nclex random
A new mother who is breastfeeding her infant asks the nurse, "What kind of stools will my baby have, and how many will there be during the next month?" Which of the following would be the best response by the nurse? "Your baby should have:" 1.‐ "One or two well‐formed yellow‐orange stools per day." 2.‐ "As many as 6-10 small, loose, yellow stools per day." 3.‐ "A well‐formed brown stool at least every other day." 4.‐ "Frequent loose, green stools."
2.‐ "As many as 6-10 small, loose, yellow stools per day."
Which of the following statements by a client indicates a need for further instruction regarding treatment for hypokalemia? 1.‐ "I will eat more bananas and cantaloupes for breakfast." 2.‐ "I will eat more bran flakes to increase my potassium level." 3.‐ "I will take my potassium in the morning after breakfast so it doesn't upset my stomach." 4.‐ "I will tell my doctor if I start having any of the symptoms on the list you gave me."
2.‐ "I will eat more bran flakes to increase my potassium level."
The mother of a child undergoing an emergency appendectomy tells the nurse "If I had brought him in yesterday when he complained of an upset stomach, this wouldn't have happened." The nurse's best response is: 1.‐ "It's okay; you got him here just in time before it ruptured." 2.‐ "It is often difficult to predict when a simple complaint will become more serious." 3.‐ "Next time he seems sick, you should bring him in immediately." 4.‐ "Sometimes parents can make a mistake without meaning to do so."
2.‐ "It is often difficult to predict when a simple complaint will become more serious."
The nurse is discussing dietary modifications with a client experiencing irritable bowel syndrome (IBS) and offers which of the following suggestions? 1.‐ "Eat a diet high in protein." 2.‐ "Limit your intake of products containing caffeine." 3.‐ "Consume a low‐fiber diet." 4.‐ "Avoid eating foods high in cholesterol."
2.‐ "Limit your intake of products containing caffeine."
A client with acute leukemia is admitted for a bone marrow transplant. The nurse concludes that the client understands teaching based on which of the following statements? 1.‐ "The bone marrow will be transplanted into my iliac crest." 2.‐ "The bone marrow is given to me through an intravenous line." 3.‐ "The bone marrow will be transplanted into my sternum." 4.‐ "The bone marrow is injected into my muscle."
2.‐ "The bone marrow is given to me through an intravenous line."
A client is admitted in diabetic ketoacidosis (DKA) and is given both regular and NPH insulin. After 2 days, the glucose levels are maintained at 200 to 300 mg/dL. NPH and regular insulin is administered every day at 7:30 A.M. The nurse knows to watch for a hypoglycemic reaction between 1.‐ 9:20 A.M. to 11:30 A.M. 2.‐ 9:30 A.M. to 7:30 P.M. 3.‐ 3:30 P.M. to 7:30 P.M. 4.‐ 9:30 A.M. to 3:00 P.M
2.‐ 9:30 A.M. to 7:30 P.M.
The nurse is preparing for beginning‐of‐shift rounds on assigned postpartum clients. After reviewing the assignment, the nurse plans to assess for hematoma formation in which of the following clients, who is at greatest risk for this postpartum complication? 1.‐ A 17‐year‐old client who gave birth to a small‐for‐gestational‐age infant 2.‐ A 26‐year‐old client with gestational diabetes and forceps delivery of a large‐for‐gestational‐age infant 3.‐ A 35‐year‐old client having twins 4.‐ A 40‐year‐old client having her first infant
2.‐ A 26‐year‐old client with gestational diabetes and forceps delivery of a large‐for‐gestational‐age infant
Which of the following clients has the greatest risk of developing a thromboembolism? 1.‐ A 20‐year‐old client 2.‐ A client with a cardiac disease 3.‐ A female client who is Jewish 4.‐ A client with known kidney disease
2.‐ A client with a cardiac disease
A 7‐year‐old child is brought to the Emergency Department for an acute asthma attack. He is wheezing, tachypneic, and diaphoretic, and looks frightened. The nurse should prepare to administer: 1.‐ IV methylprednisolone. 2.‐ Albuterol. 3.‐ Oral prednisone. 4.‐ Cromolyn sodium.
2.‐ Albuterol.
You would anticipate that a client with liver failure would have an elevated serum blood level of which of the following? 1.‐ Glucose 2.‐ Ammonia 3.‐ Albumin 4.‐ Platelet count
2.‐ Ammonia
An elderly gentleman enters the Emergency Department with complaints of back pain and feeling fatigued. Upon examination, his blood pressure is 200/110, pulse is 120, and hematocrit and hemoglobin are both low. The nurse palpates the abdomen which is soft, non‐tender, and ausculates an abdominal pulse. The most likely diagnosis is: 1.‐ Secondary hypertension. 2.‐ Aneurysm. 3.‐ Congestive heart failure (CHF). 4.‐ Buerger's disease
2.‐ Aneurysm.
The nurse is implementing a plan of care. Which of the following actions would the nurse take in this phase of the nursing process? 1.‐ Listen for carotid bruits 2.‐ Assist the client to use the incentive spirometer every two hours 3.‐ Prioritize care issues 4.‐ Consult the physical therapist about the client's progress
2.‐ Assist the client to use the incentive spirometer every two hours
The client in the coronary care unit with a diagnosis of heart failure states his chest feels "funny." The nurse assesses the client and monitor, noting an irregular rhythm with a rate of 110. All the QRS complexes look alike, but there are no discernable P waves and the rhythm is irregular. The client is most likely experiencing: 1.‐ Normal sinus rhythm with premature ventricular contractions. 2.‐ Atrial fibrillation. 3.‐ Accelerated junctional rhythm. 4.‐ Normal sinus rhythm with premature junctional contractions
2.‐ Atrial fibrillation.
Which of the following actions of pancreatic enzymes can cause pancreatic damage? 1.‐ Utilization by the intestine 2.‐ Autodigestion of the pancreas 3.‐ Reflux into the pancreas 4.‐ Clogging of the pancreatic duct
2.‐ Autodigestion of the pancreas
A child has been treated with chemotherapy for cancer. The nurse anticipates that neutropenia is an expected consequence and teaches the parents to: 1.‐ Avoid contact sports. 2.‐ Avoid crowded spaces. 3.‐ Avoid spicy foods. 4.‐ Avoid all immunizations.
2.‐ Avoid crowded spaces.
Which of the following foods should the nurse instruct the client who is taking spironolactone (Aldactone) to avoid? 1.‐ Bread 2.‐ Cantaloupe 3.‐ Green beans 4.‐ Squash
2.‐ Cantaloupe
A female prostitute enters the clinic for treatment of a sexually transmitted disease. Given that this disease is the most prevalent in the United States, the nurse can anticipate that the woman has which of the following? 1.‐ Herpes 2.‐ Chlamydia 3.‐ Gonorrhea 4.‐ Syphilis
2.‐ Chlamydia
The nurse is assigned to the care of a client receiving radiation therapy for cancer. Which of the following activities needed in the care of a client receiving external beam radiation therapy could be safely delegated to an unlicensed assistive person (UAP) working on the nursing unit? Select all that apply. 1.‐ Observe the skin site following a treatment session. 2.‐ Document intake from the meal trays. 3.‐ Assess variations in level of fatigue during the shift. 4.‐ Explore how the client is coping with treatment. 5.‐ Assist the client to ambulate in the hall.
