Ati test review bank

A child with a tracheal obstruction is brought to the emergency department by emergency medical services. The child aspirated a grape, and the foreign body was removed by direct laryngoscopy. Following the procedure, the nurse plans to inform the mother of the child that: 1. The child will need to be hospitalized for observation. 2. The child may go home with a prescription for antibiotics. 3. The child will need to return to the hospital for a chest x-ray in 1 week. 4. The child will require a bronchoscopy for follow-up evaluation in 1 month.

1

A client has a closed-chest tube drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets that: 1. The tube is patent. 2. The client is retaining airway secretions. 3. Hemothorax is not resolving. 4. Suction should be added to the system.

1

A client has a history of left-sided heart failure. The nurse would look for the presence of which of the following to determine whether the problem is currently active? 1. Bilateral lung crackles 2. Pedal edema bilaterally 3. Jugular vein distention 4. Presence of ascites

1

A client has been given an order for chloral hydrate (Somnote) for short-term use. The nurse includes which of the following nursing interventions in caring for this client? 1. Instruct the client to call for help to get out of bed. 2. Leave the lights on in the client's room. 3. Perform a neurological assessment every 4 hours. 4. Monitor the vital signs every 4 hours.

1

A client has been started on medication therapy with alprazolam (Xanax). When the nurse teaches the client that the medication should not be discontinued abruptly, the client asks why. The nurse should incorporate which of the following in formulating a reply? 1. Rebound central nervous system (CNS) excitation could occur, including seizure activity. 2. It will make the medication much less effective if it must be restarted. 3. The client is likely to become resistant to medication effects. 4. The client is likely to suffer irreversible kidney damage.

1

A client has just been admitted with a diagnosis of myxedema coma. If all of the following interventions were prescribed, the nurse would place highest priority on completing which of the following first? 1. Administering oxygen as ordered 2. Administering thyroid hormone 3. Warming the client 4. Giving fluid replacement

1

A client has sustained multiple fractures in the left leg and is in skeletal traction. The nurse has obtained an overhead trapeze for the client's use to aid in bed mobility. The nurse would pay particular attention to monitoring for which of the following high-risk areas for pressure and breakdown? 1. Right heel 2. Left heel 3. Scapulae 4. Back of the head

1

A client has sustained partial-thickness burns on the posterior thorax and legs. The nurse who is assisting in caring for the client would monitor for which of the following during the first 24 hours after the burn injury? 1. Elevated hematocrit levels 2. Increased urinary output 3. Decreased heart rate 4. Decreased blood pressure

1

A client has undergone a right pneumonectomy. The nurse positioning this client following admission from the postanesthesia care unit avoids placing the client in which harmful position? 1. Right lateral 2. Low Fowler's position 3. Semi-Fowler's position 4. High Fowler's position

1

A client is about to undergo a lumbar puncture (LP). The nurse tells the client that which of the following positions will be used during the procedure? 1. Side-lying with the legs pulled up and the head bent down onto the chest 2. Side-lying with a pillow under the hip 3. Prone with a pillow under the abdomen 4. Prone in slight Trendelenburg's position

1

A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse would prioritize that which of the following symptoms or behaviors requires immediate intervention? 1. Constant physical activity and poor oral intake 2. Constant, incessant talking with sexual innuendos 3. Outlandish behaviors and wearing odd, eccentric clothing 4. Grandiose delusions of being the King of England

1

A client is admitted to the surgical nursing unit following transurethral resection of the prostate (TURP) for benign prostatic hypertrophy. The client has a bladder irrigation infusing, and output is light cherry colored. The blood pressure is 134/82 mm Hg, the pulse is 84 beats per minute, and the client is afebrile with a respiratory rate of 18 breaths per minute. The licensed practical nurse (LPN) assisting in caring for the client collects assessment data 1 hour after admission to the nursing unit. The LPN notifies the registered nurse (RN) immediately if which of the following is noted on data collection? 1. Blood pressure of 102/50 mm Hg, pulse 110 beats per minute 2. Pain related to bladder spasms 3. Red urine 4. Urinary output of 200 mL greater than intake

1

A client is diagnosed with catatonic stupor. The client is lying on the bed, hidden under the sheets, with her body pulled into a fetal position. The nurse should take which appropriate action? 1. Sit beside the client in silence with occasional open-ended questions. 2. Ask direct questions to encourage talking. 3. Leave the client alone but check on her every 30 minutes. 4. Take the client into the dayroom with other clients for added supervision.

1

A client is receiving oral anticoagulant therapy with warfarin (Coumadin). The result of a newly drawn prothrombin time (PT) is 28 seconds. The nurse anticipates carrying out an order to: 1. Hold the next dose of warfarin. 2. Stop the warfarin and administer heparin. 3. Administer the next dose of warfarin. 4. Increase the next dose of warfarin.

1

A client is receiving tacrolimus (Prograf) to prevent organ rejection. The nurse expects to administer the dose with which of the following medications that is also normally prescribed? 1. Prednisone (Deltasone) 2. Erythromycin (E-Mycin) 3. Fluconazole (Diflucan) 4. Carbamazepine (Tegretol)

1

A client receiving desmopressin (DDAVP) begins to complain of a headache. The nurse notes that the client is listless and falls asleep easily. The nurse interprets that the client is most likely experiencing which of the following? 1. Adverse medication effects 2. Effects of underdosing 3. Allergy to the medication 4. Medication-food interaction

1

A client taking buspirone hydrochloride (BuSpar) for 1 month is scheduled for a follow-up appointment. The nurse gathers data from the client and interprets that the medication is effective if the client reports an absence of: 1. Palpitations and anxiety 2. Delusions 3. Alcohol withdrawal symptoms 4. Paranoid thoughts

1

A client was transferred to the nursing unit from the coronary care unit after experiencing a myocardial infarction (MI). When reviewing the client's serum creatinine phosphokinase (CPK) levels recorded in the chart, the nurse knows that an elevation of which of the following was due to the MI? 1. MB 2. MM 3. MK 4. BB

1

A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin grains 1/150 sublingually. Five minutes later the client is still experiencing chest pain. If the blood pressure is still stable, the nurse should take which action next? 1. Administer another nitroglycerin tablet. 2. Call for a 12-lead electrocardiogram (ECG) to be performed. 3. Wait an additional 5 minutes, then give a second nitroglycerin tablet. 4. Apply 10 L of oxygen via nasal cannula.

1

A client with a perforated gastric ulcer is scheduled for emergency surgery. The client cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which of the following actions in the care of this client? 1. Obtain a telephone consent from the family member witnessed by two persons. 2. Obtain a court order for the surgery. 3. Send the client to surgery without the consent form being signed. 4. Have the hospital chaplain sign the informed consent immediately.

1

A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse describes the components of this form of therapy to the client and instructs the client that: 1. The client will be introduced to short periods of exposure to the phobic object while in a relaxed state. 2. The client will talk to self to control actions more effectively. 3. The client will meet with others with the same problem in a support group. 4. The client will take medication daily to control the condition.

1

A client with acute pancreatitis is experiencing severe pain. After noting an absence of an analgesic order on the physician order sheet, the nurse would suggest contacting the physician to request an order for which of the following medications? 1. Meperidine hydrochloride (Demerol) 2. Morphine sulfate 3. Acetylsalicylic acid (aspirin) 4. Acetaminophen with codeine (Tylenol No. 3)

1

A client with cancer has received a course of chemotherapy with fluorouracil (Adrucil). The nurse should plan to tell the client which of the following to promote the client's health? 1. Do not get any immunizations without physician approval. 2. Visit a flu clinic to receive a yearly flu vaccine. 3. Use aspirin (acetylsalicylic acid, ASA) as the medication of choice for headache. 4. Use alcohol in moderation as a means of coping with the disease process

1

A client with chronic glaucoma is being started on medication therapy with acetazolamide (Diamox). The nurse teaches the client that which symptoms that can occur early in use subsides or disappears in time? 1. Diuresis 2. Fatigue 3. Headache 4. Loss of libido

1

A client with dermatitis has been prescribed a topical corticosteroid for use on the affected areas, and the nurse has provided instructions about the use of this medication. Which statement by the client indicates the need for further instructions? 1. "I will apply a bandage over the site after applying the medication." 2. "The medication reduces inflammation and itching." 3. "I will apply the medication in a thin film." 4. "I will massage the medication gently into the skin."

1

A client with diabetes mellitus has a blood glucose on admission of 596 mg/dL. The nurse anticipates that this client would be experiencing which of the following types of acid-base imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1

A client with diabetes mellitus is scheduled to have a fasting blood glucose level determined in the morning. The nurse tells the client not to eat or drink after midnight. When the client asks for further information, the nurse clarifies by stating that which of the following would be acceptable to take before the test? 1. Water 2. Coffee without any milk 3. Tea without any sugar 4. Clear liquids such as apple juice

1

A client with history of seizure disorder is having a routine serum phenytoin level drawn. The nurse who receives a telephone report of the results notes that the client's blood level of the medication is within the normal range if the value reported is: 1. 15 mcg/mL 2. 6 mcg/mL 3. 28 mcg/mL 4. 35 mcg/mL

1

A client with liver cancer who is receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter. The nurse would try to limit which of the following foods that is most likely to have this taste for the client? 1. Beef 2. Potatoes 3. Custard 4. Cantaloupe

1

A client with peptic ulcer disease has a new order for propantheline (Pro-Banthine). The nurse instructs the client to take this medication: 1. 30 minutes before meals 2. With antacids 3. With meals 4. Just after meals

1

A client with type 1 diabetes mellitus has had a left above-the-knee amputation. The nurse carefully inspects the residual limb for which of the following complications due to the history of diabetes? 1. Separation of wound edges 2. Pain 3. Edema of the stump 4. Hemorrhage

1

A client's serum calcium level is 7.9 mg/dL. The nurse is immediately concerned, knowing that this level could lead to: 1. High blood pressure 2. Stroke 3. Cardiac arrest 4. Urinary stone formation

1

A clinic nurse is collecting psychosocial data on a client who has been told that she is pregnant. Which of the following findings would indicate to the nurse that the client is at high risk for contracting human immunodeficiency virus (HIV)? 1. A history of intravenous (IV) drug use 2. A history of one sexual partner for the past 10 years 3. No history of any sexually transmitted diseases 4. A significant other who is heterosexual

1

A female adolescent with type 1 diabetes mellitus will become a member of the school's football cheerleader team. The adolescent excitedly reports to the school nurse to obtain information regarding adjustments needed in the treatment plan for the diabetes. The school nurse would instruct the adolescent to: 1. Eat six graham crackers or drink a cup of orange juice before practice or game time. 2. Eat half the amount of food normally eaten at lunchtime. 3. Take the prescribed insulin one half hour before practice or game time rather than in the morning. 4. Take two times the amount of prescribed insulin on practice and game days.

1

A licensed practical nurse (LPN) has been assigned to assist a community nurse, who is the leader of a task force, to identify interventions for teenagers from a local community who are abusing drugs. At the first meeting of the task force, the group members express concern that more information is needed to determine appropriate measures for the target teenagers. The LPN suggests which of the following to the community nurse to direct the group most effectively? 1. Prepare a survey that can be distributed to community members to determine their understanding of the drug abuse problem. 2. Initiate a drug abuse program in all of the schools. 3. Seek out the teenage drug abusers and refer them to drug abuse centers. 4. Prepare posters that can be distributed to the schools.

1

A licensed practical nurse (LPN) is assisting in gathering data on a client who is scheduled for a cesarean delivery. Which of the following findings would indicate a need to contact the registered nurse (RN)? 1. Fetal heart rate of 180 beats per minute 2. White blood cell count of 12,000/mm3 3. Maternal pulse rate of 85 beats per minute 4. Hemoglobin of 11 g/dL

1

A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN would assist the RN by placing the bed in which of the following positions for the reading? 1. Flat 2. Trendelenburg's 3. Reverse Trendelenburg's 4. Semi-Fowler's

1

A licensed practical nurse (LPN) is assisting in the care of a client who overdosed on aspirin 24 hours ago. The LPN would report to the registered nurse (RN) which of the following findings associated with an anticipated acid-base disturbance? 1. Drowsiness, headache, and tachypnea 2. Decreased respiratory rate and depth, cardiac irregularities 3. Disorientation and dyspnea 4. Tachypnea, dizziness, and paresthesias

1

A licensed practical nurse (LPN) is assisting in the care of a pregnant teen-aged client with preeclampsia receiving magnesium sulfate. The LPN plans to notify the registered nurse immediately if which sign of magnesium toxicity is noted? 1. Respiratory rate of 10 breaths per minute 2. Serum magnesium level of 5 mEq/L 3. Proteinuria 4. Hyperactive deep tendon reflexes

1

A licensed practical nurse (LPN) is caring for a client in preterm labor who is receiving an infusion of ritodrine hydrochloride, when the client suddenly begins to complain of shortness of breath. The LPN should take which action first? 1. Notify the registered nurse. 2. Count the respiratory rate for at least 2 minutes. 3. Bring a manual resuscitation bag to the bedside. 4. Assist the client to lie down.

1

A licensed practical nurse (LPN) is reviewing laboratory results for a client taking dantrolene sodium (Dantrium). The LPN should suggest to the registered nurse to notify the physician if which of the following was noted on the laboratory report sheet? 1. Lactate dehydrogenase (LDH) 600 units/L 2. Platelet count 290,000 cells/mm3 3. Blood urea nitrogen 9 mg/dL 4. Creatinine 0.6 mg/dL

1

A licensed practical nurse (LPN) is reviewing the medical record of a newly assigned client and notes that the client is receiving cyclobenzaprine hydrochloride (Flexeril) for the treatment of muscle spasms. The LPN questions the order if which of the following disorders is noted in the admission history? 1. Angle-closure glaucoma 2. Hypothyroidism 3. Chronic bronchitis 4. Recurrent pneumonia

1

A licensed practical nurse (LPN) is told that baclofen (Lioresal) is prescribed for an assigned client. The LPN questions the registered nurse about the physician's order if which of the following conditions is noted on the client problem list? 1. Seizure disorder 2. Hyperthyroidism 3. Coronary artery disease 4. Diabetes mellitus

1

A long-term-care nurse about to give a daily dose of digoxin (Lanoxin) is told that a serum digoxin level drawn earlier in the day measured 2.7 ng/mL. The nurse should take which of the following actions first? 1. Gather data from the client related to signs of toxicity. 2. Report the finding to the health care provider. 3. Record the normal value on the intershift report sheet. 4. Administer the daily dose of the medication.

1

A new mother is seen in the health care clinic 2 weeks after the birth of a healthy newborn. The mother says that she feels as though she has the flu and complains of fatigue and aching muscles. On further data collection the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse how the condition occurs. The appropriate nursing response is which of the following? 1. "The infection can occur at anytime during breast-feeding." 2. "The infection is most common for women who have breast-fed in the past." 3. "The infection usually involves both breasts." 4. "The infection usually is caused by wearing a supportive bra."

1

A nurse arrives at the scene of a code and begins to assist in performing cardiopulmonary resuscitation (CPR) on an adult client. After determining proper hand placement, the nurse begins delivering compressions by pushing down on the chest to a depth of: 1. 1 to 2 inches 2. 2 to 3 inches 3. 1/2 to 1 inch 4. 1/4 to 1/2 inch

1

A nurse educator is describing the yin and yang theory of the ancient Chinese philosophy of Tao to a group of nursing students. The nurse explains that foods are classified as hot and cold in this theory and are transformed into yin and yang energy when metabolized by the body. The nursing student understands this theory when the student verbalizes that a client who practices this belief: 1. Consumes cold foods when a "hot" illness is present 2. Consumes hot foods when a "hot" illness is present 3. Believes that yin foods are hot foods 4. Believes that yang foods are cold foods

1

A nurse employed in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. The nurse immediately: 1. Removes the clients from the waiting room 2. Activates the fire alarm 3. Confines the fire 4. Extinguishes the fire

1

A nurse has an order to give a dose of Rho(D) immune globulin (RhoGAM) to a client who has delivered an infant. The nurse understands that this medication will prevent the next infant from experiencing which of the following? 1. Being affected by Rh incompatibility 2. Having Rh-positive blood 3. Developing perinatal infection 4. Experiencing high bilirubin levels

1

A nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. The nurse planning the work assignment for the shift makes a notation to check the IV sites of these clients every: 1. 1 hour 2. 2 hours 3. 3 hours 4. 4 hours

1

A nurse has just been given an order to administer albuterol (Proventil HFA) to a client. The nurse evaluates the effectiveness of the medication by noting which of the following before and during therapy? 1. Dyspnea and lung sounds 2. Headache and level of consciousness 3. Urine output and blood urea nitrogen 4. Nausea and vomiting

1

A nurse has provided discharge instructions to a client being placed on long-term anticoagulant therapy with warfarin sodium (Coumadin). The nurse reminds the client to do which of the following? 1. Avoid taking products containing acetylsalicylic acid (aspirin). 2. Reduce alcohol intake to 12 oz daily. 3. Take any over-the-counter medications as needed. 4. Alternate the timing of the daily dose.

