from a podiatrist for removal of corns, calluses, and ingrown toenails.

2: Avoid the use of tobacco products. 3: Wear rounded toe shoes with soft insoles. 4: Wash feet daily with warm water and mild soap and dry well. 6: Seek assistance from a podiatrist for removal of corns, calluses, and ingrown toenails.

A nurse is caring for a client diagnosed with Paget disease. The nurse plans care, knowing that this condition usually affects which of the following bones? 1: Anterior rib cage and sternum 2: Axial skeleton including vertebrae 3: Bones of the hands and feet 4: Shoulder and humerus

2: Axial skeleton including vertebrae

A hospice nurse visits a client dying of ovarian cancer. During the visit the client expresses, "If I can just live long enough to attend my daughter's graduation, I'll be ready to die." Which phase of coping is this client experiencing? 1: Isolation 2: Bargaining 3: Depression 4: Acceptance

2: Bargaining

A client is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurse assesses the client for which of the following manifestations? 1: Weight loss 2: Bilateral crackles 3: Distended neck veins 4: Peripheral pitting edema

2: Bilateral crackles

A client with chronic renal failure has received dietary counseling about potassium restriction in the diet. The nurse determines that the client has learned the information correctly if the client states to do which of the following for the preparation of vegetables? 1: Eat only fresh vegetables. 2: Boil them and discard the water. 3: Use salt substitute on them liberally. 4: Buy frozen vegetables whenever possible.

2: Boil them and discard the water.

A client is diagnosed with hypothyroidism. The nurse performs an assessment on the client, expecting to note which findings? (Select all that apply.) 1: Weight loss 2: Bradycardia 3: Hypotension 4: Dry, scaly skin 5: Heat intolerance 6: Decreased body temperature

2: Bradycardia 3: Hypotension 4: Dry, scaly skin 6: Decreased body temperature

A client is admitted to the hospital with a venous stasis leg ulcer. The nurse checks the ulcerated area for which of the following expected appearances? 1: Pale, cool, and dry skin surrounding the ulcer 2: Brown and edematous skin surrounding the ulcer 3: Pale, deep ulcer base 4: Brown ulcer base with no edema surrounding the ulcer

2: Brown and edematous skin surrounding the ulcer

A client comes into the health care clinic stating that she thinks she has restless leg syndrome. The nurse assesses the client and determines that which data are characteristics of this disorder? (Select all that apply.) 1: A heavy feeling in the legs 2: Burning sensations in the limbs 3: Symptom relief when lying down 4: Decreased ability to move the legs 5: Symptoms that are worse in the morning 6: Feeling the need to move the limbs repeatedly

2: Burning sensations in the limbs 6: Feeling the need to move the limbs repeatedly

A nurse participating in a free health screening at the local mall obtains a random blood glucose level of 190 mg/dL on an otherwise healthy client. The nurse should tell the client to do which of the following? 1: Begin blood glucose monitoring three times a day. 2: Call the physician to have the value rechecked as soon as possible. 3: Seek treatment for diabetes mellitus. 4: See the physician about starting insulin therapy.

2: Call the physician to have the value rechecked as soon as possible.

To work with a woman victimized by physical abuse successfully and appropriately, the nurse should take which of the following steps first? 1: Agree with the woman that it is possible that she might have acted in a manner that provoked the abuse. 2: Carefully examine her own personal attitudes toward the victim and abuser before working with the client. 3: Establish firm timelines for the woman to make the necessary changers in her life situation. 4: Reinforce with the woman that dealing with the psychological and physical aspects is the priority.

2: Carefully examine her own personal attitudes toward the victim and abuser before working with the client.

A nurse is performing nasopharyngeal suctioning of a client and suddenly notes the presence of bloody secretions. Which action should the nurse take first? 1: Continue suctioning to remove the blood. 2: Check the amount of suction pressure being applied. 3: Remove the suction catheter from the nose and begin vigorous suctioning through the mouth. 4: Encourage the client to cough out the bloody secretions.

2: Check the amount of suction pressure being applied.

A nurse is checking the reflexes on a neonate. In eliciting the startle reflex, the nurse should perform which of the following? 1: Stimulate the perioral cavity with a finger 2: Clap the hands or slap on the mattress. 3: Stimulate the pads of the hands by firm pressure. 4: Stimulate the ball of the foot by firm pressure.

2: Clap the hands or slap on the mattress.

A nurse has finished suctioning a client. The nurse uses which of the following parameters to best determine the effectiveness of suctioning? 1: SaO2 is 98% by pulse oximetry 2: Clear breath sounds 3: Client's statement of comfort 4: Pink client color

2: Clear breath sounds

A client with an anxiety disorder is also diagnosed with an acute inferior myocardial infarction and is placed on bed rest. The nurse includes measures in the plan of care to avoid which of the following potential complications related to bed rest? 1: Increased chest pain 2: Constipation 3: Diarrhea 4: Arthritis

2: Constipation

A nurse is giving a bed bath to an assigned client. The nurse learns that another assigned client is in pain and needs pain medication. Which of the following actions is appropriate for the nurse to take? 1: Finish the bed bath, and then administer the pain medication to the other client. 2: Cover the client, provide the client with the call bell, tell the client that you will return shortly, and administer the pain medication to the other client. 3: Ask the nursing assistant to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4: Ask the nursing assistant to find out when the last pain medication was given to the client.

2: Cover the client, provide the client with the call bell, tell the client that you will return shortly, and administer the pain medication to the other client.

Which assessment finding indicates a therapeutic response to baclofen (Lioresal)? 1: Decreased nausea 2: Decreased muscle spasms 3: Increased muscle tone and strength 4: Increased range of motion of all extremities

2: Decreased muscle spasms

A client with a personality disorder will begin recreational therapy as a component of the treatment plan. The nurse provides information to the client regarding the therapy, knowing that the modality is helpful for clients who show which of the following characteristics? 1: Anger 2: Difficulty socializing 3: Violent tendencies toward others 4: "Numbness" when experiencing intense feelings

2: Difficulty socializing

A young male client with Hodgkin disease is going to receive radiation therapy. The nurse should include which of the following psychosocial interventions in the plan of care for the client? 1: Checking skin integrity 2: Discussing sperm banking with the client 3: Measuring vital signs before each treatment 4: Monitoring temperature daily to prevent infection

2: Discussing sperm banking with the client

A nurse is monitoring a client diagnosed with a ruptured appendix for signs of peritonitis and assesses for which of the following? (Select all that apply.) 1: Bradycardia 2: Distended abdomen 3: Subnormal temperature 4: Rigid, boardlike abdomen 5: Diminished bowel sounds 6: Inability to pass flatus or feces

2: Distended abdomen 4: Rigid, boardlike abdomen 5: Diminished bowel sounds 6: Inability to pass flatus or feces

A nurse is caring for a term small-for-gestational-age (SGA) infant immediately after delivery. The nurse's initial plan of care in the delivery room to prevent heat loss to the infant would include which of the following? 1: Placing the infant in a prewarmed transport unit 2: Drying the infant with a warm blanket 3: Submerging the infant's body into a warm-water bath 4: Allowing the mother to hold the infant immediatey after delivery

2: Drying the infant with a warm blanket

A hospitalized client has developed a superficial thrombophlebitis of the right hand at an intravenous catheter site. The nurse should plan to do which of the following? (Select all that apply.) 1: Place an ice bag on the right hand. 2: Elevate the right arm above the heart level. 3: Offer acetaminophen (Tylenol) for pain. 4: Assess the hand for coolness and pallor. 5: Apply a warm compress to the right hand. 6: Immediately remove the intravenous catheter.

2: Elevate the right arm above the heart level. 3: Offer acetaminophen (Tylenol) for pain. 5: Apply a warm compress to the right hand. 6: Immediately remove the intravenous catheter.

A nurse is caring for a client with ascites. Which action should the nurse avoid in the management of this client? 1: Recording of abdominal girth daily at the level of the umbilicus 2: Encouraging frequent exercise to prevent atelectasis 3: Elevating the legs while in bed 4: Carefully maintaining a limit on sodium intake

2: Encouraging frequent exercise to prevent atelectasis

A nurse is planning care for a client with an obsessive-compulsive disorder. The nurse assigns initial priority to which of the following nursing interventions? 1: Educating the client about self-control techniques. 2: Establishing a trusting nurse-client relationship. 3: Monitoring the client for abnormal behavior. 4: Encouraging participation in daily self-care and unit activities.

2: Establishing a trusting nurse-client relationship.

A nurse has delegated several nursing tasks to staff members. The nurse's primary responsibility after the delegation of the tasks is to take which of the following actions? 1: Allow each staff member to make judgments when performing the tasks. 2: Follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task. 3: Document that the task was completed. 4: Assign the tasks that were not complete to the next nursing shift.

2: Follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task.

A nurse has delegated several nursing tasks to staff members. The nurse's primary responsibility after the delegation of the tasks is to take which of the following actions? 1: Allow each staff member to make judgments when performing the tasks. 2: Follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task. 3: Document that the task was completed. 4: Assign the tasks that were not completed to the next nursing shift.

2: Follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task.

A client diagnosed with hypothyroidism 3 months ago is at the clinic for a checkup. The nurse performs an assessment using which type of database? 1: Problem-centered database 2: Follow-up database 3: Comprehensive health database 4: Emergency database

2: Follow-up database

A client is diagnosed with terminal carcinoma of the lung, and the nurse is assisting the client to plan for end-of-life issues. The appropriate nursing intervention is to assist the client to take which of the following actions? 1: Explore all treatments before death, even if they seem futile. 2: Gain control over the end-of-life issues through creation of advance directives. 3: Engage an attorney to make all decisions for the client. 4: Direct the insurance company to pay all expenses upon death.

2: Gain control over the end-of-life issues through creation of advance directives.

A nurse prepares to discharge a female client who is 48 years old and experiencing family-related stress. Which goal does the nurse include to help the client achieve her primary developmental task? 1: Improve the client's acceptance of aging. 2: Help the client to resume her familial role. 3: Develop the client's critical thinking skills. 4: Adjust her lifestyle to ease stress response.

2: Help the client to resume her familial role.

A nurse is reviewing the serum laboratory test results for a client with sickle cell anemia. Which of the following parameters does the nurse anticipate will be elevated? 1: Sodium 2: Hemoglobin-S 3: Prothrombin time 4: Hemoglobin A1C

2: Hemoglobin-S

A nurse should review the laboratory results of a client with Cushing syndrome for which characteristic manifestation? 1: Hypokalemia 2: Hyperglycemia 3: Decreased plasma cortisol levels 4: Low white blood cell count

2: Hyperglycemia

A client with glomerulonephritis is at risk of developing acute renal failure. The nurse should monitor the client for which of the following signs of this complication? 1: Bradycardia 2: Hypertension 3: Decreased cardiac output 4: Decreased central venous pressure

2: Hypertension

An adult client is brought to the emergency department by ambulance after being hit by a car. The client is unconscious and in shock. A perforated spleen is suspected, and emergency surgery is required immediately to save the client's life. No family members are present, but the nurse finds identification on the client. In regard to informed consent for the surgical procedure, which of the following is the best nursing action? 1: Call a family member to obtain telephone consent before the surgical procedure. 2: Immediately transport the client to the surgical department. 3: Ask the hospital chaplain to sign the consent form. 4: Call the nursing supervisor to initiate a court order for the surgical procedure.

2: Immediately transport the client to the surgical department.

A client newly diagnosed with type 1 diabetes mellitus exercises daily. When teaching this client about medication therapy, the nurse tells the client to inject the daily dose of insulin in which of the following sites? 1: In any site as long as it is after exercise 2: In a site that will not be exercised 3: Only in the abdomen before exercise 4: Only in the arm before exercise

2: In a site that will not be exercised

A nurse caring for a hospitalized client participates in planning a birthday party for the client. When the family arrives and the party starts, the nurse enters the room and takes photographs of the client and the family. Which of the following violations has the nurse committed? 1: Breach of confidentiality 2: Invasion of privacy 3: Assault 4: Negligence

2: Invasion of privacy

A nurse is caring for a client who is receiving colchicine. The nurse determines that the client is responding favorably to the medication if which of the following signs and symptoms decrease? 1: Headaches 2: Joint inflammation 3: Blood glucose level 4: Serum triglyceride level

2: Joint inflammation

A nurse is planning stress management strategies for the client with irritable bowel syndrome. Which of the following suggestions should the nurse give to the client? 1: Try to avoid every possible stressful situation. 2: Learn measures such as biofeedback or progressive relaxation. 3: Limit exercise to reduce bowel stimulation. 4: Rest in bed as much as possible.

2: Learn measures such as biofeedback or progressive relaxation.

A mother of a toddler who is hospitalized with mild dehydration must leave her child to go to work. Which behavior would the nurse expect to observe in the toddler immediately after the mother's departure? 1: Silently curled in bed with a blanket 2: Loudly crying and kicking both legs 3: Playing quietly with a favorite toy 4: Sucking his thumb and rocking back and forth

2: Loudly crying and kicking both legs

A client's laboratory test results reveal a decreased serum transferrin and total iron-binding capacity. The nurse expects to note which disorder documented in the client's record as the most likely cause of the client's anemia? 1: Infection 2: Malnutrition 3: Iron deficiency 4: Sickle cell disease

2: Malnutrition

A client arrives at the emergency department complaining of increased anxiety and a sense of being "directionless" and "of no use to anyone." The client has recently retired from his job as a longshoreman. In planning for his care, the nurse knows that the client is suffering from which of the following types of crisis? 1: Situational crisis 2: Maturational crisis 3: Adventitious crisis 4: Nonspecific crisis

2: Maturational crisis

A nurse is evaluating the effectiveness of electroconvulsive therapy. An expected outcome of this therapy is which of the following? 1: No seizure activity accompanies the treatment. 2: Minor memory deficits are present after three months. 3: No long- or short-term memory deficits occur. 4: All symptoms of depression are absent.

2: Minor memory deficits are present after three months.

A nurse is called by a group of neighbors to the scene of a rural house fire, where a person fell down the stairs head first trying to escape the fire. The house is filling with smoke. Which of the following actions should the nurse take? 1: Place a wet towel over the victim's face and wait with the victim for the arrival of the fire department. 2: Move the victim by holding the head and neck in a neutral position. 3: Move the victim by logrolling the victim to a face-down position on a blanket. 4: Move the victim by pulling the victim's legs with the victim's back flat on the floor.

2: Move the victim by holding the head and neck in a neutral position.

A client is admitted to the emergency department with drug-induced anxiety related to overingestion of prescribed antipsychotic medication. The most important piece of information the nurse should obtain initially is the: 1: Name of the nearest relative and his or her phone number. 2: Name of the ingested medication and the amount ingested. 3: Cause of the attempt and if the client plans another attempt. 4: Length of time on the medication and any noted side effects.

2: Name of the ingested medication and the amount ingested.

During history taking of a client admitted to the hospital with newly diagnosed early-stage Hodgkin disease, which of the following would the nurse expect the client to report? 1: Weight gain 2: Night sweats 3: Severe lymph node pain 4: Headache with minor visual changes

2: Night sweats

A nurse notes that a client's eyes are continuously moving back and forth within the eye sockets. The nurse documents that the client is experiencing which of the following conditions? 1: Ataxia 2: Nystagmus 3: Pronator drift 4: Hyperreflexia

2: Nystagmus

A client is not able to leave home without checking several times to be sure that the iron is turned off. The client then rechecks the coffeepot several times to be sure that it is turned off. The client arrives late to many appointments and other functions because of this repetitive ritual and misses other engagements completely. The nurse interprets that the symptoms exhibited by this client are consistent with which of the following disorders? 1: Posttraumatic stress disorder 2: Obsessive-compulsive disorder 3: Generalized anxiety disorder 4: Phobia

2: Obsessive-compulsive disorder

A nurse is assessing the neurological status of a client who had a craniotomy 3 days ago. The nurse should notify the surgeon immediately if the client exhibits which of the following signs or symptoms? 1: Pupils equal and reactive at 4 mm in size 2: Pain with forward flexion of the neck onto the chest 3: Mild headache relieved by codeine sulfate 4: Disorientation to date

2: Pain with forward flexion of the neck onto the chest

The nurse develops a care plan for a client receiving hemodialysis who has an arteriovenous (AV) fistula in the right arm. The nurse includes which interventions in the plan to ensure protection of the AV fistula? (Select all that apply.) 1: Assess pulses and circulation proximal to the fistula. 2: Palpate for thrills and auscultate for a bruit every 4 hours. 3: Check for bleeding and infection at hemodialysis needle insertion sites. 4: Avoid taking blood pressure or performing venipunctures in the extremity. 5: Instruct the client not to carry heavy objects or anything that compresses the extremity. 6: Instruct the client not to sleep in a position that places his or her body weight on top of the extremity.

