Selected Topics

a nurse is assessing an infant following a motor vehicle crash. which of the following findings should the nurse monitor to identify increased intracranial pressure?

increased sleeping

A nurse is assessing a preschooler. Which of the following findings should indicate tot he nurse a need for speech therapy? (SATA)

- the preschooler mispronounces words. - the preschooler speaks in a nasally tone

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. the nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?

- the client runs 4 miles outdoors every afternoon

a nurse is assessing a client for hypoxemia during an asthma attack. which of the following manifestations should the nurse expect?

agitation

A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make?

"An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."

A nurse is teaching a client who is starting to take methotrexate to threat rheumatoid arthritis. Which of the following instructions should the nurse include in the teaching?

"drink at least 2 liters of water daily"

a nurse is caring for a client who reports taking bisacodyle to promote a daily bowel movement. which of the following assessment questions should be the nurse's priority?

"how long have you been taking bisacodyl"

a nurse is caring for a client who has deep view thrombosis and has been on heparin continuous infusion for 5 days. the provider prescribes warfarin PO without discontinuing the heparin. the client asks the nurse why both anticoagulants are necessary. which of the following statements should the nurse make?

"warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level"

A nurse is developing a program about strategies to prevent food borne illnesses for a community group. The nurse should plan to include which of the following recommendation? (SATA)

- avoid unpasteurized dairy products - keep cold food temperatures below 4.4 - reheat leftovers before eating - wash raw vegetables throughly in clean water

a nurse is caring for a client who has emphysema. which of the following findings should the nurse expect to assess in the client? (SATA)

- dyspnea - barrel chest - clubbing of the fingers

a nurse is caring for a client who has HIV. which of the following laboratory values is the nurse's priority?

CD4-T-cell count 180 cells/mm3

A nurse is caring for a client who is postoperative and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?

Check the stockings for wrinkles.

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 98.2 degrees Fahernheit. Which of the following actions should the nurse perform?

Complete a neurological check.

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Elevate the head of the client's bed 30° to 45°.

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

Elevated central venous pressure (CVP).

A nurse is caring for a client who reports bilateral knee pain after hiking this past weekend in the mountains on rough ground. He says he is concerned because his cousin died from bone cancer recently. Which of the following actions should the nurse take?

Explain that the provider will see him and determine a course of action.

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following medications should the nurse plan to administer?

Finasteride

A nurse finds radioactive pellets on the floor of the surgical. Which of the following actions should the nurse take first?

Follow safety data sheet (SDS) instructions.

An occupational health nurse in the clinic of an industrial plant is developing a guidebook for clinic workers. Which of the following actions should the nurse include as a secondary prevention strategy?

Help plant workers identify signs of carpal tunnel syndrome.

At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personal (AP). which of the following tasks should the nurse assign to the LPN

Inserting a nasogastric tube for a client

A nurse is providing discharge teaching for a client who is postoperative following an inner maxillary fixation for facial fractures. Which of the following instructions should the nurse include in the teaching?

Keep wire cutters with you.

A nurse is discussing emergency response with a newly licensed nurse. The nurse should identify which of the following as a triage officer during the time of a disaster?

Nurses and other emergency medical personnel

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take?

Obtain an EKG.

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first?

Obtain vital signs for both clients.

A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?

Perform a neurovascular assessment.

a nurse is preparing for client for outpatient surgery. after the nurse inserts the IV catheter, the client reports pain in the insertion area. which of the following actions should the nurse take?

remove the catheter and inset another into a different site

a nurse is reviewing laboratory values for a client who has systemic lupus erythemotosis (SLE). which of the following values should give the nurse the best indication of the client's renal function?

serum creatinine

a nurse is providing dietary teaching for a client who has just learned that she has type 2 diabetes mellitus. the nurse should explain that which of the following sweeteners will add calories to the client's carbohydrate count?

sorbitol

A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?

"Do you have difficulty staying awake when you are driving?"

A nurse is providing teaching to a client who is at 30 weeks of gestation and is to have a non stress test (NST). Which of the following statements by the client indicates a need for further teaching?

"I will have to lie on my back during the test."

a nurse is providing discharge teaching to a client who was recently diagnosed with a latex allergy. which of the following client statements indicates an understanding of the teaching?

"I will use ink pens for writing"

A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client as an indication of inhibition of parental attachment?

"I wish he had more hair. I will keep a hat on his head until he grows some."

A public health nurse is teaching a group of nurses about smallpox. Which of the following statements by one of the nurses indicates understanding of the teaching?

"Unlike chickenpox, the vesicles of smallpox are more abundant on the face."

A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

"I'll feed my baby every 2 hours."

A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity?