1

A nurse has provided discharge instructions to the mother of an 18-month-old child following surgical repair of hypospadias. Which statement by the mother indicates a need for further instruction? 1. "I should carry my child by straddling the child on my hip." 2. "I should use double diapers to hold the surgery site in place." 3. "I should avoid toilet training right now." 4. "I should encourage fluid intake.

1

A nurse has reviewed the physician's orders for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic procedures that will confirm the diagnosis. The nurse prepares to: 1. Collect a 24-hour urine sample. 2. Perform a neurological assessment. 3. Send the child to the radiology department for a chest x-ray. 4. Assist with a bone marrow aspiration

1

A nurse in a physician's office has scheduled a client with dermatitis to be seen in 1 week for a patch test. The nurse would tell the client to do which of the following before the procedure? 1. Discontinue the prescribed antihistamine 2 days before the test. 2. Refrain from eating solid food on the day of the test. 3. Do not eat or drink anything on the morning of the test. 4. Shower using povidone-iodine on the morning of the test.

1

A nurse in the prenatal clinic is taking a nutritional history from a 16-year-old adolescent. Which statement by the adolescent would alert the nurse to a potential psychosocial problem? 1. "I only want to gain 10 pounds because I want to have a small, petite baby." 2. "I will continue drinking my afternoon milkshake." 3. "I don't like dairy products." 4. "I'm not used to eating so much food but I will try."

1

A nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which of the following actions should the nurse plan to take first? 1. Recheck the vital signs in 15 minutes. 2. Call the surgeon immediately. 3. Cover the client with a warm blanket. 4. Shake gently to arouse.

1

A nurse is assigned to care for a child admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The nurse prepares the child for which of the following diagnostic tests that will confirm the diagnosis? 1. Blood cultures 2. Chest x-ray 3. Echocardiogram 4. Transesophageal echocardiography

1

A nurse is assigned to care for a client with metastatic breast cancer who is taking tamoxifen citrate (Nolvadex). The nurse monitors for which of the following trends in laboratory values that could indicate an adverse effect? 1. Rising serum calcium level 2. Prolonged bleeding time 3. Decreasing sodium level 4. Increasing blood glucose level

1

A nurse is assigned to collect data from a Hispanic-American client during the hospital admission. On initial meeting of the client, the nurse should plan to: 1. Greet the client with a handshake. 2. Avoid touching the client. 3. Avoid any affirmative nods during the conversations with the client. 4. Smile and use humor throughout the entire admission process.

1

A nurse is assisting a client who is new to a low-potassium diet to select food items from the menu. Which of the following food items is lowest in potassium and would be recommended to the client who is on this dietary restriction? 1. Lima beans 2. Strawberries 3. Cantaloupe 4. Spinach

1

A nurse is assisting a physician with the insertion of a chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse plans to take which appropriate action? 1. Document the accurate functioning of the tube. 2. Reinforce the occlusive dressing. 3. Ensure that suction is turned on. 4. Encourage the client to deep breathe.

1

A nurse is assisting in admitting a client who experienced seizure activity in the emergency department. The nurse avoids doing which of the following when managing this client's environment? 1. Keeping the bed position raised to the nurse's waist level 2. Having intravenous (IV) equipment ready for insertion 3. Ensuring that an airway, oxygen, and suction equipment are at the bedside 4. Placing padding on the side rails of the bed

1

A nurse is assisting in caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy (DIC). Which of the following findings is least likely associated with DIC? 1. Swelling of the calf of one leg 2. Prolonged clotting times 3. Decreased platelet count 4. Petechiae, oozing from injection sites, and hematuria

1

A nurse is assisting in developing a plan of care for a child who will be returning from the operating room following a tonsillectomy. The nurse plans to place the child in which position on return from the operating room? 1. Side-lying 2. Trendelenburg's and on the right side 3. Supine 4. High Fowler's and on the left side

1

A nurse is assisting in developing a plan of care for a client with a psychotic disorder who is experiencing altered thought processes. On review of the client's record, the nurse notes documentation that the client believes that the food is being poisoned. The nurse develops strategies that will promote adequate nutrition and encourage the client to discuss feelings, and plans to: 1. Use open-ended questions and silence. 2. Instruct the client about the need for adequate nutrition. 3. Focus on the fact that the client's beliefs are untrue. 4. Focus on the components of adequate nutrition.

1

A nurse is assisting in the care of a client diagnosed with rheumatic heart disease. When teaching the client about self-management of this health problem, the nurse reminds the client to alert his dentist about the condition because: 1. The client requires prophylactic antibiotics before treatment. 2. The client is at risk for episodes of heart failure triggered by stressful events. 3. The dentist should use a lidocaine solution without epinephrine. 4. The dentist should use a low-speed drill to avoid dysrhythmias.

1

A nurse is assisting in the care of a client who had an ileostomy created a few days ago. Owing to the normally high output of drainage from this type of ostomy, the nurse monitors the client for signs of: 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1

A nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The health care provider gives a test dose of edrophonium (Tensilon). The nurse recalls that the client would have which of the following reactions if the client does actually have this disease? 1. An increase in muscle strength within 1 to 3 minutes 2. A decrease in muscle strength within 1 to 3 minutes 3. Joint pain for the next 15 minutes 4. Feelings of faintness or dizziness for 5 to 10 minutes

1

A nurse is attempting to inspect the lacrimal apparatus of a client's eye. Because of its anatomical location, the nurse should do which of the following? 1. Retract the upper eyelid and ask the client to look down. 2. Retract the upper eyelid and ask the client to look up. 3. Retract the lower eyelid and ask the client to look up. 4. Retract the lower eyelid and ask the client to look down.

1

A nurse is caring for a child following surgical removal of a brain tumor. The nurse is monitoring the child and notes that the pulse rate has increased and the blood pressure has dropped significantly. Bloody drainage is also noted on the posterior dressing. The initial nursing action is to: 1. Notify the registered nurse (RN). 2. Document the findings. 3. Recheck the vital signs in 1 hour. 4. Place the child in Trendelenburg's position.

1

A nurse is caring for a child who was burned in a house fire. The nurse assists in developing a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which of the following assessments as providing the most accurate guide to determine the adequacy of fluid resuscitation? 1. Level of consciousness 2. Amount of edema at the site of the burn injury 3. Heart rate 4. Lung sounds

1

A nurse is caring for a client following craniotomy who has a supratentorial incision. The nurse reviews the client's plan of care, expecting to note that the client should be maintained in which of the following positions? 1. Semi-Fowler's position 2. Dorsal recumbent position 3. Prone position 4. Supine position

1

A nurse is caring for a client in labor. The nurse reviews the physician's orders and notes that the client has an order for butorphanol tartrate (Stadol). The nurse understands that the action of this medication is to: 1. Decrease pain. 2. Increase uterine contractions. 3. Decrease uterine contractions. 4. Promote fetal lung maturity.

1

A nurse is caring for a client who was recently admitted for anorexia nervosa. Upon entering the client's room, the nurse finds the client in the middle of a series of sets of rapid sit-ups. Which action should the nurse to take initially? 1. Interrupt the client and offer to take her for a walk. 2. Interrupt the client and weigh her immediately. 3. Allow the client to complete her exercise program. 4. Tell the client that she is not allowed to exercise rigorously.

1

A nurse is caring for a newborn following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be appropriate? 1. Document the findings. 2. Notify the registered nurse (RN) immediately. 3. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes. 4. Reinforce the dressing.

1

A nurse is caring for a pregnant client who was diagnosed with acquired immunodeficiency syndrome (AIDS) and asks the nurse if she will be able to breast-feed the infant after delivery. Which response by the nurse is appropriate? 1. "Breast-feeding is contraindicated." 2. "Breast-feeding is allowed as long as the mother is taking zidovudine [AZT]." 3. "Breast-feeding is allowed as long as the infant is not showing signs of human immunodeficiency virus [HIV] infection." 4. "Breast-feeding is allowed as long as the infant receives an immunization for HIV."

1

A nurse is collecting data from a pregnant client with a history of cardiac disease. The nurse is checking for venous congestion. The nurse inspects which of the following areas, knowing that venous congestion is most commonly noted here? 1. Vulva 2. Fingers 3. Around the eyes 4. Around the abdomen

1

A nurse is collecting data on an infant with a diagnosis of suspected Hirschsprung's disease. Which of the following questions to the mother will most specifically elicit information regarding this disorder? 1. "Does your infant have foul-smelling, ribbon-like stools?" 2. "Is your infant constantly vomiting?" 3. "Does your infant constantly spit up feedings?" 4. "Does your infant have diarrhea?

1

A nurse is discussing skin biopsy with a client scheduled for the procedure. The nurse tells the client to expect how much discomfort during the procedure? 1. Slight, because the local anesthetic may burn or sting 2. None, because it is done under general anesthesia 3. None, because it is painless 4. Somewhat painful, but easily managed with opioids afterward

1

A nurse is gathering data from a client with a history of untreated cataracts. The nurse asks the client about the presence of which of the following signs of a cataract? 1. Difficulty with driving at night and blurred vision 2. Pain in the eyes when in dim light 3. Either excessive itching or tearing of the eyes 4. A blank spot in the field of vision

1

A nurse is getting a client who underwent umbilical hernia repair ready for discharge. The nurse tells the client that it is important to continue to do which of the following after discharge? 1. Avoid coughing. 2. Irrigate the drain. 3. Restrict pain medication. 4. Maintain bedrest.

1

A nurse is having a conversation with a depressed client in an inpatient psychiatric unit. The client says to the nurse, "Things would be so much better for everyone if I just weren't around." Which response by the nurse would be appropriate at this time? 1. "You sound very unhappy. Are you thinking of harming yourself?" 2. "Those feelings will go away once your medication really takes effect." 3. "I know what you mean; everyone gets that way when they are depressed." 4. "Have you talked to anyone specifically about what is bothering you?"

1

A nurse is instructing a group of nursing assistants in the principles of body mechanics. The nurse determines that a student is using the principles appropriately if the nurse observes the nursing assistant: 1. Positioning a box that is to be lifted between the knees 2. Turning the back to change position while moving a client 3. Helping a client requiring total care into a chair without additional assistance 4. Leaning forward when turning a client in bed

1

A nurse is monitoring a child who is receiving calcium disodium edetate (EDTA) for the treatment of lead poisoning. The nurse reviews the laboratory results of the child during treatment with this medication and is particularly concerned with monitoring which laboratory test result? 1. Blood urea nitrogen 2. Hemoglobin and hematocrit (H&H) level 3. Complete blood cell (CBC) count 4. Cholesterol level

1

A nurse is monitoring a client for hypercalcemia. Which of the following would the nurse note in hypercalcemia? 1. Slight muscle weakness 2. Tingling sensations 3. Hyperactive reflexes 4. Muscle cramps

1

A nurse is monitoring the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes thrombocytopenic and the platelet count is less than: 1. 20,000/mm3 2. 100,000/mm3 3. 120,000/mm3 4. 150,000/mm3

1

A nurse is obtaining the intershift report for a group of assigned clients. The nurse plans to monitor which client for signs of hyperkalemia because of the physiology associated with the health problem? 1. A client with a new burn injury 2. A client with Cushing's syndrome 3. A client with ulcerative colitis 4. A client who has a history of long-term laxative abuse

1

A nurse is preparing to administer pentamidine isethionate (Pentam 300) to an assigned client by the intramuscular route. The nurse plans to monitor which of the following most closely after administering this medication? 1. Blood pressure (BP) 2. Level of consciousness 3. Peripheral pulses 4. Capillary refill

1

A nurse is providing discharge instructions to a Chinese client regarding prescribed dietary modifications. During the teaching session the client continually turns away from the nurse. Which of the following nursing actions is most appropriate? 1. Continue with the instructions, verifying client understanding. 2. Identify the importance of the instructions for the maintenance of health care. 3. Walk around the client so that the nurse continually faces the client. 4. Give the client a dietary booklet and return later to continue with the instructions.

1

A nurse is providing discharge instructions to the mother of a child who had a myringotomy with insertion of tympanostomy tubes. The nurse instructs the mother that if the tubes should fall out, she should: 1. Contact the physician. 2. Bring the child to the emergency department immediately. 3. Replace them immediately. 4. Immediately immerse the tubes in half-strength hydrogen peroxide.

1

A nurse is providing instructions to a child with cystic fibrosis regarding how to perform the "huff" maneuver. The child asks the nurse about the purpose of this type of breathing. The appropriate nursing response is which of the following? 1. "This type of breathing is used to mobilize secretions so that they can be easily coughed out." 2. "This type of breathing prolongs inspiration time." 3. "This type of breathing moves air out of the lower lungs." 4. "This type of breathing moves air through the lungs."

1

A nurse is providing instructions to a client beginning medication therapy with divalproex sodium (Depakote ER) for the treatment of absence seizures. The nurse instructs the client that which of the following is the most frequent side effect of this medication? 1. Nausea and vomiting 2. Blue vision 3. Irritability 4. Tinnitus

1

A nurse is providing instructions to a mother of a child with atopic dermatitis (eczema) regarding the application of topical cortisone cream to the affected skin sites. Which of the following statements, if made by the mother, indicates an understanding of the use of this medication? 1. "I need to wash the sites gently before I apply the medication." 2. "The medication is applied everywhere except the face." 3. "I need to apply the medication generously and allow it to absorb." 4. "I shouldn't rub the medication into the skin."

1

A nurse is providing instructions to the mother of a 2-year-old child regarding dental care. Which statement by the mother indicates the need for further instructions? 1. "Proper dental care is not necessary for toddlers until their permanent teeth erupt." 2. "It is best to substitute sweets or snacks with food items such as cheese." 3. "I should schedule my child's first dental examination when his first primary tooth erupts." 4. "I do not need to be concerned if my child swallows some toothpaste while he is brushing his teeth

1

A nurse is providing instructions to the mother of a child with juvenile idiopathic arthritis regarding measures to take if a painful exacerbation of the disease occurs. Which statement by the mother indicates the need for further instructions? 1. "The full range-of-motion [ROM] exercises must be performed every day, even during the exacerbations." 2. "Hot or cold packs will assist in reducing discomfort." 3. "The painful joint should be splinted and positioned in a neutral position." 4. "I should have my child perform simple isometric exercises during exacerbations."

1

A nurse is reading the laboratory results for a client being treated with carbamazepine (Tegretol) for prophylaxis of complex-partial seizures. The nurse interprets that which of the following values is consistent with an adverse reaction to this medication? 1. White blood cell count 3200/mm3 2. Blood urea nitrogen 19 mg/dL 3. Sodium 136 mEq/L 4. Platelet count 350,000/mm3

1

A nurse is reviewing the laboratory results of a child with aplastic anemia and notes that the white blood cell (WBC) count is 2000/μL and the platelet count is 150,000/mm3. Which of the following nursing interventions will the nurse incorporate into the plan of care? 1. Maintain strict isolation precautions. 2. Encourage the child to use a soft toothbrush. 3. Avoid unnecessary injections. 4. Encourage quiet play activities.

1

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

1

A nurse is reviewing the record of a client who is hospitalized for treatment of a panic disorder. The nurse notes that the client was admitted by voluntary hospitalization. During the day, the client runs down the hallway and demands release from the hospital. The nurse notes that the client is exhibiting signs of anxiety and attempts to assist the client back to the client's hospital room. The next appropriate nursing action at this time is which of the following? 1. Notify the registered nurse (RN). 2. Help the client pack his or her personal belongings in preparation for discharge. 3. Inform the client that discharge is not possible because of the type of admission process involved. 4. Call security and persuade the client to stay.