2: Palpate for thrills and auscultate for a bruit every 4 hours. 3: Check for bleeding and infection at hemodialysis needle insertion sites. 4: Avoid taking blood pressure or performing venipunctures in the extremity. 5: Instruct the client not to carry heavy objects or anything that compresses the extremity. 6: Instruct the client not to sleep in a position that places his or her body weight on top of the extremity.

The nurse is assessing a client who has been hospitalized with acute pericarditis for signs of complications. The nurse monitors the client for which manifestation of cardiac tamponade? 1: Bradycardia 2: Paradoxical pulse 3: Flattened jugular veins 4: Bounding heart sounds

2: Paradoxical pulse

A nurse develops a plan of care for a client who will be hospitalized for insertion of an internal cervical (vaginal) radiation implant. Which of the following should the nurse include in the plan of care for the client? 1: Place the client in a private room close to the nurses' station. 2: Place a radiation sign outside the door of the client's room. 3: Reinsert the implant into the vagina immediately if it becomes dislodged. 4: Limit visitors to 60-minute visits.

2: Place a radiation sign outside the door of the client's room.

The nurse instructs a mother of a child who had a plaster cast applied to the arm about measures that will help the cast dry. Which instructions should the nurse provide to the mother? (Select all that apply.) 1: Lift the cast using the fingertips. 2: Place the child on a firm mattress. 3: Direct a fan toward the cast to facilitate drying. 4: Support the cast and adjacent joints with pillows. 5: Place the extremity with the cast in a dependent position. 6: Reposition the extremity with the cast every 2 to 4 hours.

2: Place the child on a firm mattress. 3: Direct a fan toward the cast to facilitate drying. 4: Support the cast and adjacent joints with pillows. 6: Reposition the extremity with the cast every 2 to 4 hours.

A nurse is preparing to teach the parents of a child with anemia about the dietary sources of iron that are easy for the body to digest and absorb. Which food item should the nurse include in the teaching plan? 1: Fruits 2: Poultry 3: Apricots 4: Vegetables

2: Poultry

A nurse who has strong negative feelings toward a fellow employee tends to use the defense mechanism of projection. This nurse is likely to react to a disagreement with this employee by taking which of the following actions? 1: Slamming cupboards in the office 2: Telling a friend that this employee hates her of him 3: Getting angry at the supervisor 4: Apologizing and offering to go out to lunch together

2: Telling a friend that this employee hates her of him

A client is diagnosed with diabetes insipidus. The nurse performs an assessment on the client and expects to note which of the following? (Select all that apply.) 1: Bradycardia 2: Hypertension 3: Poor skin turgor 4: Increased urinary output 5: Dry mucous membranes 6: Decreased pulse pressure

3: Poor skin turgor 4: Increased urinary output 5: Dry mucous membranes 6: Decreased pulse pressure

A nurse is developing an educational session on client advocacy for the nursing staff. The nurse plans to tell the nursing staff that which of the following are examples of the nurse acting as a client advocate? (Select all that apply.) 1: Obtaining an informed consent for a surgical procedure 2: Providing information necessary for a client to make informed decisions 3: Providing assistance in asserting the client's human and legal rights if the need arises 4: Telling a client that he will need to defend himself about health care rights 5: Ignoring the client's religious or cultural beliefs when assisting the client in making an informed decision 6: Defending the client's rights by speaking out against policies or actions that might endanger the client's well-being

2: Providing information necessary for a client to make informed decisions 3: Providing assistance in asserting the client's human and legal rights if the need arises 6: Defending the client's rights by speaking out against policies or actions that might endanger the client's well-being

Two weeks after being diagnosed positive for human immunodeficiency virus infection, a client is referred for a mental health assessment. In assessing the client, the nurse understands that which of the following is characteristic two weeks after diagnosis? 1: The shock and disbelief would be resolved by anger, self-pity, and malingering. 2: Responding with symptomatology similar to posttraumatic stress disorder is common during the first few weeks in which the diagnosis is learned. 3: Experiencing anxiety and hypervigilance after the first week in which the diagnosis is learned is uncommon for the client. 4: Becoming depressed after learning of the diagnosis is uncommon because anxiety is the prevailing affective response.

2: Responding with symptomatology similar to posttraumatic stress disorder is common during the first few weeks in which the diagnosis is learned.

A nurse expects a client experiencing an acute myocardial infarction to first manifest which of the following patterns on the electrocardiogram? 1: An abnormal Q wave 2: ST segment elevation 3: T wave elevation 4: Absent P waves

2: ST segment elevation

A nurse is assessing a client with a suspected diagnosis of acute pancreatitis. The nurse should check the client for which characteristic sign of this disorder? 1: Severe abdominal pain relieved by lying flat and still 2: Severe abdominal pain that is unrelieved by vomiting 3: Hypothermia 4: Epigastric pain radiating to the neck area

2: Severe abdominal pain that is unrelieved by vomiting

The nurse notes that a client's cardiac rhythm on the cardiac monitor shows a rate of 53 beats per minute and a regular rhythm. The nurse interprets that the client is experiencing with of the following? 1: Atrial fibrillation 2: Sinus bradycardia 3: Ventricular fibrillation (VF) 4: Premature ventricular contractions (PVCs)

2: Sinus bradycardia

A nurse manager attends an educational conference on leadership styles. The nurse is seeking a leadership style that is adaptable depending on the situation and events. Which of the following leadership styles should the nurse select to achieve this goal? 1: Autocratic 2: Situational 3: Democratic 4: Laissez-faire

2: Situational

A nurse manager attends an educational conference on leadership styles. The nurse is seeking a leadership style that is adaptable depending on the situation and events. Which of the following leadership styles should the nurse select to achieve this goal? 1: Autocratic 2: Situational 3: Democratic 4: Laissez-faire

2: Situational

A physician is discussing the fluid balance of a postoperative client. The physician states that the client's insensible fluid loss is approximately 600 mL daily. The nurse interprets that the physician is referring to fluid loss that is occurring through which of the following? 1: Wound drain and skin 2: Skin and lungs 3: Nasogastric tube and wound drain 4: Foley catheter and nasogastric tube

2: Skin and lungs

A nurse is caring for a client with schizophrenia and notes that the client is experiencing poverty of speech. The nurse documents this finding based on which of the following assessment findings? 1: Speech is adequate in amount but conveys little information because of vagueness, empty repetitions, or use of stereotypes or obscure phrases. 2: Speech is restricted in amount and ranges from brief to monosyllabic one-word answers. 3: The client stops talking in the middle of a sentence. 4: The client remains quiet.

2: Speech is restricted in amount and ranges from brief to monosyllabic one-word answers.

A nurse is caring for a client in labor is receiving an oxytocin (Pitocin) infusion. The nurse notes the presence of tachycardia, decreased variability, and late decelerations on the fetal heart monitor. The nurse should immediately take which of the following steps? 1: Contact the physician 2: Stop the oxytocin infusion 3: Place the client in the Trendelenburg position 4: Check the maternal heart rate and blood pressure

2: Stop the oxytocin infusion

A client began receiving an intravenous (IV) infusion of packed red blood cells 30 minutes ago. The client turns on the call light and describes difficulty breathing, itching, and a tight sensation in the chest. Which of the following is the first action of the nurse? 1: Call the physician 2: Stop the transfusion 3: Check the client's temperature 4: Recheck the unit of blood for compatibility

2: Stop the transfusion

What equipment should the nurse plan to have at the bedside when initiating a clear liquid diet in a postoperative client who has had general anesthesia? 1: Oxygen via nasal cannula 2: Suction equipment 3: Cardiac monitor 4: A straw and a Styrofoam cup

2: Suction equipment

A nurse has collected nutritional data from a client with a diagnosis of cystitis. The nurse determines that which of the following beverages needs to be eliminated from the client's diet to minimize the recurrence of cystits? 1: Fruit juice 2: Tea 3: Water 4: Lemonade

2: Tea

A nurse is caring for a client with severe cardiac disease. During care, the client states, "If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me." Based on the client's statement, which of the following nursing actions is appropriate? 1: Tell the client that cardiopulmonary resuscitation, which includes external cardiac massage, cannot legally be refused by a client if the doctor feels that it is necessary to save the client's life. 2: Tell the client that it is necessary to notify the physician of the client's request. 3: Tell the client that the family must agree with the client's request. 4: Plan a client conference with the nursing staff to share the client's request.

2: Tell the client that it is necessary to notify the physician of the client's request.

A nurse is caring for a hospitalized child who is immobilized as a result of traction. The nurse develops a plan of care and formulates outcomes for a nursing diagnosis of delayed growth and development related to immobilization and hospitalization. Using this nursing diagnosis, which of the following indicates a positive outcome for this child? 1: The fracture heals without complications. 2: The child displays age-appropriate developmental behaviors. 3: The caregivers verbalize the desire to provide safe and effective home care. 4: The child maintains normal joint and muscle integrity.

2: The child displays age-appropriate developmental behaviors.

A client has a Mantoux skin test done. The results indicate an area of induration that is 8 mm in size. The nurse should make which interpretation based on this finding? 1: The client has active tuberculosis. 2: The client has a negative response. 3: The client has a history of tuberculosis. 4: The client has been exposed to tuberculosis.

2: The client has a negative response.

A nurse observes that a client who had a brain attack (stroke) 2 weeks ago is using foul language when speaking with his wife. The nurse's interpretation of the situation is which of the following? 1: The client is abusive. 2: The client is frustrated. 3: The wife lacks attention. 4: A need for family counseling exists.

2: The client is frustrated.

Which goal would be appropriate for the client in the emergency department being treated for rape-trauma syndrome? 1: The client will accept the trauma that has happened. 2: The client will begin the healthy grief process. 3: The client will not experience psychological trauma. 4: The client will not use defense mechanisms.

2: The client will begin the healthy grief process.

A nurse administers hydralazine hydrochloride (Apresoline) to a client with autonomic dysreflexia. Which of the following findings indicates that the medication is effective? 1: The client's muscle spasms subside. 2: The client's blood pressure declines. 3: The intensity of the client's seizure activity declines. 4: The client states that he or she feels better.

2: The client's blood pressure declines.

A nurse is analyzing the assessment data obtained from a client with physical injuries and suspected family-related violence. In analyzing the data, the nurse should first consider: 1: The client's support systems 2: The client's vital signs 3: The evidence and extent of past injuries 4: The client's explanations as to how the injuries occurred

2: The client's vital signs

A family is experiencing the impending death of their youngest child who is 4 years old. The siblings are ages 6,9, and 10 years of age. The nurse develops which appropriate goal for the family? 1: The three siblings will be kept from visiting the dying child to protect them from being upset unnecessarily. 2: The parents and siblings will spend private family time together with the dying child. 3: The parents will frequently remind the dying child to talk about getting better and going home. 4: The parents will wait for the children to bring up the subject of death and dying.

2: The parents and siblings will spend private family time together with the dying child.

A client says to the nurse, "I hate these discolored areas on my skin." The nurse determines which of the following problems exists for this client? 1: The presence of chronic low self-esteem 2: The presence of body image disturbance 3: The inability to cope 4: The presence of skin breakdown

2: The presence of body image disturbance

A client is admitted to the cardiac intensive care unit after coronary artery bypass graft surgery. The nurse notes that in the first hour after admission, the mediastinal chest tube drainage was 75 mL. During the second hour, the drainage has dropped to 5 mL. The nurse interprets that: 1: This is normal. 2: The tube may be occluded. 3: The lung has fully reexpanded. 4: The client needs to cough and take deep breaths.

2: The tube may be occluded.

A nurse has completed nutritional counseling with an overweight client about weight reduction to modify the risk for coronary artery disease. The nurse would determine the teaching as successful if the client states that a safe weight loss goal is: 1: One half pound per day 2: Two pounds per week 3: Four pounds per week 4: Six pounds per week

2: Two pounds per week

A client with angina pectoris tells the nurse that chest pain usually occurs after going up two flights of stairs. Recently the client has had three more severe episodes of chest pain while watching television, while going down stairs, and after falling asleep. The nurse interprets that the client is now experiencing which of the following types of angina? 1: Nocturnal angina 2: Unstable angina 3: Variant angina 4: Intractable angina

2: Unstable angina

A client with an endotracheal tube is easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which of the following methods for communication may be easiest for the client? 1: Ask the family to interpret for the client's needs. 2: Use a picture or word board. 3: Use a pad and paper. 4: Devise a system of hand signals.

2: Use a picture or word board.

A nurse understands that people from the Hispanic cultural group tend to exhibit which of the following characteristics or actions? 1: Be offended if the interviewer makes direct eye contact 2: Use home medicines in addition to prescription medications 3: Defer all questions to the male members of the family 4: Do not permit treatment with blood transfusions

2: Use home medicines in addition to prescription medications

A nurse instructor is speaking about immunizations, specifically killed or inactivated vaccines. The nursing student correctly describes these vaccines as: 1: Vaccines that have their virulence (potency) diminished so as to not produce a full-blown clinical illness 2: Vaccines that contain pathogens made inactive by either chemicals or heat 3: Bacterial toxins that have been made inactive by either chemicals or heat 4: Vaccines that have been obtained from the pooled blood of many people and provide antibodies to a variety of diseases

2: Vaccines that contain pathogens made inactive by either chemicals or heat

When assessing a child with a dog bite, which of the following is a priority question for the nurse to ask? 1: "How old is the dog?" 2: "Did the dog have rabies?" 3: "Are the child's immunizations up-to-date?" 4: "Did the dog have all of its recommended shots?"

3: "Are the child's immunizations up-to-date?"

A nurse provides information about the influenza vaccine to a client. The nurse determines that the client needs additional information if the client states: 1: "I shouldn't get the vaccine because I'm allergic to eggs." 2: "I'll get the flu vaccine this fall." 3: "I don't need the vaccine this year because I had one last year." 4: "I should get a flu vaccine even though I'm healthy."

3: "I don't need the vaccine this year because I had one last year."

A nurse suspects that a female client is a victim of physical abuse. Which statement encourages the client to confide in the nurse? 1: "You've got a huge bruise on your face. Did your husband hit you?" 2: "If your husband has hit you, you can take him to court or get a restraining order for that." 3: "I sometimes see women who have been hurt by their boyfriends or husbands. Did anyone hit you?" 4: "That looks very sore. I don't know how people can do that to one another."

3: "I sometimes see women who have been hurt by their boyfriends or husbands. Did anyone hit you?"

Which statement by the mother of a 2 1/2-year-old child indicates the need for education regarding dental care? 1: "Aged cheese is a good snack instead of sweets for a young child." 2: "I took my child for his first dental examination right after his second birthday." 3: "It is not necessary to teach proper dental care to a toddler. Their baby teeth just fall out anyway." 4: "I have my child brush his teeth with clear water because he sometimes swallows the toothpaste."

3: "It is not necessary to teach proper dental care to a toddler. Their baby teeth just fall out anyway."

A home care nurse is caring for an older client. The client is a widower and competent, but his son, daughter-in-law, and their three children have unexpectedly moved into the house "to care for him." Which statement by the client indicates to the nurse that the client is being exploited? 1: "My son won't let me pay for anything. They're helping me with everything. This is such a help to me because my income's been reduced since my wife died." 2: "Once in a while the children get to be to noisy, but overall it's been the best thing that's happened to me since my wife died." 3: "My son wants me to turn over the deed to the house to him. He says I'll always have a place there, but I'll feel like a tenant in my own home. What do you think?" 4: "It's nice to have my family around me again. Since my wife died, I've been lonely, and they're keeping me young and spoiling me rotten."