2.‐ Document intake from the meal trays. 5.‐ Assist the client to ambulate in the hall.
A client had a total hip replacement with the insertion of a Hemovac suction drain for drainage during the postoperative period. When assessing the drainage, which statement would require immediate intervention by the nurse? 1.‐ In the first hour postoperative, 250 mL of sanguineous fluid was drained. 2.‐ During a four‐hour period on the second day, 500 mL of sanguineous fluid was noted. 3.‐ On the third day post‐op, less than 30 mL/hour of serous fluid was noted. 4.‐ A 3‐inch circle of sanguineous fluid was noted on the 4‐by‐4 dressing after the client was up walking after the drain was removed on the third da
2.‐ During a four‐hour period on the second day, 500 mL of sanguineous fluid was noted.
An infant is admitted with an acyanotic heart defect. Which assessment finding should be discussed with the physician? 1.‐ Heart murmur 2.‐ Dyspnea 3.‐ Weight gain 4.‐ Eupnea
2.‐ Dyspnea
Which of the following would be a priority nursing problem for a client with Conn's syndrome (hyperaldosteronism)? 1.‐ Fluid volume deficit 2.‐ Fluid volume excess 3.‐ Hyperkalemia 4.‐ Hyponatremia
2.‐ Fluid volume excess
A client with hypercalcemia is receiving digoxin (Lanoxin). The nurse plans to incorporate which of the following in client assessments? 1.‐ Checking for Trousseau's sign 2.‐ Frequent pulse checks 3.‐ Auscultation of bowel sounds 4.‐ Inspection of skin for signs of bleeding
2.‐ Frequent pulse checks
A client on the unit with hepatitis B suddenly develops anorexia, vomiting, abdominal pain, progressive jaundice, lethargy, and disorientation. The nurse knows that these indicate which of the following? 1.‐ Laennec's cirrhosis 2.‐ Fulminant hepatitis 3.‐ Portal hypertension 4.‐ Cancer of the liver
2.‐ Fulminant hepatitis
When caring for a client with hyperthyroidism, the nurse will consult with a dietitian to consider the client's need for: 1.‐ Increased protein. 2.‐ Increased energy. 3.‐ Vitamin supplements. 4.‐ Iron supplements
2.‐ Increased energy.
A client receiving external radiation expresses concern to the nurse about physical intimacy with spouse. When offering sexual counseling to the client and spouse, the nurse tells them which of the following about intimate physical contact? 1.‐ It should be avoided during treatment to avoid radiation exposure to the spouse. 2.‐ It is safe during treatment; there is no risk of radiation exposure to the spouse. 3.‐ It should be avoided during treatment to conserve energy. 4.‐ It increases the risk of infection to the client with cancer
2.‐ It is safe during treatment; there is no risk of radiation exposure to the spouse.
When inserting an 18‐gauge French urinary catheter into a male client, the nurse met resistance when the catheter was inserted less than one‐half of the distance required. What actions would be most beneficial to complete the insertion of the catheter into the bladder? 1.‐ Removing that catheter and getting a smaller size 2.‐ Lifting the shaft of the penis to a 90‐degree angle to the abdomen 3.‐ Getting a stylette and using it to insert the urinary catheter 4.‐ Pulling the penile shaft to a parallel position with the body
2.‐ Lifting the shaft of the penis to a 90‐degree angle to the abdomen
A client s laboratory report indicates that his potassium level is 2.8 mEq/L. The nurse should assess the client for which of the following manifestations? 1.‐ Hyperactive bowel sounds 2.‐ Muscle weakness 3.‐ Presence of Chvostek's sign 4.‐ Blurred vision
2.‐ Muscle weakness
The nurse is admitting a neonate two hours after delivery. About which assessment data should the nurse be concerned? Select all that apply. 1.‐ Hands and feet blue. 2.‐ Nasal flaring 3.‐ Minimal response to verbal stimulation 4.‐ Apical heart rate 156 5.‐ Retraction
2.‐ Nasal flaring 5.‐ Retraction
A client is admitted to the hospital with a medical diagnosis of viral pneumonia. The nurse assesses for which of the following most frequent manifestations? 1.‐ Presence of Ghon's tubercle on chest x‐ray 2.‐ Nonproductive cough 3.‐ Elevated white blood cell count 4.‐ High fever
2.‐ Nonproductive cough
The nurse is caring for a preterm infant who is at risk for an intraventricular hemorrhage (IVH). Which daily assessment is most critical for this infant? 1.‐ Blood pressure 2.‐ Occipital frontal circumference (OFC) 3.‐ Intake and output 4.‐ Moro reflex
2.‐ Occipital frontal circumference (OFC)
The client who has peripheral edema during the day states he wakes up in bed at night with difficulty breathing. Which of the following is he most likely experiencing? 1.‐ Angina pectoris 2.‐ Orthopnea caused by recumbent position 3.‐ A sinus infection 4.‐ Sleep apnea
2.‐ Orthopnea caused by recumbent position
A client with cirrhosis of the liver and esophageal varices suddenly begins vomiting copious amount of dark‐colored blood. The sign/symptom that is least expected would be which of the following: 1.‐ Hypertension. 2.‐ Pain. 3.‐ Melena. 4.‐ High ammonia level
2.‐ Pain.
When caring for a client who has a potassium level of 2.8 mEq/L, the nurse should assess for which of the following? 1.‐ Perforated bowel 2.‐ Paralytic ileus 3.‐ Renal failure 4.‐ Diabetes mellitus
2.‐ Paralytic ileus
The nurse would take which of the following actions as part of nursing care of the baby experiencing neonatal abstinence syndrome? 1.‐ Place stuffed animals and mobiles in the crib to provide visual stimulation. 2.‐ Position the baby's crib in a quiet corner of the nursery. 3.‐ Avoid the use of pacifiers. 4.‐ Spend extra time holding and rocking the baby.
2.‐ Position the baby's crib in a quiet corner of the nursery.
The nurse anticipates using which of the following as the most effective route to administer sodium polystyrene sulfonate (Kayexalate) ordered for a client who has a serum potassium level of 6.0 mEq/L? 1.‐ Intravenous 2.‐ Rectal 3.‐ Oral 4.‐ Subcutaneous
2.‐ Rectal
A child with severe combined immunodeficiency disorder (SCID) is being discharged from the hospital to home. Client teaching is important to reach client goals. The nursing care goal for the client before and after discharge would be that the child 1.‐ Remains well oxygenated. 2.‐ Remains free of infection. 3.‐ Maintains hydration. 4.‐ Avoids contact with other people.
2.‐ Remains free of infection.