1

A nurse is reviewing the record of a client with acute respiratory distress syndrome (ARDS). The nurse determines that which finding documented in the client's record is consistent with the most expected characteristic of this disorder? 1. Arterial PaO2 of 48 2. Arterial PaO2 of 81 3. Respiratory rate of 10 breaths per minute 4. Central cyanosis

1

A nurse is suctioning a client through an endotracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. The nurse should: 1. Stop the procedure and oxygenate the client. 2. Notify the registered nurse immediately. 3. Continue to suction the client at a quicker pace. 4. Ensure that the suction is limited to 15 seconds.

1

A nurse is teaching the client who is about to begin external radiation therapy how to maintain optimal skin integrity during therapy. The nurse determines that further teaching is needed if the client states that he will do which of the following? 1. Apply tight dressings over the area to prevent bleeding. 2. Eat a high-protein diet. 3. Avoid exposure to sunlight. 4. Wash the skin with a mild soap and pat dry.

1

A nurse is working in a long-term care facility and is observing a new nursing assistant caring for a client who requires a security device (wrist restraints). The nurse determines that the nursing assistant is providing safe care if the nurse observes the nursing assistant assessing skin integrity by completely removing the client's wrist restraints: 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 6 hours

1

A nurse is working with a client who is delusional. The client says to the nurse, "The leaders of a religious cult are being sent to assassinate me." Which of the following is the best response by the nurse? 1. "I don't know about a religious cult. Are you afraid that people are trying to hurt you?" 2. "What makes you think that cult members are being sent to hurt you?" 3. "There are no religious cults in this area that are going to kill you." 4. "I don't believe that what you are telling me is true.

1

A nurse notes that a 5-year-old child is choking but is awake and alert at this time. As the nurse rushes to aid the child, the nurse plans to place the hands between which of the following landmarks to remove the foreign body? 1. The umbilicus and xiphoid process 2. The lower abdomen and chest 3. The umbilicus and the groin 4. The groin and the xiphoid process

1

A nurse reviews the plan of care for a child with Reye's syndrome. The nurse prioritizes the nursing interventions included in the plan and prepares to monitor for: 1. Signs of increased intracranial pressure 2. The presence of protein in the urine 3. Signs of a bacterial infection 4. Signs of hyperglycemia

1

A nurse reviews the plan of care for a suicidal client admitted to the hospital. The nurse notes documentation of a nursing diagnosis of Dysfunctional grieving related to the loss of a spouse. The client progresses well and is approaching discharge. Which of the following is an appropriate outcome for this nursing diagnosis? 1. The client verbalizes stages of grief and plans to attend a community grief group. 2. The client verbalizes connections between significant losses and low self-esteem. 3. The client verbalizes decreased desire for self-harm and discusses two alternatives to suicide. 4. The client reports three additional coping strategies.

1

A nurse witnesses a person starting to choke in the hospital cafeteria. Before performing abdominal thrusts, the nurse should first: 1. Ask the client, "Are you choking?" 2. Begin rescue breathing. 3. Place the arms around the victim's waist. 4. Look for pallor or cyanosis.

1

A nurse witnesses an accident on a highway and stops to provide assistance to the victim. The nurse notes that the client sustained a head injury and a compound fracture to the left leg. The nurse provides the appropriate care prior to transport of the victim to the hospital by ambulance. The client develops a severe bone infection at the site of the fracture that requires amputation of the leg and files suit against the nurse who provided care at the scene of the accident. Which of the following is accurate regarding the nurse's immunity from this suit? 1. A Good Samaritan law will protect the nurse. 2. A Good Samaritan law will not protect the nurse. 3. A Good Samaritan law will provide immunity from suit even if the nurse accepted compensation for the care provided. 4. A Good Samaritan law protects laypersons and not professional health care providers.

1

A nursing instructor asks a nursing student to identify situations that indicate a secondary level of prevention in health care. Which statement, if made by the student, would indicate a need for further study of the levels of prevention? 1. Teaching a stroke client how to use a walker 2. Encouraging a client to take antihypertensive medications as prescribed 3. Screening for hypertension in a community 4. Encouraging a woman older than age 40 to obtain periodic mammograms

1

A nursing instructor asks a nursing student to identify the priorities of care for an assigned client. The student correctly identifies the client needs that are the priority by telling the nursing instructor that: 1. Actual or life-threatening concerns are the priority. 2. Time constraints related to the client's needs are the priority. 3. Obtaining needed supplies to care for the client is the priority. 4. Completing care in a reasonable time frame is the priority.

1

A nursing student caring for a 6-month-old infant is asked to collect a urine specimen from the infant. The student collects the specimen by: 1. Attaching a urinary collection device to the infant's perineum for collection 2. Obtaining the specimen from the diaper by squeezing the diaper after the infant voids 3. Catheterizing the infant using the smallest available French Foley catheter 4. Noting the time of the next expected voiding and preparing to collect the specimen into a cup when the infant voids

1

A physician has written an order for ranitidine (Zantac) 300 mg once daily on the client's discharge medication list. The nurse plans to instruct the client to take the medication at which of the following times? 1. At bedtime 2. With supper 3. After lunch 4. Before breakfast

1

A physician is about to perform a paracentesis on a client with abdominal ascites. The nurse would assist the client to assume which of the following positions? 1. Upright 2. Supine 3. Right side-lying 4. Left side-lying

1

A postoperative client has received a dose of naloxone for respiratory depression. The nurse anticipates that the client will have which of the following additional effects from the administration of this medication? 1. Sudden increase in pain 2. Scattered lung wheezes 3. Pupillary changes 4. Sudden vomiting

1

A postoperative client has regained bowel sounds and is ready to start a clear liquid diet. The nurse is told that the physician has written an order to remove the nasogastric (NG) tube. The nurse assists in the procedure and asks the client to do which of the following during tube removal? 1. Exhale until the tube is out. 2. Inhale until the tube is out. 3. Perform the Valsalva maneuver. 4. Hold the breath to the count of five.

1

A postoperative client with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed to: 1. Expel mucus from the airways. 2. Dilate the terminal bronchioles. 3. Provide for increased oxygen tension in the alveoli. 4. Exercise the muscles of respiration.

1

A postpartum nurse is providing instructions to a mother regarding how to provide a bath to the newborn. Which statement by the mother indicates the need for further instructions? 1. "I need to bathe my newborn after a feeding." 2. "I need to fill a clean basin or sink with 2 to 3 inches of water and then check the temperature using the wrist." 3. "I will never leave the newborn in the tub of water alone." 4. "I will gather all my supplies before I start bathing my newborn.

1

An adolescent is seen in the emergency department following an athletic injury, and it is suspected that the child sprained an ankle. X-rays are taken, and a fracture has been ruled out. The nurse provides instructions to the adolescent regarding home care for treatment of the sprain and tells the adolescent which of the following? 1. Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 hours. 2. Apply heat to the injured area every 4 hours for the first 48 hours, then begin to apply ice. 3. Immobilize the extremity and maintain the extremity in a dependent position. 4. Elevate the extremity and maintain strict bedrest for a period of 7 days.

1

An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which of the following? 1. 22.5% 2. 31.5% 3. 36% 4. 40.5%

1

An automatic external defibrillator (AED) is available to treat a client who goes into cardiac arrest. The nurse uses this equipment to determine cardiac rhythm by doing which of the following? 1. Applying the adhesive patch electrodes to the skin and moving away from the client 2. Connecting standard electrocardiographic (ECG) electrodes to a transtelephonic monitoring device 3. Applying standard ECG monitoring leads to the client and observing the rhythm 4. Holding the defibrillator paddles firmly against the chest

1

An older adult client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client for which of the following manifestations that correlates with this client's fluid imbalance? 1. Flat neck veins 2. Lung crackles 3. Increased blood pressure 4. Decreased pulse

1

An older client has been treated for dehydration and pneumonia. The nurse evaluates that the client's dehydration has been successfully treated if the blood urea nitrogen (BUN) level drops to: 1. 19 mg/dL 2. 5 mg/dL 3. 46 mg/dL 4. 32 mg/dL

1

Calcitriol (Rocaltrol) is prescribed for the client with hypocalcemia. The nurse instructs the client to avoid excessive amounts of which of the following food items that interfere with calcium absorption? 1. Bran 2. Milk 3. Clams 4. Orange juice

1

During routine postoperative assessment of a client who has undergone hypophysectomy, the client complains of thirst and frequent urination. Knowing the expected complications of this surgery, the nurse would next check the: 1. Urine specific gravity 2. Serum glucose 3. Respiratory rate 4. Blood pressure

1

Fibrinolysin and desoxyribonuclease (Elase) in powder form is prescribed to treat a skin ulcer. The nurse would avoid which of the following when using this medication? 1. Applying in a thick layer and covering with a dry sterile dressing. 2. Applying in a thin layer and covering with a petrolatum gauze. 3. Cleaning the wound with a sterile solution prior to use. 4. Preparing the solution from the powder just prior to use.

1

In preparing to care for a hospitalized child with a diagnosis of measles (rubeola), which supplies would the nurse bring to the child's room to prevent the transmission of the virus? 1. Mask and gloves 2. Gown and gloves 3. Goggles and gloves 4. Gown, gloves, and goggles

1

Ketoconazole (Nizoral) is prescribed for an assigned client. The nurse prepares to administer the medication: 1. With food 2. With 8 oz of water 3. On an empty stomach 4. With an antacid

1

Which of the following interventions would be contraindicated in the postprocedure care of the client following a bone biopsy of the left arm? 1. Place the left arm in a dependent position for 24 hours. 2. Monitor vital signs every 4 hours. 3. Monitor site for swelling, bleeding, hematoma. 4. Administer oral analgesics as needed.

1

A nurse in the newborn nursery is collecting data on a neonate who was born of a mother addicted to cocaine. Which of the following would the nurse expect to note in the neonate? Select all that apply. 1. Tremors 2. Bradycardia 3. Irritability 4. Hypertension 5. Flaccid muscles 6. Exaggerated startle reflex

1, 2, 3, 5

A nursing student is preparing a clinical conference, and the topic of the discussion is caring for the child with cystic fibrosis (CF). The student prepares a handout for the group and lists which of the following on the handout? Select all that apply. 1. It is a disease that causes mucus formation to be abnormally thick. 2. It is a chronic multisystem disorder affecting the exocrine glands. 3. It is transmitted as an autosomal recessive trait. 4. It is a disease that causes dilation of the passageways of all organs. 5. It is a disease that affects males only. 6. It is a disease that affects the lungs only.

1,2,3

A CD4+ count has been ordered for a child with human immunodeficiency virus (HIV) infection. The mother asks the nurse about the purpose of the test and why the test needs to be done if it is already known that the child has HIV. The nurse should provide which information to the mother? Select all that apply. 1. The CD4+ count is used to determine the child's immune status. 2. The CD4+ count is used to identify the risk for disease progression. 3. The CD4+ count identifies the need for Pneumocystis jiroveci pneumonia prophylaxis after 1 year of age. 4. The CD4+ count identifies the specific diagnosis of HIV infection. 5. The CD4 count is measured at ages 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. 6. More frequent monitoring of CD4+ counts is indicated when pneumonia prophylaxis and antiretroviral therapy are administered.

1,2,3,5,6

A nurse is assisting in preparing a plan of care for a child who is being admitted to the pediatric unit with a diagnosis of seizures. Which of the following would be a component of the plan of care? Select all that apply. 1. Pad the side rails of the bed with blankets. 2. Maintain the bed in a low position. 3. Restrain the child if a seizure occurs. 4. Place the child in a side-lying lateral position if a seizure occurs. 5. Protect the child's head, body, and extremities if a seizure occurs. 6. Place a padded tongue blade in the child's mouth if a seizure occurs

1,2,4,5

A nurse is monitoring a newborn who was born to a drug-addicted mother. Which of the following findings would the nurse expect to note during data collection for this newborn? Select all that apply. 1. Irritable 2. Difficult to console 3. Lethargic 4. Cries incessantly 5. Cuddles easily 6. Hyperextends and postures

1,2,4,6

Ampicillin sodium (Omnipen) 250 mg in 50 mL of normal saline (NS) is being administered over a period of 30 minutes. The drop (gt) factor is 10 drops (gtt) per mL. The nurse is asked to check the flow rate of the infusion. The nurse determines that the infusion is running at the prescribed rate if the infusion is delivering how many gtt per minute? (Round answer to the nearest whole number.)

17 gtt/minute Rationale: The prescribed 50 mL is to be infused over 30 minutes. Follow the formula and multiply 50 mL by 10 (gt factor). Then divide the result by 30 minutes. Round answer to the nearest whole number. The infusion is to run at 17 gtt/minute. Formula: Total volume in mL × gt factor = Flow rate in gtt per minute Time in minutes 50 mL × 10 gtt = 500 = 16.6 or 17 gtt/minute 30 minutes 30

A 4-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are both partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies anticipating that which of the following will be prescribed initially? 1. Insertion of a nasogastric tube 2. Insertion of a Foley catheter 3. Administration of an anesthetic agent for sedation 4. Application of an antimicrobial agent to the burns

2

A 5-week-old infant is brought to the well-baby clinic by the mother because the mother has noted white patches in the infant's mouth. Following assessment, the infant is diagnosed with oral candidiasis (thrush). Nystatin oral suspension is prescribed. The mother is concerned because she is breast-feeding the infant and asks the nurse if breast-feeding can be continued. Which of the following responses is appropriate? 1. "Breast-feeding must be stopped immediately." 2. "Breast-feeding can continue, but your breasts should also be treated with nystatin." 3. "You should bottle-feed the infant for 1 week and then resume breast-feeding." 4. "You will need to take the oral nystatin also because the infant probably contracted the infection from you."

2

A client admitted with depression 3 days ago could hardly get out of bed without coaxing and needed constant encouragement to get dressed and participate in unit activities. Today the client appears in the dayroom dressed and well groomed, without any guidance from the staff. The client appears to be calm and relaxed, yet more energetic than before. The nurse should take which initial action after noting this client's behavior? 1. Notify the staff of these observations at the team meeting due to begin in 3 hours' time. 2. Speak to the client personally about the nurse's observations and ask if the client is thinking about suicide. 3. Document that the client is adapting to the unit and is feeling safe. 4. Continue to monitor the client's behavior from a distance.

2

A client admitted with depression states to the nurse, "My life has been such a failure; nothing I do turns out right." Which of the following responses by the nurse would be therapeutic? 1. "I know just how you feel. I have those days myself once in a while." 2. "You seem very discouraged. Can you think of anything recently that went as you planned?" 3. "I disagree with you; we all have some value and accomplishments in life." 4. "You are certainly entitled to your own opinion."

2

A client arrives in the emergency department with an eye injury due to metal fragments that hit the eye while the client was drilling into metal. The nurse assesses the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse take first? 1. Perform complete visual acuity tests. 2. Irrigate the eye with sterile saline. 3. Remove the objects using a sterile eye clamp. 4. Apply an eye patch.

2

A client has a new medication order for allopurinol (Zyloprim). A practical nursing student coassigned with the licensed practical nurse (LPN) states, "I know this is for gout, but how does it work?" In formulating a response, the LPN includes that allopurinol: 1. Lowers the risk of sulfa crystal formation in the urine 2. Decreases uric acid production 3. Reduces the production of fibrinogen 4. Prevents influx of calcium ions during cell depolarization

2

A client has an arteriovenous (AV) shunt in place for hemodialysis. The nurse would take which of the following priority precautions, knowing that bleeding is a potential complication? 1. Check the shunt for the presence of a bruit and thrill. 2. Ensure that small clamps are attached to the AV shunt dressing. 3. Check the results of blood tests as they are ordered. 4. Observe the site once per shift.

2

A client has been given a prescription for trimethoprim (Proloprim). The nurse determines that the client understands how to use the medication properly if the client states to: 1. Restrict fluids while taking the medication. 2. Drink extra fluids while taking the medication. 3. Discontinue the medication once symptoms subside. 4. Call the physician if the urine becomes brown.

