Review #1

A client with a history of command hallucinations was admitted to the hospital yesterday. What questions are most important for the nurse to ask?

1. "Are you hearing voices today?" 2. "What are the voices saying?" 3. "How are you feeling today?" 4. "Did you have difficulty sleeping last night?" 5. "Are the voices telling you to harm yourself or anyone else?" 1,2,5- correct

The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat for an adult client. What is the least amount of time that the nurse can safely administer this medication?

1. 1 minute 2. 2 minutes 3. 5 minutes 4. 10 minutes 2-correct

The nurse is performing morning care on a client on the medical unit. What should the nurse do after changing a client's bed linen?

1. Hold the linen close to the body while transporting it to the dirty utility room. 2. Wear a gown and gloves to transport the linen to the biohazard container. 3. Place the linen into a leak proof container sitting outside the room. 4. Place the linen in a pillow case and set it on the floor until client care is completed. 3- correct

A low income family with children lives in an old, run-down apartment building situated close to a salvage yard in a poor neighborhood. Which area of assessment would be most important for the home health nurse?

1. Immunization status 2. School-related problems 3. Lead poisoning 4. Signs of child abuse 3-correct

A group of women ask a community health nurse how to prevent stress incontinence. What points should the nurse teach these women?

1. Limit alkaline foods. 2. Avoid caffeine. 3. Maintain a healthy weight. 4. Eat less fiber. 5. Perform high-impact exercise. 2,3-correct

What assignment would be most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?

1. Teaching the client perineal care. 2. Changing a colostomy bag on a client. 3. Serving the diet tray for a diabetic client. 4. Taking the initial vital signs on a client who is to receive blood. 3- correct

The nurse is teaching a newly diagnosed diabetic about the action of regular insulin. The nurse verifies that teaching has been successful when the client verbalizes being at greatest risk for developing hypoglycemia at what time following the 8:00 a.m. dose of regular insulin?

1. 8:30 AM 2. 11:00 AM 3. 1:30 PM 4. 4:00 PM 2-correct

Which statement, made by a client scheduled for a total laryngectomy, indicates to the nurse a need for further preoperative teaching?

1. After the surgery, I will breathe only through a hole in my neck. 2. My wife will have to get a hearing aid because I will not be able to talk above a whisper. 3. I must have smoke detectors installed at home since I may not be able to smell after surgery. 4. After surgery, I will have a tube going through my nose to my stomach for feeding. 2- correct

On the third postoperative day, a client develops a fever of 103.3ºF (39.6ºC) shivering and nausea. The primary healthcare provider writes these prescriptions. Which should the nurse do first

1. Apply cooling blanket for fever. 2. Give ceftriaxone 1 gram IVPB stat. 3. Draw blood cultures. 4. Give promazine 50 mg po PRN for nausea. 3- correct

What interventions should the nurse initiate to keep the airway free of secretions in a client with pneumonia?

1. Evaluate results of ABG's and report abnormal findings. 2. Increase oral intake to at least 2000 mL/day. 3. Administer a cough suppressant medication. 4. Educate client on incentive spirometry. 5. Perform percussion to affected area. 2,4,5-correct

Which assessment finding by a nurse would best indicate a positive Mantoux tuberculin skin test in a client?

1. Formation of a vesicle that is 4 mm in diameter 2. A sharply demarcated region of erythema of 10 mm 3. A central area of induration of 15 mm surrounded by erythema 4. A circle of blanched skin surrounding the injection site 3- correct

The nurse is teaching the Type II diabetic about monitoring average blood glucose levels over time. The nurse evaluates teaching has been effective when the client verbalizes the need to return to the clinic for which test?

1. Glucose tolerance test 2. Glycosylated hemoglobin 3. Glucose-6-phosphate dehydrogenase 4. Fasting blood glucose 2- correct

During a conversation with a client on a psychiatric unit the client tells the nurse, "Everyone here hates me." Which response by the nurse is best?

1. No, they do not hate you. 2. What did you do to make others not like you? 3. Just don't pay attention to what others think of you. 4. I can't speak for the other people, but I don't hate you. 4- correct

A client with cancer of the larynx undergoes radiation therapy for 5 weeks prior to a neck dissection and tumor excision. The client asks the nurse how long the post surgical recovery time will be. How should the nurse reply?

1. "I really don't know. It is different for everyone, but speak to your surgeon." 2. "Your medical insurance will cover the whole length of your stay, so don't worry." 3. "You shouldn't worry about how long you are going to stay. You should focus on getting better." 4. "It may be a little longer than average. The radiation you received sometimes delays tissue healing." 4- correct

A newly admitted client with schizophrenia has an unkempt appearance and needs to attend to personal hygiene. Which statement by the nurse is most therapeutic?

1. A shower will make you feel better. 2. It is time to take a shower. 3. Have you thought about taking a shower? 4. I need you to take a shower. 2-correct

Which interventions should be included in the plan of care for an adult client with constipation?

1. Allow adequate time for defecation. 2. Provide privacy for bowel elimination. 3. Suggest increasing fluid intake (unless contraindicated). 4. Encourage client to increase fiber in the diet. 5. Encourage the client to delay the urge to defecate until after a meal. 1,2,3,4- CORRECT

A nurse from an adult unit was reassigned to the pediatric unit. Which client would be least appropriate to assign to this nurse?

1. Ten year old with 2nd and 3rd degree burns. 2. Five year old that was in a MVA and has a femur fracture. 3. Six year old admitted for evaluation of possible sexual abuse by a parent 4. Two month old with bronchopulmonary dysplasia being admitted for reflux. 3- correct

Which snack selection by a client receiving chemotherapy would indicate to the nurse that teaching has been successful?