A client is taking colchicine for gout. The client complains of weakness, abdominal pain, nausea, vomiting, and diarrhea for the past 2 days. The nurse interprets these complaints indicating which of the following? 1.‐ Therapeutic effects of the medication 2.‐ Signs of toxicity 3.‐ Expected side effects 4.‐ An allergic response
2.‐ Signs of toxicity
A client is taking colchicine for gout. The client complains of weakness, abdominal pain, nausea, vomiting, and diarrhea for the past 2 days. The nurse interprets these complaints indicating which of the following? 1.‐ Therapeutic effects of the medication 2.‐ Signs of toxicity 3.‐ Expected side effects 4.‐ An allergic response
2.‐ Signs of toxicity
A 12‐year‐old male is admitted to the adolescent unit with a diagnosis of slipped capital femoral epiphysis. Which of the following activities should not be allowed by the nurse prior to surgical correction? 1.‐ Ambulation with crutches; avoid bearing weight on the affected leg 2.‐ Sitting in a wheelchair 3.‐ Moving on a stretcher 4.‐ Maintaining bed rest
2.‐ Sitting in a wheelchair
When evaluating the effectiveness of nursing care plans used for an anxious client, it is important to validate that the client understands that: 1.‐ Defense mechanisms should not be used. 2.‐ Some anxiety can be helpful. 3.‐ He should strive to never experience anxiety. 4.‐ He should try to avoid the fight or flight response.
2.‐ Some anxiety can be helpful.
The nurse has emptied a Jackson Pratt wound‐ drainage device and needs to reestablish suction to the tube. Which of the following actions should the nurse take to accomplish this objective? 1.‐ Ensure the tubing has no kinks. 2.‐ Squeeze the collection chamber. 3.‐ Wipe the port with alcohol. 4.‐ Close the cap on the device.
2.‐ Squeeze the collection chamber.
When the client resists taking a liquid medication that is essential to treatment, the nurse demonstrates critical thinking by doing which of the following first? 1.‐ Omitting this dose of medication and waiting until the client is more cooperative 2.‐ Suggesting the medication can be diluted in a beverage 3.‐ Asking the nurse manager about how to approach the situation 4.‐ Notifying the physician that the nurse was unable to give the client this medication
2.‐ Suggesting the medication can be diluted in a beverage
Which of the following instructions would be appropriate for the nurse to include in the discharge teaching of an adolescent following a spinal fusion? 1.‐ No contact sports will be allowed again. 2.‐ The adolescent should not bend at the waist. 3.‐ Walking is limited to only one half mile per day. 4.‐ The adolescent should not climb stairs.
2.‐ The adolescent should not bend at the waist.
4 The pediatric nurse is observing a new nurse perform chest physiotherapy (CPT) on a child. Which observation by the new nurse indicates the need for the first nurse to intervene? 1.‐ The child has on only a T‐shirt. 2.‐ The nurse delayed the treatment until the child had finished breakfast. 3.‐ The nurse s hand makes a popping sound when doing percussion. 4.‐ The child is positioned in various head‐down positions.
2.‐ The nurse delayed the treatment until the child had finished breakfast.
In assessing a hospitalized client 1 hour after receiving hydralazine (Apresoline) 20 mg PO, the nurse notes that the BP is 68/42. The client has been taking this medication for several years at home without difficulty. Which of the following factors most likely contributed to this episode of hypotension? 1.‐ Dose is excessive for this medication. 2.‐ Total intake for the previous 24 hours is 1,000 mL. 3.‐ Serum potassium is 5.8 mEq/L. 4.‐ Heart rate is 145 beats per minute
2.‐ Total intake for the previous 24 hours is 1,000 mL.
The nurse is administering factor VIII to a child with hemophilia. The nurse should observe for which potential complication during the infusion? 1.‐ Fluid overload 2.‐ Transfusion reaction 3.‐ Emboli formation 4.‐ Contracting AIDS
2.‐ Transfusion reaction
The nurse is caring for the client who is recovering from partial thickness burns. Which of the following breakfast options indicates client understanding of the recommended diet? 1.‐ Two slices of toast with butter, orange juice, skim milk 2.‐ Two poached eggs, hash brown potatoes, whole milk 3.‐ Three pancakes with syrup, two slices of bacon, apple juice 4.‐ One cup of oatmeal with skim milk, 1/2 grapefruit, coffee
2.‐ Two poached eggs, hash brown potatoes, whole milk
A new postoperative client has hourly hemodynamic assessments. Which would indicate that an imbalance is present, and needs urgent care? 1.‐ CVP pressures: 8, 11, 10, 9 mm of Hg 2.‐ Urinary output: 40 mL, 30 mL, 20 mL, 20 mL 3.‐ Chest tube drainage: 60 mL, 45 mL, 50 mL, 20 mL 4.‐ Pulses: 94, 100, 98, 92 beats per minute
2.‐ Urinary output: 40 mL, 30 mL, 20 mL, 20 mL
The nurse identifies which of the following clients to have an increased metabolism and plans for additional caloric intake? The client: 1.‐ Just diagnosed with hypothyroidism. 2.‐ With a fever of 102° F. 3.‐ Who is one day post‐op colon resection. 4.‐ Who is elderly and obese.
2.‐ With a fever of 102° F.
Which of the following ABG results would the nurse expect to see when a client is admitted with diarrhea that has lasted for four days? 1.‐ pH 7.50; PaCO2 60 mmHg; HCO3‐ 28 mEq/L 2.‐ pH 7.30; PaCO2 40 mmHg; HCO3‐ 18 mEq/L 3.‐ pH 7.40; PaCO2 < 38 mmHg; HCO3‐ 28 mEq/L 4.‐ pH 7.50; PaCO2 38 mmHg; HCO3‐ 32 mEq/L
2.‐ pH 7.30; PaCO2 40 mmHg; HCO3‐ 18 mEq/L
The nurse concludes that a client has an understanding of the side effects of furosemide (Lasix) and its relationship to potassium levels when the client states: 1.‐ "I don't need to take my pulse anymore when I take my Digoxin." 2.‐ "I should call the doctor if I develop diarrhea." 3.‐ "I should call my doctor if I feel myself becoming dizzy when I stand up." 4.‐ "I don t need to eat bananas for breakfast any more, since I am taking this medication."
3.‐ "I should call my doctor if I feel myself becoming dizzy when I stand up."
The nurse is caring for a client at risk for short bowel syndrome. The nurse would choose which of the following statements to explain the role of the small intestine in absorption of nutrients? 1.‐ "Nutrients are delivered to the small intestine in a rapid manner to facilitate absorption." 2.‐ "The acidic environment of the small intestine enhances digestive enzyme function." 3.‐ "Increased surface area of the microvilli on the lining of the intestine favors absorption of nutrients." 4.‐ "The small intestine is able to facilitate the absorption of dietary fibers."
3.‐ "Increased surface area of the microvilli on the lining of the intestine favors absorption of nutrients."
The nurse is providing discharge instructions for a child who has suffered a head injury within the last four hours. The nurse determines there is a need for additional teaching when the mother states: 1.‐ "I will call my doctor immediately if my child starts vomiting." 2.‐ "I won't give my child anything stronger than Tylenol for headache." 3.‐ "My child should sleep for at least 8 hours without arousing after we get home." 4.‐ "I recognize that continued amnesia about the injury is not uncommon.
3.‐ "My child should sleep for at least 8 hours without arousing after we get home."
Which of the following statements should the nurse include when teaching a client about oral potassium supplementation? 1.‐ "When you take your potassium pill, if you can't swallow it, you can crush it up and put it in orange juice." 2.‐ "Potassium should only be taken in the morning on an empty stomach." 3.‐ "Take your potassium tablet after you have eaten breakfast." 4.‐ "You can continue to use salt substitute while you are taking your potassium supplement.