2

A client has been newly diagnosed with glaucoma. As part of the discharge instructions, the nurse should plan to include which of the following? 1. The need to decrease table salt in the diet 2. The need for lifelong medication therapy 3. The need to restrict fluids in order to reduce intraocular pressure 4. The need to avoid straining or overworking the eyes

2

A client has just had an application of a nonplaster (fiberglass) leg cast, and the nurse is giving the client instructions on cast care at home. Which statement by the client indicates the need for further instructions? 1. "I should not use anything to scratch underneath the cast." 2. "I should use a hair dryer set to the hot setting to dry my cast if it gets wet." 3. "I need to avoid walking on wet or slippery floors." 4. "I can use a damp cloth to wipe off surface dirt on the cast."

2

A client has just undergone a renal biopsy. In planning care for this client, the nurse would avoid which intervention? 1. Test urine for occult blood periodically. 2. Ambulate in the room and hall for short distances. 3. Encourage fluids to at least 3 L in the first 24 hours. 4. Administer opioid analgesics as needed.

2

A client in renal failure is receiving epoetin alfa (Epogen). The nurse would monitor this client for which adverse reaction to this medication? 1. Hypotension 2. Hypertension 3. Depression 4. Bradycardia

2

A client is admitted to the surgical unit postoperatively with a wound drain (Hemovac) in place. Which of the following nursing actions would the nurse avoid in the care of the drain? 1. Check the drain for patency. 2. Curl the drain tightly and tape it firmly to the body. 3. Maintain aseptic technique when emptying. 4. Observe for bright red bloody drainage.

2

A client is admitted with a diagnosis of pheochromocytoma. The nurse would monitor which of the following to detect the most common sign of pheochromocytoma? 1. Skin temperature 2. Blood pressure 3. Urine ketones 4. Weight

2

A client is beginning to take trimethoprim-sulfamethoxazole (Bactrim) for a recurrent urinary tract infection (UTI). The nurse would give the client which of the following instructions regarding this medication? 1. Take most doses early in the day when fluid intake is largest. 2. Take each dose with 8 oz of water and drink extra water each day. 3. Expect rashes or skin changes as a result of therapy. 4. Discontinue the medication once symptoms subside.

2

A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse would plan to most carefully note the levels of which of the following electrolytes, which could dramatically decline with effective treatment of the acidosis? 1. Sodium 2. Potassium 3. Magnesium 4. Phosphorus

2

A client is diagnosed with stage I of Lyme disease. In addition to the rash, the nurse would check the client for which manifestation? 1. Arthralgias 2. Flulike symptoms 3. Neurologic deficits 4. Enlarged and inflamed joints

2

A client presents to the urgent care center with complaints of abdominal pain. Suddenly the client vomits bright red blood. The nurse takes which immediate action? 1. Performs a complete abdominal assessment 2. Takes the client's vital signs 3. Obtains a thorough history of the recent health status 4. Prepares to insert a nasogastric (NG) tube and test pH and occult blood

2

A client rings the call bell and complains of pain at the site of an intravenous (IV) infusion. The licensed practical nurse (LPN) inspects the site and determines that the client has developed phlebitis. The LPN would plan to avoid which of the following actions in the care of this client? 1. Prepare to apply warm moist packs to the site. 2. Prepare to start a new line in a proximal portion of the same vein. 3. Prepare to discontinue the IV catheter at that site. 4. Notify the registered nurse (RN).

2

A client taking theophylline (Theo-24) has a serum theophylline level of 15 mcg/mL. The nurse interprets that this result is: 1. Below the therapeutic range. 2. In the middle of the therapeutic range. 3. Near the top of the therapeutic range. 4. In excess of the therapeutic range.

2

A client who has sustained an eye injury has been prescribed corticosteroid eye drops. The nurse would most carefully monitor for side effects of this medication if the client has which of the following health problems listed on the medical record? 1. Hypertension 2. Diabetes mellitus 3. Cirrhosis 4. Chronic constipation

2

A client who is receiving antineoplastic medication by the intravenous (IV) route complains of pain at the insertion site of the IV. The nurse inspects the site and finds the area is swollen and reddened. The nurse further observes that the solution is no longer infusing. The nurse immediately takes which priority nursing action? 1. Administers a local anesthetic to reduce the discomfort 2. Notifies the registered nurse (RN) 3. Applies heat to the IV site and slows the infusion 4. Applies ice and elevates the extremity

2

A client who recently began medication therapy with levodopa (Larodopa) for Parkinson's disease complains of nausea. The nurse reminds the client to do which of the following to best manage this problem? 1. Take the medication with three glasses of water. 2. Eat a snack before taking the medication. 3. Take an antiemetic at the same time as the levodopa. 4. Lie down and rest after taking the dose.

2

A client who returned to the nursing unit 8 hours ago after hypophysectomy has clear drainage saturating the nasal dressing. The nurse should take which action first? 1. Continue to observe for further drainage. 2. Test the drainage for glucose. 3. Put the head of the bed flat. 4. Test the drainage for occult blood.

2

A client who suffered a cervical spine injury had Crutchfield tongs applied in the emergency department. The nurse would avoid which of the following actions in the care of the client? 1. Checking the amount of traction in use against the order each shift 2. Removing the weights when repositioning the client 3. Placing the client on a Stryker frame 4. Assessing the status and integrity of the weights and pulleys

2

A client who will undergo thyroidectomy at a later date has been started on medication therapy with potassium iodide (Lugol solution). As the licensed practical nurse (LPN) prepares to administer a scheduled dose, the client states that there is a burning sensation and a brassy taste in the mouth. The LPN should: 1. Give half the prescribed dose and notify the registered nurse (RN). 2. Withhold the medication and notify the RN. 3. Continue to administer the medication. 4. Stop the medication for 24 hours.

2

A client with Bell's palsy exhibits facial asymmetry and cannot close the eye completely on one side. The client is also drooling and has loss of tearing in one eye. The nurse documents that the client displays symptoms of involvement of which of the following cranial nerves (CNs)? 1. CN VI 2. CN VII 3. CN III 4. CN V

2

A client with a brain attack (stroke) is experiencing residual dysphagia. The nurse would remove which of the following food items that arrived on the client's meal tray from the dietary department? 1. Mashed potatoes 2. Peas 3. Cheese casserole 4. Scrambled eggs

2

A client with a burn injury is applying mafenide acetate (Sulfamylon) to the wound. The client calls the physician's office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. The nurse instructs the client to: 1. Apply a thinner film than prescribed to the burn site. 2. Continue with the treatment, because this is expected. 3. Discontinue the medication. 4. Come to the office to see the physician immediately.

2

A client with a pituitary tumor will undergo transsphenoidal hypophysectomy. The nurse includes which of the following priority items in the preoperative teaching plan for the client? 1. Brushing the teeth vigorously and frequently is important to minimize bacteria in the mouth. 2. Blowing the nose following surgery is prohibited. 3. A small area will be shaved at the base of the neck. 4. It will be necessary to cough and deep breathe following the surgery.

2

A client with a urinary tract infection with dysuria is given a prescription for phenazopyridine hydrochloride (Pyridium) for symptom relief. The nurse reinforces medication instructions with this client by reminding the client to: 1. Notify the physician if a headache occurs. 2. Expect the urine to become reddish orange. 3. Take the medication 1 hour before meals. 4. Take the medication at bedtime.

2

A client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine isethionate (Pentam 300). The nurse assisting in caring for the client monitors the client most closely for signs of: 1. Nausea 2. Anemia 3. Restlessness 4. Gastrointestinal discomfort

2

A client with an infected leg wound that is draining purulent material has an order for sodium hypochlorite (Dakin solution) to be used in the care of the wound. The nurse would do which of the following while using this solution? 1. Let the solution run freely over normal skin tissue. 2. Rinse off immediately following irrigation. 3. Pour onto sterile sponges and pack in the wound. 4. Use each bottle of solution for 1 month before replacing.

2

A client with heart disease who is taking digoxin (Lanoxin) complains of having no appetite. The nurse notes that the client also has a low serum potassium (K+) level. The nurse checks the results of the digoxin level obtained this morning, anticipating that the level is likely to be: 1. Low 2. High 3. Within therapeutic range 4. Uncertain

2

A client with hypertension has been prescribed a low-sodium diet. The nurse teaching this client about foods that are allowed would include which of the following in a list provided to the client? 1. Tomato soup 2. Summer squash 3. Instant oatmeal 4. Boiled shrimp

2

A client with methicillin-resistant Staphylococcus aureus (MRSA) needs to be placed on contact precautions, and the licensed practical nurse (LPN) in charge asks a newly licensed LPN to initiate contact precautions. Which action by the new LPN would indicate the need to review the procedure for contact precautions? 1. Wears gloves, gown, and goggles when changing the client's colostomy bag 2. Wears a gown when caring for the client and removes the gown immediately after leaving the client's room 3. Places the client in a semiprivate room with another client who has active infection with the same microorganism but who has no other infection 4. Places the client in a private room

2

A client with myasthenia gravis becomes increasingly weaker. The physician injects a dose of edrophonium (Tensilon) to determine whether the client is experiencing a myasthenia crisis or a cholinergic crisis. The nurse expects that the client will have which of the following reactions if the client is in cholinergic crisis? 1. An improvement of the weakness 2. A temporary worsening of the condition 3. No change in the condition 4. Complaints of muscle spasms

2

A client with myocardial infarction is a candidate for alteplase (Activase) therapy. The nurse assisting in the care of this client is aware that it will be necessary to monitor for which frequent adverse effect if the client receives this treatment? 1. Infection 2. Bleeding 3. Allergic reaction 4. Muscle weakness

2

A client with new-onset renal failure is having a first hemodialysis treatment. The nurse is especially careful to monitor the client for which of the following on return from the dialysis treatment? 1. Restlessness, irritability, and generalized weakness 2. Headache, decreasing level of consciousness, and seizures 3. Hypertension, tachycardia, and fever 4. Hypotension, bradycardia, and hypothermia

2

A client with spinal cord injury has experienced more than one episode of autonomic dysreflexia. The nurse would plan to avoid which of the following that could trigger an episode of this complication? 1. Rigidly adhering to a bowel retraining program 2. Allowing the client's bladder to become distended 3. Keeping the linen under the client free of wrinkles 4. Preventing pressure on the client's lower limbs

2

A client's medication sheet contains an order for sertraline hydrochloride (Zoloft). To ensure safe administration of the medication, the nurse would administer the dose: 1. Evenly spaced around the clock 2. At the same time each evening 3. On an empty stomach 4. On an as-needed basis when the client complains of depression

2

A clinic nurse periodically cares for a client diagnosed with acquired immunodeficiency syndrome. The nurse assesses for an early manifestation of Pneumocystis jiroveci infection by monitoring for which of the following at each client visit? 1. Fever 2. Cough 3. Dyspnea on exertion 4. Dyspnea at rest

2

A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse would suspect that which of the following findings will be reported from this blood test? 1. Increased red blood cell count 2. Decrease of all cell types 3. Increased white blood cell count 4. Increased neutrophils

2

A female client has an order for a clean-catch urine culture. After providing a sterile specimen cup to the client, the nurse would give which instruction so that the specimen is collected properly? 1. Cleanse the labia using cleansing towels, position the container, and begin to void. 2. Cleanse the labia using cleansing towels, begin to void into toilet, and then collect the specimen. 3. Void into the container, saving the full amount of urine. 4. Wipe the labia front to back with toilet paper and void into the sterile specimen container.

2

A female client undergoing chemotherapy with intravenous vincristine sulfate (Oncovin) has been given information about the treatment. The nurse determines that the client has adequate understanding of the side effects of treatment if the client states that her hair: 1. May be lost temporarily but will grow back normally 2. May be lost temporarily but may grow back with a different color and texture 3. Will not be lost with this medication 4. Will permanently be lost with this medication

2

A hospitalized client with a history of alcohol abuse tells a nurse, "I am leaving now. I don't want help. I have other things to attend to that are more important." The nurse attempts to discuss the client's concerns, but the client dresses and begins to walk out of the hospital room. The nurse should take which action at this time? 1. Tell the client that readmission is not possible after leaving against medical advice (AMA). 2. Call the nursing supervisor. 3. Restrain the client and call the physician. 4. Call security to block the exits from the nursing unit.

2

A licensed practical nurse (LPN) has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client will the LPN plan to care for first? 1. A client who is ambulatory 2. A client with a fever who is diaphoretic and restless 3. A client scheduled for physical therapy at 1:00 PM 4. A postoperative client who has just received pain medication

2

A licensed practical nurse (LPN) is administering medications to a client with chronic rheumatoid arthritis. The client has difficulty swallowing, and the film-coated form of diflunisal (Dolobid) is ordered. Which action by the LPN is most appropriate? 1. Give the client a large glass of water to aid in swallowing. 2. Consult with the registered nurse (RN) about contacting the physician regarding a medication change. 3. Crush the tablet and mix it with applesauce. 4. Open the tablet and mix the contents with food.

2

A licensed practical nurse (LPN) is collecting data on a child and notes the presence of old and new bruises on the child's back and legs. The LPN suspects physical abuse and reports the findings to the registered nurse, knowing that which of the following is necessary? 1. Filing charges against the mother and father of the child 2. Reporting the case to legal authorities 3. Asking the mother to identify the person who is physically abusing the child 4. Telling the child that he or she will need to go to a foster home until the situation is straightened out

2

A licensed practical nurse (LPN) is planning the client assignments for the day. Which of the following is an appropriate assignment for the nursing assistant? 1. A client with difficulty swallowing food and fluids 2. A client who requires a 24-hour urine collection 3. A client requiring a colostomy irrigation 4. A client receiving continuous tube feedings

2

A licensed practical nurse has observed a client self-administer a dose of an adrenergic bronchodilator via metered-dose inhaler. Within a short time, the client begins to wheeze loudly. Which action should the nurse take first? 1. Tell the registered nurse (RN) that a stronger medication is needed. 2. Report the client's symptoms to the RN. 3. Tell the client to administer a second dose of the medication. 4. Ask the client about any over-the-counter medications taken recently.

2

A long-term care nurse notes that an older female client has leaking of urine when sneezing, coughing, or laughing. The nurse reports that this client has which of the following types of incontinence? 1. Urge incontinence 2. Stress incontinence 3. Reflex incontinence 4. Functional incontinence

2

A nurse answers the call bell of a client who had insertion of an internal cervical radiation implant. The client states that the implant fell out, and the nurse sees it lying in the bed after moving back the sheet. Which of the following actions should the nurse take first? 1. Reinsert the implant into the vagina. 2. Use a long-handled forceps to place the implant in a lead container. 3. Call the radiation department. 4. Pick up the implant with gloved hands and place it in sterile saline

2

A nurse assisting in the care of a newborn has a standing order to administer the hepatitis B vaccine to the infant. The nurse should plan to do which of the following when carrying out this order? 1. Spread the skin under the injection site. 2. Obtain written parental consent. 3. Use the dorsogluteal muscle. 4. Select a 21-gauge, 1-inch needle.

2

A nurse assisting in the labor room is preparing to care for a client with hypertonic dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention in caring for the client is to: 1. Monitor the oxytocin (Pitocin) infusion closely. 2. Provide pain relief measures. 3. Prepare the client for an amniotomy. 4. Promote ambulation every 30 minutes.