1. Fresh salad with cucumbers, carrots, and tomatoes. 2. Orange slices with yogurt. 3. Strawberries with whipped cream. 4. Milk shake with a packet of instant breakfast added. 4- correct

During the insertion of a urinary catheter, the tip of the catheter touches the client's thigh. What action should the nurse take?

1. Wipe the tip of the catheter with alcohol. 2. Call for another urinary catheter and a pair of sterile gloves. 3. Insert the catheter and obtain a prescription for antibiotics. 4. Leave the room to obtain another sterile urinary catheter kit. 2- correct

The charge nurse is observing the work of an unlicensed assistive personnel (UAP). Which observation will require the nurse to intervene?

1. Placing soiled linen in a hazardous waste linen bag outside of the client's room. 2. Closing the door when exiting the room of a client diagnosed with tuberculosis (TB). 3. Going between client rooms wearing the same pair of gloves to collect I&O reports. 4. Cleaning a blood pressure cuff with a disinfectant. 3- correct

A client is hospitalized for recurrent angina with hypertension and has been started on new medications. When reviewing the admission forms, the nurse should immediately question which prescription?

1. 2 gram sodium diet. 2. Metoprolol 25 mg. P.O. once daily. 3. Potassium 10 meq. P.O. once daily. 4. Diltiazem 120 mg. P.O. once daily. 3- correct

Which client could the charge nurse assign to an LPN/VN?

1. Eight year old in diabetic ketoacidosis (DKA) 2. Six year old in sickle cell crisis 3. Two month old with dehydration 4. Five year old in skeletal traction. 4- correct

What medication should the nurse anticipate giving to a client in preterm labor to stimulate maturation of the baby's lungs?

1. Magnesium sulfate 2. Terbutaline 3. Methotrexate 4. Betamethasone 4-correct

To reduce the risk of developing a complication following balloon angioplasty, the nurse should implement which measure?

1. Monitor cardiac rhythm 2. Assess the puncture site every 8 hours 3. Measure urinary output hourly 4. Prevent flexion of the affected leg 5. Avoid lifting buttocks off the bed 1,3,4,5- correct

A client in a psychiatric unit sings over and over, "It is hot, I am a hot tot in a lot, I sit all day on a cot drinking a pop." How should the nurse document this form of thought?

1. Neologisms 2. Dissociation 3. Fugue 4. Clang Association 4-correct

How would the nurse determine the correct size oropharyngeal airway for a client?

1. Select the same size as the little finger of the victim. 2. Measure from the tip of the lips to the epiglottis. 3. Determine the length from the earlobe to the xiphoid process. 4. Measure from the earlobe to the corner of the mouth. 4- is correct

Which client will the charge nurse intervene on behalf when making rounds?

1. The client turned to left side 1 ½ hour ago. 2. Client who has been sitting in a chair for 2 ½ hours. 3. Client who is day one postop from hip replacement with abduction pillow in place. 4. The client who is in buck's traction with foot boots. 2- correct

Which assessment finding would indicate to a nurse that a client receiving chemotherapy may have difficulty maintaining proper nutrition?

1. Fatigue 2. Mucositis 3. Neutropenia 4. Diarrhea 2-correct

The nursing supervisor notified the charge nurse on a pediatric unit that a child with a history of developmental delays is being admitted with shingles. The nurses on the floor have the following assignments. It would be inappropriate for the charge nurse to assign the new admit to which nurse?

1. A nurse caring for clients with nephritis, irritable bowel syndrome, and appendectomy. 2. A new nurse just out of orientation caring for clients diagnosed with RSV, asthma, and anorexia nervosa. 3. A nurse caring for clients diagnosed with spina bifida, Hirschsprung's Disease, and irritable bowel syndrome. 4. A pregnant nurse caring for clients with cystic fibrosis, myelomeningocele, and rheumatoid arthritis. 4- correct

A 70 year old client was admitted to the vascular surgery unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the client's BP is 198/94. What would be the best action for the charge nurse to delegate at this time?

1. Ask the UAP to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm in 15 minutes. 3. Have the LPN/LVN administer the 0900 furosemide and enalapril now. 4. Ask the LPN/LVN to assess the client for pain. 3- correct

A home health nurse inspects the home of a client scheduled to be discharged home after receiving care for a cerebrovascular accident with generalized weakness. What safety interventions should the nurse recommend based on findings within the home?

1. Place ramp over the front steps. 2. Move client's bedroom downstairs. 3. Remove throw rugs. 4. Secure furniture so client can use for support. 5. Apply nonskid strips to shower stall. 1,2,3,5- correct

A client, who only speaks Spanish, is admitted to the surgical unit. What is the best method for the nurse to inform the client about a pre-surgical procedure?

1. Use an audiotape made in Spanish to inform the client of the pre-surgical procedure. 2. Draw pictures of what the client can expect prior to surgery. 3. Facial expressions and gestures can be used to let the client know what to expect. 4. Enlist the help of a Spanish speaking family friend to tell the client what to expect prior to surgery. 1- correct

An adult client has just returned to the nursing care unit following a gastroscopy. Which intervention should the nurse include on the plan of care?

1. Vital sign checks every 15 min x 4 2. Supine position for 6 hours 3. NPO until return of gag reflex 4. Irrigate NG tube every 2 hours 5. Raise four siderails 1,3- correct

The triage nurse in the emergency department (ED) assesses 4 clients. Which client is in need of emergent care?