3: "My son wants me to turn over the deed to the house to him. He says I'll always have a place there, but I'll feel like a tenant in my own home. What do you think?"

A nurse is monitoring a client for complications following thyroidectomy. The nurse notes that the client's voice is very hoarse, and the client is concerned about the hoarseness and asks the nurse about it. The nurse should make which of the following responses to alleviate the client's concern? 1: "Hoarseness and a weak voice may indicate permanent damage to the nerves." 2: "This complication is expected." 3: "This problem is temporary and will probably subside in a few days." 4: "It is best that you not talk at all until the problem is further evaluated."

3: "This problem is temporary and will probably subside in a few days."

A nurse uses the proverb, "While the cat's away, the mice will play!" to evaluate for abstract thinking ability in a schizophrenic client. Which of the following client responses demonstrates appropriate abstract thinking? 1: "Cats and mice don't play. They fight." 2: "I don't have a cat." 3: "When the boss is gone, everyone relaxes in the office." 4: "When the cat is gone, then the mice can get the cheese."

3: "When the boss is gone, everyone relaxes in the office."

A nurse checks the laboratory result for a serum digoxin level that was drawn on an adult client taking digoxin (Lanoxin) 0.125 mg daily. Which laboratory result would indicate a therapeutic level? 1: 0.1 ng/mL 2: 0.3 ng/mL 3: 1.8 ng/mL 4: 2.4 ng/mL

3: 1.8 ng/mL

A client is brought to the emergency department immediately after a smoke inhalation injury. The initial nursing action would be to prepare the client to receive which of the following: 1: Pain medication 2: Oxygen via nasal cannula 3: 100% humidified oxygen by face mask 4: Endotracheal intubation

3: 100% humidified oxygen by face mask

A nurse is a physician's office is reviewing the results of a client's phenytoin (Dilantin) level that was drawn that morning from a client with a seizure disorder. The nurse determines that the level is therapeutic if which of the following values is documented? 1: 3 mcg/mL 2: 8 mcg/mL 3: 15 mcg/mL 4: 24 mcg/mL

3: 15 mcg/mL

A registered nurse (RN) is implementing a team nursing approach. The RN has a licensed practical nurse and a nursing assistant on the team and is planning the client assignments for the day. The RN appropriately assigns which of the following clients to the licensed practical nurse? 1: A client who needs assistance with grooming. 2: A client who needs frequent ambulation. 3: A client who needs to be suctioned as needed (PRN). 4: A client who needs assistance with hygiene measures.

3: A client who needs to be suctioned as needed (PRN).

Which client is at the greatest risk for developing a skin disorder? 1: An athlete 2: An adolescent 3: A client who uses an indoor tanning bed 4: An older client

3: A client who uses an indoor tanning bed

A woman is admitted to the inpatient mental health unit. When asked her name, she responds, "I am the First Lady, the President of the United States' wife." The nurse concludes that this client is experiencing which of the following? 1: A visual illusion 2: An auditory hallucination 3: A grandiose delusion 4: A loose association

3: A grandiose delusion

A client receiving therapy with carbidopa/levodopa (Sinemet) is upset and tells the home care nurse that his urine has turned a darker color since he began to take this medication. The client wants to discontinue its use. The nurse interprets these concerns as which of the following? 1: An indication of developing toxicity 2: A sign of interaction with another medication 3: A harmless side effect of the medication 4: A result of taking the medication with milk

3: A harmless side effect of the medication

A client asks a nurse about the risk factors and methods of prevention of prostate cancer, and the nurse reviews the information with the client. Which statement by the client indicates a need to further review this information? 1: Men aged 50 years and older should be monitored with a yearly digital rectal examination. 2: An occupationally related risk factor is exposure to and handling cadmium batteries. 3: A high-fat diet will assist in preventing this type of cancer. 4: African-American men have a high incidence of this type of cancer.

3: A high-fat diet will assist in preventing this type of cancer.

A nurse is caring for a client with hypertension receiving furosemide (Lasix) daily. Which of the following would indicate to the nurse that the client might be experiencing a side effect related to the medication? 1: A chloride level of 98 mEq/L 2: A sodium level of 135 mEq/L 3: A potassium level of 3.1 mEq/L 4: A blood urea nitrogen (BUN) level of 15 mg/dL

3: A potassium level of 3.1 mEq/L

In reviewing the record of a client, a nurse notes that the physician has documented the presence of Chvostek sign. Based on this documentation, which of the following would the nurse expect to note on assessment of the client? 1: Discoloration of the abdomen and periumbilical area is present. 2: Carpal spasm is elicited by compressing the upper arm and causing ischemia to the nerves distally. 3: A spasm of the facial muscles is elicited by tapping the facial nerve in the region of the parotid gland. 4: The epidermal skin layer can be rubbed off by slight friction.

3: A spasm of the facial muscles is elicited by tapping the facial nerve in the region of the parotid gland.

When working with clients diagnosed with anxiety disorders, the nurse interprets that a client with which of the following problems is least likely to be treated with behavior therapy? 1: Obsessive-compulsive disorder 2: Posttraumatic stress disorder 3: Agoraphobia 4: Panic disorder

3: Agoraphobia

A nurse is caring for a client who recently had a jugular catheter inserted. After connected new tubing at the insertion site, the client states, "I feel lightheaded, weak, and somewhat short of breath." Which of the following should the nurse suspect may be occurring? 1: Fluid overload 2: Pneumothorax 3: Air embolism 4: Septicemia

3: Air embolism

The nurse determines that fetal tissue perfusion is adequate in a client diagnosed with placental abruption if which of the following is noted? 1: Decreased fetal heart rate (FHR) variability 2: Presence of late decelerations in FHR 3: Presence of accelerations in FHR 4: Evidence of fetal bradycardia

3: Presence of accelerations in FHR

A 14-year-old female client is having difficulty adjusting to the long confinement in the hospital in Crutchfield traction. Which nursing intervention is appropriate to assist the client? 1: Allow the client dye her hair blue to conform to what her peers are doing. 2: Allow the client to play loud music in the hospital room. 3: Allow the client wear her own clothes when friends visit. 4: Honor the client's request to stay in a private, darkened room with no visitors.

3: Allow the client wear her own clothes when friends visit.

The nurse is teaching a mother about follow-up care for her 6-month-old child, who just received a third diphtheria, tetanus, and pertussis (DTP) immunization. The nurse stresses that: 1: Local reactions will occur 2 weeks after the injection. 2: Acetylsalicylic acid (aspirin) should be used prophylactically for discomfort. 3: Any unusual side effects should be reported immediately to the physician. 4: The child must avoid contact with immunosuppressed individuals.

3: Any unusual side effects should be reported immediately to the physician.

An adult calls the emergency department and tells the nurse that he received a bee sting to his arm while weeding a garden. The client states that he is not allergic to bees. The client also states that the site is painful and asks the nurse for advice to alleviate the pain. The nurse should tell the client to take which action to alleviate the pain? 1: Take two acetaminophen (Tylenol.) 2: Place a heating pad to the site. 3: Apply ice and elevate the site. 4: Lie down and elevate the arm.

3: Apply ice and elevate the site.

A nurse is developing a teaching plan for a client with diabetes mellitus about proper foot care. The nurse should include which of the following information in the teaching session? 1: Cut toenails down to the nail plate. 2: Place a heating pad on the feet if they become chilled. 3: Apply lotion to dry skin areas except between the toes. 4: Wear open-heel and open-toe shoes in warm weather.

3: Apply lotion to dry skin areas except between the toes.

A nurse is performing a sterile wound irrigation on an assigned client. A nursing assistant enters the client's room and tells the nurse that a physician has telephoned and requests to speak to the nurse. The appropriate nursing action is which of the following? 1: Finish the wound irrigation while the physician waits on the telephone. 2: Cover the client and answer the telephone call. 3: Ask the nursing assistant to obtain a telephone number from the physician so that the call can be returned after the wound irrigation. 4: Ask the nursing assistant to take a message.

3: Ask the nursing assistant to obtain a telephone number from the physician so that the call can be returned after the wound irrigation.

A nurse who has never had chickenpox is assigned to care for a client with a diagnosis of herpes zoster. Which of the following is the appropriate nursing action regarding care for this client? 1: Wear a particulate filtered mask while caring for the client. 2: Have the client wear a mask during care. 3: Ask to be assigned to a different client. 4: Ask another staff member to assist with care to limit the time exposed to the client.

3: Ask to be assigned to a different client.

An infant crawling on the floor of the playroom suddenly begins to cough and make loud, high-pitched wheezing sounds when breathing. The nurse immediately considers which of the following? 1: Difficulty clearing the airway because of the developmental stage 2: Increased susceptibility for infection related to an immature immune function 3: Aspiration caused by the ingestion of a foreign object 4: Difficulty breathing related to inhalation of an allergen

3: Aspiration caused by the ingestion of a foreign object

A nurse reviews an electrocardiogram rhythm strip and finds an irregular baseline with no identifiable P waves. Additionally, the QRS complexes are very irregular. The nurse analyzes this finding as which of the following? 1: Normal findings 2: Major ventricular dysrhythmia 3: Atrial fibrillation 4: A cause of increased cardiac output

3: Atrial fibrillation

A client has parental nutrition initiated per physician's prescription at 75 mL per hour. The nurse caring for the client plans to monitor which of the following parameters? 1: Urine output hourly 2: Vital signs hourly 3: Blood glucose levels every 4 to 6 hours 4: Dependent edema hourly

3: Blood glucose levels every 4 to 6 hours

A home care nurse provides instructions to the client with a halo vest. The nurse tells the client to: 1: Loosen the bolts once a day for bathing. 2: Have the spouse use the metal frame to assist the client to sit up. 3: Carry the correct size wrench to loosen the bolts in an emergency. 4: Perform pin care three times a week using hydrogen peroxide or alcohol.

3: Carry the correct size wrench to loosen the bolts in an emergency.

A client says to the nurse, "On the track, have a Big Mac, or get in the sack." The nurse recognizes that this is an example of which of the following disturbed thoughts or language patterns? 1: Thought broadcasting 2: Word salad 3: Clang associations 4: Echolalia

3: Clang associations

A client complains of pain in the mouth 10 days after receiving chemotherapy. Which of the following should the nurse address as a priority? 1: Inadequate nutritional intake 2: Presence of skin breakdown 3: Client complaints of pain 4: Increased susceptibility for infection

3: Client complaints of pain

A nurse assigned to care for a client with anorexia nervosa sees a notation about the presence of body image disturbance in the client's record. The nurse determines that which of the following would be an appropriate goal for this client? 1: Client verbalizes knowledge of maintenance diet and expected average weight. 2: Client practices problem-solving approaches to deal with issues such as roles, sexuality, and social interactions with others. 3: Client verbalizes body size accurately and states a beginning acceptance of a more mature-appearing body. 4: Client practices beginning assertive behavioral skills.

3: Client verbalizes body size accurately and states a beginning acceptance of a more mature-appearing body.

A construction worker who fell from a building was brought to the emergency department by the ambulance team. Despite emergency measures, the client dies. The client's fiancée who quickly arrives at the emergency room after notification of the accident tells the nurse that the client is an organ donor. In anticipation that the client's eyes will be donated, which of the following interventions should the nurse implement initially? 1: Call the National Eye Bank to confirm that the client is a donor. 2: Position the deceased client supine and place dry sterile dressings over the eyes. 3: Close the deceased client's eyes and place a gauze pad and small ice pack on the eyes. 4: Ask the fiancée to obtain the client's will from the lawyer.

3: Close the deceased client's eyes and place a gauze pad and small ice pack on the eyes.

A client enters the health care clinic after an episode of Raynaud phenomenon. The nurse should ask the client about a history of which of the following that may be associated with this disorder? 1: Microemboli as a result of atrial fibrillation 2: Chronic peripheral venous insufficiency 3: Collagen disorder such as lupus erythematosus 4: Lung disorders such as chronic airflow limitation

3: Collagen disorder such as lupus erythematosus

A client with Parkinson disease quickly develops akinesia while ambulating, increasing the risk for falls. Which of the following suggestions should the nurse provide to the client to alleviate this problem? 1: Stand erect, and use a cane to ambulate. 2: Keep the feet close together while ambulating, and use a walker. 3: Consciously think about walking over imaginary lines on the floor. 4: Use a wheelchair to move around.

3: Consciously think about walking over imaginary lines on the floor.

Which of the following actions must be taken for a client receiving tranylcypromine (Parnate) and sertraline (Zoloft) concurrently? 1: Teach the client how to take these two prescribed medications. 2: Ensure client understanding that it will take a week for the sertraline to exert its effects. 3: Consult with the physician and instruct the client to discontinue the sertraline for 2 weeks before starting tranylcypromine. 4: Instruct the client to limit alcohol to two glasses of wine daily.

3: Consult with the physician and instruct the client to discontinue the sertraline for 2 weeks before starting tranylcypromine.

A nurse is monitoring a postoperative client who just had a radical neck dissection. The nurse notes a coarse, high-pitched sound on inspiration when auscultation over the trachea. Based on this finding, which immediate action should the nurse take? 1: Suction the client. 2: Place the client in a supine position. 3: Contact the physician. 4: Obtain a pulse oximetry machine.

3: Contact the physician.

A client diagnosed with acquired immunodeficiency syndrome (AIDS) shares feelings of social isolation with the nurse. Which strategy does the nurse suggest to the client to decrease these feelings? 1: Using the internet to facilitate communication 2: Using television and newspapers to maintain a feeling of being "in touch" with the world 3: Contacting any of the local support groups for clients with AIDS 4: Reinstituting contact with the client's family, who live in a distant city

3: Contacting any of the local support groups for clients with AIDS

A multigravida woman with a history of multiple cesarean births is admitted to the maternity unit in labor. The client is experiencing excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which of the following findings is an indication that complete uterine rupture may have occurred? 1: Excessive vaginal bleeding 2: Maternal bradycardia 3: Decreasing blood pressure 4: Increased uterine contractions

3: Decreasing blood pressure

The nurse is assessing the respiratory status of the client following thoracentesis. The nurse would become most concerned with which of the following assessment findings? 1: Equal bilateral chest expansion 2: Respiratory rate of 22 breaths per minute 3: Diminished breath sounds on the affected side 4: Few scattered wheezes, unchanged from baseline

3: Diminished breath sounds on the affected side

A nurse notes that a client with acquired immunodeficiency syndrome appears anxious and is reluctant to ask questions. Which of the following actions does the nurse take first to best deal with these observations? 1: Minimize the time spent talking to the client. 2: Ask a family member to be present when caring for the client. 3: Discuss common fears and questions expressed by other clients with the same diagnosis. 4: Ask the client why he is reluctant to ask questions.

3: Discuss common fears and questions expressed by other clients with the same diagnosis.

A client hospitalized in the mental health unit is angry and punches the wall. Which defense mechanism is the client using? 1: Denial 2: Regression 3: Displacement 4: Reaction formation

3: Displacement

A nurse is caring for a client who has just had a mastectomy. The nurse assists the client in doing which of the following exercises during the first 24 hours after surgery? 1: Hand wall climbing 2: Pendulum arm swinging 3: Elbow flexion and extension 4: Shoulder abduction and external rotation

3: Elbow flexion and extension

A client is experiencing acute cardiac and cerebral symptoms as a result of an excess fluid volume. The nurse should implement which of the following measures to increase the client's comfort until specific therapy is prescribed by the physician? 1: Measure urine output on an hourly basis. 2: Measure intravenous and oral fluid intake. 3: Elevate the client's head to at least 45 degrees. 4: Administer oxygen at 4 liters per minute by nasal cannula.

3: Elevate the client's head to at least 45 degrees.