2

A nurse discusses the risk factors associated with gastric cancer as part of a health promotion program. The nurse determines that further discussion is necessary if a member attending the program states that which factor is a risk? 1. A diet of smoked, highly salted, and spicy food 2. High meat and carbohydrate consumption 3. History of gastric polyps 4. History of pernicious anemia

2

A nurse employed in the emergency department is collecting data on a 7-year-old child with a fractured arm. The child is hesitant to answer questions that the nurse is asking and consistently looks at the parents in a fearful manner. The nurse suspects physical abuse and continues with the data collection procedures. Which of the following findings would most likely assist in verifying the suspicion? 1. Poor hygiene 2. Bald spots on the scalp 3. Lacerations in the anal area 4. Swelling of the genitals

2

A nurse employed in the pediatric unit working on the 11:00 PM to 7:00 AM shift finds an infant unresponsive and without respiration or a pulse. After opening the airway and initiating ventilation, the nurse plans to deliver chest compressions at a rate of at least: 1. 140 times per minute 2. 100 times per minute 3. 80 times per minute 4. 60 times per minute

2

A nurse has admitted a client to the clinical nursing unit following a right mastectomy. The nurse plans to place the right arm in which of the following positions? 1. Elevated above shoulder level 2. Elevated on one or two pillows 3. Level with the right atrium 4. Dependent to the right atrium

2

A nurse has an order to give ear drops to a 2-year-old child. The nurse positions the child's ear properly by pulling the pinna of the ear: 1. Downward and outward 2. Downward and backward 3. Upward and outward 4. Upward and backward

2

A nurse has assisted the physician with a liver biopsy, which was done at the bedside. Upon completion of the procedure, the nurse assists the client into which of the following positions? 1. Left side-lying with a small pillow or towel under the puncture site 2. Right side-lying with a small pillow or towel under the puncture site 3. Left side-lying with the right arm elevated above the head 4. Right side-lying with the left arm elevated above the head

2

A nurse has been assigned to a client with a hearing impairment. To enhance nurse-client communication, the nurse should plan to communicate with the client by speaking: 1. Directly into the impaired ear 2. In a normal tone while facing the client 3. On a more frequent basis 4. Very loudly to the client

2

A nurse has been caring for a client with a diagnosis of depression. The client says to the nurse, "I wish you would just be my friend." The appropriate response by the nurse is which of the following? 1. "I am your friend." 2. "Our relationship is a therapeutic and helping one." 3. "I can't be your friend. I'm the nurse and you're the client." 4. "You have plenty of friends. You don't need me to be your friend, too."

2

A nurse has completed five cycles of compressions after beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client. At this time, the nurse should: 1. Prepare for defibrillation. 2. Reassess the client. 3. Prepare for the administration of bicarbonate. 4. Stop CPR.

2

A nurse has just supervised a newly diagnosed diabetic mellitus client self-inject NPH insulin at 7:30 AM. The nurse reviews the time frames for peak insulin action with the client, telling the client to be especially watchful for a hypoglycemic reaction between: 1. 9:30 and 11:30 AM 2. 1:30 and 7:30 PM 3. 7:30 and 11:30 PM 4. 1:30 and 7:30 AM

2

A nurse has provided diabetic teaching with the family of a client newly diagnosed with diabetes. The nurse determines that the family understands the reason for having glucagon on hand for emergency home use if the family indicates that the purpose of the medication is to treat: 1. Hyperglycemia from insufficient insulin 2. Hypoglycemia from insulin overdose 3. Diabetic ketoacidosis 4. Hyperglycemia occurring on "sick days"

2

A nurse in the newborn nursery is assisting in monitoring a preterm newborn for respiratory distress syndrome (RDS). Which of the following findings if noted in the newborn would alert the nurse to the possibility of this syndrome? 1. Hypotension and bradycardia 2. Tachypnea and retractions 3. Acrocyanosis and grunting 4. The presence of a barrel chest with acrocyanosis

2

A nurse in the pediatric unit is admitting a 2-year-old child. The nurse plans care, knowing that the child is in which stage of Erikson's psychosocial stages of development? 1. Trust vs. mistrust 2. Autonomy vs. shame and doubt 3. Initiative vs. guilt 4. Industry vs. inferiority

2

A nurse is administering a dose of a prescribed diuretic to an assigned client. The nurse would plan to monitor the client for hypokalemia as a side effect of therapy if the client were receiving which of the following medications? 1. Spironolactone (Aldactone) 2. Bumetanide (Bumex) 3. Triamterene (Dyrenium) 4. Amiloride HCl (Midamor)

2

A nurse is administering a dose of prochlorperazine (Compazine) to a client for nausea and vomiting. The nurse tells the client to report which of the following symptoms, which is a frequent side effect of this medication? 1. Excessive perspiration 2. Blurred vision 3. Diarrhea 4. Drooling

2

A nurse is administering gentamicin sulfate (Garamycin) ophthalmic ointment to a client. After instilling the ointment, the nurse instructs the client to close the eye and: 1. Keep it shut tightly for 2 minutes. 2. Roll the eyeball in all directions. 3. Press on the nasolacrimal duct for 10 minutes. 4. Press tissue onto the closed eyelids.

2

A nurse is asked to prepare for the admission of a child to the pediatric unit with a diagnosis of Wilms' tumor. The nurse assists in developing a plan of care for the child and suggests including which of the following in the plan of care? 1. Palpate the abdomen for an increase in the size of the tumor every 8 hours. 2. Inspect the urine for the presence of hematuria at each voiding. 3. Monitor the temperature for hypothermia. 4. Monitor the blood pressure for hypotension.

2

A nurse is assigned to care for a client with a diagnosis of toxoplasmosis. The physician has prescribed sulfasalazine (Azulfidine). The nurse preparing to administer this medication understands that this medication is a(n): 1. Antibiotic 2. Sulfonamide 3. Opioid analgesic 4. Nonsteroidal anti-inflammatory

2

A nurse is assigned to care for a newly admitted client and is reviewing the physician's orders. The nurse notes that the physician has prescribed a medication dose that is twice the amount that the client reports taking prior to admission. The appropriate nursing action is to: 1. Question the client regarding the accuracy of the reported dosage. 2. Consult with the registered nurse (RN). 3. Administer the medication as prescribed. 4. Administer half of the prescribed dose and then notify the RN.

2

A nurse is assisting a client who has just been given a hearing aid to wear for the first time. The nurse provides teaching about the device, including that: 1. "The hearing aid contains a lifelong battery, so there is no need to be concerned about changing batteries." 2. "The hearing aid should not be worn if an ear infection is present." 3. "The ear mold should be washed with mild soap and water once a month." 4. "The hearing aid should be removed at the end of the day and then turned off after removal."

2

A nurse is assisting a client who will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. The nurse takes which of the following actions to assist this client? 1. Shaves the front of the client's chest 2. Gives the client a device holder to wear around the waist 3. Teaches the client to rest as much as possible during the next 24 hours 4. Tells the client to enclose the monitor in plastic wrap before taking a bath

2

A nurse is assisting in admitting to the hospital a 4-month-old infant with a diagnosis of vomiting and dehydration. The nurse assists in developing a plan of care for the infant and suggests including in the plan to position the infant in a(n): 1. Prone position 2. Side-lying position 3. Modified Trendelenburg's position 4. Infant car seat with the head of the seat in a flat position

2

A nurse is assisting in conducting a group therapy session. A female client, who has shared with the group at a previous session that she isolates herself when she feels depressed, suddenly gets up to leave. The appropriate nursing action is which of the following? 1. Lock the door so that the client cannot leave at this potentially vulnerable time. 2. Encourage the client to stay and ask the client what she is feeling. 3. Tell the client that it is not safe to leave. 4. Tell the client that if she leaves, she cannot return to this therapy group.

2

A nurse is assisting in preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that surgery is necessary. Considering the client's religious preferences, the nurse documents that: 1. Surgery is prohibited in this religious group. 2. The administration of blood and blood products is forbidden. 3. Medication administration is not allowed. 4. Faith healing is primarily practiced.

2

A nurse is assisting in preparing to care for a child with a brain tumor who will be returning from the recovery room following debulking of the tumor. Which of the following items will the nurse place at the bedside in preparation for the child's return from surgery? 1. A suction machine 2. A cooling blanket 3. Protective isolation equipment 4. Skeletal traction equipment

2

A nurse is assisting in the care of a client diagnosed with systemic lupus erythematosus (SLE). The nurse administers which of the following ordered medications that is needed to manage the condition? 1. Antidiarrheal 2. Corticosteroid 3. Antibiotic 4. Opioid analgesic

2

A nurse is assisting in the care of a client for whom an arterial blood gas (ABG) must be drawn. The nurse notes that the person who draws the blood sample from the radial artery performs Allen's test first. The nurse understands that this is being done to determine the adequacy of the: 1. Carotid circulation 2. Ulnar circulation 3. Femoral circulation 4. Brachial circulation

2

A nurse is assisting in the care of a client with myocardial infarction who should reduce intake of saturated fat and cholesterol. The nurse should help the client comply with diet therapy by selecting which of the following food items from the dietary menu? 1. Cheeseburger, pan-fried potatoes, whole kernel corn, sherbet 2. Baked haddock, steamed broccoli, herbed rice, sliced strawberries 3. Spaghetti and sweet sausage in tomato sauce, vanilla pudding (with 4% milk) 4. Pork chop, baked potato, cauliflower in cheese sauce, ice cream

2

A nurse is assisting in the care of a group of clients on the nursing unit. The nurse determines that a client with which of the following diagnoses is the one who has the least amount of risk for developing third-spacing of body fluid? 1. Laënnec's cirrhosis 2. Ischemic stroke 3. Major burn 4. Renal failure

2

A nurse is caring for a child who sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse plans to monitor for the earliest sign of increased ICP by assessing for: 1. Tachycardia 2. Changes in level of consciousness (LOC) 3. Posturing 4. Apnea

2

A nurse is caring for a client who is nervous and is hyperventilating. The nurse would monitor the client for signs of which of the following acid-base imbalances? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic alkalosis 4. Metabolic acidosis

2

A nurse is caring for a client with severe cardiac disease. While the nurse is caring for the client, the client states, "If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me." The appropriate nursing action is to: 1. Tell the client that this procedure cannot legally be refused by a client if the physician feels that it is necessary to save the client's life. 2. Tell the client that it is necessary to notify the physician of the client's request. 3. Tell the client that the family must agree with the request. 4. Plan a client conference with the nursing staff to share the client's request.

2

A nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this finding, which of the following actions would the nurse take? 1. Lower the head of the bed. 2. Document the findings. 3. Place the infant on nothing-per-mouth (NPO) status. 4. Ask the registered nurse to notify the physician immediately.

2

A nurse is caring for an elderly client whose husband died approximately 6 weeks ago. The client says, "There's no one left to care about me. Everyone that I have loved is now gone." The nurse would make which appropriate response? 1. "I'm sure you have someone if you think hard enough." 2. "It sounds as though you are feeling all alone right now." 3. "I don't believe that, and I really don't think you do either." 4. "That doesn't sound like the real you talking!"

2

A nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests and would expect to note which of the following? 1. An elevated T4 level 2. An elevated thyroid-stimulating hormone (TSH) level 3. A decreased TSH level 4. A normal T4 level

2

A nurse is collecting data from a client seen in the health care clinic for a first prenatal visit. The nurse asks the client when the first day of her last menstrual period was, and the client reports February 9, 2011. Using Nägele's rule, the nurse determines that the estimated date of confinement is: 1. October 16, 2011 2. November 16, 2011 3. October 7, 2011 4. November 7, 2011

2

A nurse is collecting data on a 12-month-old child with iron deficiency anemia. Which of the following findings would the nurse expect to note in this child? 1. Bradycardia 2. Tachycardia 3. Hyperactivity 4. A reddened appearance to the cheeks

2

A nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which of the following questions to the mother would elicit information about the cause of this disease? 1. "Did your child sustain any injuries to the kidney area?" 2. "Did your child recently complain of a sore throat?" 3. "Has your child had any diarrhea?" 4. "Have you noticed any rashes on your child?"

2

A nurse is initiating one-rescuer cardiopulmonary resuscitation on an adult client. After ventilating the client, the nurse places the hands in which of the following positions to begin chest compressions? 1. On the upper third of the sternum 2. On the lower half of the sternum 3. On the lower third of the sternum 4. On the upper half of the sternum

2

A nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which of the following signs, if noted in the mother, would indicate an early sign of excessive blood loss and shock? 1. A temperature of 100.4° F 2. A increase in the pulse rate from 88 to 102 beats per minute 3. An increase in the respiratory rate from 18 to 22 breaths per minute 4. A blood pressure change from 130/88 to 124/80 mm H

2

A nurse is monitoring the status of the postoperative client. The nurse would become most concerned with which of the following signs, which could indicate an evolving complication? 1. Blood pressure of 110/70 mm Hg with a pulse of 86 beats per minute 2. Increasing restlessness 3. Hypoactive bowel sounds in all four quadrants 4. A negative Homans' sign

2

A nurse is preparing a poster for a health fair about prevention and early detection of skin cancer. The nurse would include on the poster instructions to avoid which of the following activities? 1. Wearing a hat, opaque clothing, and sunglasses when in the sun 2. Being in the sun for prolonged periods between 10:00 AM and 3:00 PM 3. Using sunscreen when spending time outdoors 4. Examining the skin monthly for any lesions that might be cancerous

2

A nurse is preparing the client for transfer to the operating room (OR). The nurse should take which of the following actions in the care of this client at this time? 1. Administer all the daily medications. 2. Ensure that the client has voided. 3. Verify that the client has not eaten for the last 24 hours. 4. Practice postoperative breathing exercises.

2

A nurse is preparing to administer a measles, mumps, rubella (MMR) vaccine to a 15-month-old child. Before administering the vaccine, which of the following questions would the nurse ask the mother of the child? 1. "Is the child allergic to any antibiotics?" 2. "Has the child had any sore throats?" 3. "Has the child been eating properly?" 4. "Has the child been exposed to any infections?"

2

A nurse is preparing to care for a child who received an allogenic bone marrow transplant (BMT). The nurse understands that which of the following is the priority concern? 1. Bleeding 2. Infection 3. Sensory alterations 4. Social isolation

2

A nurse is preparing to care for a woman in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the woman's vital signs: 1. Every 30 minutes during the first hour and then every hour for the next 2 hours 2. Every 15 minutes during the first hour and then every 30 minutes for the next 2 hours 3. Every hour for the first 2 hours and then every 4 hours 4. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours

2

A nurse is preparing to deliver a food tray to a client whose religion is Judaism. The nurse checks the food on the tray and notes that the client has received a roast beef dinner with whole milk as a beverage. Which of the following actions will the nurse take? 1. Deliver the food tray to the client. 2. Call the dietary department and ask for a new meal tray. 3. Replace the whole milk with fat-free milk. 4. Ask the dietary department to replace the roast beef with pork.

2

A nurse is providing home care instructions to the mother of a child diagnosed with pneumonia. Which statement by the mother indicates the need for further instructions? 1. "I can administer acetaminophen [Tylenol] for a fever." 2. "I can use a warm mist humidifier to keep the secretions loose." 3. "I should administer the antibiotics until the prescribed amount is completed." 4. "I can give my child warm liquids to loosen secretions."

2

A nurse is providing information to a client with systemic lupus erythematosus (SLE) about dietary alterations. The nurse should remind the client to avoid which of the following foods? 1. Chicken 2. Beef 3. Melons 4. Cauliflower

2

A nurse is providing instructions to a client with a urinary tract infection being started on medication therapy with cinoxacin (Cinobac). The nurse reminds the client to take this medication: 1. One hour before meals 2. With meals 3. At bedtime 4. In the morning 2 hours before breakfast

2

A nurse is providing instructions to a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. The nurse advises the client to do which of the following to increase comfort while minimizing symptoms? 1. Remove the plastic cover on the pillow. 2. Keep liquids on the nightstand at home. 3. Reduce fluid intake before bedtime. 4. Take an antipyretic after the fever spikes.

2

A nurse is providing instructions to the client who has just been fitted for a halo vest. Which statement by the client indicates the need for further instructions? 1. "I will use a straw to make drinking easier." 2. "I will avoid driving at night because the vest limits the ability to turn the head." 3. "I will use caution because the vest alters the center of gravity and balance." 4. "I will wash my skin daily under the lamb's wool liner of the vest.

2

A nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further instruction? 1. "I need to remain in the kitchen when I prepare meals." 2. "I need to be sure to place my cup of coffee on the counter." 3. "I need to use the back burners for cooking." 4. "I need to turn pot handles inward and to the middle of the stove.

2

A nurse is providing postprocedure instructions to a client returning home after arthroscopy of the shoulder. The nurse would encourage the client to: 1. Not eat or drink anything until the following morning 2. Report to the physician the development of fever or redness and heat at the site 3. Keep the shoulder completely immobilized for the rest of the day 4. Resume regular full activity the following day

2

A nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which assessment finding would the nurse expect to note documented in the infant's record regarding this condition? 1. Asymmetric adduction of the affected hip when placed supine with the knees and hips flexed 2. Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table 3. An apparent short femur on the unaffected side 4. Full range of motion in the affected hip

2

A nurse is reviewing the immunization schedule for a child with human immunodeficiency virus (HIV) infection with the mother. Which of the following will be a component of the instructions that the nurse provides to the mother? 1. The immunization schedule needs to altered because of the HIV infection. 2. No live virus vaccines should be administered to the child. 3. Immunizations will not be given to the child with HIV infection. 4. Immunizations will be given to the child with HIV infection but will not be initiated until the child is 3 years old.

