NCLEX Review Study Guide (Summer 2022)

The nurse in the intensive care unit gives a report to the nurse in the postsurgical unit about a client who had a gastrectomy. Which method does the first nurse select to best assure essential information about the client is reported? a. Give the report face-to-face with both nurses in a quiet room. b. Audiotape the report for future reference and documentation. c. Use a printed checklist with information individualized for the client. d. Document essential transfer information in the client's electronic health record.

Use a printed checklist with information individualized for the client.

A client is to receive peritoneal dialysis. What should the nurse do to prepare for the procedure? a. Assess the dialysis access for a bruit and thrill. b. Insert an indwelling urinary catheter. c. Ask the client to turn toward the left side. d. Warm the dialysis solution in the warmer.

Warm the dialysis solution in the warmer.

When assessing a client for early septic shock, the nurse should assess the client for which of the following? A. Cool, clammy skin B. Warm, flushed skin C. Increased blood pressure D. Hemorrhage

Warm, flushed skin Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock include fever with restlessness and confusion; normal or decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase). Hemorrhage is not a factor in septic shock.

The nurse is taking care of a client with Clostridium difficile. To prevent the spread of infection, what should the nurse do? Select all that apply. a. Wear a particulate respirator. b. Wear sterile gloves when providing care. c. Cleanse hands with alcohol-based hand sanitizer. d. Wash hands with soap and water. e. Wear a protective gown when in the client's room. Moderate

Wash hands with soap and water. Wear a protective gown when in the client's room. Moderate

Captopril, furosemide and metoprolol are prescribed for a client with systolic heart failure. The client's blood pressure is 136/82 mm Hg, and the heart rate is 65 bpm. Prior to medication administration at 0900, the nurse reviews the lab tests. What action should the nurse take next? a. Administer the medications. b. Request the furosemide dose be increased. c. Withhold the captopril. d. Question the metoprolol dose.

Withhold the captopril

The nursing team on an oncology unit consists of a registered nurse, a licensed practical/vocational nurse, and one unlicensed assistive personnel. Which client should be assigned to the registered nurse? a. a 52-year-old client with lung cancer admitted for acute dyspnea b. a 45-year-old client receiving tube feedings c. a 28-year-old client being evaluated for a bone marrow transplant d. a 65-year-old client diagnosed with endometrial cancer who underwent an abdominal hysterectomy 3 days ago

a 52-year-old client with lung cancer admitted for acute dyspnea

The nurse has received a change of shift report on clients. Which client should the nurse assess first? a. a client with COPD with a PaO2 of 56 mm Hg who is being discharged home on oxygen b. a client with asthma with respirations of 36 breaths/min whose wheezing has diminished c. a client with asthma who has a heart rate of 90 bpm and whose beta blocker is scheduled to be administered now d. a client who is scheduled for an angiogram now and is ready to be transported

a client with asthma with respirations of 36 breaths/min whose wheezing has diminished

The nurse is caring for a client with end-stage cancer whose health status is declining. A prescription is written by the attending health care provider (HCP) to withhold all fluid, but the health care team cannot locate a family member or guardian. The nurse requests an ethics consultation. Which information is true of an ethics consultation? Select all that apply. a. Persons requesting an ethics consultation may do so without intimidation or fear of reprisal. b. Ethics consultations may prevent poor outcomes in cases involving ethical problems. c. The recommendations of ethics consultants are advisory only. d. Requests for ethics consultations may only be made by the HCP or nurse. e. Ethics consultation is intended to provide legal advice on client care.

a. Persons requesting an ethics consultation may do so without intimidation or fear of reprisal. b. Ethics consultations may prevent poor outcomes in cases involving ethical problems. c. The recommendations of ethics consultants are advisory only.

The newborn nurse has just received shift report about a group of newborns and is to receive another admission in 30 minutes. In order to provide the safest care and plan for the new admission, the nurse should do which tasks in order of first to last? All options must be used. a. Review notes from shift report and prioritize all clients; make rounds on the most critical first. b. Move quickly from room to room and assess all clients. c. Log on to the clinical information system and determine if there are new orders. d. Check the room to which the new client will be admitted to ensure all supplies and equipment are available.

a. Review notes from shift report and prioritize all clients; make rounds on the most critical first. b. Move quickly from room to room and assess all clients. c. Log on to the clinical information system and determine if there are new orders. d. Check the room to which the new client will be admitted to ensure all supplies and equipment are available.

The nurse is collaborating with the healthcare provider to obtain consent for a bone marrow aspiration. Which actions should the nurse take? Select all that apply. a. Witness the client signing the consent form. b. Evaluate that the client understands the procedure. c. Explain the risks of the procedure to the client. d. Verify that the client is signing the consent form of his or her own free will. e. Determine that the client understands pre-procedure care.

a. Witness the client signing the consent form. b. Evaluate that the client understands the procedure. d. Verify that the client is signing the consent form of his or her own free will. e. Determine that the client understands pre-procedure care.

A home health care nurse makes an initial visit to a 68-year-old client recently discharged from a rehabilitation facility after experiencing a stroke. The client has significant left-sided weakness and needs assistance with dressing and hygiene. The client lives with a 68-year-old partner with chronic obstructive pulmonary disease. Assessment findings include vital signs within normal parameters and intact pink, moist skin. The client denies any problems with swallowing or elimination. Based on the client's assessment, the nurse would most likely initiate referrals to which discipline? Select all that apply. a. physical therapy b. occupational therapy c. home health aide d. skilled nursing service e. speech therapy

a. physical therapy b. occupational therapy c. home health aide

There has been an increase in medication errors and errors in prescribing laboratory studies in the emergency department. The nurse manager is conducting a staff education session on when to use "read-back" procedures. "Read-back" procedures should be performed in which situations? Select all that apply. a. when a medication prescription or critical laboratory result is received verbally or over the telephone b. when any verbal or phone prescription is received c. whenever a written prescription or printed critical test result is received d. when the unit secretary takes a phone prescription e. when the agency uses computerized health care records

a. when a medication prescription or critical laboratory result is received verbally or over the telephone b. when any verbal or phone prescription is received

A 12-year-old with cystic fibrosis is being treated in the hospital for pneumonia. The health care provider (HCP) is calling in a telephone prescription for ampicillin. The nurse should take which actions? Select all that apply. a. Ask the unit clerk to listen on the speakerphone with the nurse and write down the prescription. b. Ask the HCP to come to the hospital and write the prescription on the medical record. c. Repeat the prescription to the HCP. d. Ask the HCP to confirm that the prescription is correct as understood by the nurse. e. Ask the nursing supervisor tocosign the telephone prescription as transcribed by the nurse.

c. Repeat the prescription to the HCP. d. Ask the HCP to confirm that the prescription is correct as understood by the nurse.

A 5 month old infant is brought to the emergency department with vomiting and diarrhea, which the parent states started 3 days ago. The nurse should conduct a focused assessment for which signs and symptoms? Select all that apply a. decreased or absent tearing b. dry mucous membranes c. sunken fontanel d. clear, pale, yellow urine e. bounding pulse

decreased or absent tearing dry mucous membranes sunken fontanel

A client is brought to the hospital's emergency department by a friend, who states, "I guess he had some bad heroin today." The nurse should assess the client further for which signs and symptoms? a. increased heart rate, dilated pupils and fever b. tremulousness, impaired coordination, and increased blood pressure c. decreased respirations, constricted pupils and pallor d. eye irritation, tinnitus and irritation of nasal and oral mucosa

decreased respirations, constricted pupils and pallor

Even when the client understands problems and is motivated to change, the client may have fears about failing. Which intervention is most likely to facilitate change? a. reality testing about the need for change b. asking the client about fears that need to be overcome c. teaching new communication skills d. having the client practice new behaviors

having the client practice new behaviors

The nurse obtains a blood sample to screen a neonate for phenylketonuria. From what site should the nurse obtain the sample? a. heel b. radial artery c. scalp vein d. brachial artery

heel

A client is receiving total parenteral nutrition (TPN) solution. The nurse should assess a client's ability to metabolize the TPN solution adequately by monitoring the client for which sign? a. tachycardia b. hypertension c. elevated blood urea nitrogen concentration d. hyperglycemia

hyperglycemia

An unconscious client in the emergency department is given IV naloxone due to an overdose of heroin. Which findings would indicate a therapeutic response to the naloxone? Select all that apply. a. decreased pulse rate b. warm moist skin c. dilated pupils d. increased respirations e. consciousness

increased respirations consciousness

The nurse is evaluating a client who is using a flow incentive spirometer following abdominal surgery 1 day ago. The client is performing the procedure correctly when the client does what? Select all that apply a. inhales before using the spirometer b. inhales for 3 second following fully expanding the lungs c. coughs after suing the spirometer d. uses the spirometer once every 8 hours e. exhales passively before using the spirometer again f. sits upright

inhales for 3 second following fully expanding the lungs coughs after suing the spirometer exhales passively before using the spirometer again sits upright