"My vision seems yellow."

A nurse is preparing an in-service about St. John's wort. Which of the following information should the nurse include in the teaching?

"St. John's wort can cause photophobia."

A nurse is caring for a group of clients. Which of the following clients should the nurse refer to a social worker? (Select all that apply.)

- A client who requires placement in an assisted living facility. - A client who requests to secure an emergency notification system in the home. - A client who requests to get school assignments while hospitalized on a pediatric unit.

A nurse is caring for an older adult client who is disoriented and has a history of falls. Which of the following actions should the nurse take? (Select all that apply.)

- Check on the client hourly. - Instruct the client in the use of the call light. - Apply an ambulation alarm to the client's leg.

A nurse is providing teaching to a client who has cancer about foods that prevent protein-energy malnutrition. Which of the following foods should the nurse include in the teaching? (Select all that apply.)

- Cottage cheese - Milkshakes - Tuna fish - Egg and ham omelet

A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.)

- Hallucinations - Blunt affect

A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment? (Select all that apply.)

- Irrigating a client's abdominal wound - Suctioning a client's new tracheostomy tube

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

- Offer finger foods to the client every 2 hr. - Maintain an environment with low stimuli. - Monitor vital signs every 1 to 2 hr throughout the day.

A community health nurse is providing a community education program about disaster preparedness. Which of the following should the nurse recommend that clients include in their family's disaster readiness kit or "go bag"? (SATA)

- Pencil and paper - whistle - copies of insurance - household bleach

A nurse is planning a staff education session regarding biological weapons of mass destruction. Which of the following should he plan to include in the session? (Select all that apply.)

- Smallpox - Anthrax - Botulism

A nurse in a provider's office is caring for a 9-month-old infant. The nurse is providing teaching to the guardians of the infant. Select the 3 instructions the nurse should include in the teaching.

- apple zinc oxide with each diaper change - change diaper when wet - cleanse diaper area with soap and water

a nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. idenitify the sequence fo actions the nurse should take

1. open the airway using jaw-thrust maneuver 2. determine effectiveness of centrilaor efforts 3. establish IV assess 4. perform a glahow coma scale assessment 5. remove clothing for a thorough assessment

A nurse is preparing to administer ticarcillin / clavulanate 3.1 g by intermittent IV bolus over 30 min. Available is ticarcillin / clavulanate 3.1 g in 50 mL 0.9% sodium chloride (NSS). The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

100mL

A nurse on a medical unit is assessing four clients for urinary retention. Which of the following clients have manifestations of urinary retention?

A client who reports urinary frequency

A nurse is assessing four female clients for obesity. Which of the following clients have manifestations of obesity?

A client who weighs 28% above ideal body weight

A nurse is caring for a client who is in her third trimester of pregnancy. The client asks the nurse about over-the-counter medications. The nurse should recognize which of the following medications is a pregnancy risk category B?

Acetaminophen

A nurse is caring for a child who has asthma and a prescription for montelukast granules. Which of the following instructions should the nurse provide the client's parent on administering the medication?

Administer the medication 2 hr before exercise.

A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan?

Apply pressure to needlestick sites for 10 min.

A nurse is caring for a client who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following actions should the nurse take first?

Ask the client to rate her pain on a scale from 0 to 10.

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take?

Attach a humidifier bottle to the base of the flow meter.

A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi?

Dehydration

A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?

Dyspnea

A nurse in a pediatric clinic is caring for a child who has iron deficiency anemia and a new prescription for ferrous sulfate tablets. Which of the following instructions should the nurse provide the parents regarding administration of this medication?

Give with orange juice.

A nurse is caring for a client who has cirrhosis and has a prescription for bumetanide. When delivering the client's lunch tray, which of the following items should the nurse identify as contraindicated for the client?

Ham sandwich

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?

Hematemesis

A nurse is assessing a client who has type 1 diabetes mellitus and finds the client lying in bed, sweating, and reporting feeling anxious. Which of the following complications should the nurse suspect?

Hypoglycemia

During the assessment of a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following complications should the nurse suspect?

Infection

A nurse in a provider's clinic is caring for a client who reports erectile dysfunction and requests a prescription for sildenafil. Which of the following medications currently prescribed for the client is a contraindication to taking sildenafil?

Isosorbide

A nurse is formulating a teaching plan about herpes zoster for a group of older adults at a community center. The nurse should include which of the following information in the plan?

Many clients experience pain in the affected area for weeks after the lesions have resolved.

A community health nurse in a pediatric clinic is reviewing the history of a 12-year-old client. Which of the following immunizations should the nurse expect to administer?