3.‐ "Take your potassium tablet after you have eaten breakfast."
At a hemophilia camp, several children with injuries arrive at the clinic at the same time. When prioritizing care for the children, the child who requires the most immediate care from the nurse is the child with: 1.‐ A swollen knee. 2.‐ Abrasions on both arms. 3.‐ A slight head injury. 4.‐ A puncture wound in the foot.
3.‐ A slight head injury.
As the nursing unit representative member serving on the hospital quality management committee, the nurse has been asked to evaluate the quality of nursing services on the unit. What would be an appropriate quality improvement activity for the nurse to ask team members to participate in? 1.‐ Tracking the number of accidents or incidents on the unit 2.‐ Documenting nursing time and activities spent on direct client care 3.‐ Administering a client and family satisfaction survey 4.‐ Assessing clients and report acuity to shift managers daily
3.‐ Administering a client and family satisfaction survey
Endotoxins differ from exotoxins in that exotoxins have which of the following characteristics? 1.‐ Are composed of lipopolysaccharides 2.‐ Are found only in Gram‐negative bacteria 3.‐ Are easily destroyed by heat 4.‐ Are typically not very toxic
3.‐ Are easily destroyed by heat
When a female client preparing for surgery suddenly bursts into tears, the preoperative holding unit nurse should take which of the following actions? 1.‐ Pull the curtain closed and leave the area to provide privacy. 2.‐ Be silent as a sign of compassion. 3.‐ Ask the client to share what she is feeling. 4.‐ Continue with the physical preparation of the client.
3.‐ Ask the client to share what she is feeling.
The evaluation process of a nursing plan of care would include which of the following? 1.‐ Ambulating the client 20 feet down the hallway 2.‐ Questioning the client about his family medical history 3.‐ Assessing the client's progress toward a desired outcome 4.‐ Assigning a nursing diagnosis to an identified need
3.‐ Assessing the client's progress toward a desired outcome
A client with a terminal illness states, "If I could only live until I can walk my daughter down the aisle at her wedding, I will donate all of my money to research." The nurse reports that the client is in which phase of the grief process? 1.‐ Denial 2.‐ Seeking 3.‐ Bargaining 4.‐ Resolution
3.‐ Bargaining
A newly registered nurse asks the nurse preceptor what qualifications are needed in order to administer chemotherapy agents. The nurse preceptor should reply that a requirement is to 1.‐ Hold a bachelor s degree in nursing. 2.‐ Be certified by an approved chemotherapy administration program. 3.‐ Be certified as an oncology nurse. 4.‐ Have at least one year of clinical experience after graduation
3.‐ Be certified as an oncology nurse.
Two hours after a child had a cast applied for a fractured radius, the nursing assessment reveals swelling in the hand, which is elevated higher than the heart. Ice has been applied continuously. The child does not complain of pain but does complain of numbness and tingling. Which should the nurse do first? 1.‐ Medicate for pain. 2.‐ Elevate the injured extremity even higher. 3.‐ Call the physician. 4.‐ Provide the child with diversional activities.
3.‐ Call the physician.
The nurse determines that the intravenous (IV) administration of calcium gluconate to a client with hyperkalemia has been effective when which of the following is seen on assessment? 1.‐ Urine output increases. 2.‐ Bowel movements are loose. 3.‐ Cardiac dysrhythmia is corrected. 4.‐ Bowel sounds become less hyperactive
3.‐ Cardiac dysrhythmia is corrected.
After reviewing the client's health history, the nurse concludes that which of the following is the most significant factor related to the development of bronchogenic carcinoma for this client? 1.‐ Asthma 2.‐ Smokeless tobacco 3.‐ Cigarette smoking 4.‐ Air pollution
3.‐ Cigarette smoking
The nurse is setting up the breakfast tray for a client with gastroesophageal reflux disease (GERD) and notices one food that the client should not eat. Which food should the nurse remove from the meal tray? 1.‐ Poached egg 2.‐ Dry toast 3.‐ Coffee with cream 4.‐ Skim milk
3.‐ Coffee with cream
A client is scheduled to have a closed reduction of a right ankle fracture. The nurse determines the client understands the procedure when the client states that the procedure involves which of the following? 1.‐ Applying an endoscopic procedure to realign the bones 2.‐ Realigning the bone using surgery 3.‐ Correcting the bone alignment using manual manipulation 4.‐ Inserting pins, rods, or other implantable devices
3.‐ Correcting the bone alignment using manual manipulation
The nurse concludes that which of the following conditions most likely contributed to the formation of ketones in an assigned client? 1.‐ Metabolic alkalosis 2.‐ Adequate carbohydrates in the diet 3.‐ Dehydration 4.‐ Increased fluid intake
3.‐ Dehydration
The nurse is caring for a child diagnosed with thalassemia major who is receiving her first chelation therapy. The nurse reinforces teaching about chelation therapy with the parents by stating that it is done to: 1.‐ Decrease the risk of hypoxia. 2.‐ Decrease the risk of bleeding. 3.‐ Eliminate excess iron. 4.‐ Prevent further sickling of red blood cells (RBCs).
3.‐ Eliminate excess iron.
Client teaching concerning the causes of contact dermatitis would include which of the following? 1.‐ Heat 2.‐ Poor hygiene 3.‐ External irritants 4.‐ An infection
3.‐ External irritants
A client has been admitted to the hospital with chest pain. The pain has not been relieved after one dose of nitroglycerine (NTG) sublingually. Upon monitoring the vital signs (VS), the nurse notices that the blood pressure has dropped to 126/84 from 130/90. Which of the following actions should the nurse take next? 1.‐ Notify the physician. 2.‐ Obtain an electroencephalogram (EEG). 3.‐ Give another dose of nitroglycerine. 4.‐ Add a dose of nitroglycerine paste
3.‐ Give another dose of nitroglycerine.
The nurse is administering a liquid iron preparation to a 3‐year‐old with iron deficiency anemia. It will be most appropriate to: 1.‐ Mix the medication in the child's milk and give it at lunch. 2.‐ Give the medication after lunch with a sweet dessert to disguise the taste. 3.‐ Give the medication in a small cup and allow the child to sip it through a straw. 4.‐ Allow the child to decide whether to take the medicine with breakfast or dinner.
3.‐ Give the medication in a small cup and allow the child to sip it through a straw.