A client and family have just received the initial diagnosis of colon cancer. In which way can the nurse act as an advocate? a. helping them maintain a sense of optimism and hopefulness b. determining their understanding of the results of the diagnostic testing c. listening carefully to their perceptions of what their needs are d. providing them with written materials about the cancer site and its treatment

listening carefully to their perceptions of what their needs are

The nurse is teaching a client about the use of nicotine gum for assistance with smoking cessation. Which instruction should be included? a. eat within 15 minutes of chewing the gum b. perform meticulous oral care c. notify healthcare provider of any sleep disturbances d. limit the dose to 6 pieces daily.

perform meticulous oral care

The nurse is assessing a client of a different culture who is being admitted to the hospital. What assessment would the nurse prioritize to best develop a culturally congruent plan of care? a. personal values and beliefs b. valued cultural traditions or ceremonies c. health-related cultural practices d. cultural restrictions to foods or medicines

personal values and beliefs

The healthcare team wishes to establish a policy regarding sleep positions for infants with gastroesophageal reflux disease. The first step should be to search for which information? a. policies from other hospitals b. data from retrospective studies c. published national standards d. expert opinions

published national standards

After the nurse administers a prescribed medication to a client who becomes restless at night and has difficulty falling asleep, which nursing action is most appropriate? a. sitting quietly with the client at the bedside until the medication takes effect b. engaging the client in interaction until the client falls asleep c. reading to the client with the lights turned down low d. encouraging the client to watch television until the client feels sleepy

sitting quietly with the client at the bedside until the medication takes effect

A client experienced a pneumothorax after the placement of central venous pressure line. Which assessment supports a diagnosis of pneumothorax? a. sudden, sharp pain on the affected side b. tracheal deviation toward the affected side c. bradypnea and elevated blood pressure d. presence of crackles and wheezes.

sudden, sharp pain on the affected side

A child is admitted with a fracture of the femur and placed in skeletal traction. What should the nurse assess first? a. the pull of traction on the pin b. the elastic bandage c. the pin sites for signs of infection d. the dressings for tightness

the pull of traction on the pin

For the child diagnosed with an asthma attack, which manifestation would best correlate with the child's arterial blood gas results, which include pH of 7.46, bicarbonate of 21 mEq/L (21 mmol/L) and a partial pressure of carbon dioxide (PCO2 ) of 33 mm Hg (4.4 kPa)? a. greatly diminished breath sounds b. tingling sensation in the fingertips c. heart rate of 68 bpm d. absence of urination for several hours

tingling sensation in the fingertips

A client was admitted with an exacerbation of heart failure breath at 0200. At 0700, which information is most important for the nurse who admitted the client to communicate during the hand-off of care report to the nurse who will next take care of the client? a. admission weight of 210 lbs (95 kg) b. elevated B-type natriuretic peptide of 600 mg/mL c. reaching 250 mL by incentive spirometer d. urinary output of 120 mL

urinary output of 120 mL

The nurse has completed breastfeeding discharge instructions and determines the mother understands the instructions when she makes which statement(s)? Select all that apply. a. "My calorie intake will need to increase by 1,000 calories per day." b. "Any drugs I take may pass through to my baby through my breast milk." c. "Babies should have six to eight wet diapers a day after the first 3 days of life." d. "I have the phone number for the lactation consultant if I have questions." e. "Babies should be content 5 to 6 hours after daytime feedings."

"Any drugs I take may pass through to my baby through my breast milk." "Babies should have six to eight wet diapers a day after the first 3 days of life." "I have the phone number for the lactation consultant if I have questions."

A child who is 18 months of age is brought to the emergency department by her babysitter. The babysitter states, "She fell from the sofa an hour ago and hasn't been herself since." On questioning, the babysitter appears to be unsure of time and other facts about the incident. Which question would be most effective in obtaining more information about the child's injuries? a. "Why did you leave the child alone on the couch?" b. "Have you taken a course in safe babysitting?" c. "Tell me what was happening before she fell." d. "Where are her parents? Do they know this happened?"

"Tell me what was happening before she fell."

During a preparation for parenting class, one of the participants asks the nurse, "How will I know if I'm really in labor? " What should the nurse tell the participant about true labor contractions? a. "Walking around helps to decrease true contractions." b. "True labor contractions may disappear with rest or sleep." c. "The duration and frequency of true labor contractions remain the same." d. "True labor contractions are felt first in the lower back, then the abdomen."

"True labor contractions are felt first in the lower back, then the abdomen."

A 17 year old high school senior calls the clinic because she thinks she might have gonorrhea. She wants to be seen but wants assurances that no one will know. Which is the most appropriate response by the nurse? a. "Because you are underage, you will need your parent's consent to treat you" b. "We can treat you without your parent's consent, but they have the right to review your medical record" c. "We can see you without your parents consent, but have to report any positive results to the public health department" d. "We can see you, treat any infection, and will not share your results with anyone"

"We can see you without your parents consent, but have to report any positive results to the public health department"

A client with diabetes mellitus that is well controlled reports that she participated in strenuous aerobic exercise before becoming pregnant. She asks the nurse if she can continue exercising. What is the nurse's best response? a. "You probably should discontinue your strenuous exercise program while you're pregnant so you don't injure the fetus." b. "You need to curtail your exercise program a little so that you don't overexert yourself while you're pregnant." c. "You can continue exercising while pregnant, but make sure that you eat a carbohydrate or protein snack before exercising." e. "It's probably a good idea for you to check your blood sugar before beginning any exercise program."

"You can continue exercising while pregnant, but make sure that you eat a carbohydrate or protein snack before exercising."

A nurse is cleaning out her locker after being terminated. She slams the locker door shut and yells, "What am I going to do? I have three kids!" Which principles of cognitive rehearsal should the nurse manager choose for this situation?

"You have the right to withdraw consent, so let's discuss your decision"

The nurse is teaching two unlicensed assistive personnel (UAP) who are new to the inpatient unit about caring for a client who is suicidal. The nurse determines that additional teaching is needed when one of the UAPs makes which statement? a. "I need to check the client precisely at 15-minute intervals." b. "Documenting suicide checks is absolutely necessary." c. "Clients on one-to-one suicide precautions can never be left alone." d. "All clients using razors must be supervised by staff."

. "I need to check the client precisely at 15-minute intervals."

A client is being admitted with nursing home-acquired pneumonia. The unit has four empty beds in semiprivate rooms. The room that would be most suitable for this client is the one with which client? a. 60-year-old client admitted for investigation of transient ischemic attacks b. 45-year-old client with abdominal hysterectomy c. 24-year-old client with non-Hodgkin's lymphoma d. 55-year-old client with alcoholic cirrhosis

60-year-old client admitted for investigation of transient ischemic attacks

A client has refused to take a shower since being admitted 4 days earlier. He tells a nurse, "There are poison crystals hidden in the showerhead. They'll kill me if I take a shower." Which nursing action is most appropriate? A. Dismantling the showerhead and showing the client that there is nothing in it B. Explaining that other clients are complaining about the client's body odor C. Asking a security officer to assist in giving the client a shower D. Accepting these fears and allowing the client to take a sponge bath

Accepting these fears and allowing the client to take a sponge bath By acknowledging the client's fears, the nurse can arrange to meet the client's hygiene needs in another way. Because these fears are real to the client, providing a demonstration of reality by dismantling the shower head wouldn't be effective at this time. Explaining that other clients are complaining about his body odor or asking a security officer to assist in giving the client a shower would violate the client's rights by shaming or embarrassing him.