Meningococcal conjugate

A nurse is admitting a client who reports flu-like symptoms with hyperactive reflexes and a new onset of confusion. The nurse should recognize that the client is experiencing which of the following conditions?

Metabolic alkalosis

A nurse is preparing to administer nalbuphine to a postoperative client who is experiencing pain. The nurse should monitor the client for which of the following potential adverse effects of this medication?

Miosis

A nurse manager is presenting to a group of unit nurses the categories regulated under the Controlled Substances Act. Which of the following medication prescriptions should the nurse include under Schedule II?

Morphine

A nurse is caring for a preterm newborn who has a nasogastric tube and who recently began intermittent gavage feedings of formula. The nurse notes increased abdominal distention, lethargy, bloody stools, and increasing gastric residuals before feedings. The nurse should suspect which of the following?

Necrotizing enterocolitis

A nurse is working with an interdisciplinary disaster committee to develop a community-wide emergency response plan in the event of a nonbiological or chemical incident. The nurse should include which of the following agencies to be notified immediately after calling 911?

Office of Emergency Management (OEM)

A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine?

Pale pink

A school nurse is assessing a school-age child and notices white flakes that don't brush off the hair and a rash on the back of the child's neck. The nurse should suspect which of the following disorders?

Pediculosis capitis

A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first?

Position the client supine.

A nurse in an emergency department receives report from an emergency responder who states a client is being transported following exposure to a "dirty bomb." The nurse should prepare to care for a client that has been exposed to which of the following types of agents?

Radiologic

A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client?

Regular insulin

A nurse is caring for a client who attacked one of there friends and is admitted tot he psychiatric unit. Which of the following actions should the nurse take first?

Set behavioral limits for the client

A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorder. Which of the following client goals is the highest priority?

The client's withdrawal from alcohol will be managed without complications.

A nurse is caring for a client who receives intermittent internal feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

To identity delayed gastric emptying

A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?

Urinary frequency

A nurse is teaching a client who has acute kidney injury about the oliguric phase. Which of the following information should the nurse include in the teaching?

Urine output is less than 400 mL per 24 hr.

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Use a transfer device to lift the client up in bed.

A nurse is developing a teaching plan for a client who has psoriasis. Which of the following information should the nurse include in the plan?

Use bath oils to soften and soothe the skin.

A charge nurse is teaching a group of health care workers about hand hygiene to prevent infection. Which of the following information should the charge nurse include in the teaching?

Use chlorhexidine to wash hands if the client is immunosuppressed.

A nurse in a mental health facility is interacting with a client who is angry and becoming increasingly aggressive. Which of the following actions should the nurse take?

Use clarification to determine what the client is feeling.

A nurse is planning to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take?

Use sterile forceps to move the sterile items on the sterile field.

. A nurse is caring for a client who has cirrhosis and a prothrombin time of 30 seconds. Which of the following medications should the nurse plan to administer?

Vitamin K

a nurse is triaging clients in an urgent care clinic. which of the following clients should the nurse have the provider care for immediately?

a middle-aged adult male who is diaphoretic and reports epigastiv pain

a nurse is preparing for administer a dose of lactulose to a client who has cirrhosis. the client states "I dont need this medication. I am not constipated." the nurse should explain that in clients who has cirrhosis, lactulose is used to decrease levels of which of the following components in the bloodstreamm?

ammonia

a client who has a history of myocardial infection (MI) is prescribed aspirin 325mg. the nurse recognizes that the aspirin is given due to which for the following actions of the medication?

anti platelet aggregate

a nurse is caring for a client who has a prescription for a stool test for guaiac. the nurse understands the purpose of the test is to check the stool for which of the following substances?

blood

A nurse is reviewing the laboratory results of a client who was admitted with a history of multiple myeloma. The nurse should expect to find an increase in which of the following laboratory values?

calcium

a nurse is caring for a client who has a new diagnosis of urlithiosis. which of the following should the nurse identify as an associated risk factor?

family history

a nurse is planning care for a child who has suspected epiglottis. which of the following actions should the nurse take?

place the child in an upright position

a nurse is reviewing the laboratory data on a client who has a new perscriptrion for heparin for treatment of a pulmonary embolism. which of the filling data should the nurse report to the provider?

platelets 74,000/mm3

a nurse is providing teaching about a low FODMAP diet for a client who has irritable bowel syndrome. the nurse should instruct the client to avoid which of the following foods?

raisins

A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated?

sudden decrease in abdominal pain

A nurse is providing dietary teaching to a client who has frequent kidney stones. Which of the following instructions should the nurse include in the teaching?

"Avoid eating tree nuts, such as almonds."

A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?

"I only need to catheterize myself twice every day."