2

A nurse is reviewing the physician's order sheet for the preoperative client, which states that the client must be on nothing per mouth (NPO) status after midnight. The nurse would clarify whether which of the following medications should be given to the client and not withheld? 1. Conjugated estrogen (Premarin) 2. Atenolol (Tenormin) 3. Cyclobenzaprine (Flexeril) 4. Ferrous sulfate

2

A nurse is teaching a mother how to administer ear drops to an infant. The nurse plans to demonstrate by pulling the ear: 1. Down and back and directing the solution onto the eardrum 2. Down and back and directing the solution toward the wall of the canal 3. Up and back and directing the solution onto the eardrum 4. Up and back and directing the solution toward the wall of the canal

2

A nurse is teaching the client with a below-the-knee amputation (BKA) measures to protect the residual limb, or stump. The nurse would be sure to include which of the following points in discussions with the client? 1. Apply lotion daily to prevent cracking of the skin of the residual limb. 2. Use a mirror to inspect all areas of the residual limb. 3. Put a clean nylon sock on the residual limb daily. 4. Toughen the skin of the residual limb by rubbing it with alcohol.

2

A nurse must ambulate a client who has a nephrostomy tube attached to a drainage bag. The nurse plans to do this most safely and effectively by: 1. Asking the client to hold the drainage bag lower than the level of the bladder 2. Changing the drainage bag to a leg collection bag 3. Tying the drainage bag to the client's waist while ambulating 4. Hanging the drainage bag from a walker while ambulating

2

A nurse of a well-baby clinic prepares to administer an immunization to a child. The mother of the child tells the nurse that the child has had a fever and is taking antibiotics. The nurse takes the child's temperature and notes that it is 101.5° F rectally. The nurse plans to implement which of the following? 1. Administer the immunization. 2. Delay the immunization. 3. Administer one half of the prescribed dose of each scheduled immunization. 4. Administer one of the three scheduled immunizations

2

A nurse walking in a downtown business area sees a worker fall from a ladder while working on a sign above the door to a store. The nurse rushes to the victim, who is unresponsive. The nurse then uses which of the following most appropriate methods to open the victim's airway? 1. Head tilt-jaw thrust 2. Jaw thrust maneuver 3. Head tilt-chin lift 4. Neutral or sniffing position

2

A nurse working in the day care center is told that a child with autism will be attending the center. The nurse collaborates with the staff of the day care center and assists in planning activities that will meet the child's needs. The nurse understands that the priority consideration in planning activities for the child is to ensure: 1. Social interactions with other children in the same age group 2. Safety with activities 3. Familiarity with all activities and providing orientation throughout the activities 4. Activities providing verbal stimulation

2

A nursing instructor asks the nursing student to plan and conduct a clinical conference on phenylketonuria (PKU). The student researches the topic and plans to include which of the following in the conference? 1. PKU is an autosomal dominant disorder. 2. PKU results in central nervous system (CNS) damage. 3. Some state laws require routine screening of all newborn infants for PKU. 4. Treatment includes dietary restriction of sodium.

2

A nursing student is asked to administer a tepid bath to a child with a fever. The student avoids which of the following when performing this procedure? 1. Squeezes water over the child's body, using a washcloth 2. Applies alcohol-soaked cloths over the child's body 3. Uses a water toy to distract the child during the bath 4. Places lightweight pajamas on the child after the bath

2

A nursing student is assigned to care for a child with hemophilia. The nursing instructor reviews the plan of care with the student and asks the student to describe the characteristics of this disorder. Which statement by the student indicates a need for further research? 1. Hemophilia is inherited in a recessive manner via a genetic defect on the X chromosome. 2. Males inherit hemophilia from their fathers. 3. Females inherit the carrier status from their fathers. 4. Hemophilia A results from deficiency of factor VIII.

2

A nursing student is assisting the clinic nurse with the administration of immunizations in the well-baby clinic. The student is asked to administer a measles, mumps, and rubella (MMR) vaccine to a child and prepares to administer the vaccine: 1. Subcutaneously in the gluteal muscle 2. Subcutaneously in the upper arm 3. Intramuscularly in the deltoid muscle 4. Intramuscularly in the thigh

2

A physician is about to remove a chest tube from a client. Once the dressing is removed and the sutures have been cut, the nurse assisting the physician asks the client to: 1. Exhale immediately. 2. Perform the Valsalva maneuver. 3. Breathe deeply and rapidly. 4. Breathe in and out rapidly.

2

A physician writes an order to apply a heating pad to a client's back. The nurse implements the prescribed order and avoids which of the following? 1. Setting the heating pad on a low setting 2. Placing the heating pad under the client 3. Assessing the heating pad periodically for proper electrical function 4. Assessing the skin integrity frequently for signs of burns

2

A postpartum nurse has reinforced instructions to a new mother on how to bathe her newborn. The nurse demonstrates the procedure to the mother and on the following day asks the mother to perform the procedure. Which of the following observations, if made by the nurse, indicates that the mother is performing the procedure correctly? 1. The mother cleans the newborn's ears and then moves to the eyes and the face. 2. The mother begins to wash the newborn by starting with the eyes and face. 3. The mother washes the arms, chest, and back followed by the neck, arms, and face. 4. The mother washes the entire newborn's body and then washes the eyes, face, and scalp.

2

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, and the nurse determines that the client is experiencing Braxton Hicks contractions. Which of the following nursing actions would be appropriate? 1. Instruct the client to maintain bedrest for the remainder of the pregnancy. 2. Instruct the client that these are common and may occur throughout the pregnancy. 3. Contact the physician. 4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition.

2

A registered nurse has administered a dose of naloxone intravenously to a client with intravenous opioid overdose. The licensed practical nurse assigned to assist in monitoring the client ensures that which of the following equipment is available in the immediate vicinity of the client? 1. Central line insertion kit 2. Resuscitation equipment 3. Nasogastric tube 4. Thoracentesis tray

2

An adult client has increased fluid in the middle ear, which is causing vertigo. The nurse assesses this client for which associated signs and symptoms of this condition? 1. Headache and flushing 2. Nausea and vomiting 3. Ear pain and tinnitus 4. Hearing loss and difficulty in swallowing

2

An anxious client is experiencing respiratory alkalosis from hyperventilation due to anxiety. The nurse would do which of the following to help the client experiencing this acid-base disorder? 1. Withhold all sedative or antianxiety medications. 2. Provide emotional support and reassurance. 3. Tell the client to breathe very deeply but more slowly. 4. Put the client in a supine position.

2

The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse would monitor the status of breath sounds in that area by placing the stethoscope: 1. Posteriorly under the left scapula 2. Just under the left clavicle 3. In the fifth intercostal space 4. Near the lateral twelfth rib

2

The mother of a 4-year-old who was recently hospitalized brings the child to the clinic for a follow-up visit. The mother tells the nurse that the child has begun to wet the bed and that it started when the child was brought home from the hospital. The mother is concerned and asks the nurse what to do. The appropriate nursing response is which of the following? 1. "You need to discipline the child." 2. "This is a normal occurrence following hospitalization." 3. "We will need to discuss this behavior with the physician." 4. "The child probably has developed a urinary tract infection."

2

When performing a postpartum assessment on a client, the licensed practical nurse (LPN) notes clots in the lochia. The LPN examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is appropriate? 1. Document the findings. 2. Notify the registered nurse (RN). 3. Reassess the client in 2 hours. 4. Encourage increased oral intake of fluids.

2

A physician orders an intramuscular (IM) dose of 250,000 units of penicillin G benzathine (Bicillin). The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine 300,000 units/mL. How much medication will the nurse prepare to administer the correct dose? 1. 0.25 mL 2. 0.8 mL 3. 1.5 mL 4. 8 mL

2 Rationale: Use the formula for calculating the appropriate medication dosage. In this question, it is not necessary to perform a conversion. The data needed to perform this calculation are the physician's order (250,000 units of penicillin G benzathine) and the available amount of 300,000 units/mL. Formula: Desired × mL = mL per dose Available 250,000 units × 1 mL = mL per dose 300,000 units 250,000 = 0.83 mL 300,000

A physician prescribes digoxin (Lanoxin), 0.25 mg by mouth (PO) daily, for a client with congestive heart failure. The medication label states 0.125 mg per tablet. How many tablet(s) will the nurse administer to the client?

2 tablets Rationale: Use the formula for calculating the appropriate medication dosage. In this question, it is not necessary to perform a conversion. Formula: Desired × 1 tablet = Tablet per dose Available 0.25 mg × 1 tablet = 2 tablets 0.125 mg

A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions would the nurse initiate? Select all that apply. 1. Restrict all visitors. 2. Place the child on a low-bacteria diet. 3. Change dressings using sterile technique. 4. Encourage the consumption of fresh fruits and vegetables. 5. Perform meticulous handwashing before caring for the child. 6. Allow fresh-cut flowers in the room as long as they are kept in a vase with fresh water.

2,3,5

A physician prescribes 1000 mL of normal saline (NS) to be infused over a period of 10 hours. The drop (gt) factor is 15 drops (gtt) per mL. The nurse adjusts the flow rate at how many gtt per minute?

25 gtt per minute Rationale: The prescribed 1000 mL is to be infused over 10 hours. Follow the formula and multiply 1000 mL by 15 (gt factor). Then divide the result by 600 minutes (10 hours × 60 minutes). The infusion is to run at 25 gtt/minute. Formula: Total volume in mL × gt factor = Flow rate in gtt per minute Time in minutes 1000 mL × 15 gtt = 15,000 = 25 gtt/minute 600 minutes 600

A 4-year-old child is hospitalized for severe gastroenteritis. The child is crying and clinging to the mother. The mother becomes very upset and is afraid to leave the child. Which of the following nursing interventions would be most appropriate to alleviate the child's fears and the mother's anxiety? 1. Reassure the mother that the child will be fine after she leaves. 2. Give the mother the telephone number of the pediatric unit, and tell the mother to call at any time. 3. Ask the mother if she would like to stay overnight with the child. 4. Tell the mother to bring the child's favorite toys the next time she comes to the hospital to visit.

3

A blood glucose measurement is performed on a pregnant client. The results indicate that her blood glucose is elevated. Which of the following would the nurse anticipate to be prescribed for the mother? 1. An oral hypoglycemic agent 2. NPH insulin on a daily basis 3. A 3-hour glucose tolerance test 4. A sliding scale Regular insulin dose

3

A camp nurse is providing instructions to the parents of the children who are attending a daytime camp for the summer. The nurse instructs the parents to check their child daily for the presence of tick bites and tells the parents if a tick is found to first: 1. Remove the tick with a sterilized sewing needle. 2. Bring the child to the emergency department at the nearest hospital. 3. Suffocate the tick with a substance such as nail polish. 4. Remove the tick with tweezers immediately.

3

A child is admitted to the hospital, and a diagnosis of bacterial meningitis is suspected. A lumbar puncture is performed, and the results reveal cloudy cerebrospinal fluid (CSF) with high protein and low glucose levels. The nurse determines that these results are indicative of: 1. The need to repeat the test 2. Possible contamination of the specimen 3. Confirmation of the diagnosis 4. A negative test

3

A client asks the nurse about which product should be taken for headache. The client is taking lansoprazole (Prevacid) for long-term management of Zollinger-Ellison syndrome. The nurse determines that which of the following would be the best choice for this client? 1. Naproxen (Aleve) 2. Acetylsalicylic acid (aspirin) 3. Acetaminophen (Tylenol) 4. Ibuprofen (Motrin)

3

A client brought to the emergency department is dead on arrival (DOA). The family of the client tells the physician that the client had terminal cancer. The emergency department physician examines the client and asks the nurse to contact the medical examiner regarding an autopsy. The family of the client tells the nurse that they do not want an autopsy performed. Which response to the family is appropriate? 1. "It is required by federal law. Why don't we talk about it, and why don't you tell me how you feel?" 2. "The decision is made by the medical examiner." 3. "I will contact the medical examiner regarding your request." 4. "An autopsy is mandatory for any client who is DOA."

3

A client diagnosed with diabetes insipidus is beginning medication therapy with lypressin. The nurse teaches the client that this medication is taken: 1. Orally to relieve headaches that accompany the disorder 2. Orally to stimulate the production of aldosterone 3. Intranasally to promote water reabsorption 4. Intranasally to decrease the production of antidiuretic hormone

3

A client diagnosed with scabies has lindane prescribed. The nurse should plan to include which of the following pieces of information when telling the client about the use of this product? 1. Apply the cream as per product literature for 2 days in a row. 2. Apply to the entire body and scalp, but not the face. 3. Leave the cream on for 8 to 12 hours and then remove by washing. 4. Apply a thick layer of cream to the entire body.

3

A client experiencing preterm labor at 29 weeks' gestation has been admitted to the hospital. The client has an order to receive betamethasone. The nurse explains to the client that the medication will do which of the following? 1. Prevent spontaneous delivery 2. Stop the uterine contractions 3. Promote maturation of the fetal lungs 4. Accelerate the growth rate of the fetus

3

A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 15:00. The nurse, making rounds at 15:45, finds that the client is complaining of a pounding headache, is dyspneic with chills, is apprehensive, and has an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which of the following actions first? 1. Sit the client up in bed. 2. Place the client in Trendelenburg's position. 3. Shut off the infusion. 4. Discontinue the angiocatheter and IV.

3

A client has a new order to take guaifenesin (Humibid) every 4 hours as needed. The nurse giving medication instructions to the client tells the client to be sure to: 1. Be aware of irritability as a side effect. 2. Crush the sustained-release tablet if immediate relief is needed. 3. Take the tablet with a full glass of water. 4. Take an extra dose if the cough is accompanied by fever.

3

A client has been brought to the emergency department after attempting to commit suicide by hanging. The nurse should take which nursing action first? 1. Encourage the client to talk about the experience. 2. Administer an anxiolytic medication as prescribed at once. 3. Examine the neck area and assess the airway. 4. Obtain a detailed history of events leading to the attempt.

3

A client has been given a prescription for metoclopramide (Reglan) four times a day. The nurse determines that the client is taking the medication at optimal times if the client reports using the medication: 1. One hour after each meal and at bedtime 2. Every 6 hours spaced evenly around the clock 3. 30 minutes before meals and at bedtime 4. With each meal and at bedtime

3

A client has been instructed to alternate the use of hydrogen peroxide and glycerin eardrops to loosen an impacted accumulation of earwax. The nurse gives the client which of the following directions to accomplish this daily procedure safely and independently? 1. Use the solutions chilled for 3 to 5 days. 2. Use the solutions heated to 120 degrees for 5 to 7 days. 3. Use the solutions at body temperature for 7 to 14 days. 4. Use the solutions at room temperature for 1 to 3 days.

3

A client has begun taking lansoprazole (Prevacid). The nurse monitors for which of the following intended effects of this medication? 1. Relief of abdominal pain 2. Decrease in intestinal gas 3. Relief of nighttime heartburn 4. Absence of nausea and vomiting

3

A client has just had skeletal traction applied following insertion of pins. The nurse should place highest priority on doing which of the following while caring for the client? 1. Provide for diversion such as television or newspaper. 2. Explain to the client the upcoming pin care procedure. 3. Ensure that the weights on the traction setup are hanging free. 4. Perform pin site care.

3

A client in her second trimester of pregnancy is seen at the health care clinic. The nurse collects data from the client and notes that the fetal heart rate is 100 beats per minute. Which of the following nursing actions would be appropriate? 1. Document the findings. 2. Inform the mother that everything is normal and fine. 3. Notify the physician. 4. Instruct the mother to return to the clinic in 1 week for revaluation of the fetal heart rate.