A nurse is accepting a postcraniectomy client in transfer from the postanesthesia care unit. Because the client's incision is supratentorial, the nurse plans to assist the client into which of the following positions that will most likely be prescribed? 1: Lowering the head of the bed flat 2: Lying supine 3: Elevating the head of the bed 30 degrees 4: Lying on the operative side

3: Elevating the head of the bed 30 degrees

A client hospitalized with hepatitis complains of fatigue and feelings of depression. The nurse should plan which of the following strategies to help the client cope effectively during recuperation? 1: Encourage lengthy visits by the family. 2: Have the client remain in the unit lounge during the day. 3: Encourage restful diversional activities per client preference. 4: Concentrate all activities requiring exertion early in the day.

3: Encourage restful diversional activities per client preference.

A client receives a diagnosis of late-stage human immunodeficiency virus infection, and the client and family are extremely upset about the diagnosis. The priority psychosocial nursing intervention for the client and family is to: 1: Tell the client and family to stop smoking because it will predispose the client to respiratory infections. 2: Tell the client and family that raw or improperly washed foods can produce microbes. 3: Encourage the client and family to discuss their feelings about the disease. 4: Advise the client to avoid becoming pregnant because of the risk of transmission of the infection.

3: Encourage the client and family to discuss their feelings about the disease.

A staff nurse makes negative comments about a unit manager's leadership style, and the unit manager overhears the staff nurse. Which of the following actions by the unit manager is appropriate? 1: Tell the staff nurse to stop making the comments. 2: Propose a tentative solution regarding the comments, and discuss it with the staff nurse. 3: Encourage the staff nurse to discuss the comments. 4: Persuade the staff nurse to stop being so critical.

3: Encourage the staff nurse to discuss the comments.

A nurse assigned to care for a postpartum client plans to promote parent-infant bonding by encouraging the parents to take which of the following actions? 1: Use a low-pitched voice to speak to the infant. 2: Allow the nursing staff to assume the infant care during hospitalization so they may rest. 3: Hold and cuddle the infant closely. 4: Allow the infant to sleep in the parental bed between the parents.

3: Hold and cuddle the infant closely.

A clinic nurse is gathering data from a client and notes that the client is taking terazosin hydrochloride (Hytrin). Based on the action of this medication, the nurse asks the client about a history of which of the following disorders? 1: Cushing syndrome 2: Peptic ulcer disease 3: Hypertension 4: Esophagitis

3: Hypertension

A nurse is obtaining a history from a client diagnosed with coronary artery disease (CAD). The nurse determines that which items pertinent to the client's history are modifiable risk factors for CAD? 1: Age and obesity 2: Family history and stress 3: Hypertension and cigarette smoking 4: Gender and ethnicity

3: Hypertension and cigarette smoking

A client has been newly diagnosed with hypertension. The nurse plans to do which of the following as the first step in teaching the client about the disorder? 1: Gather all available resource materials. 2: Plan for the evaluation of the session. 3: Identify the client's knowledge and needs. 4: Decide on the teaching approach.

3: Identify the client's knowledge and needs.

A home care nurse visits a client who has just been discharged from the hospital after a fenestration procedure for the treatment of otosclerosis. Which of the following instructions should the nurse provide the client? 1: Drink liquids through a straw for the next few weeks. 2: Showering is permitted but swimming is to be avoided. 3: Increase fluids and take a stool softener daily. 4: No limitations with activities are recommended with this type of surgery.

3: Increase fluids and take a stool softener daily.

A nurse is providing dietary instructions to a client with uric acid renal calculi. The nurse should tell the client that it would be helpful to: 1: Include organ meat-type foods in the diet. 2: Increase intake of seafood in the diet. 3: Increase intake of legumes in the diet. 4: Increase intake of cranberries and citrus fruits.

3: Increase intake of legumes in the diet.

A client being seen in the ambulatory care clinic has a history of being treated for syphilis infection. The nurse determines that the client has been reinfected if which of the following characteristics is noted in a penile lesion? 1: Papular areas and erythema 2: Cauliflower-like appearance 3: Induration and absence of pain 4: Multiple vesicles, with some that have ruptured

3: Induration and absence of pain

A client has undergone urinary diversion after cystectomy for bladder cancer. The nurse assesses the client's urostomy stoma to ensure that it shows which of the following characteristics? 1: It is pale and pink 2: It is pink and dry 3: It is red and moist 4: It is dusky to beefy colored

3: It is red and moist

A nurse develops a plan of care for an adolescent being admitted to the hospital for treatment of a slipped capital femoral epiphysis. Which priority consideration should the nurse note? 1: The presence of grief that is due to life-threatening diagnosis 2: The presence of interrupted personal identity that is due to immobilization 3: Lack of diversional activity that is due to immobilization and bed confinement 4: Increased susceptibility for deficient fluid volume that is due to a negative nitrogen balance

3: Lack of diversional activity that is due to immobilization and bed confinement

A nurse is developing a plan of care for a client placed in Buck extension traction after a hip fracture. The nurse determines that the priority consideration in caring for the client receiving this treatment is which of the following? 1: Lack of diversional activity as a result of bed rest. 2: Difficulty with bathing and other self-care measures because of the need for traction. 3: Lack of mobility as a result of the traction device. 4: Difficulty with social interactions because of the need for traction.

3: Lack of mobility as a result of the traction device.

A community health nurse has been called to assist with problem solving for a group of homeless people in a certain area of a city. In planning for the needs of this group, what immediate concern should the nurse attend to? 1: Encourage peer support through structured groups 2: Setting up a 24-hour crisis center and hotline 3: Meeting the client's basic needs (food, shelter, and clothing) 4: Finding affordable housing for the group

3: Meeting the client's basic needs (food, shelter, and clothing)

A community health nurse is providing a teaching session regarding the risks of breast cancer. The nurse determines that further information needs to be provided if an attendee states that which of the following is an associated risk factor for this type of cancer? 1: Family history of any first-degree relative with breast cancer. 2: History of cancer in one breast 3: Menstrual history of late menarche 4: History of late menopause

3: Menstrual history of late menarche

A nurse is developing a plan of care for a client who is experiencing a decrease in fluid volume after a burn injury. Which nursing intervention is appropriate to include in the plan? 1: Obtain and record weight every other day. 2: Monitor intake and output (I&O) every shift. 3: Monitor mental status every hour. 4: Monitor vital signs every 4 hours

3: Monitor mental status every hour.

A hospitalized client is diagnosed with scabies. The infection control nurse provides an educational session for the nursing staff to provide them with information regarding the assessment findings associated with this disorder. Which of the following would the infection control nurse identify as the characteristic assessment finding of this disease? 1: The appearance of vesicles or pustules located on the hands only 2: The presence of white patches scattered about the trunk 3: Multiple straight or wavy threadlike lines beneath the skin 4: Patchy hair loss and round red macules with scales

3: Multiple straight or wavy threadlike lines beneath the skin

A nurse is taking pulmonary artery catheter measurements on a client with acute respiratory distress syndrome. The pulmonary capillary wedge pressure reading of 12 mmHg is interpreted as which of the following? 1: High and expected 2: Low and unexpected 3: Normal and expected 4: Uncertain and unexpected

3: Normal and expected

A nurse is monitoring a group therapy session. During this session the members are expressing intimate personal opinions and feelings about personal tasks. The nurse determines that these behaviors are characteristic of which of the following stages of group development? 1: Forming 2: Storming 3: Norming 4: Performing

3: Norming

The nurse notes that the client's physical examination record states the client's eyes moved normally through the six cardinal fields of gaze. The nurse interprets the client has normal: 1: Peripheral vision 2: Central vision 3: Ocular movements 4: Corneal reflexes

3: Ocular movements

A nurse is caring for a client with a history of mild heart failure who is receiving diltiazem hydrochloride (Cardizem) for hypertension. The nurse should assess the client for which of the following signs while the client is receiving this therapy? 1: Bradycardia 2: Wheezing 3: Peripheral edema and weight gain 4: Apical pulse rate lower than baseline

3: Peripheral edema and weight gain

A hospitalized client is on warfarin sodium (Coumadin) therapy. The nurse who is monitoring the client for adverse effects ensures that which of the following medications is available for use if overdosage occurs? 1: Acetylcysteine (Mucomyst) 2: Heparin sodium 3: Phytonadione (Vitamin K) 4: Protamine sulfate

3: Phytonadione (Vitamin K)

A client who has had abdominal surgery calls the nurse and reports that she felt that "something gave way" in the abdominal incision. The nurse checks the abdominal incision and notes the presence of wound dehiscence. The nurse should take which action first? 1: Contact the physician. 2: Document the findings. 3: Place the client in a low-Fowler position and instruct the client to lie quietly. 4: Cover the abdominal wound with a sterile dressing moistened with sterile saline solution.

3: Place the client in a low-Fowler position and instruct the client to lie quietly.

A nurse's aide pulls an emergency call light in a client's room. On answering the light, the nurse finds a new postoperative client experiencing tachycardia, tachypnea, and hypotension. Which action should the nurse take first? 1: Check the hourly urine output. 2: Check the intravenous site for infiltration. 3: Place the client in a modified Trendelenburg position. 4: Call the physician.

3: Place the client in a modified Trendelenburg position.

An emergency department nurse prepares a client who sustained a gunshot wound for surgery. The nurse removes the client's clothing and places a gown on the client to prepare for the surgical procedure. Which of the following is the appropriate nursing action regarding the client's clothing, which is stained with blood? 1: Discard the clothing. 2: Give the clothing to the family member or significant other. 3: Place the clothing in a paper bag. 4: Place the clothing in a plastic bag and in a locked cabinet.

3: Place the clothing in a paper bag.

After being on bed rest in a private room for 1 week, the client exhibits periods of confusion. The physician writes a prescription to start progressive crutch walking as tolerated. Which nursing intervention would decrease the client's confusion? 1: Ambulating in the room, increasing the distance by 5 feet each time 2: Ambulating to the bathroom in the client's room three times a day 3: Progressive ambulation in the hall three times a day 4: Range of motion three times a day to increase strength

3: Progressive ambulation in the hall three times a day

A charge nurse observes that a staff nurse is not able to meet client needs in a reasonable time frame, does not problem-solve situations, and does not prioritize nursing care. The charge nurse has the responsibility to: 1: Supervise the staff nurse more closely so that tasks are completed. 2: Ask other staff members to help the staff nurse get the work done. 3: Provide support and identify the underlying cause of the staff nurse's problem. 4: Report the staff nurse to the supervisor so that something is done to resolve the problem.

3: Provide support and identify the underlying cause of the staff nurse's problem.

A woman comes into the emergency department in a severe state of anxiety after witnessing a fatal car accident. Which of the following is the appropriate nursing intervention? 1: Encourage the client to talk about the accident. 2: Put the client in a quiet room until the psychiatric crisis team arrives. 3: Remain with the client. 4: Teach the client deep breathing exercises and insist that the client start the exercises immediately.

3: Remain with the client.

A nurse is caring for a 9-month-old child after cleft palate repair and has applied elbow restraints to the child. The mother visits the child and asks the nurse to remove the restraints. Which of the following is an appropriate nursing action? 1: Removed both restraints. 2: Tell the mother that the restraints cannot be removed. 3: Remove a restraint from one extremity. 4: Loosen the restraints but tell the mother that they cannot be removed.

3: Remove a restraint from one extremity.

The nurse determines that which population is at highest risk for tuberculosis (TB)? 1: Persons admitted to the hospital for day surgery 2: Children older than 6 years of age in a summer school program 3: Residents of a long-term care facility 4: A family who has recently emigrated from Australia

3: Residents of a long-term care facility

A nursing staff member approaches a nurse manager and tells the manager that another nurse is tying knots in the air vent of Salem sump nasogastric tubes that are connected to suction. The nurse manager appropriately handles this situation by taking which of the following actions? 1: Providing an inservice educational session on the care of Salem sump nasogastric tubes for everyone on the nursing unit 2: Telling the nurse that it is inappropriate to report other nurses 3: Reviewing the skills checklist of the nurse who is tying the knots to assess if this skill has ever been performed and validated 4: Telling the nurse who reported the occurrence that knots in a Salem sump air vent will not harm the client

3: Reviewing the skills checklist of the nurse who is tying the knots to assess if this skill has ever been performed and validated

A nursing student is instructed by a registered nurse (RN) to monitor a client who has dark skin for cyanosis. The RN determines that the student needs instructions regarding physical assessment techniques for the dark-skinned client if the student states that the best area to assess for cyanosis is in the: 1: Nail beds 2: Lips 3: Sclera of the eye 4: Tongue

3: Sclera of the eye

A clinic nurse is performing an assessment on a client diagnosed with primary hypertension. The nurse would do which of the following to assess the client's blood pressure accurately? 1: Use a cuff with a rubber bladder that encircles at least 50% of the limb 2: Ensure that the client has not had nicotine or caffeine in the past 10 minutes 3: Seat the client with the arm bared, supported, and at heart level 4: Measure the blood pressure after the client is seated quietly for 1 minute

3: Seat the client with the arm bared, supported, and at heart level

A nurse is going to suction an adult client with a tracheostomy who has copious amounts of secretion. The nurse does which of the following to accomplish this procedure safely and effectively? 1: Hyperoxygenates the client after the procedure only. 2: Applies continuous suction in the airway for up to 20 seconds. 3: Sets the wall suction pressure range between 80 and 120 mm Hg. 4: Occludes the Y-port of the catheter while advancing it into the tracheostomy.

3: Sets the wall suction pressure range between 80 and 120 mm Hg.

A nurse is performing an assessment on a female client who is suspected of having mittelschmerz. Which of the following would the nurse expect to note if this condition is present? 1: Pain at the beginning of menstruation 2: Profuse vaginal bleeding 3: Sharp pain located on the right side of the pelvis 4: Pain that occurs during intercourse

3: Sharp pain located on the right side of the pelvis

A client is being prepared for a lumbar puncture. The nurse should assist the client into which of the following positions for the procedure? 1: Prone in a slight Trendelenburg position 2: Prone with a pillow under the abdomen 3: Side-lying with the legs pulled up and the head bent down onto the chest 4: Side-lying with a pillow under the hip

3: Side-lying with the legs pulled up and the head bent down onto the chest

The nurse is assigned to care for a client diagnosed with catatonic stupor. On entering the client's room, the nurse finds the client lying on the bed with the body pulled into a fetal position. The appropriate nursing action is which of the following? 1: Leave the client alone. 2: Move the client into the visitor's lounge. 3: Sit beside the client in silence. 4: Ask the client direct questions to encourage talking.

3: Sit beside the client in silence.

To maintain a child's developmental skills while hospitalized, a nurse encourages a 1-year-old child who was born 2 months earlier than the estimated date of delivery to: 1: Indicate wants by pointing and grunting 2: Walk independently 3: Sit independently 4: Build a tower of three blocks

3: Sit independently

A client will be receiving parenteral nutrition at home for long-term nutritional therapy, and the infusion will run continuously at 100 mL per hour. The nurse would be concerned about which of the following potential problems? 1: Fluid volume deficit 2: Lack of hope 3: Social isolation 4: Low self-esteem

3: Social isolation

Which emotional response related to chronic respiratory disease requires immediate nursing intervention? 1: Anxiety 2: Depression 3: Suicidal ideation 4: Ineffective coping

3: Suicidal ideation

A nurse is caring for a postoperative client and is monitoring the client for signs of shock. The nurse monitors for which signs of this postoperative complication? 1: Cold skin, drowsiness, and hypertension 2: Fever, irritability, and rapid respirations 3: Tachycardia, cold skin, and hypotension 4: Slow pulse, warm skin, and restlessness

3: Tachycardia, cold skin, and hypotension

A nurse should monitor a client after myocardial infarction for which signs that are indicative of cardiogenic shock? 1: Bradycardia, hypertension, and a pale appearance 2: Peripheral edema, distended neck veins, and hepatic engorgement 3: Tachycardia, confusion, and hypotension 4: Oliguria, bradypnea, and warm dry skin

3: Tachycardia, confusion, and hypotension

A clinic nurse evaluates the effectiveness of a client's involvement in a Reach to Recovery group after undergoing a mastectomy. Which of the following is the accurate indicator of successful involvement in the group? 1: The client states that she attends the group every month. 2: The client states that she is thrilled with her involvement in the group. 3: The client attributes her positive attitude about her recovery to her group involvement. 4: The client states that she looks forward to group meetings.