The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the medical record(See exhibit) for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 1530 is 75% taken on the infant's right wrist. What should the nurse do first? a. Administer oxygen via mask. b. Obtain a pulse oximeter reading in a lower extremity. c. Reassess the oximetry reading in 30 minutes. d. Draw blood gases for oxygen and carbon dioxide levels.

Administer oxygen via mask.

A nurse is managing the care of a client with osteoarthritis. Appropriate treatment strategies for osteoarthritis include: A. Administration of opioids for pain control B. Administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program C. Administration of monthly intra-articular injections of corticosteroids D. Vigorous physical therapy for the joints

Administration of nonsteroidal anti-inflammatory drugs (NSAIDs) and initiation of an exercise program NSAIDs are routinely used for anti-inflammatory and analgesic effects. NSAIDs reduce inflammation, which causes pain. Opioids aren't used for pain control in osteoarthritis. Intra-articular injection of corticosteroids is used cautiously for an immediate, short-term effect when a joint is acutely inflamed. Normal joint range of motion and exercise (not vigorous physical therapy) are encouraged to maintain mobility and reduce joint stiffness.

Because both parents are nearsighted, the mother is concerned that her 4-year old child may be nearsighted. She says that he likes to look at books and knows some of the alphabet. Which assessment techniques should the nurse use to test the child's visual acuity? a. Cover and crossover test b. Allen picture cards c. Snellen alphabet chart d. Ishihara test

Allen picture cards

The nurse administers a bolus tube feeding to a client with cancer. What should the nurse do to decrease the risk of aspiration? a. Place the client on bed rest with the head of the bed elevated to 60 degrees for 2 hours. b. Turn the client on the left side with the head of the bed at 45 degrees for 15 minutes. c. Assist the client out of bed to sit upright in a chair for 1 hour. d. Ask the client to rest in bed with the head of the bed elevated to 30 degrees for 20 minutes.

Assist the client out of bed to sit upright in a chair for 1 hour.

A client who uses an insulin pen asks the nurse how to dispose of the needles. The client's job requires frequent travel by airplane. What information should the nurse include in the teaching plan? Select all that apply. a. At home, dispose of needles in a sharps container or solid plastic container. b. Put full sharps containers in recycling bins for home waste management pick-up. c. Carry a travel size disposal container and dispose of needles in the hotel recycling bin. d. Check with federal transportation guidelines for labeling medications and safe disposal. e. Wipe the needle

At home, dispose of needles in a sharps container or solid plastic container. Check with federal transportation guidelines for labeling medications and safe disposal.

A client with a tracheostomy tube coughs and dislodges the tracheostomy tube. The nurse's first action should be to: A. Call for emergency assistance B. Attempt reinsertion of tracheostomy tube C. Position the client in semi-Fowler's position with the neck hyperextended D. Insert the obturator into the stoma to reestablish the airway

Attempt reinsertion of tracheostomy tube The nurse's first action should be to attempt to replace the tracheostomy tube immediately so that the client's airway is reestablished. Although the nurse may also call for assistance, there should be no delay before attempting reinsertion of the tube. The client is placed in a supine position with the neck hyperextended to facilitate reentry of the tube. The obturator is inserted into the replacement tracheostomy tube to guide insertion and is then removed to allow passage of air through the tube.

The experienced licensed practical nurse (LPN) under the supervision of the RN team leader is providing nursing care for an infant with respiratory syncytial virus. Which tasks are appropriate for the RN to assign to the LPN? Select all that apply. a. Auscultate breath sounds. b. Administer prescribed aerosolized medications. c. Initiate the nursing care plan. d. Check oxygen saturation using pulse oximetry. e. Complete an in-depth admission assessment. f. Evaluate the parent's ability to administer aerosolized medications.

Auscultate breath sounds. Administer prescribed aerosolized medications. Check oxygen saturation using pulse oximetry.

The nurse is assessing a client who had epidural anesthesia 4 hours ago. What should the nurse assess first? a. Bladder distention. b. Headache. c. Postoperative pain. d. Ability to move legs

Bladder distention.

A 15-year-old client needs life-saving emergency surgery, but the relatives live an hour away from the hospital and cannot sign the consent form. What is the nurse's best response? a. Send the client to surgery without the consent. b. Call the family for a consent over the telephone, and have another nurse listen as a witness. c. No action is necessary in this case because consent is not needed. d. Have the family sign the consent form as soon as they arrive.

Call the family for a consent over the telephone, and have another nurse listen as a witness.

The nurse observes the cardiac rhythm (see below) for a client who is being admitted with a myocardial infarction. Which action should the nurse take first? a. Prepare for immediate cardioversion. b. Begin cardiopulmonary resuscitation. c. Check for a pulse. d. Prepare for immediate defibrillation.

Check for a pulse.

The nurse is caring for an infant with suspected transposition of the great arteries (TGA). The nurse will prepare the infant and family for which diagnostic test first? a. Blood Cultures b. Cardiac Catheterization c. Chest Xray d. Echocardiogram

Chest X-Ray Rationale: Chest x ray would be done first to visualize congenital heart disease such as TGA. Blood Cultures will not diagnose TGA. Cardiac Catheterization and an echocardiogram would be done after TGA is seen on the chest X-ray.

A parent reports they cannot afford the antibiotic azithromycin, which was prescribed by the health care provider (HCP) for her toddler's otitis media. What is the nurse's best response? a. Instruct the parent on the importance of the medication. b. Ask the parent if they have considered using a medical assistance programs. c. Confer with the HCP about whether a less expensive drug could be prescribed. d. Consult with the social worker.

Confer with the HCP about whether a less expensive drug could be prescribed.

The nurse is making rounds and observes the client receiving oxygen. What should the nurse do next? a. Position the mask lower on the client's nose. b. Verify that the reservoir bag remains deflated. c. Confirm that the flow rate is set to deliver oxygen at 6 to 10 L/min. d. Loosen the elastic band on the client's face.

Confirm that the flow rate is set to deliver oxygen at 6 to 10 L/min.

The healthcare provider (HCP) prescribes carbamazepine extended release for a client with cerebral palsy who also has a seizure disorder. The client has a gastrostomy feeding tube, and carbamazepine is on the hospital's "no crush" list. What should the nurse do to administer the medication? a. Cut the medication into four pieces that can be placed in the feeding tube. b. Dissolve the medication in 30 mL of juice. c. Ask the pharmacist for an oral suspension. d. Contact the HCP to change the prescription.

Contact the HCP to change the prescription.

The nurse caring for a post term client scheduled for an induction of labor has completed the necessary assessments. The client has been placed on electronic fetal monitoring, and venous access has been established. After reviewing the titration prescription for oxytocin , the nurse should perform what action next ? a. Begin the oxytocin infusion at 2 milliunits/min. b. Contact the health care provider to clarify the prescription. c. Ensure that adult resuscitation equipment is in the room. d. Implement a two-nurse verification of a high-alert medications

Contact the health care provider to clarify the prescription.

The nurse reads the new medication prescriptions for a 4-year-old child with nephrotic syndrome on the chart as shown. What should the nurse do? a. Discontinue the prednisolone 40 mg and give the 30-mg dose today. b. Check the medication record first to see when the last dose of prednisolone was given. c. Start the 30-mg dose tomorrow. d. Contact the prescriber for clarification.

Contact the prescriber for clarification.

The healthcare team has noticed an increase in IV infiltrations on the pediatric floor. As part of a Plan, Do, Study, Act quality improvement plan, the team should perform the actions in which order? All options must be used. a. Analyze the data. b. Perform chart audits. c. Decide to monitor IV gauges. d. Write a new IV insertion policy.

Decide to monitor IV gauges. Perform chart audits. Analyze the data. Write a new IV insertion policy.

The nurse has been assigned to a client who is hearing impaired and reads speech. Which strategies should the nurse incorporate when communicating with the client? Select all that apply. a. Do not block out the person's view of the speaker's mouth. b. Face the client when talking. c. Have bright light behind the individual speaking. d. Ensure the client is familiar with the subject material before discussing. e. Talk to the client while performing other nursing procedures.

Do not block out the person's view of the speaker's mouth. Face the client when talking. Ensure the client is familiar with the subject material before discussing.

The nurse assesses a client's risk for breast cancer. Which finding would be considered a risk factor? a. Menopause before age 40 b. Early onset of menstruation c. Having more than 2 children d. Breastfeeding longer than 2 years.