3

A client in the clinical unit who is allergic to shellfish unknowingly ate a dish brought by a friend that had shellfish as an ingredient. The client quickly develops anaphylaxis. The nurse would focus on which of the following first until additional help arrives? 1. Preparing a dose of epinephrine (Adrenalin) 2. Preparing a dose of a corticosteroid 3. Maintaining a patent airway 4. Telling the client to obtain a Medic-Alert bracelet

3

A client in the postpartum unit complains of sudden sharp chest pain. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. The initial nursing action would be which of the following? 1. Check the client's blood pressure. 2. Prepare for the insertion of an intravenous (IV) line. 3. Prepare to administer oxygen at 8 to 10 L by tight face mask. 4. Prepare to administer morphine sulfate.

3

A client in the prenatal clinic asks the nurse about her delivery date. The client began her last menses on September 7, 2012, and ended the menses on September 14, 2012. Using Nägele's rule, the nurse would tell the client that the estimated date of birth is which of the following? 1. July 14, 2013 2. June 21, 2013 3. June 14, 2013 4. July 1, 2013

3

A client is being discharged to home with a prescription for eye drops to be given in the left eye. The nurse has shown the client how to self-administer the drops. The nurse determines that the client needs further instruction if the client does which of the following during a return demonstration? 1. Lies with the head to the right, puts the drop in the inner canthus, and slowly turns to the left while blinking 2. Lies supine, pulls down on the lower lid, and puts the drop in the lower lid 3. Lies supine, pulls up on the upper lid, and puts the drop in the upper lid 4. Tilts the head back, pulls down on the lower lid, and puts the drop in the lower lid

3

A client is brought to the emergency department with suspected diabetic ketoacidosis (DKA). Which of the following findings would the nurse note as being consistent with this diagnosis? 1. High serum glucose level and an increase in pH 2. Low serum potassium and high serum bicarbonate level 3. High serum glucose level and low serum bicarbonate level 4. Decreased urine output and Kussmaul's respirations

3

A client is experiencing an acute exacerbation of bursitis. The nurse encourages the client to avoid which of the following least helpful measures until the current episode is resolved? 1. Applying moist heat 2. Resting the joint 3. Active intermittent range of motion 4. Elevation of the joint

3

A client is newly admitted to the hospital with cellulitis of the lower leg. The nurse checks the physician's order sheet to see if which of the following therapies has been ordered for site care? 1. Intermittent heat lamp treatments 2. Alternating hot and cold compresses 3. Warm compresses 4. Cold compresses

3

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse encourages the client to eat which of the following foods that are naturally high in vitamin C to promote wound healing? 1. Chicken 2. Bananas 3. Oranges 4. Milk

3

A client reports to the health care clinic to obtain testing regarding human immunodeficiency virus (HIV) status after being exposed to an individual who is HIV positive. The test results are reported as negative, and the client tells the nurse that he feels so much better knowing that he had not contracted HIV. The nurse explains the test results to the client, telling the client that: 1. There is no further need for testing. 2. A negative HIV test is considered accurate. 3. A negative HIV test is not considered accurate during the first 6 months after exposure. 4. The test should be repeated in 1 week.

3

A client who attempted suicide by overdosing with a very large number of antidepressant pills has been admitted to the psychiatric unit. The nurse, being most concerned with the client's safety, would take which immediate action? 1. Have the client put on a hospital gown and remove the client's clothing from the room. 2. Request that a friend of the client remain with the client at all times. 3. Stay with the client at all times. 4. Suggest placing the client in a seclusion room where all potentially dangerous articles are removed.

3

A client who exhibits fatigue, lack of energy, constipation, and depression is diagnosed with hypothyroidism. The physician prescribes levothyroxine (Synthroid). To increase the likelihood of medication compliance in the early course of treatment, the nurse plans to alert the client that: 1. Diarrhea as an early side effect diminishes with time. 2. Weight gain or edema formation is greatest in the first month. 3. Full therapeutic effect may take 1 to 3 weeks. 4. Full therapeutic effect may take up to 4 months.

3

A client who has just been diagnosed with glaucoma has been given a prescription for a miotic medication. When teaching the client about medication effects, the nurse plans to tell the client that the medication will: 1. Reshape the lens to eliminate blurred vision. 2. Interrupt the drainage of aqueous humor from the eye. 3. Lower intraocular pressure and enhance blood flow to the retina. 4. Dilate the pupil to reduce intraocular pressure.

3

A client who is recovering from a brain attack (stroke) has residual dysphagia. The licensed practical nurse instructs the nursing assistant to avoid which of the following at mealtime? 1. Placing food on the unaffected side of the mouth 2. Allowing ample time for chewing and swallowing 3. Giving the client thin liquids 4. Giving foods and fluids with the consistency of oatmeal

3

A client who sustained a closed head injury has a new onset of copious urinary output. Urine output for the previous 8-hour shift was 3300 mL, and 2800 mL for the shift before that. The findings have been reported to the physician, and the nurse anticipates an order for which of the following medications? 1. Ethacrynic acid (Edecrin) 2. Mannitol (Osmitrol) 3. Desmopressin (DDAVP) 4. Dexamethasone (Decadron)

3

A client who was recently paroled as a sex offender is in therapy for pedophilia. The client says, "I've served my sentence and I'm still in therapy, so why does this group have posters of me all over the neighborhood? It has my picture on it and tells all about me." Which of the following would be the therapeutic response by the nurse? 1. "You seem angry, but you must understand that your neighbors are frightened because of your serious crimes against children." 2. "Try to realize how fortunate you are that our society doesn't let the group escalate to more punitive measures after your crimes against children." 3. "Are you saying that you understand people are afraid for their children but that you feel you are being unfairly treated?" 4. "It's sad for you, but when children are hurt as you hurt them, people want you identified and isolated."

3

A client with a history of hypertension has been prescribed triamterene (Dyrenium). The nurse determines that the client understands the effect of this medication on the diet if the client states to avoid which of the following fruits? 1. Apples 2. Pears 3. Bananas 4. Cranberries

3

A client with a potential for violence is exhibiting agitated behavior. The client is using aggressive gestures and making belligerent comments to the other clients and is continually pacing in the hallway. Which of the following comments by the nurse would be therapeutic at this time? 1. "You are going to be restrained if you do not change your behavior." 2. "Please stop so I don't have to put you in seclusion." 3. "What is causing you to become agitated?" 4. "Why are you intent on upsetting the other clients?"

3

A client with cancer is at risk for experiencing vena cava syndrome. The nurse would monitor this client for which of the following as an early sign of this oncological emergency? 1. Mental status changes 2. Cyanosis 3. Periorbital edema 4. Arm edema

3

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/minute. The nurse responds that this would be harmful because it could: 1. Increase the risk of pneumonia from drier air passages 2. Be drying to nasal passages 3. Decrease the client's oxygen-based respiratory drive 4. Decrease the client's carbon dioxide-based respiratory drive

3

A client with newly diagnosed Cushing's syndrome expresses concern about personal appearance, specifically about the "buffalo hump" that has developed at the base of the neck. When counseling the client about this manifestation, the nurse should incorporate the knowledge that: 1. This is a permanent feature. 2. It can be minimized by wearing tight clothing. 3. It may slowly improve with treatment of the disorder. 4. It will quickly disappear once medication therapy is started.

3

A client with osteoarthritis is receiving diclofenac sodium (Voltaren). The licensed practical nurse (LPN) reviewing the client's medication order sheet would plan to verify the order with the registered nurse (RN) if which of the following other medications were listed? 1. Primidone (Mysoline) 2. Calcium carbonate (Tums) 3. Warfarin (Coumadin) 4. Vitamin C supplement

3

A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The appropriate response to the client is which of the following? 1. "I will sign as a witness to your signature." 2. "You will need to find a witness on your own." 3. "I will call the nursing supervisor to seek assistance regarding your request." 4. "Whoever is available at the time will sign as a witness for you."

3

A licensed practical nurse (LPN) is assigned to assist in caring for a hospitalized child who is receiving a continuous infusion of intravenous (IV) potassium for the treatment of dehydration. The LPN monitors the child closely and notifies the registered nurse if which of the following is noted? 1. Temperature of 100.8° F rectally 2. Weight increase of 0.5 kg 3. A decrease in urine output to 0.5 mL/kg/hr 4. Blood pressure (BP) unchanged from baseline

3

A licensed practical nurse (LPN) is assisting in insertion of a nasogastric (NG) tube for an adult client. The LPN helps determine the correct length to insert the tube by measuring: 1. A 30-inch length on the tube 2. An 18-inch length on the tube 3. From the tip of the client's nose to the earlobe and then down to the xiphoid process 4. From the tip of the client's nose to the earlobe and then down to the top of the sternum

3

A licensed practical nurse (LPN) is assisting in the care of a client receiving a continuous intravenous (IV) infusion of heparin sodium for deep vein thrombosis (DVT). The LPN notes that the result of a newly drawn activated partial thromboplastin time (aPTT) level is 90 seconds. The client's baseline before the initiation of therapy was 30 seconds. The LPN should take which of the following actions? 1. Leave the report for the registered nurse (RN) to review later in the day. 2. Ask the client about worsening pain from the DVT. 3. Notify the RN about the value immediately. 4. Check to see if additional heparin is available on the unit.

3

A licensed practical nurse (LPN) is reviewing the medication list of the client with a history of glaucoma. The LPN would consult with the registered nurse if which of the following medications is ordered for this client? 1. Pilocarpine (Ocusert Pilo-20) 2. Pilocarpine hydrochloride (Isopto Carpine) 3. Atropine sulfate (Isopto Atropine) 4. Carteolol hydrochloride (Ocupress)

3

A long-term care nurse is caring for an older client taking cimetidine (Tagamet). The nurse observes this client frequently for which most frequent central nervous system (CNS) side effect of this medication? 1. Tremors 2. Hallucinations 3. Confusion 4. Dizziness

3

A mental health nurse on the evening shift is receiving report about a client who was admitted to the nursing unit. The nurse is told that the client was admitted by involuntary status. Based on this type of admission, the nurse would expect that the client: 1. Has the right to demand and obtain release from the hospital 2. Requested the admission 3. Is in need of psychiatric treatment 4. Provided written application to the facility for admission

3

A nonstress test is prescribed for a pregnant client, and the client asks the nurse about the procedure. Which of the following information will the nurse provide to the client? 1. "The test is an invasive procedure and requires that you sign an informed consent." 2. "The test will take about 2 hours and will require close monitoring for 2 hours after the procedure is completed." 3. "An ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal heart is heard most clearly." 4. "The fetus is challenged by uterine contractions to obtain the necessary information."

3

A nurse assists in making a plan of care for a client and is developing goals that will help the client achieve an optimal level of functioning and use resources. When the nurse enters the client's room, the client says to the nurse, "Could you ask the physician to let me have a pass for the weekend?" The appropriate nursing response to assist the client in achieving the goal that has been set for this client is which of the following? 1. "When your physician comes in, I will ask for a pass for the weekend." 2. "I will call the physician and find out if you can have a pass so that you can make your arrangements." 3. "When the physician arrives on the unit, I will let him know that you have a question." 4. "You can't have a pass for the weekend. You are not ready, and I'm sure that your physician will say no."

3

A nurse enters a client's room to check the client who began receiving a blood transfusion 45 minutes earlier. The client is flushed and dyspneic. The nurse listens to the client's lung sounds and notes the presence of crackles in the lung bases. The client states that she was just going to ring the call bell for the nurse. The nurse determines that this client is most likely experiencing which of the following complications of blood transfusion therapy? 1. Hypovolemic shock 2. Transfusion reaction 3. Fluid overload 4. Bacteremia

3

A nurse has assisted in developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan and selects which nursing intervention as the highest priority? 1. Keeping the significant other informed of the progress of the labor 2. Providing comfort measures 3. Monitoring fetal status 4. Changing the client's position frequently

3

A nurse has provided dietary instructions to a client with renal calculi who must learn to eat an alkaline-ash diet. The nurse determines that the client has properly understood the information presented if the client chooses which of the following selections from a diet menu? 1. Chicken, potatoes, and cranberries 2. Peanut butter sandwich, milk, and prunes 3. A spinach salad, milk, and a banana 4. Linguini with shrimp, tossed salad, and a plum

3

A nurse has provided information to the mother of a toddler regarding toilet training. Which statement by the mother would indicate a need for further instructions? 1. "I should wait until my child is at least 24 months old." 2. "I know that my child will develop bowel control before bladder control." 3. "I should have my child sit on the potty until my child urinates." 4. "I know my child is ready to begin toilet training if my child can walk well."

3

A nurse in a physician's office receives a telephone call from the mother of a child who tells the nurse that the child was just stung by a bee. The mother asks the nurse for instructions regarding removal of the stinger. Which of the following instructions should the nurse provide to the mother? 1. Leave the stinger alone because it will dissolve. 2. Squeeze the stinger out of the skin. 3. Remove the stinger by carefully scraping it out horizontally. 4. Wash the area with soap and water and apply heat to help the stinger move out of the skin.

3

A nurse in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip. Based on this finding, the nurse prepares for which appropriate nursing action? 1. Placing the mother in a supine position 2. Documenting the findings and continuing to monitor the fetal patterns 3. Administering oxygen via face mask 4. Increasing the rate of the intravenous (IV) oxytocin infusion

3

A nurse in the prenatal clinic is conducting a session about nutrition for a group of adolescents who are pregnant. The most appropriate measure to teach the adolescents is which of the following? 1. Avoid meals in fast-food restaurants. 2. Eliminate snacks during the day. 3. Monitor for appropriate weight gain patterns. 4. Eat only when hungry.

3

A nurse is asked to assist in changing the bed assignments in a nursing unit after receiving a call from the admitting department about a client who will require isolation on admission. The nurse must choose a roommate for a client who is in a state of starvation due to anorexia nervosa. The nurse would avoid choosing which client as a roommate for the client with anorexia nervosa? 1. A client who had a myocardial infarction 2. A client who had back surgery 3. A client with pneumonia 4. A client with a fractured pelvis

3

A nurse is assigned to a client who is psychotic. The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines that which of the following is the immediate priority of care? 1. Provide the other clients on the unit with a sense of comfort and safety by isolating the client. 2. Assist in caring for the client in a controlled environment, such as a quiet room. 3. Provide safety for both the client and other clients on the unit. 4. Offer the client a less stimulating area in which to calm down and gain control.

3

A nurse is assigned to assist in caring for a client who has a pneumothorax. The nurse notes continuous bubbling in the water seal chamber of the client's closed-chest drainage system. The nurse determines that which of the following is occurring? 1. The system must have a crack in it. 2. The suction to the system is shut off. 3. There is an air leak somewhere in the system. 4. The pneumothorax is resolving.

3

A nurse is assisting a client admitted to the hospital with pulmonary edema to prepare for discharge. The nurse would reinforce with the client the importance of complying with which of the following measures to prevent a recurrence? 1. Adjust diuretic dose based on severity of peripheral edema. 2. Take additional digoxin (Lanoxin) if respiratory distress occurs. 3. Weigh self every morning before breakfast. 4. Sleep with the head elevated on only one pillow.

3

A nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which of the following signs experienced by the client should be reported immediately to the registered nurse (RN)? 1. Respiratory rate of 26 breaths per minute 2. Lung congestion 3. Stridor 4. Occasional pink-tinged sputum

3

A nurse is assisting in conducting a prepared childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the women to perform the procedure by: 1. Contracting and then consciously relaxing different muscle groups 2. Contracting an area of the body such as an arm or leg and then concentrating on letting tension go from the rest of the body 3. Massaging the abdomen during contractions using both hands in a circular motion 4. Instructing the significant other to stroke or massage a tightened muscle by the use of touch

3

A nurse is assisting in developing a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. Following review of the plan of care, the nurse determines that which of the following is the priority for the child? 1. Restricting oral fluids 2. Allowing the child to play with the other children in the playroom 3. Promoting bedrest 4. Encouraging visits from friends

3

A nurse is assisting in developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse suggests that the child should be monitored for signs of: 1. Failure to thrive 2. Bleeding 3. Congestive heart failure (CHF) 4. Decreased tolerance to stimulation

3

A nurse is assisting in developing a plan of care for an older client to prevent a fall. Which of the following actions would be least likely to prevent a fall? 1. Placing the bed in the lowest position 2. Placing the call light within the client's reach 3. Keeping the bathroom light off at nighttime 4. Keeping the side rails up while the client is in bed

3

A nurse is assisting in planning discharge instructions to the mother of a child following orchiopexy, which was performed on an outpatient basis. Which of the following is the priority in the plan of care? 1. Pain control measures 2. Measurement of intake 3. Wound care 4. Cold and heat applications

3

A nurse is assisting in preparing a plan of care for a client with an autistic disorder. A behavior modification approach (operant conditioning) is being used to care for the client to improve communication. Which of the following would be appropriate for the nurse to suggest including in the plan of care? 1. Provide consistent negative reinforcement to promote appropriate behaviors. 2. Avoid providing rewards to the client. 3. Reward the client when a desired behavior is performed. 4. Promote complete independence in the client.