3: The client attributes her positive attitude about her recovery to her group involvement.

A nursing instructor is observing a nursing student perform an otoscopic examination on an adult client. Which of the following observations if made by the instructor indicates the correct assessment procedure? 1: The nursing student uses a small speculum to decrease the discomfort of the examination. 2: The nursing student pulls the earlobe down and back before inserting the speculum. 3: The nursing student pulls the pinna up and back before inserting the speculum. 4: The nursing student tilts the client's head forward and down before inserting the speculum.

3: The nursing student pulls the pinna up and back before inserting the speculum.

A registered nurse prepares to care for a client with paranoia who experiences disturbed thought processes. Which interventions should the nurse carry out in the care of the client? (Select all that apply.) 1: Sit with the client and hold the client's hand. 2: Use a warm approach when working with the client. 3: Use simple and clear language when speaking to the client. 4: Diffuse angry and hostile verbal attacks with a nondefensive stand. 5: Use a nonjudgmental attitude when working with the client.

3: Use simple and clear language when speaking to the client. 4: Diffuse angry and hostile verbal attacks with a nondefensive stand. 5: Use a nonjudgmental attitude when working with the client.

A nurse manager notes that an employee is demonstrating an unacceptable level of absenteeism. Which of the following actions should the nurse manager take first to handle this problem? 1: Send the employee home, and ask the employee to think about a plan to change the behavior. 2: Provide a written reminder to the employee about the employment standards of the agency. 3: Verbally remind the employee of the employment standards of the agency. 4: Tell the employee that termination will occur if employment standards are not adhered to.

3: Verbally remind the employee of the employment standards of the agency.

A nurse is preparing a chemotherapy infusion to be administered to a client with a diagnosis of Hodgkin disease. Which of the following precautions should the nurse take during the preparation of this intravenous infusion? 1: Wear gloves and a mask. 2: Wear gloves and a gown. 3: Wear gloves, masks, and eye protectors. 4: Wear gloves, masks, and a head covering.

3: Wear gloves, masks, and eye protectors.

A nurse is providing instructions regarding home care to the parents of a 3-year-old child hospitalized with hemophilia. Which statement by a parent indicates a need for further instructions? 1: "I need to watch my child closely." 2: "I should pad the table corners in my home." 3: "I need to keep unnecessary household items out of the way." 4: " My child should not receive dental hygiene care from a dentist."

4: " My child should not receive dental hygiene care from a dentist."

A nurse provides discharge instructions to a client after a vasectomy. Which statement by the client indicates a need for further instructions? 1: "If I have pain or swelling, I can use an ice bag and take Tylenol." 2: "I can use a scrotal support if I need to." 3: "I can resume sexual intercourse whenever I want." 4: "I don't need to practice birth control any longer."

4: "I don't need to practice birth control any longer."

A client tells a nurse that he has seen many articles in the health care section of the newspaper about case management. The client asks the nurse what this means. Which of the following responses does the nurse make to the client? 1: "A single case manager plans the care for all of the clients in the nursing unit." 2: "One nurse takes care of one client and is responsible for that client." 3: "One nurse supervises all of the other employees when they care for clients." 4: "It represents an interdisciplinary health care delivery system."

4: "It represents an interdisciplinary health care delivery system."

A nurse is interviewing the parents of a newborn infant who has spina bifida (myelomeningocele). Which of the following statements by a parent indicates a need to discuss coping issues? 1: "Will our baby ever be normal?" 2: "What is the best position to feel our baby?" 3: "Will our baby be incontinent all the time?" 4: "Should we tell our friends about the baby?"

4: "Should we tell our friends about the baby?"

A nurse prepares to instruct a pregnant client how to perform Kegel exercises. Which statement by the client indicates an understanding of the purpose of these exercises? 1: "The exercises will help reduce backache." 2: "The exercises will help prevent ankle edema." 3: "The exercises will help prevent urinary tract infections." 4: "The exercises will help strengthen the pelvic floor in preparation for delivery."

4: "The exercises will help strengthen the pelvic floor in preparation for delivery."

A school nurse is teaching a class of high school students about the risk of sexually transmitted infections (STIs). What opening statement will best encourage participation within the group? 1: "Please feel free to share your personal experiences with the group." 2: "At the end of the class, condoms will be distributed to everyone in class." 3: "Our goal today is to describe ways to prevent acquiring a sexually transmitted infection." 4: "The topic today is very personal. For this reason, anything shared with the group will remain confidential."

4: "The topic today is very personal. For this reason, anything shared with the group will remain confidential."

The client with obesity says to the clinic nurse, "I'm not sure that attending my Weight Watchers support group is the best thing for me to do." The nurse should make which of the following responses to the client? 1: "Weight Watchers has been successful for many of our clients." 2: "Your physician has decided that you should give Weight Watchers a chance." 3: "I feel certain that you have made the right decision by giving Weight Watchers a try." 4: "You have concerns about attending the Weight Watchers support group?"

4: "You have concerns about attending the Weight Watchers support group?"

What is the compression-to-ventilation ratio for one-person cardiopulmonary resuscitation? 1: 15:2 2: 15:4 3: 30:1 4: 30:2

4: 30:2

A community health nurse is providing an educational session to a group of community members regarding the subject of organ donation. The nurse informs the members of the group about which of the following donation options? 1: An individual can sign papers to become a donor if they are 13 years of age or older. 2: Written consent is not required to become a donor. 3: The family is responsible for making the decision about organ donation at the time of death. 4: A donor must be 18 years or older to provide consent.

4: A donor must be 18 years or older to provide consent.

Which information would the nurse provide to the client about the early signs of testicular cancer? 1: Sharp pain is felt. 2: A palpable, painful lump is present. 3: A sensation of scrotal heaviness without a lump is noted. 4: A palpable, painless lump with possible scrotal enlargement is found.

4: A palpable, painless lump with possible scrotal enlargement is found.

During a prenatal visit, a pregnant woman in the second trimester of pregnancy complains of constipation and describes the home care measures she is taking to relieve the problem. Which of the following would the nurse determine is a harmful measure in preventing constipation? 1: Daily activity such as walking or swimming 2: Drinking six to eight glasses of water daily 3: Increasing whole grains and fresh vegetables in the diet 4: Adding 1 tablespoon of mineral oil to a bowl of cereal daily

4: Adding 1 tablespoon of mineral oil to a bowl of cereal daily

A client admitted to the hospital with Laennec cirrhosis is ready for discharge and expresses the motivation to prevent this condition from worsening. The nurse should inform the client about which of the following resources to assist the client? 1: Public library 2: American Cancer Society 3: Overeaters Anonymous 4: Alcoholics Anonymous

4: Alcoholics Anonymous

A nurse is performing a skin assessment on a client diagnosed with a malignant melanoma. The nurse would expect to note which characteristic of this type of skin lesion? 1: A small papule with a dry, rough scale 2: A firm nodular lesion topped with crust 3: A pearly papule with a central crater and a waxy border 4: An irregularly shaped lesion

4: An irregularly shaped lesion

Which of the following herbal therapies may be prescribed for use as an antispasmodic? (Select all that apply.) 1: Aloe 2: Kava 3: Ginger 4: Angelica 5: Chamomile 6: Peppermint oil

4: Angelica 5: Chamomile 6: Peppermint oil

A client has prescriptions for an intravenous (IV) infusion to be started, blood to be drawn, and surgical skin preparation before surgery for a right below-the-knee amputation. Which priority concern does the nurse consider in providing preoperative care? 1 The potential for fluid volume deficit related to IV therapy 2: Increased susceptibility for fluid volume excess related to IV therapy 3: Presence of acute pain related to surgery 4: Anxiety because of the need for preoperative therapies

4: Anxiety because of the need for preoperative therapies

A nurse administers an antiemetic medication to a client who has vomited. Three hours later the client tells the nurse that she is hungry and would like something to eat. Which of the following foods is best for the nurse to offer to the client? 1: Chicken broth 2: Buttered toast 3: Hot tea 4: Apple juice

4: Apple juice

The nurse witnesses an accident in which a pedestrian is hit by an automobile. The nurse stops at the scene and assesses the victim and notes that the client is responsive and has suffered a flail chest involving at least three ribs. The nurse should do which of the following to assist the client's respiratory status until help arrives? 1: Remove the victim's shirt. 2: Assist the victim to sit up. 3: Turn the client onto the side with the flail chest. 4: Apply firm but gentle pressure with the hands to the flail segment.

4: Apply firm but gentle pressure with the hands to the flail segment.

A nurse is developing a plan of care for a newborn infant with spina bifida (meningomyelocele type). The nurse includes assessment measures in the plan to monitor for increased intracranial pressure (ICP). Which of the following assessment techniques should be performed to detect the presence of increased ICP? 1: Monitoring blood pressure for signs of hypotension 2: Monitoring for signs of dehydration 3: Monitoring urine for specific gravity 4: Assessing the anterior fontanelle for bulging

4: Assessing the anterior fontanelle for bulging

A nurse is developing a research proposal related to family violence and plans to focus on the topic of the abused woman. The nurse lists primary, secondary, and tertiary prevention interventions in the proposal. Which of the following identifies a tertiary prevention intervention? 1: Identifying families at risk 2: Early case finding and decisive intervention 3: Changing societal views toward abuse of women 4: Assisting the abused woman to overcome the physical and psychological effects of the abuse

4: Assisting the abused woman to overcome the physical and psychological effects of the abuse

A psychiatric nurse who is a member of a mobile crisis team is called to respond to a person who is threatening to jump off a bridge in a suicide attempt. On arrival at the site, which of the following nursing actions should the nurse immediately take? 1: Attempt to grab the client to prevent the jump 2: Ask the police officer to grab the client to prevent the jump 3: Immediately tell the client that he is making a big mistake 4: Attempt to communicate with the client and try to develop a therapeutic relationship

4: Attempt to communicate with the client and try to develop a therapeutic relationship

A young adult college student begins to throw objects, shout insults, and stamp his feet after an instructor returned work, noting it was substandard. Using Erikson's theory of personality development, which developmental stage has this individual unsuccessfully mastered? 1: Initiative vs Guilt 2: Industry vs Inferiority 3: Identity vs Role Confusion 4: Autonomy vs Shame and Doubt

4: Autonomy vs Shame and Doubt

A nurse is developed a plan of care for a client who is depressed. Which therapeutic nursing intervention should be included in the plan of care for this client? 1: Be very cheerful, and do not talk of anything that is negative for the client. 2: Avoid talking about serious issues that can depress the client. 3: Promote superficial social discussions only for the first week. 4: Be matter-of-fact, displaying a hopeful but not overly cheerful attitude.

4: Be matter-of-fact, displaying a hopeful but not overly cheerful attitude.

A nurse is caring for a client with Cushing syndrom who demonstrates withdrawn behavior. The nurse recognizes that this client's behavior is likely related to which of the following problems? 1: Lack of diversional activity 2: Lack of power 3: Lack of hope 4: Body image disturbance

4: Body image disturbance

The home care nurse visits a client with chronic obstructive pulmonary disease who is on home oxygen at 2 liters per minute. The client's respiratory rate is 22 breaths per minute, and the client is complaining of increased dyspnea. What is the initial nursing action? 1: Determine the need to increase the oxygen. 2: Call emergency services to come to the home. 3: Reassure the client that there is no need to worry. 4: Collect more information about the client's respiratory status.

4: Collect more information about the client's respiratory status.

Quinidine gluconate is prescribed for a client. The nurse reviews the client's medical history for which condition that is a contraindication in the use of this medication? 1: Asthma 2: Infection 3: Muscle weakness 4: Complete atrioventricular block

4: Complete atrioventricular block

A nurse who has been employed in an ambulatory care unit for 8 weeks is consistently 10 to 20 minutes late for work. The nurse's lateness has caused unrest with other staff members. She is due to receive a 3-month probation evaluation in 1 month. The nurse manager should appropriately deal with this situation by taking which of the following actions? 1: Address the lateness with the nurse at the 3-month probation evaluation. 2: Tell the other staff members to cover for the nurse until she arrives. 3: Tell the nurse that she will be fired if her behavior does not change. 4: Confront the nurse to discuss the lateness and initiate problem-solving measures.

4: Confront the nurse to discuss the lateness and initiate problem-solving measures.

A client undergoing long-term peritoneal dialysis at home is currently experiencing a problem with reduced outflow from the dialysis catheter. The home care nurse should inquire whether the client has had a recent problem with which of the following? 1: Diarrhea 2: Vomiting 3: Flatulence 4: Constipation

4: Constipation

A nurse is preparing to administer medications to an assigned client and notes that the prescription for furosemide (Lasix) is higher than the recommended dosage. The nurse calls the physician to clarify the prescription and asks the physician to prescribe a dosage within the recommended range. The physician refuses to change the prescription and instructs the nurse to administer the dose as prescribed. Which of the following actions should the nurse take? 1: Discontinue the prescription. 2: Administer the dose as prescribed. 3: Call the state medical board and report the physician. 4: Contact the nursing supervisor.

4: Contact the nursing supervisor.

A client is receiving a course of chemotherapy on an outpatient basis for the diagnosis of lung cancer. Which home care instruction should the nurse provide to the client? 1: A bathroom can be shard with any member of the family. 2: Urinary and bowel excreta is not considered contaminated. 3: Disposable plates and plastic utensils must be used during the entire course of chemotherapy and for 2 months thereafter. 4: Contaminated linens should be washed separately and then washed a second time if necessary.

4: Contaminated linens should be washed separately and then washed a second time if necessary.

A nurse receives a report that a client is experiencing depression after an acute myocardial infarction. The nurse verifies this finding if which of the following is noted? 1: Hesitating to be transferred from the coronary care unit to a medical unit 2: Ignoring activity restrictions 3: Talking about rehabilitation measures 4: Crying off and on during the day

4: Crying off and on during the day

A client is hospitalized with a diagnosis of severe depression. The client is withdrawn and exhibits poor motivation and concentration. The nurse plans to involve the client in which of the following activities at this time? 1: Small group discussion 2: Simple two-person card games 3: Cooking class 4: Dance therapy

4: Dance therapy

A nurse leader of a maternity unit is concerned because staff members openly verbalize racial comments about clients on the unit. The nurse leader appropriately manages this concern by taking which of the following steps? 1: Ignoring the racial comments 2: Leaving articles about racial prejudice in the nurses' lounge 3: Reporting the racial comments to the grievance committee 4: Discouraging the racial comments

4: Discouraging the racial comments

The "low exhaled volume" alarm sounds on a mechanical ventilator attached to a client with an endotracheal tube. The nurse anticipates that the cause of this alarm may be a result of which of the following? 1: Excessive secretions 2: The presence of a mucous plug 3: Kinks in the ventilator circuits 4: Displacement of the endotracheal tube

4: Displacement of the endotracheal tube

A home care nurse is caring for a client with tuberculosis. While assessing the client's knowledge regarding respiratory precautions at home, the nurse should examine compliance with which of the following behaviors? 1: Keeping an oxygen mask on at all times. 2: Staying secluded in the bedroom. 3: Keeping the house closed up to minimize the spread of disease. 4: Disposing of contaminated tissues in container-lined receptacles.

4: Disposing of contaminated tissues in container-lined receptacles.