1. A 52 year old who has a partially amputated finger. 2. A 9 month old with temperature of 103°F (39.4°C). 3. A two year old with excessive drooling and a weak cough. 4. A 28 year old experiencing a migraine headache for three days. 3- CORRECT

An angry client visits the primary healthcare provider's office and requests a copy of their medical records. The client is angry after being placed on hold several times for over 10 minutes when requesting an appointment. What should the nurse tell this client?

1. All client appointment calls are transferred to the scheduling clerk. 2. The client will have to speak to the primary healthcare provider. 3. A copy of the record may be obtained within 24 hours of the request. 4. Medical records must stay within the facility unless requested by another primary healthcare provider. 3- correct

A nurse is planning to provide information regarding suicide to a high school assembly. What information should the nurse include?

1. Do not keep secrets for the suicidal person. 2. Express concern for a person expressing thoughts of suicide. 3. Teens often don't mean what they say, so only take suicide seriously if grades are dropping as well. 4. Inform group of suicide intervention sources. 5. Do not leave a suicidal person alone. 1,2,4,5-correct

The nurse is working in a long term care facility. What actions by the nurse are appropriate when taking a telephone prescription from a primary healthcare provider?

1. Document the prescription prior to the end of the shift. 2. Explain to the pimary healthcare provider that nurses cannot take telephone prescriptions. 3. Repeat the prescription back to the primary healthcare provider prior to hanging up. 4. Transcribe the prescription in the client's record. 5. Ask the primary healthcare provider to wait and write the prescription during rounds. 3,4- CORRECT

A client's last two central venous pressure (CVP) readings were 13 cm of water. The nurse would expect the client to manifest which associated signs and symptoms?

1. Dry oral mucus membranes 2. Tachypnea 3. Orthostatic hypotension 4. Rales in the posterior chest 5. Jugular vein distention 6. Weight gain 2,4,5,6

An 82 year old client tells the nurse at the clinic, "I have lived a good, successful life and married my best friend". Which of Erikson's developmental tasks does the nurse recognize that this client has probably accomplished?

1. Ego Integrity versus Despair 2. Generativity versus Stagnation 3. Intimacy versus Isolation 4. Industry versus Inferiority 1-correct

A client diagnosed with a duodenal ulcer is prescribed lansoprazole and sucralfate. What should the nurse teach the client about how to take these medications?

1. Take together immediately before meals. 2. Take together immediately after meals. 3. Take the sucralfate first, wait at least 30 minutes, then take the lansoprazole. 4. Take the lansoprazole first, wait at least 30 minutes, then take the sucralfate. 4- correct

Which client should the nurse place in the room with a 6 year old with glomerulonephritis?

1. Twenty-two month old diagnosed with respiratory syncytial virus (RSV). 2. Four year old with nephrotic syndrome. 3. Three year old admitted with febrile seizures. 4. Two year old who has a fractured tibia. 2- correct

The nurse is caring for a client on the surgical unit. The primary healthcare provider prescribed morphine sulfate 20 mg IM one time dose. The nurse has available: morphine sulfate in a 20 mL vial, labeled 15 mg per mL. How many mL should the nurse administer? Record answer using one decimal place.

1.3

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client?

1. Alternating pressure mattress 2. Hospital bed 3. Walker 4. Suction equipment 5. Oxygen 1,2,4,5- correct

Which factors should the nurse include when teaching a parent about risk factors for otitis media?

1. Breast-feeding 2. Contact with siblings 3. Day care attendance 4. Season of the year 5. Age over 5 2,3,4- correct

Two hours after a gastrectomy, a client has pink tinged drainage from the nasogastric (NG) tube, and the tube appears occluded. What is the nurse's initial action at this time?

1. Call the primary healthcare provider. 2. Reposition the client. 3. Increase the suction level. 4. Irrigate the tube. 1- correct

The nurse is caring for a client who is receiving a prostaglandin agonist for the treatment of glaucoma. Which comment by the client indicates a lack of understanding of the treatment regimen?

1. I must only use the drops in the eye with the increased pressure. 2. My eyes may be different colors, so I will use the drops in both eyes. 3. I must be careful not to overmedicate even if it is just an eye drop. 4. The eyelashes in the eye with the higher pressure may get longer. 2- correct

A client is preparing to be discharged after a total hip replacement. Which statements, if made by the client, would indicate to the nurse that teaching has been successful regarding prevention of hip prosthesis dislocation?

1. I should not cross my affected leg over my other leg. 2. I should not bend at the waist more than 90 degrees. 3. While lying in bed, I should not turn my affected leg inward. 4. It is necessary to keep my knees together at all times. 5. When I sleep, I should keep a pillow between my legs. 1,2,3,5 - correct

Which prescriptions would the nurse recognize as being appropriate for the client with shingles?

1. Private room 2. Negative pressure airflow 3. Respirator mask 4. Face Shield 5. Positive pressure room 1,2,3-correct

The nurse is preparing a client for a renal biopsy. Which is most important for the nurse to assess prior to this procedure?

1. BUN and creatinine 2. NPO status and signature on consent 3. Bleeding time and coagulation studies 4. Serum potassium and urine sodium 3- correct

The nurse is caring for a client who has just arrived at the emergency department with suspected acute myocardial infarction. Which medications should the nurse administer immediately?

1. Oxygen 2. Heparin 3. Morphine 4. Sublingual nitroglycerin 5. Furosemide 1,3,4- CORRECT

The nurse is caring for a client who was admitted to the hospital following a severe motor vehicle crash (MVC) in which the client was trapped in the car for several hours. The client is being closely monitored for the development of renal failure. Which assessment finding would warrant immediate reporting?