Early onset of menstruation

A nurse is caring for a postsurgical client with two types of drains. Which activities can the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply a. Assess the drainage of an open drainage system, such as a Penrose drain. b. Document drain site and surrounding tissue status. c. Stabilize an open drainage system, such as a Penrose drain. d. Empty a closed drainage system, such as a Jackson-Pratt drain or Hemovac drain. e. Record the output from a closed-drainage system, such as a Jackson-Pratt drain or Hemovac drain.

Empty a closed drainage system, such as a Jackson-Pratt drain or Hemovac drain. Record the output from a closed-drainage system, such as a Jackson-Pratt drain or Hemovac drain.

The nurse is caring for a client who is using a portable wound suction unit. Six hours following surgery, the drainage unit is full. What should the nurse do first? a. Remove the drain from the incision. b. Notify the surgeon. c. Empty drainage. d. Record the amount in the unit as output on the client's medical record.

Empty drainage.

A client has an increased intracranial pressure of 20 mm Hg. What intervention should the nurse implement? a. Give the client a warming blanket. b. Administer low-dose barbiturates. c. Encourage the client to take deep breaths. d. Restrict fluids.

Encourage the client to take deep breaths.

The nurse is serving on the hospital ethics committee that is considering a proposal for the nursing staff to search the room of a client diagnosed with substance abuse disorder while the client is off the unit and without the client's knowledge. What should be considered concerning the relationship between ethical and legal standards of behavior? a. Ethical standards are generally higher than those required by law. b. Ethical standards are equal to those required by law. c. Ethical standards bear no relationship to legal standards for behavior. d. Ethical standards are irrelevant when the health of a client is at risk.

Ethical standards are generally higher than those required by law.

When planning diet teaching for the client with a colostomy, the nurse should develop a plan that emphasizes which dietary instruction? a. Foods containing roughage should not be eaten b. Liquids are best limited to prevent diarrhea c. Experiment to find the diet that works best d. High fiber diets produce regular passage of stools Difficult

Experiment to find the diet that works best

A client with pneumonia has a temperature of 102.6° F (39.2°C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care? A. Position changes every 4 hours B. Nasotracheal suctioning to clear secretions C. Frequent linen changes D. Frequent offering of a bedpan

Frequent linen changes Frequent linen changes are appropriate for this client because of the diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort. Position changes need to be done every two hours. Nasotracheal suctioning is not indicated with the client's productive cough. Frequent offering of a bedpan is not indicated by the data provided in this scenario.

When a client cannot read or write but is of sound mind, the nurse should read the informed consent to the client in the presence of two witnesses and do what next? a. Have the client's next-of-kin sign the informed consent. b. Have the client put an "X" on the signature line. c. Have a court appoint a guardian for the client. d. Have a hospital quality management coordinator sign for the client.

Have the client put an "X" on the signature line.

On initial assessment of a 7-year-old child with rheumatic fever, which of the following would require contacting the primary care provider immediately? A. Heart rate of 150 beats/minute B. Swollen and painful knee joints C. Twitching in the extremities D. Red rash on the trunk

Heart rate of 150 beats/minute A heart rate of 150 beats/minute is very high for a 7-year-old child and may indicate carditis. For this age group, the normal heart rate while awake is 70 to 110 beats/minute. Swollen and painful joints such as the knee are characteristic findings in the child with rheumatic fever and do not require immediate physician notification. Twitching in the extremities, known as chorea, is a characteristic finding in a child with rheumatic fever and does not require immediate physician notification. A red rash on the trunk typically indicates rheumatic fever and does not require immediate physician notification.

The nurse is performing a medication reconciliation, and the client requests a green coffee bean supplement to lose weight. What is the nurse's best response? a. There is limited scientific information on the connection between green coffee beans and weight loss." b. The hospital does not offer any of the green coffee bean items, but I can get you some tomorrow from my home." c. "I will call your healthcare provider and tell them you are interested in adding the supplement to your medication regime." d. The hospital does not have green coffee bean supplements in the formulary, but you can bring them from home."

I will call your healthcare provider and tell them you are interested in adding the supplement to your medication regime."

When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first? a. Administer the prescribed preanesthetic medication. b. Note this new allergy prominently on the medical record. c. Contact the scrub nurse in the operating room. d. Inform the anesthesiologist.

Inform the anesthesiologist.

The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate? A. Have the client wear eyeglasses at all times B. Lightly tape the eyelid shut C. Instill artificial tears once every shift D. Clean the eyelid with a washcloth every shift

Lightly tape the eyelid shut When the blink reflex is absent or the eyes do not close completely, the cornea may become dry and irritated. Corneal abrasion can occur. Taping the eye closed will prevent injury. Having the client wear eyeglasses or cleaning the eyelid will not protect the cornea from dryness or irritation. Artificial tears instilled once per shift are not frequent enough for preventing dryness.

A 4-year-old child is seen in the pediatrician's office. The child is due for immunizations and the provider discusses with the caregiver the need for the immunizations. The nurse returns to the room to administer the immunizations and the caregiver refuses to sign the paperwork for the administration of the immunizations. What is the most appropriate action by the nurse? a. Listen to the caregiver's concerns and discusses the risks of nonimmunization. b. Documents the interaction and escorts the caregiver and child out of the office. c. State the child must have vaccinations for preschool and injects the child without permission. d. Request the provider to return to discuss the risks of non-immunization.

Listen to the caregiver's concerns and discusses the risks of nonimmunization.

At 0500, the nurse on the antepartum unit reviews all remaining tasks to complete before giving the change of shift handoff at 0700. In what order from first to last should the nurse complete the tasks? All options must be used. a. Draw magnesium sulfate at 0600. b. Monitor fetal monitor strip for one-half hour every shift. c. Administer point-of-care blood glucose and sliding scale insulin due at 0700, 1100, 1600, and bedtime. d. Check documentation and perform a final check of each client.

Monitor fetal monitor strip for one-half hour every shift. Draw magnesium sulfate at 0600. Check documentation and perform a final check of each client. Administer point-of-care blood glucose and sliding scale insulin due at 0700, 1100, 1600, and bedtime.

A client was talking with her husband by telephone, and then she began swearing at him. The nurse interrupts the call and offers to talk with the client. She says, "I can't talk about that bastard right now. I just need to destroy something." Which of the following should the nurse do next? A. Tell her to write her feelings in her journal B. Urge her to talk with the nurse now C. Ask her to calm down or she will be restrained D. Offer her a phone book to "destroy" while staying with her

Offer her a phone book to "destroy" while staying with her At this level of aggression, the client needs an appropriate physical outlet for the anger. She is beyond writing in a journal. Urging the client to talk to the nurse now or making threats, such as telling her that she will be restrained, is inappropriate and could lead to an escalation of her anger.

A client who is on nothing-by-mouth status is constantly asking for a drink. Which nursing intervention is the most appropriate? a. Re-explain to the client why she cannot drink. b. Offer ice chips every hour to decrease thirst. c. Offer the client frequent oral hygiene care. d. Divert the client's attention by turning on the television.

Offer the client frequent oral hygiene care.

A client with a history of polysubstance abuse is admitted to the facility. The client reports nausea and vomiting 24 hours after admission. The nurse who assesses the client notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through withdrawal from which substance? a. Alcohol b. Cannabis c. Cocaine d. Opioids

Opioids

The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to: A. Keep their home warmer than usual B. Encourage plenty of outdoor activities C. Promote interactions with one friend instead of groups D. Limit bathing to prevent skin irritation

Promote interactions with one friend instead of groups Children with hyperthyroidism experience emotional labiality that may strain interpersonal relationships. Focusing on one friend is easier than adapting to group dynamics until the child's condition improves. Because of their high metabolic rate, children with hyperthyroidism complain of being too warm. Bright sunshine may be irritating because of disease-related ophthalmopathy. Sweating is common and bathing should be encouraged.

To help prevent hip flexion deformities associated with rheumatoid arthritis, the nurse should help the client assume which position in bed several times a day? a. Prone b. Low Fowlers c. Modified Trendelenburg d. Side-lying

Prone

During the evening shift on the day of a client's bowel resection surgery, the nasogastric tube drains 500 mL of green-brown fluid. What action should the nurse take? a. Call the healthcare provider. b. Increase the IV infusion rate. c. Record the amount of drainage on the client's chart. d. Irrigate the tube with normal saline solution.