A nurse is reviewing the record of a client admitted to the hospital for the treatment of bladder cancer. Which of the following risk factors related to this type of cancer would the nurse likely note in the client's record? 1: African-American female 2: Recorded age of 35 years 3: Occupation of computer analyzer 4: Drinks a pot of coffee every day

4: Drinks a pot of coffee every day

A client is suspected of having a pleural effusion. The nurse assesses the client for which typical manifestations of this respiratory problem? 1: Dyspnea at rest and moist, productive cough 2: Dyspnea at rest and dry, nonproductive cough 3: Dyspnea on exertion and moist, productive cough 4: Dyspnea on exertion and dry, nonproductive cough

4: Dyspnea on exertion and dry, nonproductive cough

A female client arrives at the emergency department and states she was just raped. In preparing a plan of care, the priority intervention is which of the following? 1: Providing instruction for medical follow-up 2: Obtaining appropriate counseling for the victim 3: Providing anticipatory guidance for police investigation, medical questions, and court proceedings 4: Exploring safety concerns by obtaining permission to notify significant others who can provide shelter

4: Exploring safety concerns by obtaining permission to notify significant others who can provide shelter

A client has been admitted to the mental health unit with a diagnosis of social phobia disorder. Which behavior does the nurse expect the client to exhibit? 1: Fear of leaving the house. 2: Shortness of breath and palpitations when riding in an elevator 3: Persistent hand washing before eating foods 4: Fear of embarrassing himself in front of others

4: Fear of embarrassing himself in front of others

A client with cirrhosis shows signs of hepatic encephalopathy. Because of these signs, the nurse should obtain a substitute food for which of the following items on the client's meal tray? 1: Whole wheat bread 2: Green peas 3: Strawberry gelatin 4: Hamburger patty

4: Hamburger patty

A nurse is preparing to administer an inactivated poliovirus vaccine to a child. Which of the following assessment questions should the nurse ask the mother before administering this vaccine? 1: Has the child had any diarrhea? 2: Has the child had any ear infections? 3: Has the child had any recent sore throats? 4: Has the child ever had an allergic reaction to neomycin?

4: Has the child ever had an allergic reaction to neomycin?

The mother of a child calls the health care clinic and tells the nurse that the child has developed a bloody nose. The nurse instructs the mother to do which of the following? 1: Pinch the nostrils for 5 minutes and then recheck for bleeding. 2: Maintain the child in a sitting position with the head tilted backward. 3: Lay the child down with a pillow tucked under the neck and stay with the child to keep the child calm. 4: Have the child sit with the head tilted forward and hold pressure on the soft part of the nose for a period of 10 minutes.

4: Have the child sit with the head tilted forward and hold pressure on the soft part of the nose for a period of 10 minutes.

The nurse is collecting data from a client with benign prostatic hyperplasia. Which of the following is a late sign of disorder? 1: Nocturia 2: Decreased force of urine stream 3: Difficulty initiating urine stream 4: Hematuria

4: Hematuria

The nurse is assisting in participating in a prostate screening clinic for men. The nurse questions each client about which sign of prostatism? 1: Ability to stop voiding quickly 2: Absence of post-void dribbling 3: Excessive force in urinary stream 4: Hesitancy when initiating urinary stream

4: Hesitancy when initiating urinary stream

A nurse is assigned to care for a group of clients on the clinical nursing unit. The nurse determines that the client who is least likely to develop third spacing of fluids is the one with the diagnosis of which of the following: 1: Major burn 2: Renal failure 3: Laennec cirrhosis 4: Hypertension

4: Hypertension

A nurse manager asks a nurse to work on her day off because of a short-staffing problem. The nurse has already made plans and does not want to work on the day scheduled to be off. The assertive response by the nurse to the nurse manager is which of the following? 1: "I can't work that day." 2: "You know how I hate to work extra shifts." 3: "I will if you need me but I might be a few minutes late." 4: I have planned to take the day off and will not be able to work on that day."

4: I have planned to take the day off and will not be able to work on that day."

A client is newly diagnosed with chronic obstructive pulmonary disease (COPD) and returns home after a short hospitalization. The home care nurse understands that the most important teaching strategies are designed to: 1: Promote membership in support groups 2: Encourage the client to become a more active person 3: Identify irritants in the home that interfere with breathing 4: Improve oxygenation and minimize carbon dioxide retention

4: Improve oxygenation and minimize carbon dioxide retention

To assess for the presence of the posterior tibialis pulse the nurse palpates which of the following areas? 1: In the groove just below the inguinal ligament 2: Behind the knee and lateral to the medial tendon 3: Lateral to and parallel with the extensor tendon of the big toe 4: In the groove behind the medial malleolus and the Achilles tendon

4: In the groove behind the medial malleolus and the Achilles tendon

A nurse is developing a plan of care for a client newly diagnosed with testicular cancer. Which priority consideration is appropriate for this client? 1: Increased susceptibility for infection that is due to the presence of the surgical incision 2: Skin breakdown related to radiation therapy 3: Difficulty coping that is due to lack of support systems 4: Inability to perform a set role that is due to diagnosis of cancer

4: Inability to perform a set role that is due to diagnosis of cancer

A nurse is planning care for a client in whom trigeminal neuralgia has been diagnosed. Which of the following is a primary consideration related to psychosocial dysfunction? 1: Inability to care for self that is due to facial discomfort 2: Presence of anxiety that is due to sexual dysfunction 3: Interruption in thought processes that is due to difficulty with memory 4: Increased susceptibility for difficulty coping that is due to sudden spasms of pain

4: Increased susceptibility for difficulty coping that is due to sudden spasms of pain

Which of the following test results does a nurse examine to determine the compatibility of blood from two different donors? 1: Rh factor 2: ABO typing 3: Direct Coombs 4: Indirect Coombs

4: Indirect Coombs

The home care nurse who is implementing standard precautions in the home should take which of the following actions? 1: Conduct hand washing only before donning gloves. 2: Use protective equipment, such as masks and gowns, when completing all physical assessments. 3: Dispose of sharps, needles, and syringes in the client's regular garbage. 4: Institute protective measures whenever the potential for exposure to body fluids or blood exists.

4: Institute protective measures whenever the potential for exposure to body fluids or blood exists.

A nurse is caring for a client with Parkinson disease who is taking benztropine mesylate (Cogentin) daily. The nurse assesses the client for side effects of this medication and specifically monitors which of the following? 1: Pupil response 2: Prothrombin time 3: Skin temperature 4: Intake and output

4: Intake and output

A nurse is caring for a child with a patent ductus arteriosus. The nurse reviews the child's assessment data, knowing that which of the following is characteristic of this disorder? 1: It involves an opening between the two atria 2: It produces abnormalities in the atrial septum 3: It involves an opening between the two ventricles 4: It involves an artery that connects the aorta and the pulmonary artery during fetal life

4: It involves an artery that connects the aorta and the pulmonary artery during fetal life

A nurse is caring for a woman in labor who is experiencing a precipitate delivery. No help is available at the moment because of an emergency with another client at the distant end of the hall. Until help arrives, the nurse should place the client into which optimal position? 1: Knee-chest 2: Semirecumbent 3: Lithotomy 4: Lateral Sims

4: Lateral Sims

A client admitted to the hospital has chronic respiratory acidosis. The nurse anticipates that which of the following methods for administering oxygen to the client will be prescribed? 1: Partial rebreather mask 2: One hundred percent oxygen nonrebreather mask 3: High-flow 60% oxygen via face mask 4: Low-flow oxygen via nasal prongs at 2 L/min

4: Low-flow oxygen via nasal prongs at 2 L/min

A nurse is caring for a client on a mechanical ventilator when the high-pressure alarm sounds. The nurse assesses the client and attempts to determine the cause of the alarm. Which initial action should the nurse take if the nurse is unable to determine the cause of the ventilator alarm? 1: Increase the oxygen to 100% temporarily. 2: Call respiratory therapy. 3: Turn off the ventilator and restart it. 4: Manually ventilate the client with a resuscitation (Ambu) bag.

4: Manually ventilate the client with a resuscitation (Ambu) bag.

A nurse is caring for a woman who is positive for the human immunodeficiency virus and has delivered a newborn infant. In the postpartum period, which of the following psychosocial assessments should the nurse initially address? 1: Reactions of extended family to the human immunodeficiency virus diagnosis 2: Quality of the relationship with her other children 3: Quality of the relationship with her spouse 4: Maternal fears

4: Maternal fears

A hospitalized client with hypertension has been started on captopril (Capoten). The nurse ensures that the client does which of the following, specific to this medication? 1: Drinks plenty of water. 2: Eats foods that are high in potassium. 3: Consumes sufficient amounts of high-fiber foods. 4: Moves from a sitting to a standing position slowly.

4: Moves from a sitting to a standing position slowly.

The nurse is preparing a client with a diagnosis of multiple myeloma for discharge. The nurse tells the client to: 1: Maintain bed rest. 2: Restrict fluid intake to 1500 mL daily. 3: Maintain a high-calorie, low-fiber diet. 4: Notify the physician if anorexia and nausea occur and persist.

4: Notify the physician if anorexia and nausea occur and persist.

A nurse is providing discharge instructions to the parents of a child who underwent a myringotomy with insertion of tympanostomy tubes. Which of the following will the nurse include in the instructions? 1: If any reddish drainage occurs, call the physician immediately. 2: Encourage the child to blow the nose gently. 3: Allow the child to swim as long as it is in a chlorinated swimming pool. 4: Notify the physician if the child complains of any pain or has a fever.

4: Notify the physician if the child complains of any pain or has a fever.

A nurse is reviewing the record of a client in the labor room and notes in the client record that the fetus is at minus one station. The nurse determines that the fetal presenting part is: 1: One inch below the iliac crest 2: One fingerbreadth below the symphysis pubis 3: One inch below the coccyx 4: One centimeter above the ischial spines

4: One centimeter above the ischial spines

A client undergoing hemodialysis has a newly created fistula in the left arm. The nurse monitors the affected extremity for which of the following signs and symptoms that indicate a complication related to steal syndrome? 1: Edema and purplish discoloration 2: Aching pain and edema 3: Warmth, redness, and pain 4: Pallor, diminished pulse, and pain

4: Pallor, diminished pulse, and pain

A nurse is caring for a client diagnosed with osteosarcoma. The alkaline phosphatase test prescribed yields a significantly increased value. Which of the following actions should the nurse take? 1: Call the physician immediately 2: Carefully assess neurological status 3: Administer antibiotic therapy as prescribed 4: Perform routines that cause movement gently

4: Perform routines that cause movement gently

A nurse is monitoring a client with abruption placentae for signs of disseminated intravascular coagulopathy (DIC). Which of the following signs would indicate the occurrence of DIC? 1: Pain and swelling of the calf of one leg 2: Rapid clotting times 3: An increased platelet count 4: Petechiae, oozing from injection sites, and hematuria

4: Petechiae, oozing from injection sites, and hematuria

A client receiving parenteral nutrition through a central venous catheter is exhibiting signs of an air embolism. The nurse should take which immediate action? 1: Notify the physician. 2: Stop the parenteral nutrition 3: Place the client in the high-Fowler position. 4: Place the client on the left side in Trendelenburg position

4: Place the client on the left side in Trendelenburg position

A registered nurse is a preceptor for a new nursing graduate and is observing the new nursing graduate organize the client assignment and daily tasks. The registered nurse intervenes if the new nursing graduate does which of the following? 1: Provides time for unexpected tasks 2: Lists the supplies needed for a task 3: Prioritizes client needs and daily tasks 4: Plans to document task completion at the end of the day

4: Plans to document task completion at the end of the day

The nurse prepares to transfer the client from the bed to a chair using a mechanical lift. Which should the nurse implement to move the client safely with this device? 1: Lower the client rapidly onto the chair. 2: Instruct the client to hold onto the sling. 3: Have three people at the bedside to assist. 4: Position the client in the center of the sling.

4: Position the client in the center of the sling.

A nurse is caring for a client who begins to experience seizure activity while in bed. The nurse determines that the client is at risk for aspiration and takes which of the following actions to prevent this from occurring? 1: Loosens restrictive clothing 2: Removes the pillow and raises the padded side rails 3: Raises the head of the bed 4: Positions the client to the side, if possible, with the head flexed foward

4: Positions the client to the side, if possible, with the head flexed foward

During the first day after admission to a mental health unit, a client experiences more than one "flashback of a distressing event." The nurse notes that these flashbacks are most likely consistent with which of the following diagnosis? 1: Paranoia 2: Schizophrenia 3: Obsessive-compulsive disorder 4: Posttraumatic stress disorder

4: Posttraumatic stress disorder

A nurse is preparing a plan of care for a client with acquired immunodeficiency syndrome who has nausea. Which of the following dietary measures should the nurse include in the plan? 1: Provide dairy products with each snack and meal. 2: Provide red meat daily. 3: Add spices to the food to make it taste more palatable. 4: Provide foods that are at a cool temperature.

4: Provide foods that are at a cool temperature.

A client with acquired immunodeficiency syndrome who has cytomegalovirus retinitis is receiving ganciclovir (Cytovene). Which of the following interventions is necessary while the client is taking this medication? 1: Monitor blood glucose levels for elevation. 2: Administer the medication on an empty stomach only. 3: Apply pressure to venipuncture sites for at least 2 minutes. 4: Provide the client with a soft toothbrush and an electric razor.

4: Provide the client with a soft toothbrush and an electric razor.

A nurse notes ventricular fibrillation on the client's cardiac monitor. The nurse hurries to the client's room, expecting the client to be: 1: Dizzy and nauseated 2: Complaining of severe palpitations 3: Hypotensive and pale 4: Pulseless and unresponsive

4: Pulseless and unresponsive

The nurse should diligently remind an older client to perform deep-breathing and coughing exercises, keeping in mind that which normal age-related change places the client at risk for respiratory infections? 1: Alveolar walls are destroyed. 2: Lung tissue becomes less elastic and less rigid. 3: Alveolar membrane thins. 4: Reduced ciliary movement creates ineffective cough.

4: Reduced ciliary movement creates ineffective cough.

A registered nurse (RN) is observing a nursing assistant (NA) ambulating a client with right-sided weakness. The RN would determine that the NA is performing the procedure safely if the nurse observes the NA taking which of the following actions? 1: Standing behind the client 2: Standing in front of the client 3: Standing on the left side of the client 4: Standing on the right side of the client

4: Standing on the right side of the client

A client is intubated and receiving mechanical ventilation. The physician has added 7 cm of positive end-expiratory pressure (PEEP) to the ventilator settings of the client. The nurse assesses for which of the following expected but adverse effects of PEEP? 1: Decreased peak pressure on the ventilator 2: Increased temperature from 98*F to 100*F rectally 3: Decreased heart rate from 78 to 64 beats per minute 4: Systolic blood pressure decrease from 122 to 98 mm Hg

4: Systolic blood pressure decrease from 122 to 98 mm Hg

A mother of a 9-year-old child in whom diabetes mellitus is newly diagnosed is very concerned about the child going to school and participating in social events. The nurse develops a plan of care with which of the following goals? 1: The child's normal growth and development will be maintained. 2: The child will use effective coping mechanisms to manage anxiety. 3: The child and family will discuss all aspects of the illness and its treatments. 4: The child and family will integrate diabetes care into patterns of daily living.

4: The child and family will integrate diabetes care into patterns of daily living.

Which of the following is the highest level of development that the nurse expects to note in a 30-month-old child? 1: The child builds a tower of two blocks. 2: The child opens a doorknob. 3: The child unzips a large zipper. 4: The child puts on simple clothes independently

4: The child puts on simple clothes independently

A nurse is monitoring a depressed female adolescent who may be suicidal. Which behavior observed by the nurse indicates that the client is a high risk for suicide? 1: The client refuses to communicate. 2: The client attempts to manipulate another nurse. 3: The client argues with her parents when they visit. 4: The client gives her special book of poems to another client.

4: The client gives her special book of poems to another client.

A nurse is caring for a client in whom anorexia nervosa has been diagnosed. The nurse assesses the client, knowing that which of the following is a characteristic of this disorder? 1: The client is not concerned about control and autonomy. 2: The client has a realistic view of the body. 3: The disorder is characterized by eating binges followed by maladaptive or inappropriate reparative behavior. 4: The client is determined to lose weight mainly by restricting food intake, even when emaciated.

4: The client is determined to lose weight mainly by restricting food intake, even when emaciated.