A 10‐year‐old client presents with weakness in the legs and history of the flu. The medical diagnosis is Guillain‐Barré syndrome. It would be imperative for the nurse to inform the physician after observing which of the following? 1.‐ Weak muscle tone in feet 2.‐ Weak muscle tone in legs 3.‐ Increasing hoarseness 4.‐ Tingling in the hands
3.‐ Increasing hoarseness
Of the following nursing diagnoses for a high‐risk newborn, which requires the most immediate intervention by the nurse? 1.‐ Acute Pain related to frequent heelsticks 2.‐ Imbalanced Nutrition: Less than Body Requirements related to limited oral intake 3.‐ Ineffective Airway Clearance related to pulmonary secretions 4.‐ Deficient Knowledge related to infant care needs
3.‐ Ineffective Airway Clearance related to pulmonary secretions
The nurse is teaching a male client with cancer about potential complications associated with bone marrow suppression as a side effect of the treatment plan. The nurse determines that the client understands the risk of complications when he states that the most life‐ threatening complication is which of the following? 1.‐ Anemia 2.‐ Hemorrhage 3.‐ Infection 4.‐ Weight loss
3.‐ Infection
A client is admitted with angina, and has a history of coronary heart disease. Which of the following laboratory values should the nurse report to the primary care provider immediately? 1.‐ Potassium 3.8 mEq/L 2.‐ Sodium 133 mEq/L 3.‐ Magnesium 1.2 mEq/L 4.‐ Carbon dioxide 26 mEq/L
3.‐ Magnesium 1.2 mEq/L
The client complains of chest pain after mowing the lawn. This pain is most likely the result of which of the following? 1.‐ Pericardial effusion of fluid 2.‐ Pulmonary edema 3.‐ Myocardial ischemia 4.‐ Pulmonary emboli
3.‐ Myocardial ischemia
A child has been admitted in renal failure. The nurse would expect to find which of the following laboratory values? Select all that apply. 1.‐ Decreased BUN 2.‐ Adequate glomerular filtration 3.‐ Oliguria 4.‐ Polyuria 5.‐ Azotemia
3.‐ Oliguria 5.‐ Azotemia
Which of the following should be removed from the client in preparation for a magnetic resonance imaging (MRI) procedure? 1.‐ Urinary catheter 2.‐ Plastic name band 3.‐ Partial dental plate 4.‐ Foam slippers
3.‐ Partial dental plate
A client with cirrhosis may have alterations in which of the following laboratory values? 1.‐ Carbon dioxide level 2.‐ pH 3.‐ Prothrombin time (PT) 4.‐ White blood cell count (WBC)
3.‐ Prothrombin time (PT)
A newborn undergoing phototherapy for jaundice experiences increased urine output and loose stools. The nurse should take which of the following actions? 1.‐ Decrease the amount of time the baby is in phototherapy. 2.‐ Recognize this as a normal occurrence needing no intervention. 3.‐ Provide extra fluids to prevent dehydration. 4.‐ Institute enteric isolation.
3.‐ Provide extra fluids to prevent dehydration.
The nurse is caring for a child with a common cold (nasopharyngitis). The primary goal of nursing care is directed toward: 1.‐ Preventing injury. 2.‐ Promoting nutrition. 3.‐ Relieving symptoms. 4.‐ Administering antibiotics
3.‐ Relieving symptoms.
The nurse anticipates which of the following responses in a client who develops metabolic acidosis? 1.‐ Heart rate will increase. 2.‐ Urinary output will increase. 3.‐ Respiratory rate will increase. 4.‐ Temperature will increase.
3.‐ Respiratory rate will increase.
The clinic nurse receives a telephone call from a seven‐day postpartum client who states she is having increased vaginal bleeding and asks if it is serious, and what could be causing it. The nurse suspects which of the following, the most common cause of such late‐ postpartum hemorrhage? 1.‐ Uterine atony 2.‐ Disseminated intravascular coagulation (DIC) 3.‐ Retained placental fragments 4.‐ Laceration
3.‐ Retained placental fragments
A 4‐year‐old child with osteogenesis imperfecta (OI) is admitted to the hospital unit for an unrelated condition. The nurse determines that which nursing diagnosis has the highest priority for this child? 1.‐ Impaired skin integrity related to cast 2.‐ Pain related to fractures 3.‐ Risk for injury related to disease state 4.‐ Disturbed body image related to short stature
3.‐ Risk for injury related to disease state
The nurse has just assisted with insertion of a Sengstaken‐Blakemore tube. Before leaving the client's room, the nurse ensures that which of the following equipment is at the bedside in case of tube dislodgement? 1.‐ Suction machine 2.‐ Oxygen mask 3.‐ Scissors 4.‐ Laryngoscope
3.‐ Scissors
The nurse plans to administer which of the following intravenous (IV) treatments to a client for treatment of hyperkalemia associated with severe acidosis? 1.‐ Calcium gluconate, to make the potassium shift from the intracellular fluid (ICF) to the extracellular fluid (ECF) 2.‐ Insulin and dextrose, to make the client hypoglycemic 3.‐ Sodium bicarbonate, to make the client alkalotic so the potassium will shift into the ECF 4.‐ Normal saline (NS), to provide extra sodium so the potassium will move out of the ICF into the ECF
3.‐ Sodium bicarbonate, to make the client alkalotic so the potassium will shift into the ECF
The nurse anticipates which of the following regarding sodium restriction for a client diagnosed with ascites secondary to cirrhosis? 1.‐ The forehead and scalp. 2.‐ In the webs of the fingers. 3.‐ The hair shafts at the nape of the neck. 4.‐ In the folds of elbows.
3.‐ The hair shafts at the nape of the neck.
The pediatric nurse interprets that which of the following infants is the least likely to be diagnosed with developmental dysplasia of the hip? 1.‐ The infant with a family history of developmental dysplasia of the hip 2.‐ The infant who weighs over 10 pounds 3.‐ The infant carried on the mother's hips 4.‐ The infant who had breech position while in the uterus
3.‐ The infant carried on the mother's hips
An adolescent is undergoing a spinal fusion for scoliosis. Which of the following would not need to be included in the preoperative teaching completed by the nurse? 1.‐ Deep‐breathing and coughing exercises, use of incentive spirometry 2.‐ Use of postoperative pain medications 3.‐ The procedure for the spinal fusion and bone grafting 4.‐ Placement of a urinary catheter to drain urine after surgery
3.‐ The procedure for the spinal fusion and bone grafting
When using vacuum‐assisted closure (VAC) for a wound, which finding would require additional modification by the nurse to prevent complications? 1.‐ VAC suction dressing is changed every two hours. 2.‐ More than one inch of intact periwound tissue is available to get a tight seal. 3.‐ The wound is closed enough to seal the dressing without foam placement. 4.‐ Irrigation with normal saline is done during each dressing change.
3.‐ The wound is closed enough to seal the dressing without foam placement.
A client has heard information about functional foods and asks how he can include them in his diet. Which of the following suggestions should the nurse provide? 1.‐ Increase milk in the diet. 2.‐ Limit refined food products in the diet. 3.‐ Use vegetables as main‐dish ingredients. 4.‐ Season food to taste with salt.
3.‐ Use vegetables as main‐dish ingredients.
An infant with respiratory syncytial virus (RSV) is receiving ribavirin. While caring for this infant, the nurse should not: 1.‐ Plan to become pregnant for at least one year. 2.‐ Care for any other children. 3.‐ Wear contact lenses. 4.‐ Stay in the room with the door closed.
3.‐ Wear contact lenses.
When caring for a client who has cirrhosis, the nurse notices flapping tremors of the wrist and fingers. How should the nurse chart this finding? 1.‐ "Trousseau's sign noted." 2.‐ "Caput medusa noted." 3.‐ "Fetor hepaticus noted." 4.‐ "Asterixis noted."
4.‐ "Asterixis noted."