1. Creatinine 1.1 mg/dl (97.24 mmol/L) 2. Urinary output of 150 mL per hour. 3. Gradual increase of BUN levels. 4. Calcium levels of 9.0 mg/dL (2.25 mmol/L 3- correct

Which statement made by a client post-thyroidectomy would require further investigation by the nurse?

1. "I have a tingling feeling of my fingers." 2. "It hurts when I move my head." 3. "I feel pressure in my arm when you take my blood pressure." 4. "My legs are weak." 1-correct

The charge nurse is making assignments for one RN and one LPN/VN on a pediatric unit. Which clients would be most appropriate for the charge nurse to assign to the RN?

1. 2 year old with asthma receiving IV medication. 2. 6 year old with new onset seizures. 3. 12 year old with colitis receiving TPN. 4. 2 month old with urinary tract infection. 5. 10 year old paraplegic needing assistance with bowel training. 1,2,3-correct

A client, admitted in Sickle Cell Crisis, is started on oxygen at 2L/NC and given a narcotic analgesic for pain control. What additional prescription is a priority for the nurse to initiate?

1. A high protein, low fat diet 2. Administration of a thrombolytic, such as streptokinase 3. Implementation of bleeding precautions 4. Administration of IV fluids for hydration 4- correct

The parents of a 4 year old child are concerned about whether the child will adapt to the newborn baby they are expecting in two weeks. What suggestions should the nurse make to assist with sibling adaptation?

1. Allow child to be one of the first to see the newborn. 2. Have child stay with parents during labor and delivery. 3. Arrange for one parent to spend time with the child while the other parent cares for the newborn. 4. Provide a gift from the newborn to give to the child. 5. Have child care for a doll. 1,3,4,5- correct

The nurse is caring for a client on the psychiatric unit with a diagnosis of obsessive-compulsive disorder. The client has frequent hand washing rituals. Which nursing interventions would be advisable for this client?

1. Allow time for ritual. 2. Provide positive reinforcement for nonritualistic behavior. 3. Provide a flexible schedule for the client. 4. Remove all soap and water sources from the client's environment. 5. Create a regular schedule for taking client to bathroom. 1,2,5- correct

A client diagnosed with major depression has been taking a selective serotonin reuptake inhibitor for the past 6 weeks. When visiting the mental health center, the nurse discusses the medication and response with the client. The nurse's assessment reveals that the client is confused about the date and about the prescribed dosage of the medication. Which question would be most important for the nurse to ask to further assess the situation?

1. Are you having trouble sleeping at night? 2. Do you have periods of muscle jerking? 3. Are you having any sexual dysfunction? 4. Is your mood improving? 2- correct

A new nurse has a prescription to insert a feeding tube. The new nurse has never performed the procedure, but learned how to do it while in nursing school. What would be the best action by this nurse?

1. Ask to observe another nurse perform the procedure. 2. Look up how to perform the procedure in the policy and procedure manual. 3. Tell the charge nurse that someone else will have to place the feeding tube down the client. 4. Insert the feeding tube as learned in nursing school. 2- correct

The nurse wants to provide anticipatory guidance for a group of young parents who have children between the ages of 18 months to 3 years. What points about the next year should the nurse be sure to provide these parents?

1. Be strict and rigid with toilet training, rather than being accepting and letting the child lead the training. 2. Tell the parents about the importance of letting the child do tasks alone. 3. Provide finger foods for the child to eat. 4. Your child will want you to provide emotional support when needed. 5. Assist your child with all tasks to promote independence. 2,3,4- correct

An RN on the general pediatric unit has been reassigned to the spinal/neurology unit. What assignment by the charge nurse would be appropriate for this RN?

1. Child with spina bifida with a previous shunt revision 2. Adolescent who is 4 days post op from a spinal fusion 3. Child with a ventriculoperitoneal shunt one day post-op 4. Child with spinal muscle atrophy who is ventilator assisted 5. Child with cerebral palsy who had a tracheostomy performed this AM 1,2- CORRECT

Which client admitted to the emergency department should the nurse assess first following shift report on assigned clients?

1. Client reporting inability to void and a distended bladder on palpation. 2. Client diagnosed with a confirmed closed fracture of the tibia. 3. Client who has a suspected corneal laceration. 4. Client with abdominal discomfort and a rigid abdomen on palpation. 4-correct

A client has sustained a major head injury as a result of a motor vehicle accident. The emergency department nurse is assessing the client's neurological status every 15 minutes. Which sign would the nurse recognize as an early indicator of an increased intracranial pressure (ICP)?

1. Dilated and unresponsive pupils 2. Cheyne-Stokes respirations 3. Cushing's triad 4. Change in level of consciousness (LOC) 4- correct

A client diagnosed with rheumatoid arthritis has been prescribed celecoxib. What should the nurse include in the client's education regarding this medication?

1. Do not take celecoxib with ibuprofen. 2. GI complaints and headache are among the most common side effects. 3. Drink a lot of water to offset the dehydration that may occur. 4. Notify the healthcare provider immediately if black stools are noted. 5. This medication provides relief of pain and swelling so you can perform normal daily activities. 1,2,4,5- correct

The nurse is caring for a client admitted to the skilled nursing unit approximately 3 months ago. Since admission, the client has lost 8 pounds. There have been no documented changes in the client's physical health. Which strategy may help to improve caloric intake for this client?

1. Encourage the client to eat meals in the room. 2. Take the client to the dining room for all meals. 3. Provide a high protein supplement 30 minutes before meals. 4. Ask the unlicensed assistive personnel to feed the client at each meal. 2- correct

A client experiencing chest pain is prescribed an intravenous infusion of nitroglycerin. After the infusion is initiated, the occurrence of which symptom would prompt the nurse to discontinue the nitroglycerin?