Record the amount of drainage on the client's chart.

A female client who has diagnosis of borderline personality disorder is manipulative and very disruptive on the hospital unit. She is not dangerous to herself or others, but she is clearly not making any therapeutic progress. She consistently refuses any medications. The nurse realizes that legally this client has which option? a. Refuse treatment. b. Receive forced treatment if the nursing team concurs. c. Be medicated if her family signs permission for treatment. d. Be guided to accept treatment recommendations by threatening loss of privileges.

Refuse treatment.

A registered nurse instructs the unlicensed assistive personnel (UAP) to check the urine intake and output (I&O) on clients of the oncology unit at the end of the 8-hour shift. It is important for the nurse to instruct the UAP to do what? a. Ask the clients if they are thirsty when calculating the I&O. b. Report back to the nurse immediately if any client has an output less than 240 mL. c. Document the I&O results on the medical records. d. Write the I&O results down for the nurse to give report to the next shift.

Report back to the nurse immediately if any client has an output less than 240 mL.

While giving report to the oncoming night shift, the charge nurse smells alcohol on the breath of one of the nurses. What should the charge nurse do? a. Report this to the nursing supervisor immediately. b. Report this to the head nurse upon arrival in the morning. c. Ask the nurse if they have been drinking. d. Assess the nurse's behavior for signs of intoxication.

Report this to the nursing supervisor immediately.

The nurse assesses an adolescent's musculoskeletal system. According to the figure the nurse should note the client has which finding? a. Dowager's hump b. Kyphosis c. Lordosis d. Scoliosis

Scoliosis

Which instructions should the nurse include in the teaching plan for a 30-year old multiparous client who will be using an intrauterine device (IUD) for family planning? a. Amenorrhea is a common adverse effect of copper IUDs. b. Additional conception protection will be needed. c. IUDs are more costly than other forms of contraception. d. Severe cramping may occur when the IUD is inserted.

Severe cramping may occur when the IUD is inserted.

42-year-old client was admitted from a homeless shelter with a diagnosis of tuberculosis and alcoholism. It is essential that which health care team member attends the care conference to discuss discharge planning and community resources? a. Dietician b. Pharmacist c. Social worker d. Infection control nurse

Social worker

The nurse walks into the room of a client who has a "do not resuscitate" prescription and finds the client without a pulse, respirations, or blood pressure. What should the nurse do first? a. Stay in the room and call the nursing team for assistance. b. Push the emergency alarm and call a code. c. Page the client's health care provider. d. Pull the curtain and leave the room.

Stay in the room and call the nursing team for assistance.

The nurse assesses the results of a gentamicin trough blood level for an adolescent with cystic fibrosis who has had been treated with gentamicin several times over the last year. The drug level is high. What is the nurse's primary concern? a. The child may develop liver dysfunction. b. The child may suffer hearing loss. c. The medication may have been administered incorrectly. d. The child may need to have a different antibiotic.

The child may suffer hearing loss.

When developing a teaching plan for a client who is prescribed acetaminophen for muscle pain, which information should the nurse expect to include? Select all that apply. a. The drug can be used if the person is allergic to aspirin. b. Acetaminophen does not affect platelet aggregation. c. This drug causes little or no gastric distress. d. Acetaminophen exerts a strong anti-inflammatory effect. e. The client should have the International Normalized Ratio (INR) checked regularly.

The drug can be used if the person is allergic to aspirin. Acetaminophen does not affect platelet aggregation. This drug causes little or no gastric distress.

The nurse is to wear personal protective equipment (PPE) to administer a chemotherapeutic agent to the client. What guidelines should the nurse use for PPE use and care? Select all that apply. a. Understand the proper use and limitations of PPE. b. Use care in removing all items to reduce contamination. c. Ensure that PPE is made of materials that allow for air ventilation d. Sanitize the hands with alcohol-based solution before putting gloves on and after removing glove e. Discard the PPE in containers for contaminated waste.

Understand the proper use and limitations of PPE. Ensure that PPE is made of materials that allow for air ventilation Discard the PPE in containers for contaminated waste.

An older adult is taking seven prescribed drugs with varied dosing schedules. What should the nurse instruct the client to do to improve compliance and medication safety? a. Use over-the-counter medications. b. Take all the medications at the same time. c. Use a pill tray or medication reminder app. d. Count the remaining pills in each bottle at the end of the day.

Use a pill tray or medication reminder app.

After completing diagnostic testing, the surgeon has scheduled a newborn with the diagnosis of an imperforate anus for surgery the next day. The infant's parents do not want the surgery to take place unless the infant has first been baptized. What should the nurse ask the parents? a. "Are you worried your baby might die?" b. "What help do you need arranging the baptism?" c. "Do you want to speak with the social worker?" d. "Would you prefer to wait for the surgery?"

"What help do you need arranging the baptism?"

A child has just ingested about 10 adult-strength acetaminophen tablets an hour ago. The mother brings the child to the emergency department. What should the nurse do? Place the interventions in the order of priority from first to last. All options must be used. a. Assess the airway b. Administer activated charcoal c. Check serum acetaminophen level d. Administer acetylcysteine

Assess the airway Administer activated charcoal Check serum acetaminophen level Administer acetylcysteine

The parent of a child with spastic cerebral palsy and a communication disorder tells the nurse, "He seems so restless. I think he's in pain." Which action is most indicated? a. Assess the child for pain using the Faces, Legs, Activity, Cry, Consolability (FLACC) scale. b. Assess the child using the pediatric FACES scale. c. Administer prescribed pain medication. d. Notify the healthcare provider of the change in behavior.

Assess the child for pain using the Faces, Legs, Activity, Cry, Consolability (FLACC) scale.

An adolescent with cystic fibrosis has been placed on ciprofloxacin for a lung infection. Which statement from the client indicates the need for more teaching? a. "I won't take this drug with any dairy products." b. "I'll need to have drug levels drawn while I'm on this medication." c. "I should immediately report any muscle or joint pain." d. "If I miss a dose, I should take it as soon as I remember."

"I'll need to have drug levels drawn while I'm on this medication."

A nurse administers cefazolin instead of ceftriaxone to an 8-year-old with pneumonia. The client has suffered no adverse effects. The nurse tells the charge nurse of the incident but fears disciplinary action from reporting the error. What should the charge nurse tell the nurse? a. "If you don't report the error, I'll have to." b. "Reporting the error helps to identify system problems to improve client safety." c. "Notify the client's healthcare provider to see if she wants this reported." d. "This is not a serious mistake, so reporting it will not affect your position."

"Reporting the error helps to identify system problems to improve client safety."

A client has anemia resulting from bleeding from ulcerative colitis and is to receive two units of packed red blood cells (PRBCs). The client is receiving an infusion of total parenteral nutrition (TPN). In preparing to administer the PRBCs, what should the nurse do to ensure client comfort and safety? a. Discontinue the TPN infusion. b. Start an IV infusion of normal saline. c. Administer PRBCs in the same IV as the TPN. d. Use the same IV line to infuse the PRBCs after the TPN is done.

Start an IV infusion of normal saline.

The nurse is irrigating a client's colostomy. The client has abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse do first? a. Stop the flow of solution. b. Reposition the client on the right side. c. Remove the irrigation tube. d. Massage the abdomen gently.

Stop the flow of solution.