Which of the following potassium levels would be of greatest concern to the nurse when seen in a client who is taking furosemide (Lasix)? 1.‐ 5.4 mEq/L 2.‐ 4.3mEq/L 3.‐ 3.4 mEq/L 4.‐ 3.1 mEq/L
4.‐ 3.1 mEq/L
A client with type 2 diabetes mellitus has blood drawn for glycosylated hemoglobin (HGB). Which of the following levels would indicate that the client has poor control of the diabetes? 1.‐ 4% 2.‐ 5% 3.‐ 7% 4.‐ 9%
4.‐ 9%
Which of the following clients is more likely to develop pancreatitis? 1.‐ A 59‐year‐old male with a history of occasional alcohol use 2.‐ A client with renal problems and hypocalcemia 3.‐ A client recovering from a myocardial infarction with hypercholesterolemia 4.‐ A client with a stone lodged in the pancreatic duct
4.‐ A client with a stone lodged in the pancreatic duct
To decrease the possibility of hepatotoxicity in a woman taking azathioprine (Imuran) to treat systemic lupus erythematosus, the nurse should instruct the client to do which of the following? 1.‐ Take acetaminophen (Tylenol) for pain. 2.‐ Take azathioprine with grapefruit juice. 3.‐ Prevent exposure to infection. 4.‐ Avoid the use of alcohol.
4.‐ Avoid the use of alcohol.
The client with pancreatitis may exhibit Cullen's sign on physical examination. Which of the following data best describes Cullen's sign? 1.‐ Jaundiced sclera 2.‐ Pain that occurs with movement 3.‐ Bluish discoloration of the left flank area 4.‐ Bluish discoloration of the periumbilical area
4.‐ Bluish discoloration of the periumbilical area
When teaching the client measures to prevent a common side effect of filgrastim (Neupogen), the nurse should instruct the client to do which of the following? 1.‐ Take a laxative daily. 2.‐ Drink 1,000 mL per day. 3.‐ Eat a high‐protein diet. 4.‐ Eat a diet high in fiber
4.‐ Eat a diet high in fiber
A 15‐year‐old child with a history of cystic fibrosis is admitted to the pediatric unit with assessment findings of crackles, increased cough, and greenish sputum. A two‐week hospitalization is anticipated. Which nursing intervention holds the highest priority? 1.‐ Referral to Child Life Services for school lesson plans 2.‐ Arranging for liberal visitation from peers 3.‐ Taking a diet history 4.‐ Gaining intravenous access
4.‐ Gaining intravenous access
A 76‐year‐old woman visits the ambulatory clinic with reports of having difficulty reading and doing needlework because of visual distortions with blurring of images directly in the line of vision. The peripheral vision assessment by the nurse yields normal findings. The nurse suspects that this client is experiencing which of the following visual problems? 1.‐ Glaucoma 2.‐ Detached retina 3.‐ Cataracts 4.‐ Macular degeneration
4.‐ Macular degeneration
Discharge instructions for the client with cellulitis should include which of the following? 1.‐ To add extra dressings if the site begins to drain 2.‐ To stop the antibiotic as soon as the area appears healed 3.‐ To squeeze pustules if they develop to prevent infection 4.‐ Monitor the site for redness, tenderness, or drainage
4.‐ Monitor the site for redness, tenderness, or drainage
A client with cancer has a calcium level of 11.8 mg/dL. Which of the following symptoms would indicate a need for the nurse to call the physician for treatment orders? 1.‐ Increased gastric motility 2.‐ Peaked T waves on 12‐lead ECG 3.‐ Muscle spasms 4.‐ Muscle weakness
4.‐ Muscle weakness
The nurse would explain to a client who underwent gastric resection that which of the following meals is most likely to cause rapid emptying of the stomach 1.‐ Broiled steak and green beans 2.‐ Fried chicken and creamed potatoes 3.‐ Baked fish and fresh carrots 4.‐ Pasta with broccoli and garlic bread sticks
4.‐ Pasta with broccoli and garlic bread sticks
A child's mother tells the nurse that her child has been on steroids for several months. Which of the following vaccines is contraindicated? 1.‐ Tetanus toxoid 2.‐ Recombinant hepatitis B vaccine 3.‐ Poliovirus vaccine inactivated 4.‐ Poliovirus vaccine live oral trivalen
4.‐ Poliovirus vaccine live oral trivalen
The nurse anticipates that there is likely to be an increased risk for major medical complications in the older adult client based on which common problem? 1.‐ Taking over‐the‐counter meds with prescription meds 2.‐ Sharing meds with family and friends 3.‐ Trouble following directions consistently and exactly 4.‐ Polypharmacy from multiple doctors that is not addressed among these doctors
4.‐ Polypharmacy from multiple doctors that is not addressed among these doctors
What would be the nurse s focus when conducting health‐promotion activities for healthy adults in their thirties, based on knowledge of the highest risks during this period of life? 1.‐ Screenings for breast, cervical, uterine, and prostate cancers 2.‐ Chest x‐rays for detection of lung cancer 3.‐ Bone density test for osteoporosis 4.‐ Safety education for accident prevention
4.‐ Safety education for accident prevention
A client has a left arteriovenous (AV) graft in the forearm. Which nursing assessment would indicate a need for additional interventions by the nurse? 1.‐ The thrill is present upon palpation of the graft. 2.‐ A bruit is noted upon auscultation. 3.‐ The graft is visible on the forearm. 4.‐ The capillary refill of the left hand is 5 seconds.
4.‐ The capillary refill of the left hand is 5 seconds.
A client is recovering from a parathyroidectomy to treat primary hyperparathyroidism. To ensure that nursing diagnosis goals have been met, the nurse monitors the level of serum ionized calcium and what other serum laboratory test? 1.‐ Serum creatinine 2.‐ Serum magnesium 3.‐ Calcitriol 4.‐ The parathyroid hormone (PTH) level
4.‐ The parathyroid hormone (PTH) level
The nurse instructs the client receiving chemotherapy to avoid what risk associated with thrombocytopenia? 1.‐ Being near individuals with upper respiratory infection 2.‐ Keeping fresh flowers and plants in the home 3.‐ Shaving with an electric razor 4.‐ Trimming nails with a nail clipper
4.‐ Trimming nails with a nail clipper
The nurse interprets that which of the following statements made by a coworker is a typical staff response when working with a client diagnosed with a paranoid personality disorder? 1.‐ "He constantly criticizes his care. I'm so frustrated." 2.‐ "He is so pleasant but so shy." 3.‐ "He has a wonderful sense of humor but he doesn't let it show often." 4.‐ "I am pleased he was so helpful with his roommate. He can be so irritable at times."
1.‐ "He constantly criticizes his care. I'm so frustrated."
A 13‐year‐old child is scheduled for a bone marrow aspiration. The nurse has explained the procedure to the patient and his mother. Which statement by the mother indicates a need for additional teaching? 1.‐ "How long will it take my child to wake up from the anesthesia?" 2.‐ "I can't believe they will take the sample out of his hip." 3.‐ "He will need to be watched for bleeding and infection after the procedure." 4.‐ "The doctors are going to use this test to find out why he can't fight infections."
1.‐ "How long will it take my child to wake up from the anesthesia?"