1. Frontal headache 2. Orthostatic hypotension 3. Decrease in intensity of chest pain 4. Cool, clammy skin 4-correct

The nurse is working with a LPN/VN and an unlicensed assistive personnel (UAP). Which clients would be appropriate for the nurse to assign to the LPN/VN?

1. In Bucks traction requiring frequent pain medication. 2. 24 hours post appendectomy. 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM. 4. Admitted 6 hours ago in adrenal insufficiency. 5. Client newly diagnosed with Type 2 diabetes. 1,2,3- correct

What should a nurse teach family members prior to them entering the room of a client who has agranulocytosis

1. Meticulous hand washing is needed. 2. Do not visit if you have any infection. 3. The client must wear a mask. 4. Children under 12 may not visit. 5. Flowers are not allowed in the room. 1,2,4,5- correct

A client has been admitted for exacerbation of ulcerative colitis with severe dehydration. What is the best indicator that this client has an actual fluid deficit?

1. Stool count of 10 episodes of diarrhea in 24 hours. 2. Weight increase of 2 kg and a 24 hour output of 1000 mL. 3. Admission weight of 74.3 kg and 2 days later a weight of 72 kg. 4. Daily intake of 2400 mL and an output of 1600 mL, plus diarrheal stools. 3-correct

A client is admitted to the emergency department reporting abdominal discomfort and constipation lasting 3 days. Which abdominal assessment data would the nurse report to the primary healthcare provider?

1. Striae. 2. Borborygmi. 3. High-pitched bowel sounds. 4. Tympany noted on percussion. 3- correct

A new nurse is preparing to give a medication to a nine month old client. After checking a drug reference book, the nurse crushes the tablet and mixes it into 3 ounces of applesauce. The new nurse proceeds to the client's room. What priority action should the supervising nurse take?

1. Tell the new nurse to recheck the drug reference book before administering the medication. 2. Suggest that the new nurse reconsider the client's developmental needs. 3. Check the prescription order and the client dose. 4. Observe the new nurse administer the medication. 2- correct

What should the nurse tell the parents of a newborn about a Guthrie test?

1. The purpose of this test is to determine the presence of phenylalanine in the blood. 2. A positive test indicates a metabolic disorder. 3. To conduct this test, a sample of blood is taken from the baby's heel. 4. An increase in protein intake can interfere with the test. 5. This test will be done when your baby is 6 weeks old. 1,2,3- correct

A nurse is caring for a client who delivered a baby vaginally two hours ago. What signs and symptoms of postpartum hemorrhage should the nurse report to the primary healthcare provider?

1. Two blood clots the size of a dime. 2. Perineal pad saturation in 10 minutes. 3. Constant trickling of bright red blood from vagina. 4. Oliguria 5. Firm fundus 2,3,4- correct

A school nurse is teaching a group of preteens with acne how to care for the skin. What points should the nurse include?

1. Wash face with soap and warm water. 2. Avoid using oily creams. 3. Do not use cosmetics that block sebaceous gland ducts. 4. Do not squeeze lesions. 5. Clean face vigorously with a terrycloth. 1,2,3,4- correct

The nurse is caring for a client in the emergency department after a violent altercation with her husband. She describes increasingly violent episodes over the past 10 years. She says, "This is the last time he will hit me." Which response by the nurse demonstrates understanding of the violence cycle?

1. When you leave, you don't have to worry anymore. 2. You are at greatest risk when you leave. 3. That is the best decision you can make. 4. I am glad that you won't be hurt ever again. 2- correct

The nurse is caring for a client admitted to the psychiatric unit with a diagnosis of major depression. What behaviors could the nurse expect upon assessment of this client?

1. Withdrawn behavior 2. Sitting in room, lights out, drapes closed 3. Unkempt appearance 4. Overeating 5. Severe insomnia 1,2,3,5- correct

The emergency department nurse is assessing a client who presents with severe epigastric pain. The client reports that three rolls of calcium carbonate were consumed in the past eight hours to treat the indigestion. Which blood gas report does the nurse associate with this situation?

1. pH - 7.49, pCO2 - 40, HCO3 - 30 2. pH - 7.32, pCO2 - 48, HCO3 - 20 3. pH - 7.38, pCO2 - 52, HCO3 - 32 4. pH - 7.29, pCO2 - 54, HCO3 - 26 1- correct

When preparing a client for surgery, the nurse realizes the operative permit has not been signed. The client tells the nurse he understands the procedure, but received his preoperative medication approximately 10 minutes ago. What would be the appropriate action by the nurse?

1. Have the client sign the permit, as he verbalizes understanding. 2. Witness the form after having the client sign it. 3. Have his wife sign the form as she witnessed his statement that he understands. 4. Call the surgical area and explain that the surgery will have to be cancelled. 4- correct

The primary healthcare provider has prescribed phenytoin 100 mg intravenous push (IVP) stat through a non-tunneled central venous catheter lumen with no other medication or fluid infusing. In what order should the nurse administer this prescription?

Cleanse access port Connect 10 mL normal saline to access port Gently aspirate for blood Flush saline using push-pause method Administer phenytoin Flush with normal saline, then with heparin

A healthy newborn has just been delivered and placed in the care of the nurse. What nursing actions should the nurse initiate? Place in the correct priority order

Assess newborn's airway and breathing. Bulb suction excessive mucus. Assess newborn's heart rate. Place identification bands on newborn and mom. Administer sterile ophthalmic ointment containing 0.5% erythromycin.

The nurse evaluates the effectiveness of discharge teaching for a client with type I diabetes mellitus. Which statement by the client would indicate to the nurse that teaching has been effective?