When teaching a client about self-care following placement of a new permanent pacemaker to the left upper chest, the nurse should indicate which information? (Select all that apply) a. Take and record daily pulse rate b. Avoid air travels because of airport security alarms c. Immobilize the affected arm for 4 to 6 weeks d. Avoid using the microwave oven e. Avoid lifting anything heavier than 3 lbs (1.36 kg)

Take and record daily pulse rate Avoid lifting anything heavier than 3 lbs (1.36 kg)

A client is admitted with post-traumatic stress disorder and continued trouble sleeping. She states that when she closes her eyes, she has vivid memories about being awakened at night. "My dad would be on top of me trying to have sex with me. I couldn't breathe." Which suggestions would be appropriate for the nurse to make for the insomnia? Select all that apply. a. trying relaxation techniques to help decrease her anxiety before bedtime b. staying in the dayroom and trying to sleep in the recliner chair near staff c. listening to calming music as she tries to fall asleep d. processing the content of her flashbacks no less than an hour before bedtime e. leaving her door slightly open to decrease noise during the nightly checks

trying relaxation techniques to help decrease her anxiety before bedtime listening to calming music as she tries to fall asleep leaving her door slightly open to decrease noise during the nightly checks

When assessing a client who is receiving tricyclic antidepressant therapy, which finding should alert the nurse to the possibility that the client is experiencing anticholinergic effects? a. tremors and cardiac arrhythmias b. sedation and delirium c. respiratory depression and convulsions d. urine retention and blurred vision

urine retention and blurred vision

The healthcare provider orders nitroglycerin transdermal patch for a client having angina pain. What priority teaching would the nurse include? Select all that apply. a. "Apply nitroglycerin patches at or around the same time every day." b. "Remove the nitroglycerin patch before going to bed." c. "Remove the nitroglycerin patch before bathing or swimming." d. "Apply a new nitroglycerin patch every morning."

"Apply nitroglycerin patches at or around the same time every day." "Apply a new nitroglycerin patch every morning."

The client received electroconvulsive therapy (ECT) an hour ago and now has a headache. Which response by the nurse is best? a. "A headache is common after ECT." b. "I'll get some acetaminophen for you." c. "A nap will help you feel better." d. "Eat your breakfast, and then let me know how you feel."

"I'll get some acetaminophen for you."

The nursing staff has safely and successfully secluded and restrained a client with acute mania who threatened the nurse and threw a chair against the wall in the community room. Which statement by the nurse is most helpful to the client at this time? a. "Threatening others and throwing furniture is not allowed." b. "You've been restrained until you can manage your behavior." c. "Since you've been here before, you know what the rules are." d. "We're only doing this for your own good, so calm down."

"You've been restrained until you can manage your behavior."

A client at 28 weeks' gestation in premature labor was placed on nifedipine. To maintain the pregnancy, the primary health care provider orders the client to have 20 mg now, followed by 20 mg every 8 hours while contractions persist, not to exceed the maximum daily oral dose of 60 mg. At what time will the client have reached the maximum dose if she begins taking the medication at 0600? Record your answer using military time. a. 2400 b. 2200 c. 2000 d. 1800

2200

The nurse is caring for a client who is paraplegic as the result of a stroke. At home, the client uses a wheelchair for mobility and can transfer independently. The client is now being treated with IV antibiotics for a sacral wound via a peripherally inserted central catheter. The client is alert and oriented and has no previous history of falling. Using the Morse Fall Scale, what is this client's total score? a. 20 b. 35 c. 50 d. 70

35

After the nurse teaches the parent of a child with a spica cast about skin care, which parental action would indicate the need for additional teaching? a. application of powder to the skin under the cast b. inspection of the cast edges for smoothness c. application of plastic film to cover the perineal cast area d. inspection of areas inside the cast

application of powder to the skin under the cast

The nurse is caring for a client with an implanted port who will need multiple I.V. medications daily. What is the appropriate action by the nurse a. Access the port with each medication administration. b. Access the port with a Huber needle and leave it in place for up to 7 days. c. Insert a peripheral line for I.V. medication administration. d. Request insertion of a PICC line for medication administration

Access the port with a Huber needle and leave it in place for up to 7 days.

A client who has been taking warfarin has been admitted with severe acute rectal bleeding and the following laboratory results: international normalized ratio, 8; hemoglobin, 11 g/dL (110 g/L); and hematocrit, 33% (0.33). After starting an IV infusion, in which order should the nurse implement the prescriptions? All options must be used. a. Administer vitamin K 2.5 mg by mouth. b. Administer IV normal saline. c. Give fresh frozen plasma. d. Schedule the client for sigmoidoscopy.

Administer IV normal saline. Give fresh frozen plasma. Administer vitamin K 2.5 mg by mouth. Schedule the client for sigmoidoscopy.

A child is being treated with vancomycin 40 mg/kg per day IV divided into three doses for osteomyelitis. The health care provider (HCP) has prescribed drug protocol management by pharmacy and a trough vancomycin level 30 minutes before the third dose scheduled for 0900 hours. The laboratory report returns prior to the third dose . What action should the nurse take? a. Administer the 0900 dose. b. Notify the health care provider. c. Notify the pharmacist. d. Draw a peak drug level.

Administer the 0900 dose. Notify the health care provider. Draw a peak drug level.

The nurse reviews the laboratory report of a child with leukemia (see exhibit). What does the nurse determine is the priority problem for this client? a. Risk for infection b. Bleeding c. Tissue perfusion d. Activity tolerance

Bleeding

As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. Which action should the nurse take first? a. Insert an airway to improve oxygenation. b. Note the time when the seizure begins and ends. c. Call for immediate assistance. d. Turn the client to her left side.

Call for immediate assistance.

On the day of surgery, a client with diabetes who takes insulin on a sliding scale is to have nothing by mouth and all medications withheld. The client's 0600 glucose level is 300 mg/dL (16.7 mmol/L). What should the nurse do? a. Withhold all medications. b. Administer the insulin dose dictated by the sliding scale. c. Call the healthcare provider for specific prescriptions. d. Notify the surgery department.

Call the healthcare provider for specific prescriptions.

Prior to going to surgery, the client tells the nurse that she cannot hear without her hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response? a. Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken. b. Tell the client that she will bring the hearing aid to the post-anesthesia care unit so that she can have it as soon as she wakes up. c. Explain to the client that she will have a premedication that will make her sleepy before she goes to surgery and she will not need to hear. d. Call the surgery unit to explain the client's concern and ask if she can wear her hearing aid to surgery.

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

A child with 20% second and third degree burns is admitted to the burn center. The child weighs 44lbs (20 kg). The nurse has started an IV infusion of lactated ringer solution and inserted an indwelling catheter. Which of the findings indicate that the child is going into shock? (Select all that apply) a. Urinary output is 25ml/hr b. Client is confused c. Pain is 7 on a pain scale 1-10 d. Heart rate is elevated e. Blood pressure is dropping

Client is confused Heart rate is elevated Blood pressure is dropping

The nurse is planning an eating disorder protocol for hospitalized clients experiencing bulimia and anorexia. Which elements should be included in the protocol? Select all that apply. a. Clients must eat within view of a staff member. b. Clients are not told their weight and cannot see their weight while being weighed. c. Clients are not allowed to discuss food or eating in groups or informal conversation with peers. d. Clients may not go to the bathroom for one-half hour to an hour after eating. e. Clients cannot participate in any groups after admission until they gain 1 lb (0.5 kg).

Clients must eat within view of a staff member. Clients are not told their weight and cannot see their weight while being weighed. Clients may not go to the bathroom for one-half hour to an hour after eating.

The nurse discovers that a client's TPN solution was running at an incorrect rate and is now 2 hours behind schedule. Which action is most appropriate for the nurse to take to correct the problem? a. Readjust the solution to infuse at the correct rate. b. Run the next bottle at an increased rate. c. Double the infusion rate for 2 hours to catch up infusion. d. Contact the healthcare provider for instructions.

Contact the healthcare provider for instructions.

The physician's order reads "digoxin 0.075 mg." The pharmacy packaging contains three digoxin tablets labeled as 0.25 mg each. The packaging states to administer all 3 tablets to the client. What should the nurse do next? a. Administer the dose according to the package instructions. b. Contact the pharmacist because the delivered dose is too high. c. Contact the pharmacist because the delivered dose is too low. d. Contact the physician to correct the original order.

Contact the pharmacist because the delivered dose is too high.

The nurse is taking care of a client who has an IV infusion pump. The pump alarm rings. What should the nurse do in order from first to last? All options must be used. a. Determine if the infusion pump is plugged into an electrical outlet. b. Assess the client's access site for infiltration or inflammation. c. Silence the pump alarm. d. Assess the tubing for hindrances to flow of solution.

Silence the pump alarm. Assess the client's access site for infiltration or inflammation. Assess the tubing for hindrances to flow of solution. Determine if the infusion pump is plugged into an electrical outlet.

A nurse is assessing a client when she returns from same-day surgery for a dilatation and curettage. The nurse checks preoperative vital signs at 0830 to compare them with the current vital signs at 2230 (see exhibit). What should the nurse do first? a. Call the health care provider for pain medication. b. Cover the client with warmed blankets. c. Administer oxygen at 4 d. Increase the IV fluid rate

Cover the client with warmed blankets.