A nurse is checking a client's disposable closed chest drainage system at the beginning of the shift and notes continuous bubbling in the water-seal chamber. The nurse interprets this observation as indicating which of the following? 1: The system is intact. 2: A client's pneumothorax is resolving. 3: The suction to the system is shut off. 4: There is an air leak somewhere in the system.

4: There is an air leak somewhere in the system.

A client with myasthenia gravis reports the occurrence of difficulty chewing. The physician prescribes pyridostigmine bromide (Mestinon) to increase muscle strength for this activity. The nurse instructs the client to take the medication at what time? 1: After dinner daily when most fatigued 2: Before breakfast daily 3: As soon as arising in the morning 4: Thirty minutes before each meal

4: Thirty minutes before each meal

A clinic nurse instructs a client with iron-deficiency anemia about the administration of oral iron preparations, knowing that it is best to take the iron with: 1: Cola 2: Soda 3: Water 4: Tomato juice

4: Tomato juice

Excessive maternal blood loss and decreased renal perfusion are complications of placental abruption. A nurse assesses for these complications by monitoring for which of the following signs? 1: Bounding pulses 2: Lethargy 3: Decreased respirations 4: Urinary output less than 30 mL/hr

4: Urinary output less than 30 mL/hr

A nurse is teaching a group of female clients how to prevent pelvic inflammatory disease (PID). The nurse tells the clients to take which of the following actions? 1: Maintain sexual relationships with multiple partners. 2: Consult with a gynecologist regarding birth control pills. 3: Douche after intercourse and on a monthly basis. 4: Use protection such as a condom for intercourse

4: Use protection such as a condom for intercourse

A postpartum nurse obtains the vital signs on a mother who delivered a healthy newborn infant 2 hours ago. The mother's temperature is 100*F (38*C). The initial nursing action is to: 1. Document the finding. 2. Notify the physician. 3. Administer acetaminophen (Tylenol). 4. Encourage oral fluid intake.

4. Encourage oral fluid intake.

The camp nurse provides instructions to a client about protecting the skin from harmful ultraviolet (UV) rays of the sun. The nurse determines client understanding if the client identified which of the following as skin protection measures: (Select all that apply.) 1: Wear long-sleeved shirts and long pants. 2: Wear a wide-brimmed hat and sunglasses. 3: Use sunscreen mixed with insect repellent. 4: Purchase sunscreen with an SPF of 15 or higher. 5: Select tightly woven materials for better sun protection. 6: Avoid using sunscreen on cloudy days and in the shade.

1: Wear long-sleeved shirts and long pants. 2: Wear a wide-brimmed hat and sunglasses. 4: Purchase sunscreen with an SPF of 15 or higher. 5: Select tightly woven materials for better sun protection.

The nurse is caring for an infant classified as small for gestational age (SGA). In assessing the maternal history, the nurse will check for which major factor that may result in an SGA infant? 1: Use of tobacco 2: Marital status 3: Maternal blood type 4: Maternal age

1: Use of tobacco

The nurse performs which assessment technique to elicit the plantar reflex? 1. Firmly strokes the lateral sole of the foot and under the toes with a blunt instrument. 2. Taps the Achilles tendon using a reflex hammer. 3. Gently pricks the client's skin on the dorsum of the foot in two places. 4. Holds the sides of the client's great toe and while moving it, asks the client what position it is in.

1. Firmly strokes the lateral sole of the foot and under the toes with a blunt instrument.

A nurse is planning home care for a 9-year-old child who is newly diagnosed with type 1 diabetes mellitus. Which of the following is an age-appropriate activity for health maintenance? 1. Independently self-administering insulin. 2. Administering insulin drawn up by an adult. 3. Making independent decisions with regard to sliding-scale coverage of insulin. 4. Having an adult assist in the self-administration of insulin and glucose monitoring.

1. Independently self-administering insulin.

A nurse is participating in a health fair and is teaching individuals about ways to decrease dietary risk factors for cancer. The nurse includes which piece of information in the instructions? 1. Limit intake of foods that contain fat. 2. Limit intake of vegetables. 3. Increase intake of processed meats. 4. Decrease intake of dietary fiber.

1. Limit intake of foods that contain fat.

A client has undergone surgery for cataracts. The nurse instructs the client to call the physician for which of the following complaints? 1. Sudden decrease in vision 2. Gradual resolution of eye redness. 3. Eye pain relieved by acetaminophen (Tylenol) 4. Small amounts of dried matter on the eyelashes after sleep.

1. Sudden decrease in vision

Which instruction should be given to the client who is prescribed amiloride (Midamor) to treat hypertension? 1. Take the medication in the morning with breakfast. 2. Withhold the medication if the blood pressure is high. 3. Eat foods with extra sodium while taking this medication. 4. Take the medication 2 hours after lunch on an empty stomach.

1. Take the medication in the morning with breakfast.

Which of the following represents the amount of blood lost in a menstrual period? 1: 40 mL 2: 60 mL 3: 80 mL 4: 100 mL

1: 40 mL

A nurse is conducting a health-screening clinic. The nurse interprets that which of the following clients participating in the screening has the greatest need for instruction to reduce the risk of developing respiratory disease? 1: A 50-year-old smoker with cracked asbestos lining on basement pipes in the home. 2: A 40-year-old smoker who works in a hospital. 3: A 36-year-old who works with pesticides. 4: A 25-year-old who does woodworking as a hobby.

1: A 50-year-old smoker with cracked asbestos lining on basement pipes in the home.

Which of the following clients is at lowest risk for developing pneumonia during hospitalization? 1: A postoperative client who had local anesthesia 2: A client with a 20 pack-a-year history of smoking 3: A postoperative client who caught a cold 4: An older client with diabetes mellitus admitted from a nursing home

1: A postoperative client who had local anesthesia

The nurse provides dietary instructions to the client hospitalized for pancreatitis, knowing that which food item needs to be avoided? 1: Chili 2: Bagel 3: Lentil soup 4: Watermelon

1: Chili

A nurse is teaching a client with multiple allergies about measures to reduce allergens in the home and should include which of the following measures? (Select all that apply) 1: Clean air conditioners periodically. 2: Use a humidifier year-round. 3: Use a damp cloth for dusting. 4: Avoid contact with pets with hair. 5: Avoid exposure to smoke and fumes.

1: Clean air conditioners periodically. 3: Use a damp cloth for dusting. 4: Avoid contact with pets with hair. 5: Avoid exposure to smoke and fumes.

The nurse assesses function of cranial nerve XII (hypoglossal nerve) by asking the client to: 1: Stick out the tongue and move it side to side. 2: Open the mouth and say "ah" 3: Swallow a sip of water. 4: Vocalize the sounds "la-la,""mi-mi," and "kuh-kuh."

1: Stick out the tongue and move it side to side.

A nurse is monitoring a pregnant woman for the presence of pitting edema. Which method should the nurse implement to check the level of the edema? 1: The nurse presses the fingertips of the index and middle fingers against the shin and holds pressure for 2 to 3 seconds. 2: The nurse uses the fingertips of the index and middle fingers and presses into the toes for a period of 3 to five seconds. 3: The nurse uses the fingertips of the index and middle fingers and presses against the abdomen and holds pressure for 2 to 3 seconds. 4: The nurse uses the fingertips of the index and middle fingers and presses against the upper arm and holds pressure for 3 to 5 seconds.

1: The nurse presses the fingertips of the index and middle fingers against the shin and holds pressure for 2 to 3 seconds.

A nurse is trying to determine the client's adjustment to a new diagnosis of coronary heart disease before discharge from the hospital. Of the following questions, which one does the nurse ask to elicit the most useful response? 1. "Do you have anyone at home to help with housework and shopping?" 2. "How do you feel about the lifestyle changes you are planning to make?" 3. "Do you understand the use of your new medications?" 4. "Are you going to book your follow-up physician visit?"

2. "How do you feel about the lifestyle changes you are planning to make?"

A nurse is preparing a postpartum client who had a cesarean delivery for discharge to home. Which statement by the client indicates a need for additional discharge preparation? 1. "I will lift nothing heavier than the baby for 2 weeks." 2. "I can start doing abdominal exercises as soon as I get home." 3. "If a fever develops, I will call my doctor." 4. "When getting out of bed, I will turn on my side and push up with my arms."

2. "I can start doing abdominal exercises as soon as I get home."

A client with a diagnosis of otosclerosis is admitted to the ambulatory care unit for stapedectomy, and the nurse prepares instructions for the client regarding home care after the procedure. Which statement by the client indicates a need for further instructions? 1. "I need to keep water out of the ear canal for at least 3 weeks." 2. "I need to avoid air travel for at least 1 year." 3. "I need to notify the physician if I experience any persistent dizziness." 4. "I need to avoide bending and lifting heavy objects for at least 3 weeks."

2. "I need to avoid air travel for at least 1 year."

Immediately after the delivery of a newborn infant, the nurse prepares to assist in the delivery of the placenta. The appropriate method to deliver the placenta is to: 1. Wait 15 minutes and then pull on the cord. 2. Wait for placental separation and then pull gently on the cord as the mother bears down. 3. Place excess traction on the cord and pull on the placenta as it enters the vaginal canal. 4. Separate the placenta from the uterine wall by using the forceps, and allow the placenta to deliver spontaneously.

2. Wait for placental separation and then pull gently on the cord as the mother bears down.

During a well-child visit a mother states she is frustrated with her 2-year-old child because whenever she asks him if he wants something to eat he says, "no", but then starts to cry when she does not give him the food. Which statement by the nurse addresses the psychosocial concepts related to growth and development of the toddler? 1: "Your toddler is only 2 years old, and you should not be giving him choices. He's too young." 2: "Your toddler is asserting his independence as he is progressing through his normal stage of development." 3: "Your toddler is still in the stage of trying to trust you, and you need to spend more time with him so that he feels more secure." 4: "Your toddler is experiencing magical thinking. With this stage if he says 'no', he believes you will know he means the opposite."

2: "Your toddler is asserting his independence as he is progressing through his normal stage of development."

A nurse is providing bottle-feeding instructions to the mother of a newborn infant regarding the amount of formula to be given, knowing that the stomach capacity for a newborn infant is approximately: 1: 5 to 10 mL 2: 10 to 20 mL 3: 30 to 90 mL 4: 75 to 100 mL

2: 10 to 20 mL

A community health nurse is providing an educational session regarding human immunodeficiency virus (HIV) to a group of prenatal clients. The nurse discusses the risks associated with the transmission of HIV and includes which of the following in the discussion? 1: Living in an urban area 2: A history of intravenous drug use 3: A history of one sexual partner 4: A spouse who is heterosexual

2: A history of intravenous drug use

A nurse performs a blood glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 50 mg/dL. The nurse determines that this result indicates: 1: Hypoglycemia 2: A normal level 3: Hyperglycemia 4: Hypotonia

2: A normal level

A school nurse is performing health screening for scoliosis on children ages 9 through 15. To assess for scoliosis the nurse should: 1: Ask the child to lie flat and lift the legs straight up. 2: Ask the child to stand with weight equally on both feet with the legs straight and the arms hanging loosely at both sides. 3. Ask the child to walk 10 feet forward and then 10 feet backward with the arms held overhead at both sides. 4. Ask the child to lie on the right side and then roll to the left side while the arms are held overhead.

2: Ask the child to stand with weight equally on both feet with the legs straight and the arms hanging loosely at both sides.

A client who has been newly diagnosed with angina pectoris asks the nurse how to prevent future angina attacks. The nurse should incorporate which instruction in a teaching session? 1: Eat fewer, larger meals for more efficient digestion. 2: Dress appropriately in very cold or very hot weather. 3: Adjust medication doses freely until symptoms do not recur. 4: Plan all activities for early in the morning, when the client is most rested.

2: Dress appropriately in very cold or very hot weather.

A nurse is performing an assessment on a pregnant client and is preparing to take the client's blood pressure. The nurse positions the client: 1: Lying down 2: In a sitting position 3: On the right side 4: On the left side

2: In a sitting position

The nurse instructs a client with a sprained ankle to implement which measure during the first 24 hours of injury to prevent edema and pain? 1: Intermittent heat applications to the injured area 2: The application of ice and elevation of the injured area 3: The application of ice for 20 minutes followed by heat for 20 minutes to the injured area 4: Intermittent compression bandages to the injured area, with 2 hours on and 2 hours off

2: The application of ice and elevation of the injured area

The nurse monitors an 18-month-old child. Which is the highest level of motor development expected to be observed in a child of this age? 1: The child builds a tower of two blocks. 2: The child builds a tower of four or five blocks. 3: The child snaps large snaps 4: The child puts on simple clothes independently

2: The child builds a tower of four or five blocks.

A client in the third trimester of pregnancy arrives at the physician's office and tells the nurse that she frequently has a backache. Which instruction would the nurse provide to the client to alleviate the backache? 1: Sleep in a supine position on a firm mattress. 2: Use good posture and body mechanics. 3: Eat small meals frequently. 4: Elevate the legs when sitting.

2: Use good posture and body mechanics.

A clinic nurse provides instructions to a client who will begin taking oral contraceptives. Which statement by the client indicates the need for further instructions? 1. "I will take one pill daily at the same time every day." 2. "If I miss a pill, I need to take it as soon as I remember." 3. "I will not need to use an additional birth-control method after I start these pills." 4. "If I miss two pills, I will take them both as soon as I remember, and I will take two pills the next day also."

3. "I will not need to use an additional birth-control method after I start these pills."

A client asks the nurse what the term "quickening" means. Which statement is a correct response made by the nurse? 1. "It is irregular, painless contractions that occur throughout pregnancy." 2. "It is the soft blowing sound that can be heard when the uterus is auscultated." 3. "It is the fetal movement that is felt by the mother." 4. "It is the thinning of the lower uterine segment."

3. "It is the fetal movement that is felt by the mother."

A postpartum client asks a nurse when she can resume sexual activity. The appropriate nursing response is: 1. "Sexual activity can be resumed at any time." 2. "Sexual activity cannot be resumed until your 8-week check-up with your physician." 3. "Sexual activity can be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped." 4. "Sexual activity can be resumed once you resume normal menstrual period."

3. "Sexual activity can be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped."

A nurse has performed the Weber test and notes that the client states that the sound is heard in both ears. The nurse interprets this finding as: 1. A sensorineural and conductive loss hearing. 2. A conductive hearing loss in the right ear. 3. A normal finding. 4. The presence of nystagmus.

3. A normal finding.

A nurse is providing an educational session to community members regarding Lyme disease and should tell the members that: 1. Insect repellent should be applied to the entire body expect around the eyes and mouth. 2. A tick should be removed by pulling it out of the skin with the fingernails. 3. Children should wear long pants, long-sleeved shirts, and hats when in wooded or grassy areas. 4. If a tick falls off a pet, it will die and not be a concern for the family members.

3. Children should wear long pants, long-sleeved shirts, and hats when in wooded or grassy areas.

A nurse performing an assessment on a client during her first prenatal visit to the clinic takes the client's temperature and notes that the temperature is 99.2*F. Which nursing action is appropriate? 1. Notify the physician. 2. Retake the temperature by the rectal route. 3. Document the temperature. 4. Inform the client that the temperature is elevated and antibiotics may be required.

3. Document the temperature.

A client has been diagnosed with endometriosis, and the client asks the nurse to describe this condition. The nurse tells the client that it: 1: Is also known as primary dysmenorrhea. 2: Is pain that occurs during ovulation. 3. Is the presence of tissue outside the uterus that resembles the endometrium. 4. Causes the cessation of menstruation.

3. Is the presence of tissue outside the uterus that resembles the endometrium.

The fundus as 16 weeks' gestation is noted at which of the following locations? 1. Just above the symphysis pubis. 2. At the umbilicus. 3. Midway between the symphysis pubis and the umbilicus. 4. At the level of the xiphoid process.