1. "Exercising regularly will decrease my insulin need." 2. "I will need to decrease my insulin dose when I develop an infection." 3. "I need to lose weight since obesity decreases insulin resistance." 4. "Increased stress levels will cause the glucose level in my blood to go down." 1- correct

The client at the mental health center has voiced suicidal thoughts and has access to firearms at home. Which action by the nurse is priority?

1. Empathize with the client and listen to feelings. 2. Inform the family and ask them to remove the guns. 3. Chart the thinking pattern and make a follow up appointment. 4. Ask the client to return to the clinic tomorrow for further evaluation. 2- correct

While examining a client's health history, which data indicates to the nurse that the client is at increased risk for developing cancer?

1. Family history 2. Alcohol consumption 3. Spicy diet 4. Human papillomavirus 5. Tobacco use 1,2,4,5-correct

A nurse is at highest risk for blood-borne exposure during which situation?

1. When removing a needle from the syringe. 2. While placing a suture needle into the self-locking foreceps. 3. Prior to inserting the intravenous (IV) line, the client moves causing a needle stick to the nurse. 4. A clean needle sticks the nurse through blood-soiled gloves. 4- correct

What measures should the unit nurse initiate after admitting a client who had a chest tube inserted for pleural effusion of the right lung?

1. Place in semi-Fowler's position. 2. Connect to oxygen saturation monitor. 3. Assess respiratory status every 2 hours. 4. Prevent dependent loops in closed drainage unit tubing. 5. Maintain closed drainage unit at the level of the client's chest. 1,2,3,4- correct

A nurse educator is explaining the Health Insurance Portability and Accountability Act (HIPAA) of 1996 to a group of nursing students. What points about HIPAA should the nurse educator include?

1. Primary healthcare providers employed at the facility where a client receives treatment can legally access any client's health information at any time. 2. Health related information revealed by a client to healthcare personnel must be kept confidential. 3. The client has the right to access personal healthcare records and to obtain copies of those records. 4. A client's information can be revealed only with the client's permission, or when the primary healthcare provider or facility is required by law to do so. 5. Unlicensed assistive personnel employed where a client receives treatment can legally access any client's health information at any time. 2,3,4- correct

The nurse should question which prescription for a client diagnosed with acute heart failure?

1. 2 gram of sodium (Na) diet. 2. Digoxin 0.25 mg IV q 4 hours times 3 doses. 3. Furosemide 40 mg IVP stat. 4. Start IV with NS at 125 mL/hr. 4- correct

The nurse is planning care for a pediatric client reporting acute pain with sickle cell crisis? What should the nurse identify as an appropriate goal for this client?

1. Client will report a pain level of less than 2 on a Faces scale. 2. The nurse will administer prescribed pain meds around the clock. 3. Client will only take breakthrough pain medication. 4. Client will use distraction instead of pain medication. 1- correct

The nurse is assisting an unlicensed assistive personnel (UAP) move an obese and dependent client toward the top of the bed. Which action is most important to prevent shearing forces on the skin?

1. Each person puts hands under the client and slides client toward the top of the bed. 2. Apply powder to the sheet before pulling client toward the top of the bed. 3. Place turn sheet under the client and use it to slide the client toward the top of bed. 4. Seek assistance of another person before pulling up in bed. 3- correct

The nurse is giving discharge instructions to an Asian client following a colonoscopy. During the instructions, the client stares directly at the floor, despite being able to speak English. Based on the client's body language, how would the nurse classify this behavior?

1. Embarrassment. 2. Attentiveness. 3. Disinterest. 4. Confusion. 2- correct

The occupational health nurse is caring for an employee after a chemical explosion at the local tire factory. The client reports a foreign body in the right eye. The right eye is watery, and the client reports photophobia. Which nursing action takes priority?

1. Evert eyelid and examine for foreign body. 2. Measure visual acuity. 3. Notify the receiving hospital immediately for transfer of the client. 4. Place an eye shield over eye. 4 - correct

An elderly male, diagnosed with chronic renal failure and depression, lives alone. Which question should the home health nurse ask first when assessing this client?

1. Have you had suicidal thoughts in the past? 2. How are you feeling today? 3. Have you had thoughts of harming yourself? 4. Do you have guns in your home? 3- CORRECT

A nurse is caring for a client admitted with chronic fatigue and weakness. During the physical assessment, the nurse notes jaundiced sclera, abdominal distension, swelling in the legs and ankles, and bruises in various stages of healing throughout the body. What nursing interventions should the nurse initiate?

1. Measure abdomen 2. Monitor intake and output 3. Obtain daily weight 4. Place on fall precautions 5. Provide three meals per day 6. Dangle legs 1,2,3,4- correct

The nurse is caring for a client diagnosed with herpes varicella zoster. What pharmacologic agent should the nurse anticipate the primary healthcare provider will prescribe?

1. Metronidazole 2. Acyclovir 3. Ceftriaxone 4. Ampicillin 2- correct

A client had an abnormal maternal serum alfa fetoprotein (MSAFP) at 18 weeks gestation. She is now 22 weeks gestation, and an amniocentesis has just been completed for genetic analysis. Which nursing action has priority?

1. Monitor the needle entry site for signs of infection. 2. Encourage the client to express her feelings. 3. Assess the maternal blood pressure for hypertension. 4. Monitor fetal heart tones and uterine activity. 4- correct

The nurse on a neuro rehabilitation unit is caring for a client with a T4 lesion. The client suddenly reports a severe, pounding headache. Profuse diaphoresis is noted on the forehead. The blood pressure is 180/112 and the heart rate is 56. What interventions should the nurse initiate?