The nurse has counseled a male 52‐year‐old client about early detection and screening for prostate cancer. The nurse evaluates that the client has understood instructions when he states which of the following? 1.‐ "I should have a digital rectal examination and prostate‐specific antigen (PSA) test done yearly." 2.‐ "I should have a prostate‐specific antigen (PSA) test done yearly." 3.‐ "I should have a digital rectal examination done yearly." 4.‐ "I don't need a screening unless I develop symptoms.
1.‐ "I should have a digital rectal examination and prostate‐specific antigen (PSA) test done yearly."
Which of the following statements indicates that the client performing insulin self‐administration understands the basic principles? 1.‐ "I will monitor myself for low glucose levels and keep a source of sugar available." 2.‐ "I will not take my insulin if my glucose level is normal." 3.‐ "I will not take my insulin if I skip a meal." 4.‐ "I will take less insulin if I have an illness.
1.‐ "I will monitor myself for low glucose levels and keep a source of sugar available."
A young infant is diagnosed with severe combined immunodeficiency disorder (SCID). The nurse has taught the mother about the disease. The statement by the mother that indicates a lack of understanding is: 1.‐ "My child will grow out of this." 2.‐ "Bone marrow transplantation may be possible." 3.‐ "The prognosis for this disease is not good." 4.‐ "My child contracted the disease because of me."
1.‐ "My child will grow out of this."
A client with a history of hiatal hernia states he has trouble sleeping because the pain is worse at night. Which response by the nurse is most appropriate? 1.‐ "Try sleeping with your upper body elevated." 2.‐ "What sleep medication do you take?" 3.‐ "Try laying flat or on your side." 4.‐ "Sleep with your feet elevated.
1.‐ "Try sleeping with your upper body elevated."
A nurse is assigned to a client with a nasogastric tube and is checking gastric pH to verify correct tube placement. The nurse determines that the tube is properly positioned after obtaining which of the following pH readings? 1.‐ 4 2.‐ 6 3.‐ 7 4.‐ 8
1.‐ 4
An adolescent with asthma says she heard her doctor say smoking was her trigger. The adolescent asks the nurse what that means. The nurse explains to the adolescent that a trigger is: 1.‐ A substance or condition that initiates an asthmatic episode. 2.‐ The term for narrowing of the airways during an asthmatic episode. 3.‐ Another way to describe asthma. 4.‐ The rapid breathing associated with an asthma attack.
1.‐ A substance or condition that initiates an asthmatic episode.
A new mother asks the nurse, "Why are my baby's hands and feet blue?" The nurse explains that this a common and temporary condition known as which of the following? 1.‐ Acrocyanosis 2.‐ Erythema neonatorum 3.‐ Harlequin color 4.‐ Vernix caseosa
1.‐ Acrocyanosis
A client is admitted with a diagnosis of Addisonian crisis. In planning the immediate care for this client, the nurse should anticipate which of the following actions? 1.‐ Administration of intravenous glucocorticoids and saline fluids 2.‐ Administration of mitotane (Lysodren) 3.‐ Preparation of client for adrenalectomy 4.‐ Administration of trilostane (Modrastane)
1.‐ Administration of intravenous glucocorticoids and saline fluids
On admission to the nursery, it is noted that the mother's membranes were ruptured for 48 hours before delivery, and her temperature is 102°F. What information from this newborn's assessment should the nurse evaluate further? 1.‐ Axillary temperature 97.2°F 2.‐ Irregular respiratory rate 3.‐ Jitteriness 4.‐ Excessive bruising of presenting part
1.‐ Axillary temperature 97.2°F
A female client comes to the clinic for a cancer screening and preventive education. When educating the client, the nurse would include information about which of the following cancers found in females, in order of occurrence? 1.‐ Breast, lung, and colorectal cancers 2.‐ Lung, breast, and colorectal cancers 3.‐ Breast, cervical, and lung cancers 4.‐ Lung, breast, and cervical cancers
1.‐ Breast, lung, and colorectal cancers
In assessing the laboratory findings for a client with chronic renal failure (CRF), the nurse should be aware that a decreased serum level of which electrolyte should be expected? 1.‐ Calcium 2.‐ Potassium 3.‐ Phosphorus 4.‐ Magnesium
1.‐ Calcium
An adult client with diabetes insipidus who has been taking desmopressin (DDAVP) intranasally comes to the clinic for a regularly scheduled appointment. The nurse assesses the client's mental status and notes some disorientation and behavioral changes. Significant pedal edema is also present. What should be the nurse's next action? 1.‐ Check vital signs and notify the physician. 2.‐ Have the client return in the morning for reevaluation. 3.‐ Instruct the client to limit salt intake for a few days. 4.‐ Suggest that the client change the route of administration to subcutaneous injections.
1.‐ Check vital signs and notify the physician.
A child is brought to the Emergency Department with excessive drooling, edema of lips and tongue, swollen mucous membranes, and is hypotensive and tachycardiac. Based on this initial assessment, the nurse suspects that the child has ingested which of the following agents? 1.‐ Corrosive agent 2.‐ Aspirin 3.‐ Hydrocarbons 4.‐ Acetaminophen
1.‐ Corrosive agent
Which symptom would indicate excessive electrolytes have been removed from a client with a nasogastric tube who has been eating large amounts of ice? 1.‐ EKG changes: U waves, flat T; anorexia, muscle weakness, ileus 2.‐ EKG changes: peaked T wave, prolonged QRS; muscle cramps, diarrhea 3.‐ Tetany, numbness of fingers/toes, twitching of nose or lips 4.‐ Pathological fractures, bradycardia, slowed reflexes
1.‐ EKG changes: U waves, flat T; anorexia, muscle weakness, ileus
A client is being evaluated for possible duodenal ulcer. The nurse assesses the client for which of the following manifestations that would support this diagnosis? 1.‐ Epigastric pain relieved by food 2.‐ History of chronic aspirin use 3.‐ Distended abdomen 4.‐ Positive fluid wave
1.‐ Epigastric pain relieved by food
A child is admitted to the hospital with a diagnosis of osteomyelitis. Which of the following would the nurse likely find when gathering the nursing history? 1.‐ History of an upper respiratory infection 2.‐ History of gastroenteritis 3.‐ History of Legg‐Calve‐Perthes disease 4.‐ History of congenital hip dysplasia
1.‐ History of an upper respiratory infection
A child with leukemia develops oral stomatitis secondary to chemotherapy treatments. Nursing assessments related to this condition should focus on: 1.‐ Hydration status. 2.‐ Vitamin C intake. 3.‐ Condition of teeth. 4.‐ Handwashing techniques.
1.‐ Hydration status.
The nurse should include diet teaching regarding adding potassium‐rich foods if which of the following diuretics are ordered? Select all that apply. 1.‐ Hydrochlorothiazide (HCTZ) 2.‐ Spironolactone (Aldactone) 3.‐ Maxizide (Triamterene with hydrochlorothiazide) 4.‐ Midamor (Amiloride) 5.‐ Furosemide (Lasix)
1.‐ Hydrochlorothiazide (HCTZ) 5.‐ Furosemide (Lasix)
The nurse anticipates alterations in weight secondary to altered hormone levels in the client with which of the following conditions? 1.‐ Hyperthyroidism 2.‐ Osteoporosis 3.‐ Cholecystitis 4.‐ Pancreatitis
1.‐ Hyperthyroidism
A nurse is assessing a new admission. The 6‐month‐ old infant displays irritability, bulging fontanels, and setting‐sun eyes. The nurse would suspect: 1.‐ Increased intracranial pressure. 2.‐ Hypertension. 3.‐ Skull fracture. 4.‐ Myelomeningocele.