The nurse determines that a client's abdominal wound has eviscerated. What should the nurse do first? a. Notify the healthcare provider b. Reinsert the protruding viscera into the abdominal cavity. c. Place the client in reverse Trendelenburg's position d. Cover the wound with sterile saline-moistened dressing

Cover the wound with sterile saline-moistened dressing

A client receiving chemotherapy for metastatic colon cancer is admitted to the hospital because of prolonged vomiting. Assessment findings include irregular pulse of 120 bpm, blood pressure 88/48 mm Hg, respiratory rate of 14 breathes/min, serum potassium of 2.9 mEq/L (2.9 mmol/L) and arterial blood gas -pH 7.46, PCO2 45 mm Hg (6.0 kPA), P)2 95 mm HG (12.6 kPa), bicarbonate level 29 mEq/L (29 mmol/L) The nurse should implement which prescription first? a. oxygen at 4L per nasal cannula b. repeat laboratory work in 4 hours c. D5W 45% NS with KCl 40 mEq/L at 125 mL/h d. 12 lead ECG

D5W 45% NS with KCl 40 mEq/L at 125 mL/h

The nurse has withdrawn a narcotic medication from the dispenser at a skilled nursing facility. The medication is ordered as needed. When the nurse enters the client's room, the client refuses the medication while the family is visiting. How will the nurse proceed with the correct procedure? Select all that apply. a. Explain to the client that refusal is not an option. b. Place the narcotic in the client's medication drawer. c. Encourage the family to have the client take the narcotic. d. Destroy the narcotic tablet immediately with a second nurse witness. e. Offer the option to have the narcotic when the client feels it is needed. f. Re-label the cup and lock the narcotic tablet in the unit medication room

Destroy the narcotic tablet immediately with a second nurse witness. Offer the option to have the narcotic when the client feels it is needed.

A client who had a hip replacement at 0900 is receiving an autologous blood transfusion that was started at 1100. At the change of shift (1500), the nurse working on the day shift reports that there is 50 mL of the unit of blood remaining to be infused. Which is a priority nursing action for the nurse working on the evening shift? a. Keep the blood transfusing at the same rate. b. Increase the rate so it will infuse by 1600. c. Discontinue the blood transfusion at the beginning of the shift. d. Maintain the current rate, and discontinue the blood transfusion at 1700.

Discontinue the blood transfusion at the beginning of the shift.

A 30-year-old G3, T2, P0, A0, L2 is being monitored internally. She is being induced with IV oxytocin because she is post term. The nurse notes the pattern below. The client is wedged to her side while lying in bed and is approximately 6-cm dilated and 100% effaced. What should the nurse do first? a. Continue to observe the fetal monitor. b. Anticipate rupture of the membranes. c. Prepare for fetal oximetry. d. Discontinue the oxytocin infusion.

Discontinue the oxytocin infusion

The nurse notices drops of a liquid on the hallway floor of a health care facility. What should the nurse do first? a. Place paper towels over the drops of liquid. b. Don clean gloves and wipe up the drops of liquid. c. Post "wet floor" signs around the area. d. Call the Environmental Services Department.

Don clean gloves and wipe up the drops of liquid.

A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode? a. Sit quietly with the client until the episode is over. b. Ignore the behavior. c. Attempt to divert the client's attention. d. Tell the client that this behavior is unacceptable.

Sit quietly with the client until the episode is over.

The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. What information should be included in the plan? Select all that apply. a. Splint or support the incision to promote maximal comfort. b. Inhale slowly through the nostrils; exhale through pursed lips. c. Hold the breath for about 5 seconds to expand the alveoli. d. Repeat this breathing method 5 to 10 times hourly. e. Close one nostril while inhaling.

Splint or support the incision to promote maximal comfort. Inhale slowly through the nostrils; exhale through pursed lips. Hold the breath for about 5 seconds to expand the alveoli. Repeat this breathing method 5 to 10 times hourly.

An older adult is admitted to the hospital with sudden onset of severe pain in the back, flank, and abdomen. The client reports feeling weak; the blood pressure is 68/31 mm hg. There has been no urine output. Bilateral leg pulses are weak, although bruit and pulsation are noted at the umbilicus. What action should the nurse take first? a. Obtain consent for emergency surgery b. Assess leg pulses with a Doppler test c. Palpate the abdomen for presence of a mass d. Start an IV infusion.

Start an IV infusion

The nurse realizes being an hour and 30 minutes late in administering a dose of medication for a 4-year-old child. The nurse gives the medication immediately and assesses the child. The child isn't harmed by the delay. Which action should the nurse take next? a. No further action is necessary. b. Notify the physician of the error. c. Follow facility procedures for reporting an error. d. Document a medication error in the client's chart.

Follow facility procedures for reporting an error.

A preterm infant born 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breathe sounds on one side, and shift in location of heart sounds. The nurse should prepare to assist with which procedure? a. Placement of the neonate on a ventilator b. Administration of bronchodilators through the nares c. Suctioning of the neonate's nares with wall suction d. Insertion of a chest tube into the neonate

Insertion of a chest tube into the neonate

A client has a patient a controlled analgesia (PCA) infusion to manage postoperative pain. In spite of receiving a dose of pain medication, the client rates the pain at 8 on a 0 to 10 pain scale. What should the nurse do first? a. Check the PCA pump function. b. Inspect the infusion site. c. Assess vital signs. d. Notify the health care provider.

Inspect the infusion site.

An adult comes into the emergency department with crushing substernal chest pain that radiates to the shoulder and left arm. The admitting diagnosis is acute myocardial infraction. Prescription include oxygen by nasal cannula at 4 L/min, complete blood count, a chest radiography, a 12 lead electrocardiogram (ECG), and 2 mg of morphine sulfate given IV. After applying oxygen which prescription should the nurse implement next? a. 12 lead electrocardiogram (ECG) b. Chest radiograph c. Morphine 4. Complete blood count

Morhpine

A nurse is walking down the hall in the main corridor of a hospital when the infant security alert system sounds, and a code for an infant abduction is announced. The first responsibility of the nurse when this situation occurs is to take which action? a. Move to the entrance of the hospital and check each person leaving. b. Go to the obstetrics unit to determine if they need help with the situation. c. Call the nursery to ask which baby is missing. d. Observe individuals in the area for large bags or oversized coats.

Observe individuals in the area for large bags or oversized coats.

The nurse is working with a client who is distraught after being diagnosed with late-stage pancreatic cancer. In addition to active listening, what nursing action is most appropriate? a. Offer to facilitate a referral to spiritual care. b. Assure the client that survival rates for pancreatic cancer are now measured in decades. c. Teach the client progressive relaxation techniques and guided imagery. d. Ask the provider to temporarily prescribe lorazepam as needed.

Offer to facilitate a referral to spiritual care.

A nurse is caring for a client who is disoriented to time, place, and person and is attempting to get out of bed and pull out an intravenous line. The nurse receives orders from a health care provider to apply a vest restraint and bilateral soft wrist restraints. In carrying out this order, which nursing actions would be appropriate? Select all that apply. a. Perform a face-to-face behavior evaluation every hour. b. Tie the restraints in quick-release knots. c. Tie the restraints to the side rails of the bed. d. Document the client's condition. e. Document alternative methods used before the restraints were applied. f. Document the client's response to the intervention.

Perform a face-to-face behavior evaluation every hour. Tie the restraints in quick-release knots. Document the client's condition. Document alternative methods used before the restraints were applied. Document the client's response to the intervention.

The nurse is planning care for a client who is at low risk for falling. What interventions would be included in the care plan? Select all that apply. a. Place call bell within easy reach. b. Secure locks on beds, stretchers, and wheelchairs. c. Remain with client during toileting. d. Keep the bed in the lowest position when possible. e. Place a commode next to bed for easy access. f. Employ a seat belt whenever a wheelchair is in use.

Place call bell within easy reach. Secure locks on beds, stretchers, and wheelchairs. Keep the bed in the lowest position when possible.