1. Place client supine with legs elevated. 2. Assess bladder and bowel for distention. 3. Examine skin for pressure areas. 4. Eliminate drafts. 5. Remove triggering stimulus. 6. Administer hydralazine if BP does not return to normal. 2,3,4,5,6

A client diagnosed with glomerulonephritis presents with generalized malaise, weight gain, generalized edema, and flank pain. The primary healthcare provider prescribes antibiotics and strict bedrest. What is the best explanation to give the client regarding the strict bedrest prescription?

1. Promotes diuresis 2. Prevents injury 3. Promotes rest 4. Stimulates RBC production 1- correct

The nurse is advising the family of a client receiving palliative care on alternative methods for pain control to be used in conjunction with pain medications. Which method should the nurse include?

1. Providing a back massage 2. Administering pain medication when pain is rated at 5 out of 10 3. Distracting with music 4. Exercise 5. Prayer 1,3,5- correct

A nurse, assigned to take care of a client who is HIV positive, refuses the assignment, stating fear of personal injury. What action should the charge nurse take first?

1. Re-assign the client to a nurse who does not mind caring for HIV positive clients. 2. Inform the nurse that refusing client care is not acceptable nursing practice. 3. Have the nurse document rationale and support for refusing the client assignment. 4. Transfer the nurse to a unit where there are no HIV positive clients. 2- correct

A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R 36. The client is extremely anxious and crying uncontrollably. Based on this assessment, the nurse should anticipate that this client is likely in which acid base imbalance?

1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 2- correct

Which clients would be appropriate for the RN to assign to an LPN/LVN?

1. Seventy four year old client with unstable angina who needs teaching for a scheduled cardiac catheterization. 2. Sixty year old client experiencing chest pain scheduled for a graded exercise test. 3. Forty eight year old client who is five days post right-sided cerebral vascular accident (CVA). 4. Eighty four year old client with heart disease and mild dementia. 5. Newly admitted ninety year old client with decreased urinary output, altered level of consciousness, and temperature of 100.8°F (38.2°C) 6. Sixty six year old client with chronic emphysema experiencing mild shortness of breath. 3,4,6- CORRECT

The nurse is teaching a client about foods containing tyramine which should be avoided while taking a monoamine oxidase inhibitor (MAOI). Which meal selection by the client would indicate understanding of an acceptable food to eat?

1. Smoked turkey and dressing, sweet peas and carrots and milk. 2. Baked chicken over pasta with parmesan sauce, baked potato and tea. 3. Fried catfish, French fries, coleslaw and apple juice. 4. Liver smothered in gravy and onions, rice, squash and water. 3- correct

A client comes into the emergency department (ED) and demands to be seen immediately, but refuses to tell the triage nurse the problem. During the assessment, the client starts yelling and shaking their fist. For the nurse's safety, what should be the nurse's initial action?

1. Tell the client to stay calm, and that treatment will be provided soon. 2. Explain that unless the client behaves, they will be sent away from the ED. 3. Notify the client that security will be called if they do not go to the waiting room immediately. 4. Find a safe place away from the client and then notify security. 4 - correct

A client diagnosed with major depression is admitted to the psychiatric unit for electroconvulsive therapy (ECT). The client asks the nurse, "How many of these treatments do you think I will need?" What is the nurse's best response?

1. That is a question you need to discuss with your primary healthcare provider. 2. Everyone responds differently, but on average clients need 6-12 treatments. 3. You will need to take a treatment every month for at least a year. 4. Let's just take one treatment at a time, shall we? 2- correct

A client was admitted to the psychiatric unit with delusions and a history of auditory hallucinations. The client reports, "The FBI has been watching my house and are going to raid it and arrest me." What is the nurse's best response?

1. The FBI would not be watching you unless there was a good reason. 2. I don't think that the FBI is watching your house. 3. I believe that your thoughts are very disturbing to you. 4. Tell me more about your thoughts. 3- correct

The family member of a schizophrenic client asks the nurse why the client is receiving chlorpromazine and benztropine. What is the best response by the nurse?

1. The chlorpromazine makes the benztropine more effective so a smaller dose of both drugs can be used. 2. Benztropine is given to treat the side effects produced by the chlorpromazine. 3. Chlorpromazine is used for severe hiccups that can occur with the use of benztropine. 4. Chlorpromazine is used for psychosis and benztropine is used for preventing agranulocytosis. 2 -correct

What information should a nurse include when educating a client regarding buccal administration of a medication

1. This route allows the medication to get into the blood stream faster than the oral route. 2. Stinging may occur after placing the medication in the cheek. 3. If swallowed, the medication may be inactivated by gastric secretions. 4. The buccal dose of medication will need to be increased from the oral dose. 5. Remove the tablet from buccal area after 15 seconds. 1,2,3- correct

A client suffers from migraine headaches. What assessment finding would the nurse expect to find during a migraine attack?

1. Unilateral, pulsating pain quality. 2. Bilateral, pressing/tightening pain quality. 3. Ipsilateral nasal congestion and rhinorrhea. 4. Headache occurs after recovering from a headache treated with narcotics. 1- correct

The school nurse has identified a large outbreak of viral conjunctivitis among one middle school class and plans to educate these students on this illness. Which data should the nurse be sure to include

1. Use personal handkerchief to wipe the eye of discharge. 2. Light cold compresses over the eyes several times a day will ease discomfort. 3. Do not share towels or linens. 4. Discard all makeup and use new makeup after infection resolves. 5. Wash hands frequently with soap and water. 2,3,4,5- correct

Which statements should a nurse make when educating a client about advance directives?