3. Midway between the symphysis pubis and the umbilicus.

A labor room nurse is assisting with a vaginal deliver. After the delivery of a viable newborn, the nurse notes that the umbilical cord lengthens and a spurt of blood flows from the vagina. The nurse interprets this occurrence as indicative of: 1. Abruptio placentae 2. Placenta previa 3. Placental separation 4. Uterine atony

3. Placental separation

A nurse is conducting a prenatal session with a group of expectant parents. The nurse instructs the parents that the primary hormone that stimulates the secretion of milk is: 1. Testosterone 2. Oxytocin 3. Prolactin 4. Progesterone

3. Prolactin

A client is trying to modify potential risk factors for coronary artery disease (CAD). Laboratory screening indicates that the total cholesterol level is 183 mg/dL, the low-density lipoprotein (LDL) level is 110 mg/dL, and the high-density lipoprotein (HDL) level is 65 mg/dL. The nurse determines that these results: 1. Put the client at very high risk for coronary artery disease. 2. Put the client at slight-to-moderately high risk for CAD. 3. Put the client at low risk for CAD. 4. Are inconclusive unless the triglyceride level also is screened.

3. Put the client at low risk for CAD.

The nurse is preparing a poster for a booth at a health fair to promote primary prevention of cervical cancer. The nurse should include which recommendation on the poster? 1. Use a commercial douche on a daily basis. 2. Perform monthly breast self-examinations (BSE). 3. Seek treatment promptly for infections of the cervix. 4. Use oral contraceptives as a preferred method of birth control.

3. Seek treatment promptly for infections of the cervix.

The nurse performs which technique as the method for assessing a client's pupillary reaction to light? 1. Turn a penlight on directly in front of the eye and watch for a response. 2. Check pupil size using a penlight; then have the client alternate watching the light and the examiner's finger. 3. Turn the penlight on, and move the light from the client's temporal area to the eye while the client looks straight ahead. 4. Ask the client to follow the light through the six cardinal positions of gaze.

3. Turn the penlight on, and move the light from the client's temporal area to the eye while the client looks straight ahead.

A client complaining of chronic dry skin and pruritus may benefit from which of the following interventions? 1. Taking baths twice daily using a diluted solution of vinegar and water. 2. Using astringents on the skin. 3. Using emollients on the skin. 4. Purchasing a dehumidifier for the home.

3. Using emollients on the skin.

A nurse has counseled a client after cardiac surgery about when it is safe to resume sexual activities. The nurse would need to correct the client if the client made which statement? 1: "I should be OK when I can walk one block or can climb two flights of stairs." 2: "I should wait for 2 hours after eating." 3: "The room should be slightly chilly so I don't get overheated." 4: "A comfortable position will probably work best."

3: "The room should be slightly chilly so I don't get overheated."

A nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt who will be discharged from the hospital. The nurse should include which instruction in the plan of care? 1: Call the physician if the infant is fussy. 2: Expect an increased urine output from the shunt. 3: Call the physician if the infant has a high-pitched cry. 4: Position the infant on the side of the shunt when the infant is put in bed.

3: Call the physician if the infant has a high-pitched cry.

A nurse is a member of a community task force on violence. The task force recognizes that it has insufficient data to make decisions about specific interventions. Using the nursing process, the first activity that the nurse should suggest to the task force is to: 1:Call other communities similar in size to determine what they do. 2: Develop a general educational program related to violence. 3: Conduct a community survey to assess community perceptions regarding violence. 4: Develop a pamphlet on violence to be distributed to the community.

3: Conduct a community survey to assess community perceptions regarding violence.

A nurse is caring for a client with a spinal cord injury. The nurse assesses sensory ability by asking the client to: 1: Spread his fingers. 2: Squeeze the nurse's hand. 3: Discriminate between touch and pinprick stimuli. 4: Move his toes or turn his feet.

3: Discriminate between touch and pinprick stimuli.

A nurse is providing instructions to a client with pulmonary sarcoidosis about long-term ongoing management. The nurse tells the client about the importance of: 1: Daily corticosteroids 2: Home oxygen 3: Frequent follow-up chest films 4: Using an incentive spirometer daily

3: Frequent follow-up chest films

A nurse is caring for a hospitalized school-aged child. The nurse determines that an appropriate play activity for the child is which of the following? 1: Playing with a push-pull toy 2: Playing "peek-a-boo" 3: Hand sewing a picture 4: Listening to music

3: Hand sewing a picture

A nurse teaches a client about breast self-examination (BSE) and tells the client that which of the following is the initial step in BSE? 1: Percussion 2: Auscultation 3: Inspection 4: Mammography

3: Inspection

When teaching the postmenopausal client about performing a breast self-examination (BSE), the nurse should tell the client to: 1: Always begin BSE on the right breast first. 2: Palpate the breasts before inspection. 3: Perform BSE on the same day every month. 4: Call the physician if both breasts are not the same size.

3: Perform BSE on the same day every month.

A nurse caring for an older adult client understands that dosages of many medications are reduced in this population because: 1: Body fat is decreased 2: Pancreatic enzymes are increased 3: Serum albumin levels are decreased 4: Glomerular filtration rate is increased

3: Serum albumin levels are decreased

Because accidents are a concern for preschool-aged children, the nurse instructs parents that their preschool-aged child can be responsible to: 1: Swim only when an adult is present. 2: Stay away from strange dogs. 3: Wear a helmet when bike riding. 4: Never play with matches or lighters.

3: Wear a helmet when bike riding.

A nurse provides discharge instructions to a client who had a mastectomy with axillary lymph node dissection. The nurse tells the client to: 1: Avoid the use of sunscreen when outdoors. 2: Cut the cuticles on a regular basis. 3: Wear protective gloves when doing the dishes. 4: Avoid the use of moisturizing cream on the affected arm.

3: Wear protective gloves when doing the dishes.

A clinic nurse is interviewing an antenatal client. For which assessment question would the nurse identify the risk for toxoplasmosis parasite infection during pregnancy? 1. "How many sexual partners have you had since you became sexually active?" 2. "Have you experienced any high fevers or unusual rashes during the first 6 weeks of your pregnancy?" 3. "Have you been exposed to children with rashes or gastrointestinal symptoms?" 4. "Do you have any cats at home, and do you handle kitty litter?"

4. "Do you have any cats at home, and do you handle kitty litter?"

During a prenatal home care visit, a nurse explains dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective when the client states: 1. "I can eat more sweets now because I need more calories." 2. "I need more fat in my diet so the baby can gain enough weight." 3. "I need to eat a high-protein, low-carbohydrate diet now to control my blood sugar." 4. "I need to increase the fiber in my diet to control my blood sugar and prevent constipation."

4. "I need to increase the fiber in my diet to control my blood sugar and prevent constipation."

A clinic nurse provides information to a married couple regarding measures to prevent infertility. Which statement made by the husband indicates the need to provide further information? 1. "We need to eat a nutritious diet." 2. "We need to avoid the excessive intake of alcohol." 3. "We need to decrease exposure to environmental hazards." 4. "I need to maintain warmth to my scrotum by taking hot baths frequently."

4. "I need to maintain warmth to my scrotum by taking hot baths frequently."

A nurse is preparing to teach a new mother to breast-feed. Which factor is important to promote an effective and positive learning experience? 1. Separation of infant and mother after birth, which is important to allow the mother to rest. 2. Previous breast-feeding experience. 3. A physician who encourages clients to breast-feed. 4. A positive nurse-client relationship.

4. A positive nurse-client relationship.

A nurse has provided instructions to a new mother with a urinary tract infection regarding foods and fluids to consume that will acidify the urine. The nurse determines that further instructions are needed if the mother indications that which fluid will acidify the urine? 1. Prune juice 2. Apricot juice 3. Cranberry juice 4. Carbonated drinks

4. Carbonated drinks

A nurse is performing an assessment on a pregnant woman to determine whether labor has begun. Which of the following findings is a sign of true labor? 1. The contractions are irregular in rhythm and duration. 2. The uterus is soft with indentable contractions. 3. Cervical changes are not apparent. 4. Contractions begin in the lower abdomen and back and then radiate over the entire abdomen.

4. Contractions begin in the lower abdomen and back and then radiate over the entire abdomen.

A nurse is reviewing the record of a client with a diagnosis of cervical cancer. Which risk factor associated with this type of cancer does the nurse expect to note in the client's record? 1. Single female, no children, has infrequent sexual intercourse. 2. Sexual intercourse with a single sex partner. 3. Sexual intercourse with circumcised males. 4. History of human papillomavirus.

4. History of human papillomavirus.

What is the priority instruction for a pregnant client diagnosed with diabetes mellitus (DM)? 1. How to test for proteinuria. 2. How to assess and manage preterm bleeding 3. How to manage the discomfort of early labor 4. How to assess for signs of hypoglycemia and the required treatment.

4. How to assess for signs of hypoglycemia and the required treatment.

A nurse-midwife is performing an assessment on a pregnant client for the presence of ballottement. To perform this procedure, the nurse would do which of the following? 1. Auscultate for fetal heart sounds. 2. Palpate the abdomen for fetal movement. 3. Assess the cervix for thinning. 4. Initiate a sudden tap on the cervix.

4. Initiate a sudden tap on the cervix.

The nurse should teach clients that Lyme disease: 1. Is contracted by contact with an infected individual. 2. Can be caused by the inhalation of spores from bird droppings. 3. Is caused by contamination from cat feces. 4. Is caused by a tick carried by deer.

4. Is caused by a tick carried by deer.

A nurse has conducted dietary teaching with a client diagnosed with iron deficiency anemia. The nurse determines that the client understands the information if the client states that he or she should increase intake of which of the following foods? 1. Refined white bread 2. Egg whites 3. Pineapple 4. Kidney beans

4. Kidney beans

A nurse has given dietary instructions to a client diagnosed with acute glomerulonephritis. The nurse determines that the client understands the information presented if the client states to do which of the following? 1. Increase intake of high-fiber foods. 2. Increase intake of potassium-rich foods. 3. Limit intake of magnesium-rich foods. 4. Limit protein intake.

4. Limit protein intake.

To relieve soreness related to breast-feeding, the nurse instructs clients to: 1. Avoid rotating breast-feeding positions. 2. Stop nursing until the nipples heal. 3. Substitute a bottle-feeding until the nipples heal. 4. Position the infant with the infant's stomach against the mother.

4. Position the infant with the infant's stomach against the mother.

A client in the first trimester of pregnancy complains of morning sickness, and the nurse provides home care instructions. The nurse determines that the client needs further instructions if she states to do which of the following to alleviate the morning sickness? 1. Eat crackers or dry toast before arising. 2. Eat small, frequent meals. 3. Avoid spicy or fatty foods. 4. Postpone eating until the supper hour.

4. Postpone eating until the supper hour.

A 10-month-old infant is hospitalized for respiratory syncytial virus (RSV). Using knowledge of growth and development according to Erik Erikson and Jean Piaget, the nurse should do which of the following to meet the infant's developmental needs? 1. Wash hands, wear a mask, and keep the infant as quiet as possible. 2. Follow the home feeding schedule, and allow the infant to be held only when the parents visit. 3. Restrain the infant continuously to prevent tubes from being dislodged. 4. Provide a consistent routine, as well as touching, rocking, and cuddling, throughout the hospitalization.

4. Provide a consistent routine, as well as touching, rocking, and cuddling, throughout the hospitalization.

A community health nurse has conducted an educational session about fetal alcohol syndrome with adolescent girls. Which statement by one adolescent indicates the need for further teaching? 1: "Fetal alcohol syndrome is a preventable cause of mental retardation." 2: "Symptoms of fetal alcohol syndrome include retarded growth of the baby and abnormalities of the nervous system." 3: "Diagnosis of fetal alcohol syndrome is based on symptoms seen in the infant and the mother's history of alcohol use." 4: "Only heavy use of alcohol by a pregnant woman is a problem. Moderate alcohol ingestion is acceptable during pregnancy."

4: "Only heavy use of alcohol by a pregnant woman is a problem. Moderate alcohol ingestion is acceptable during pregnancy."

A nurse is monitoring for the presence of pitting edema in a prenatal client and notes that the indentation from finger pressure is approximately 1 inch deep. The nurse documents that the client has which level of pitting edema? 1: +1 2: +2 3: +3 4: +4

4: +4

A pregnant client asks a nurse when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between: 1: 6 and 8 weeks' gestation 2: 8 and 10 weeks' gestation 3: 12 and 14 weeks' gestation 4: 16 and 20 weeks' gestation

4: 16 and 20 weeks' gestation

The nurse palpates the anterior fontanelle of a neonate and notes that it feels soft. This nurse understands that this finding indicates which of the following? 1: Increased intracranial pressure 2: Dehydration 3: Decreased intracranial pressure 4: A normal finding

4: A normal finding

A nurse performs a skin assessment on an assigned client and notes the presence of lesions that are red-tan scaly plaques. The nurse suspects that this finding indicates: 1: Seborrhea 2: Xerosis 3: Pruritus 4: Actinic keratoses

4: Actinic keratoses

A nurse provides discharge instructions to a client with rheumatoid arthritis (RA). The instructions focus on measures to lessen discomfort and provide joint protection. Which of the following should be included in the instructions? 1: Change positions every hour. 2: Lift items rather than sliding them. 3: Perform prescribed exercises even if the joints are inflamed. 4: Avoid stooping, bending, or overreaching.

4: Avoid stooping, bending, or overreaching.

Which of the following characteristics of lochia does the nurse expect to find for a client who is 2 hours postdelivery of a viable infant? 1: White lochia 2: Pink lochia 3: Serosanguineous lochia 4: Dark red lochia

4: Dark red lochia

A nurse is monitoring a client in labor when the client's membranes rupture spontaneously. The initial nursing action is to: 1: Take the client's blood pressure. 2: Provide peripads to the client. 3: Note the amount, color, and odor of the amniotic fluid. 4: Determine the fetal heart rate.

4: Determine the fetal heart rate.

A nurse provides instructions to the postpartum client who has developed breast engorgement. The nurse tells the client to: 1: Feed the infant less frequently using bottle-feeding in between. 2: Apply cool packs to both breasts 20 minutes before a feeding. 3: Avoid the use of a bra during engorgement. 4: Gently massage the breast from the outer areas to the nipple during feeding.

4: Gently massage the breast from the outer areas to the nipple during feeding.

A nurse should use which standardized tool as a guide in assessing a client with a head injury and increased intracranial pressure (ICP)? 1: Snellen chard 2: Pulse oximetry graph 3: Visual analogue scale 4: Glasgow coma scale

4: Glasgow coma scale

To assess the status of the median nerve, which of the following does the nurse perform? 1: Have the client spread all the fingers wide and resist pressure. 2: Monitor for flexion of the biceps by having the client raise the forearm. 3: Have the client move the thumb toward the palm and back to the neutral position. 4: Have the client grasp the nurse's hand while noting the strength of the first and second fingers.

4: Have the client grasp the nurse's hand while noting the strength of the first and second fingers.

A nurse employed in a well-baby clinic is collecting data regarding the language and communication developmental milestones of a 7-month-old infant. The nurse watches the infant for which language developmental milestone that begins to occur in the infant at this developmental age? 1: Use of gestures 2: Babbling sounds 3: Cooing sounds 4: Increased interest in sounds

4: Increased interest in sounds

Which of the following problems is the priority for the first-time mother who expresses anxiety regarding infant care? 1: Inability to cope 2: Expressions of grief that are dysfunctional 3: Verbal statements that indicate low self-esteem 4: Lack of knowledge about caring for the infant

4: Lack of knowledge about caring for the infant

A nurse is monitoring an adolescent client for signs of depression. To recognize depression, the nurse understands that a normal adolescent: 1: Spends a lot of time in self-reflection, so it is normal to become depressed. 2: Likes the unkempt, so does not care that much about appearance. 3: Is moody and acts out a lot. 4: Likes to stay up late.

4: Likes to stay up late.

A newborn infant receives the first dose of hepatitis B vaccine within 12 hours of birth. The nurse instructs the mother regarding the immunization schedule for this vaccine and tells the mother that the second vaccine is administered at: 1: Three years of age and then during adolescent years. 2: Eight months of age and then 1 year after initial dose. 3: Six months of age and then 8 months after the initial dose. 4: One to 2 months of age and then 6 months after the initial dose.

4: One to 2 months of age and then 6 months after the initial dose.