A nurse is developing a teaching plan for a client who has an ileostomy and will require stoma care. Which of the following information should the nurse include?

Empty the pouch when it is 1/2 full.

A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider?

Increased heart rate.

A nurse in an emergency department receives report from an emergency responder who states a client is being transported following exposure to a "dirty bomb". The nurse should prepare to care for a client that has been exposed to which of the following types of agents?

Radiologic

A nurse is assessing a client who is in skeletal traction. The nurse should correct which of the following findings?

The weights rest against the foot of the bed.

How many calories are contained in a food item that has 15g of carbohydrates, 4g of protein, and 10g of fat?

166g

A nurse is teaching a group of adults about nutrition. The nurse should include which of the following amounts of an appropriate daily intake of fiber for adult women?

20 to 35g

a nurse is assessing a client who has fluid overload. which of the following findings should the nurse expect (SATA)

- increased heart rate - increased blood pressure - increased respiratory rate

A client who is terminally ill tells a nurse on the medical-surgical unit that she feels hopeless. Which of the following statements by the nurse is appropriate?

"Tell me what you understand about your illness."

A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute?

"The rate and rhythm of breath are irregular in newborns."

A nurse is assisting a client who has hypothyroidism with meal planning. Which of the following foods should the nurse recommend that the client add to her diet?

Baked chicken

A client is starting celecoxib to treat osteoarthritis. The nurse should instruct the client to watch for and report which of the following adverse effects?

Black, tarry stools

A nurse is caring for a client who was exposed to anthrax. Which of the following antibiotics should the nurse plan to administer?

Ciprofloxacin

A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advanced directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?

Client

A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?

Determining if the client has psychotic thinking

A nurse is teaching a client who has fibromyalgia abound self-care strategies for managing the disorder. Which of the following information should the nurse include in the teaching?

Establish a regular sleep pattern

A nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which of the following manifestations?

Frequent mood changes

A nurse is planning care for a client who has acute dysphagia. Which of the following nursing interventions should be included in the plan of care?

Instructing the client to tilt head forward when swallowing

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?

Placenta previa

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

Plantar flexion of the legs

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions?

Shakiness and diaphoresis

A nurse is teaching a client who has a new prescription for phenytoin. The nurse should instruct the client to monitor for and report which of the following adverse effects of this medication?

Skin rash

A nurse is reviewing a client's admission record. The nurse notes that there are prescriptions for several medications. Which of the following factors should the nurse recognize is of primary consideration when determining the schedule of administration?

Specific characteristics of the medications.

A nurse is caring for a client who has a history of exposure to TB and symptoms of night sweats and hemoptysis. Which of the following tests should the nurse realize is the most reliable to confirm the diagnosis of active pulmonary TB?

Sputum culture for acid-fast bacillus

A nurse is providing teaching to a client who is pregnant and is vegan. The nurse should instruct the client that which of the following foods is a reliable source of Vitamin B12?

Sunflower margarine

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?

Test the drainage for glucose.

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

To identify delayed gastric emptying

A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions?

Ventricular gallop

A nurse is caring for a client who has cirrhosis and prothrombin time of 30 seconds. Which of the following medications should the nurse plan to administer?

Vitamin K

A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

Wait 30 min and return to measure the oral temperature.

a nurse is completing discharge teaching with a. client following arthroscopic knee surgery. which of the following instructions should the nurse include in the teaching?

apply ice to the effected area

a nurse is receiving change of shift report for a group of assigned clients. the nurse anticipates which of the following activities first in delivering client care using the nursing process

collect and organize client data

a nurse is caring for a client who is 4 days postoperative following a right radical mastectomy. which of the following activities should the nurse anticipate being the most difficult for the client to perform with her right hand ?

combing her hair

a nurse is providing health promotion teaching to the parents of an infant. which of the following conditions should the nurse identify as the leading cause of health among this age group

congential abnormalities

The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tubes is functioning properly?

fluctuations in the fluid level within the water seal chamber

A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

increased heart rate

a nurse is assessing a school-age child whose blood glucose level is 280mg/dL. which of the following findings should the nurse expect?

lethargy

a nurse is administering a tap water enema to a client who is constipated. during the administration of the enema, the client states he is having abdominal cramps. which of the following actions should the nurse take to relieve the client's discomfort

lower the height of the solution container

a nurse is assessing a client who is being admitted from the PACU following an abdominal hysterectomy. which of the following assessments is the nurse's priority?

oxygen saturation

while caring for a client, the nurse experiences a needle stick injury. which of the following actions should the nurse take first?

wash the site of injury with soap and water

a nurse is caring for a client who has a new diagnosis of myasthenia graves. For which fo the following manifestations should the nurse monitor?

weakness