A client with a hemorrhagic stroke is slightly agitated, heart rate is 118 bpm, respiration are 22 breaths/min, bilateral rhonchi are auscultated, SPO2 is 94%, blood pressure is 144/88 mm hg and oral secretions are noted. What order of interventions from first to last should the nurse follow when suctioning the client to prevent increased intracranial pressure and maintain adequate cerebral perfusion? (All options must be used) a. Suction the mouth b. Hyperoxygenation c. Provide sedation d. Suction the airway

Provide sedation Hyperoxygenation Suction the airway Suction the mouth

During assessment of a small infant admitted with a diagnosis of meningitis, the infant becomes less responsive to stimuli and exhibits bradycardia, slight hypertension, irregular respirations and a temperature of 103.2° F (39.6° C). The infant's fontanel is more tense than at the last assessment. What action should the nurse take first? a. Ask another nurse to verify the findings. b. Notify the primary care provider of the findings. c. Raise the head of the bed. d. Administer an antipyretic.

Raise the head of the bed

The nurse notices a fire in a wastebasket in a client's room. In which order of priority from first to last should the nurse perform the actions? All options must be used. a. Extinguish the fire. b. Confine the fire by closing the door to the client's room. c. Pull the fire alarm at the alarm pull station. 4. Remove the client from the room.

Remove the client from the room. Pull the fire alarm at the alarm pull station Confine the fire by closing the door to the client's room. Extinguish the fire.

When preparing a client for discharge from the hospital after a total knee replacement, the nurse should include which information in the discharge plan? Select all that apply. a. Report signs of infection to health care provider . b. Keep the affected leg and foot on the floor when sitting in a chair. c. Remove anti-embolism stockings when sleeping. d. Follow physical therapist plan for progressive ambulation with use of assistive devices. e. Change the dressing daily.

Report signs of infection to health care provider . Follow physical therapist plan for progressive ambulation with use of assistive devices.

A six-month-old infant is being admitted with a diagnosis of bacterial meningitis. What considerations should be made, by the nurse, regarding the infant's room assignment? Select all that apply. a. The child will need to be on droplet precautions. b. The infant's parents will not be allowed in the room. c. A private room is required. d. The room should be near the nurses' station. e. There must be a window in the door to view the child.

The child will need to be on droplet precautions. A private room is required. The room should be near the nurses' station.

When evaluating teaching a client how to administer insulin, which action indicates that additional teaching is necessary? a. The client draws up the regular insulin first and then the NPH. b. The client rotates sites from legs to arms. c. The client identifies that the syringe is U-100 d. The client waits 30 minutes to eat breakfast after injecting rapid-acting insulin

The client waits 30 minutes to eat breakfast after injecting rapid-acting insulin

The nurse is assessing a client for a neurocognitive disorder such as dementia. What history findings would the nurse anticipate while talking with the client and family? Select all that apply. a. The progression of symptoms has been slow b. The client acts apathetic and pessimistic. c. The family cannot determine when the symptoms first appeared. d. The client has been exhibiting basic personality changes. e. The client has great difficulty paying attention to others.

The progression of symptoms has been slow The family cannot determine when the symptoms first appeared. The client has been exhibiting basic personality changes. The client has great difficulty paying attention to others.

Which client would benefit from the application of warm, moist heat? a. a client with appendicitis b. a client with a recently sprained joint c. a client with a suspected malignancy d. a client with low back pain

a client with low back pain

The nurse-manager is teaching the staff about the medication reconciliation policy. The nurse teaches the staff that reconciliation is needed to ensure that clients are on the correct medications in which situations? Select all that apply. a. admission to the hospital b. transfer to the nursing home c. transfer of a client from surgery to the surgical unit d. admission to a home health agency from the hospital e. move to a different room on the same unit

admission to the hospital transfer to the nursing home transfer of a client from surgery to the surgical unit admission to a home health agency from the hospital

The nurse observes a constant gentle bubbling in the water-seal column of a water-seal chest drainage system. What action should the nurse take? a. continue monitoring as usual; this is expected b. check the connectors between the chest and drainage tubes and where the drainage tube enters the chest drainage system. c. decrease the suction, and continue observing the system for changes in bubbling during the next several hours. d. Notify the healthcare provider.

check the connectors between the chest and drainage tubes and where the drainage tube enters the chest drainage system.

An older adult client with a diagnosis of chronic renal failure is being discharged to home with the client's partner. The home health nurse visits the hospital before discharge to discuss home safety with the client, who reports decreased mobility and a need for greater assistance with activities of daily living. The nurse focuses home safety teaching on which factors? a. having adequate lighting, removing cluttered paths and using nonskid bathroom surfaces b. avoiding unsteady ladders, overloaded electrical outlets and pesticides c. properly storing plastic bags and guns and replacing steps without handrails d. replacing defective smoke detectors, storing flammable liquids properly and repairing steps with broken concrete

having adequate lighting, removing cluttered paths and using nonskid bathroom surfaces

A client with a history of myocardial infarction 3 years ago was admitted at 0700 for a cholecystectomy scheduled at 0900. The client has been NPO since midnight. At 0830 the client reports having has chest pains. At 0700 the client's vital signs were pulse, 80 bpm; respirations, 14 breaths/min; blood pressure, 110/70 mm Hg. At 0830 the nurse takes the vital signs again: pulse is 110 bpm; respirations, 20 breaths/min; blood pressure, 90/60 mm Hg. The nurse calls the surgeon and, using SBAR communication protocol, should discuss which information with the surgeon? Select all that apply a. that the client has remained NPO b. history of myocardial infarction and current report of chest pains c. the change in vital signs d. the type of surgery scheduled e. request for ECG f. request to administer nitroglycerine tablet

history of myocardial infarction and current report of chest pains the change in vital signs request for ECG request to administer nitroglycerine tablet

A septic preterm neonate's IV was removed due to infiltration. The nurse prioritizes restarting the IV to help which complication? a. fever b. hyperkalemia c. hypoglycemia d. tachycardia

hypoglycemia

A Client with Acute respiratory distress syndrome is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR technique for communication, the nurse calls the healthcare provider with the recommendation for which intervention? a. increasing IV sedation b. starting a high protein diet c. providing pain medication d. increasing the ventilator rate

increasing IV sedation

While assisting the healthcare provider with an amniocentesis on a multigravida client at 38 weeks' gestation, the nurse observes that the fluid is very cloudy and thick. How should the nurse interpret this finding? a. intrauterine infection b. fetal meconium staining c. erythroblastosis fetalis d. normal amniotic fluid

intrauterine infection

Which are appropriate identifiers to use when providing care or administering medications or treatments? Select all that apply. a. room number b. bed number c. medical record number d. name band e. social security number

medical record number name band

The parents of a child with sickle cell anemia ask about the chances of sickle cell disease occurring in future children. The nurse responds based on knowledge that both parents are carriers. What is the risk of one of their children having the disease? a. one chance in five for each pregnancy b. one chance in four for each pregnancy c. one chance in three for each pregnancy d. one chance in two for each pregnancy

one chance in four for each pregnancy

A nurse is reviewing updated laboratory data stating that the oncology client has a low absolute neutrophil count following the third infusion of chemotherapy. Which interventions would be added to the plan of care? Select all that apply a. placing an infection control sign on the door requiring a mask/gown/glove b. placing a sign on the door to keep the door closed at all times c. encouraging a diet of fresh fruits and vegetables d. assuring that visitors have no temperature or flu-like symptoms e. contacting the healthcare provider to move client to the intensive care unit

placing an infection control sign on the door requiring a mask/gown/glove placing a sign on the door to keep the door closed at all times assuring that visitors have no temperature or flu-like symptoms

A 9 month old is admitted because of dehydration. How should the nurse go about accurately monitoring fluid intake and output? Select all that apply a. weighing and recording all wet diapers b. changing breastfeeding's to bottle-feedings c. obtaining an accurate daily weight d. restricting fluids prior to weighing the child e. obtaining an accurate stool count

weighing and recording all wet diapers obtaining an accurate daily weight obtaining an accurate stool count

A client who had a transurethral resection of the prostate (TURP) has a threeway indwelling urinary catheter with continuous bladder irrigation. In which circumstance should the nurse increase the flow rate of the continuous bladder irrigation? a. when drainage is continuous but slow b. when drainage appears cloudy and dark yellow c. when drainage becomes bright red d. when there is no drainage of urine and irrigating solution

when drainage becomes bright red