1. Used as guidelines for client treatment should the client's family deem them necessary. 2. Legally binding document. 3. Should be documented in the client's medical record as to whether or not the client has an advance directive. 4. Specifies a client's wishes for healthcare treatment should the client become incapacitated. 5. Allows the client's spouse to make end-of-life decisions. 2,3,4-correct

A client was admitted to the medical unit with pneumonia 2 days ago. There is a history of drinking 5-6 martinis every night for the past 2 years. Today, the nurse notes that the client is disoriented to time and place and is seeing imaginary spiders on the ceiling. The nurse cannot understand what the client is saying. What is this client most likely experiencing?

1. Wernicke's Encephalopathy 2. Korsakoff's Psychosis 3. Alcohol Withdrawal 4. Alcohol Withdrawal Delirium 4- correct

A client diagnosed with serotonin syndrome is admitted to the unit. The nurse is familiar with this adverse reaction to the serotonin reuptake inhibitors. Which symptoms can the nurse expect on assessment?

1. Fever and shivering 2. Agitation 3. Decreased body temperature 4. Constipation 5. Increased heart rate 1,2,5

A female client taking captopril for hypertension tells the clinic nurse that she is planning to get pregnant. What recommendation should the nurse make?

1. "Captopril can be taken safely during pregnancy, but we will need to decrease your dose so you do not become hypotensive." 2. "We will need to increase your dose of captopril once you become pregnant." 3. "In order to prevent neural tube defects, start taking folic acid." 4. "Captopril can cause serious harm to an unborn baby, so you must prevent pregnancy while taking this medication. " 4-correct

During an assessment interview with a client, what alternative healing modalities should the nurse inquire about?

1. "Tell me about your use of teas, herbs, and vitamins." 2. "What traditional or folk remedies are used in your family?" 3. "Do you meditate, pray, or use relaxation techniques for healing purposes?" 4. "What prescription medications are you taking?" 5. "What alternative therapies have you used?" 1,2,3,5- correct

A child is being admitted with possible rheumatic fever. What assessment data would be most important for the nurse to obtain from the parent?

1. 102° F (38.89° C) temperature that started 2 days previously. 2. History of pharyngitis approximately 4 weeks ago. 3. Vomiting for 3 days. 4. A cough that started about 1 week earlier. 2- CORRECT

Which immunizations obtained by the age of two would indicate to the pediatric nurse that the child is up-to-date on immunizations?

1. Diptheria-tetanus-pertussis (DTaP). 2. Inactivated polio (IPV). 3. Herpes zoster. 4. Meningococcal 5. Haemophilus influenza type B (Hib). 1,2,5- correct

The RN is caring for a client diagnosed with an abdominal aortic aneurysm. Which prescription can the RN delegate to the LPN?

1. Obtain vital signs every 15 minutes. 2. Insert a urinary catheter for hourly urinary outputs. 3. Place a PICC line for fluid management. 4. Provide morphine 1 mg per PCA pump at a 10 minute lockout. 2- correct

A client, hospitalized with possible acute pancreatitis secondary to chronic cholecystitis, has severe abdominal pain and nausea. The client is kept NPO, an NG tube is inserted, and IV fluids are being administered. What is the rationale for the client being NPO with an NG tube to low suction?

1. Relieve nausea 2. Reduce pancreatic secretions 3. Control fluid and electrolyte imbalance 4. Remove the precipitating irritants 2- correct

A postoperative surgical client has a prescription for monitoring of intake and output (I&O). The I&O sheet has been picked up by the unlicensed assistive personnel (UAP) for the 7AM-3PM shift. Intake Output IV fluid-1025 mL Urine - 1350 mL PRBC-250 mL NG tube - 75 mL Jackson Pratt - 22 mL

Output for the day - 1447

A client has been taught guided imagery as a method to relieve pain. How should the nurse first assess for pain relief after completion of guided imagery by the client?

1. Assess vital signs 2. Use of pain intensity scale 3. Ask client to describe the pain 4. Observe ability to perform activities of daily living. 2-correct

The nurse is preparing to administer nadolol to a hospitalized client. Which client data would indicate to the nurse that the medication should be held and the primary healthcare provider notified

1. Blood pressure 102/68 2. Glucose 118 3. UOP 440 mL over previous 8 hour shift. 4. Heart rate 56/min 4-correct

Which signs and symptoms would the nurse expect to see in a client who has taken prednisone for two months?

1. Weight loss 2. Decreased wound healing 3. Hypertension 4. Decreased facial hair 5. Moon face 2,3,5-correct

The nurse in the emergency department suspects that a client's lesion is caused by anthrax. What assessment question is most important?

1. Have you traveled out of the United States recently? 2. Have you recently worked with any farm animals or any animal-skin products? 3. Have you experienced any gastrointestinal upset recently? 4. Have you eaten any home-canned foods recently? 2- correct

A client asked the nurse what could have caused them to develop right sided heart failure? What would be the best response by the nurse?

1. High blood pressure in the lungs. 2. Long term hypertension. 3. The inability of the mitral valve to close properly. 4. Narrowing of the aorta. 1-correct

The nurse is working with a committee at the local school to develop an emergency preparedness plan for tornados. What should be included in the plan?

1. Identification of safe zones. 2. Methods for accounting for all people present in the building. 3. Warning system activation. 4. Identification of the gymnasium as the routine safe place. 5. Regular practice protocols. 1,2,3,5-correct

After reviewing the nursing notes on a client receiving a unit of packed red blood cells, what action should the charge nurse take?

1. Decrease the transfusion rate to 50 mL/hour. 2. Assess the client for a transfusion reaction. 3. Check primary healthcare provider prescription for prescribed administration time. 4. Stop the transfusion and send blood bag to the lab. 4- correct