1.‐ Increased intracranial pressure.
Which of the following viruses is most likely to be acquired through casual contact with an infected individual? 1.‐ Influenza virus 2.‐ Herpes virus 3.‐ Cytomegalovirus (CMV) 4.‐ Deficiency virus (HIV)
1.‐ Influenza virus
A laboratory report on an assigned client indicates the total bilirubin level is 2.2 mg/dL. When assessing the client, the nurse anticipates which of the following physical assessment findings? 1.‐ Jaundiced sclera 2.‐ Peripheral edema 3.‐ Dark‐green stools 4.‐ Dry mucous membranes
1.‐ Jaundiced sclera
The client comes in for a follow‐up visit after discharge from the hospital with a diagnosis of acute myocardial infarction. The client explains that when he walks, he sometimes notes that his pulse is slightly irregular. The nurse assesses his pulse and finds that it is slightly irregular. The monitor confirms a slightly irregular rhythm with no ectopic beats and all the characteristics of a normal sinus rhythm. The nurse explains this to the client as a: 1.‐ Normal variation that occurs in some people and is frequently associated with deep breathing. 2.‐ Very serious condition that must be addressed by the physician. 3.‐ Condition that must be treated with medication. 4.‐ Condition that reflects a decreased oxygen supply to the myocardium
1.‐ Normal variation that occurs in some people and is frequently associated with deep breathing.
The nurse should place highest priority on which of the following nursing interventions for a client with renal failure who has a potassium level of 6.8 mEq/L? 1.‐ Obtain an electrocardiogram (ECG). 2.‐ Evaluate level of consciousness. 3.‐ Measure urinary output. 4.‐ Draw arterial blood gases.
1.‐ Obtain an electrocardiogram (ECG).
A client has a potassium level of 6.8 mEq/L. Which sign or symptom would the nurse expect to find when assessing this client? 1.‐ Peaking of T wave on the telemetry monitor 2.‐ The absence of bowel sounds, such as in an ileus 3.‐ Muscle cramping of the lower extremities 4.‐ Somnolence with early changes
1.‐ Peaking of T wave on the telemetry monitor
Which common neurological change that occurs in the "healthy" elderly would the nurse expect to note when performing a client assessment? 1.‐ Presbyopia and presbycusis 2.‐ Loss of touch sensation 3.‐ Dysuria and incontinence 4.‐ Peripheral neuropathy
1.‐ Presbyopia and presbycusis
A 14‐year‐old boy with sickle cell anemia is admitted with severe pain in his abdomen and legs. He asks why the doctor ordered oxygen when he is not having any problems breathing. The nurse will be most accurate in stating that the main therapeutic benefit of oxygen is to: 1.‐ Prevent further sickling. 2.‐ Prevent respiratory complications. 3.‐ Increase the oxygen‐carrying capacity of red blood cells (RBCs). 4.‐ Decrease the potential for infection during the crisis.
1.‐ Prevent further sickling.
A mother was diagnosed with gonorrhea immediately after delivery. When providing nursing care for her baby, an important goal of the nurse is to: 1.‐ Prevent the development of ophthalmia neonatorum. 2.‐ Lubricate the eyes. 3.‐ Prevent the development of thrush. 4.‐ Teach the danger of breastfeeding with gonorrhea.
1.‐ Prevent the development of ophthalmia neonatorum.
The nursing assistant is setting up a hospital room preparing to admit a child with disseminated intravascular coagulopathy (DIC). Which item would the nurse remove from the set‐up? 1.‐ Rectal thermometer 2.‐ Bedpan 3.‐ Intravenous therapy start kit 4.‐ Sphygmomanometer
1.‐ Rectal thermometer
2 When caring for a client with Raynaud's disease, which of the following outcomes concerning medication regimen is of highest priority? 1.‐ Relaxing smooth muscle to avoid vasospasms 2.‐ Controlling the pain once vasospasms occur 3.‐ Avoiding lesions on the feet 4.‐ Preventing major disabilities that may occu
1.‐ Relaxing smooth muscle to avoid vasospasms
The nurse is caring for an infant with a cyanotic heart defect. Symptoms that would indicate risk for congestive heart failure include: (Select all that apply.) 1.‐ Respiratory crackles and frothy secretions. 2.‐ Increased blood pressure. 3.‐ Oxygen saturation increase. 4.‐ Hepatomegaly. 5.‐ Rapid weight gain
1.‐ Respiratory crackles and frothy secretions. 4.‐ Hepatomegaly. 5.‐ Rapid weight gain
A client who took an overdose of a prescribed medication was treated with gastric lavage. The nurse assesses the client carefully for which of the following as a priority to detect possible complications of treatment? 1.‐ Respiratory status and breath sounds 2.‐ Heart rate and blood pressure 3.‐ Skin color and body temperature 4.‐ Urine output and peripheral edema
1.‐ Respiratory status and breath sounds
A 2‐year‐old child has eczema that causes extreme itching. Treatment has not been able to control the rash. It has been determined that the primary allergen is wheat. An appropriate nursing diagnosis would be: 1.‐ Risk for infection. 2.‐ Imbalanced nutrition, more than body requirements. 3.‐ Ineffective infant feeding behavior. 4.‐ Noncompliance.
1.‐ Risk for infection.
A client presents to the primary care clinic complaining of frequent scratching and itching of the skin that is worse at night. The nurse should suspect which of the following skin disorders? 1.‐ Scabies 2.‐ Hives 3.‐ Fleas 4.‐ Drug reaction
1.‐ Scabies
A client returns to the unit following a thyroidectomy. The nurse plans to frequently assess for which of the following? 1.‐ Signs of laryngospasm 2.‐ Polyuria 3.‐ Hypertension 4.‐ Hypoactive deep tendon reflexe
1.‐ Signs of laryngospasm
The nursing management for a client with thrombophlebitis would include: 1.‐ The use of anticoagulant therapy to inhibit the clotting factors. 2.‐ Keeping the client's legs in a position of comfort. 3.‐ Using low molecular weight heparin (LMWH) once a confirmed diagnosis exists. 4.‐ Elevating the head of the bed 6 inches on wooden blocks
1.‐ The use of anticoagulant therapy to inhibit the clotting factors.
A mother brings her three children to the clinic with a rash on each of their faces. On assessment, the nurse notes the areas are circular patches with raised red borders. The nurse concludes that this is compatible with which of the following problems? 1.‐ Tinea corporals 2.‐ Tinea curries 3.‐ Scabies 4.‐ Impetigo
1.‐ Tinea corporals
Which of the following actions would the nurse institute that is specific to the care of the assigned client who has tuberculosis? 1.‐ Wearing a particulate respirator mask when taking vital signs. 2.‐ Instructing the client to cover the mouth with the sheet from the stretcher when transported to other hospital departments. 3.‐ Wearing sterile gloves when collecting a sputum specimen. 4.‐ Keeping the client's door open to promote ventilation.
1.‐ Wearing a particulate respirator mask when taking vital signs.