3

A nurse is assisting in the care of a client diagnosed with acquired immunodeficiency syndrome who requires an injection. The nurse should do which of the following to dispose of the needle after the medication is given? 1. Ask the client to recap the needle on the syringe. 2. Recap the needle before placing it and the syringe in a puncture-resistant container. 3. Place the needle and syringe in a puncture-resistant container. 4. Lay the needle and syringe on the bedside table and carefully recap the needle.

3

A nurse is assisting in the care of a client receiving codeine sulfate for pain. The nurse should make note of which of the following to detect adverse effects of this medication? 1. Onset of hypertension 2. Fluid volume excess 3. Frequency of bowel movements 4. Strength of peripheral pulses

3

A nurse is assisting to admit a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe enough, the client will be at risk for which of the following acid-base imbalances? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3

A nurse is caring for a child with congestive heart failure and provides instructions to the mother regarding the procedure for administration of the prescribed lanoxin (Digoxin). Which statement by the mother indicates a need for further instruction? 1. "If the child vomits after the medication is given, I should not repeat the dose." 2. "I need to take the child's pulse before administering the medication." 3. "I can mix the medication with food." 4. "If more than one dose is missed, I need to call the physician."

3

A nurse is caring for a child with osteosarcoma following amputation of the left lower limb. The child is continually complaining of aching and cramping in the missing limb. The initial nursing action is which of the following? 1. Request a referral for a psychiatric consultation. 2. Ask the physician for an order for a placebo. 3. Reassure the child that this is a temporary condition. 4. Tell the child that the prosthesis will relieve this sensation.

3

A nurse is caring for a client in the oncology unit who has developed stomatitis during chemotherapy. The nurse would plan which of the following measures to treat this complication? 1. Use lemon and glycerin swabs liberally on painful oral lesions. 2. Brush the teeth and use nonwaxed dental floss at least twice a day. 3. Rinse the mouth with dilute baking soda or saline solution. 4. Place the client on nothing-by-mouth (NPO) status for 12 hours, then resume liquids.

3

A nurse is caring for a client taking tolbutamide (Orinase) who has just been diagnosed with a urinary tract infection. The physician plans to treat the infection with sulfamethoxazole. The nurse expects that because of medication interactions, the physician will order a: 1. Higher dose of the tolbutamide 2. Higher dose of the sulfamethoxazole 3. Lower dose of the tolbutamide 4. Lower dose of the sulfamethoxazole

3

A nurse is caring for a client with Paget's disease who has an elevated serum calcium level of 12.3 mEq/L. The nurse checks to see that which of the following medications is available in the stock medication supply area for possible use to reverse this elevation? 1. Calcium gluconate 2. Calcium chloride 3. Calcitonin (Calcimar) 4. Vitamin D

3

A nurse is caring for a client with a burn injury to the lower legs. Nitrofurazone (Furacin) is prescribed to be applied to the sites of injury. Which of the following indicates the appropriate method to apply this medication? 1. Apply saline-soaked dressings over the medication. 2. Apply a 1-inch film directly to the burn sites. 3. Apply a 1/16-inch film directly to the burn sites. 4. Apply a 1/2-inch film directly to the burn sites.

3

A nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. The nurse positions the infant: 1. With the head at a 60-degree angle with the neck slightly flexed 2. In a supine, side-lying position 3. With the head and chest at a 30-degree angle, with the neck slightly extended 4. Prone, with the head of the bed elevated 15 degrees

3

A nurse is caring for the client with a head injury secondary to a motor vehicle accident. The nurse observes the client's status regularly, monitoring closely for which changes in vital signs? 1. Increasing pulse, decreasing respirations, increasing blood pressure (BP) 2. Increasing pulse, increasing respirations, decreasing BP 3. Decreasing pulse, decreasing respirations, increasing BP 4. Decreasing pulse, increasing respirations, decreasing BP

3

A nurse is collecting data on a client in crisis. Which of the following questions would the nurse ask to determine the client's perception of the precipitating event that led to the crisis? 1. "What do you usually do to feel better?" 2. "With whom do you live?" 3. "What leads you to seek help now?" 4. "Who is available to help you?"

3

A nurse is discussing foot care with a diabetic client and spouse. The nurse includes which of the following during this informational session? 1. There is decreased risk of infection when feet are soaked in hot water. 2. Lanolin should be applied to dry feet, especially the heels and between the toes. 3. The toenails should be cut straight across. 4. Strong soap should be used to decrease skin bacteri

3

A nurse is employed at a drug abusers' residential treatment center. The nurse is preparing for the arrival of a new client and prepares to explain to the client that the emphasis of the center is on group and social interaction, and that rules and expectations are mediated by peer pressure. The most likely focus of therapy of this residential center is which of the following? 1. Systematic desensitization 2. Cognitive behavioral therapy 3. Milieu therapy 4. Aversion conditioning

3

A nurse is explaining how sound is conducted from the middle ear to the inner ear in teaching a client who is experiencing hearing loss. The nurse plans to use a diagram that illustrates how which of the following bones connects to the cochlea at the oval window? 1. Malleus 2. Hammer 3. Stapes 4. Incus

3

A nurse is monitoring a client with a history of opioid abuse for signs of withdrawal. The nurse monitors this client for which of the following signs and symptoms associated with opioid withdrawal? 1. Increased appetite, irritability, anxiety, restlessness, and altered concentration 2. Depression, high drug craving, fatigue with altered sleep (insomnia or hypersomnia), agitation, and paranoia 3. Increased pulse and blood pressure, low-grade fever, yawning, restlessness, anxiety, craving, diarrhea, and mydriasis 4. Tachycardia, mild hypertension and fever, sweating, nausea, vomiting, and marked tremor

3

A nurse is observing a nursing student listening to the breath sounds of a client. The nurse intervenes if the student performs which incorrect procedure? 1. Asks the client to sit upright 2. Asks the client to breathe slowly and deeply through the mouth 3. Places the stethoscope on the client's gown 4. Uses the diaphragm of the stethoscope

3

A nurse is preparing a subcutaneous dose of bethanechol chloride (Urecholine) ordered for a client with urinary retention. Before giving the dose, the nurse checks to see that which of the following medications is available on the emergency cart for use if needed? 1. Protamine sulfate 2. Vitamin K 3. Atropine sulfate 4. Acetylcysteine (Mucomyst)

3

A nurse is preparing for the administration of ribavirin (Virazole) to a child with respiratory syncytial virus. Which of the following supplies will the nurse obtain for the administration of this medication? 1. An intravenous (IV) pole 2. An intramuscular (IM) syringe 3. A pair of goggles 4. A protective isolation gown

3

A nurse is preparing to assist in performing a fundal assessment on a postpartum client. The nurse understands that the initial nursing action when performing this assessment is which of the following? 1. Ask the client to turn onto her side. 2. Ask the client to lie flat on her back with her knees and legs flat and straight. 3. Ask the client to urinate and empty her bladder. 4. Massage the fundus gently prior to determining the level of the fundus.

3

A nurse is preparing to clean up a blood spill on the client's bedside table. The spill occurred when a blood tube containing the client's blood specimen broke. The nurse avoids doing which of the following when cleaning up the blood spill? 1. Wearing gloves for the cleanup procedure 2. Using tongs to collect any broken glass 3. Blotting up the spill with a face cloth or cloth towel 4. Disinfecting the area of the blood spill with a dilute bleach solution

3

A nurse is preparing to give instructions to the client who has been given a prescription for diphenoxylate with atropine (Lomotil). The nurse teaches the client to: 1. Expect increased saliva production while taking the medication. 2. Anticipate excitability as a side effect. 3. Not exceed recommended dose, because it can be habit forming. 4. Take the medication with a bulk-forming laxative

3

A nurse is providing care to a Cuban-American client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. The most appropriate nursing plan is to: 1. Restrict the number of family members visiting at one time. 2. Inform the family that emotional outbursts are to be avoided. 3. Request permission to move the client to a private room, and allow the family members to visit. 4. Contact the physician to speak to the family regarding their behavior.

3

A nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions that which of the following could cause a false-negative result? 1. Iodine 2. Acetylsalicylic acid 3. Ascorbic acid 4. Colchicine

3

A nurse is providing information to the mother of a child with nephrotic syndrome regarding the edematous appearance of the child. Which of the following statements should the nurse make to the mother? 1. "Dress the child in loose-fitting clothing to hide the extra weight." 2. "Children always look a little bit fat, so don't be concerned." 3. "The fluid retention should be controlled by medication and diet." 4. "The child will always have this appearance, and preparing the child for the body image change is important."

3

A nurse is providing instructions to a 16-year-old female adolescent regarding dietary patterns. The nurse instructs the adolescent that the recommended amount of daily calories is approximately: 1. 1200 2. 1800 3. 2200 4. 3000

3

A nurse is providing instructions to a client and family regarding home care following cataract removal from the left eye. The nurse would provide the client with which of the following pieces of information about positioning in the postoperative period? 1. Lower the head between the knees three times a day. 2. Bend below the waist as frequently as able. 3. Do not sleep on the left side. 4. Sleep only on the left side.

3

A nurse is providing instructions to an adolescent who is taking phenytoin (Dilantin) for the control of seizures. Which statement by the adolescent indicates a need for further teaching regarding the medication? 1. "The medication may cause oily skin." 2. "Drinking alcohol may affect the medication." 3. "If my gums become sore, I need to stop the medication." 4. "Birth control pills may not be effective when I take this medication."

3

A nurse is providing instructions to the mother following delivery regarding care of the episiotomy site to prevent infection. Which statement by the mother indicates a need for further instructions? 1. "I will wipe my perineum from front to back after voiding and defecation." 2. "I will use warm water or an irrigation device to rinse the perineum after elimination." 3. "I will change the perineum pads three times a day." 4. "I will take warm sitz baths three times a day."

3

A nurse is providing instructions to the mother of a child who has been exposed to human immunodeficiency virus (HIV) infection. The nurse instructs the mother to notify the physician if which of the following symptoms occur in the child? 1. Lethargy or fatigue 2. Hyperactivity 3. Coughing or chest congestion 4. Irritability and fussiness

3

A nurse is providing medication instructions to a client with peptic ulcer disease. Which of the following represents correct information given by the nurse? 1. Antacids coat the lining of the stomach. 2. Omeprazole (Prilosec) will coat the ulcer to help it heal. 3. Cimetidine (Tagamet) results in decreased secretion of stomach acid. 4. Sucralfate (Carafate) changes the acidity of fluid in the stomach

3

A nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse instructs the mother that her calorie intake needs to increase by approximately: 1. 100 calories per day 2. 300 calories per day 3. 500 calories per day 4. 1000 calories per day

3

A nurse is reviewing the physician's orders for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid (aspirin) is prescribed for the child. Which of the following nursing actions is appropriate? 1. Administer the aspirin if the child's temperature is elevated. 2. Administer the aspirin if the child experiences any joint pain. 3. Consult with the registered nurse to verify the prescription. 4. Administer acetaminophen (Tylenol) instead of the aspirin for temperature elevation.

3

A nurse is reviewing the record of a client admitted to the mental health unit and notes that the client was admitted by voluntary status. The nurse determines that: 1. The admission was made without the client's consent. 2. The admission was mandated by court order. 3. The client has the right to demand and obtain release from the hospital. 4. The client was committed by a group of designated mental health professionals.

3

A nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which of the following positions because it will aggravate breathing? 1. Sitting up with elbows resting on knees 2. Standing and leaning against a wall 3. Lying on his or her back in low Fowler's position 4. Sitting up and leaning on a table

3

A nurse is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy may require: 1. Increased caloric intake 2. Decreased caloric intake 3. Increased insulin 4. Decreased insulin

3

A nurse is teaching a local women's church group about the risks of cervical cancer. The nurse determines that further teaching is necessary if a group member states that which of the following is a risk factor? 1. Multiple sexual partners 2. History of genital herpes 3. Intercourse with circumcised males 4. Early frequent intercourse

3

A nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to most carefully monitor which of the following parameters during the next hour? 1. Serous drainage on the surgical dressing 2. Blood pressure of 100/70 mm Hg 3. Urinary output of 20 mL/hour 4. Temperature of 99.6° F (37.6° C)

3

A nurse provides instructions to the mother of a child diagnosed with pediculosis (head lice). Permethrin (Nix) has been prescribed. Which statement by the mother regarding the use of the medication indicates a need for further instructions? 1. "After rinsing out the medication, I need to avoid washing my child's hair for 24 hours." 2. "I need to shampoo my child's hair, apply the medication, leave it on for 10 minutes, and then rinse it out." 3. "I need to shampoo my child's hair, apply the medication, and leave the medication on for 24 hours." 4. "I need to purchase the medication from the pharmacy."

3

A nurse teaching a group of adults about cancer warning signs presents to the group a list of the seven warning signs of cancer. The nurse determines that further teaching is necessary if a member of the group states that which of the following is a warning sign? 1. Indigestion or difficulty swallowing 2. Change in bowel or bladder habits 3. Absence or decreased frequency of menses 4. Nagging cough or hoarseness

3

A nurse will be providing postprocedure care to a client who has undergone esophagogastroduodenoscopy (EGD). The nurse would plan to do which of the following first once the client arrives? 1. Measure the client's temperature. 2. Monitor for complaints of heartburn. 3. Monitor for return of the gag reflex. 4. Give warm gargles for sore throat.

3

A nursing student is assigned to care for a hospitalized 2-year-old child. The nursing instructor reviews the plan of care with the student and asks the student to identify the expected behavior of the child in regard to separation anxiety. Which statement by the student indicates an understanding of separation anxiety that can occur in a 2-year-old? 1. "The child will withdraw." 2. "Separation anxiety is not an issue in a 2-year-old." 3. "The child may ignore the parents when they visit." 4. "Two-year-olds usually adjust well to hospitalization."

3

A physician asks the licensed practical nurse (LPN) to give preprocedure instructions to a client who will undergo a barium swallow (esophagography) in a few days. The LPN includes which of the following items in this discussion? 1. Continue to take all oral medications as scheduled. 2. Expect diarrhea for a few days after the procedure. 3. Remove all metal and jewelry before the test. 4. Eat a regular supper and breakfast.

3

A physician has written an order for calcium carbonate for the client with hypocalcemia. The nurse preparing to administer the medication schedules the medication to be given: 1. Just before meals 2. With meals 3. Two hours after meals 4. At bedtime with a snack

3

A pregnant client is seen in the health care clinic. During the prenatal visit the client informs the nurse that she is experiencing pain in the calf when she walks. Which of the following would be the most appropriate nursing action? 1. Tell the client that this is normal during pregnancy. 2. Instruct the client to avoid walking. 3. Check for the presence of Homans' sign. 4. Instruct the client to elevate the legs consistently throughout the day.

3

A pregnant client tests positive for the hepatitis B virus (HBV). The client asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which response by the nurse is appropriate? 1. "You will not be able to breast-feed the baby until 6 months after delivery." 2. "Breast-feeding is not a problem, and you will be able to breast-feed immediately after delivery." 3. "Breast-feeding is allowed once the baby has been vaccinated with immune globulin." 4. "Breast-feeding is not advised, and you should seriously consider bottle-feeding the baby."

3

An adolescent is seen in the health care clinic with complaints of chronic fatigue. On physical examination, the nurse notes that the adolescent has swollen lymph nodes. A laboratory test is performed, and the results indicate the presence of Epstein-Barr virus (mononucleosis). The nurse calls the mother of the adolescent to inform the mother of the test results and provides instructions regarding the care of the adolescent. Which statement by the mother indicates an understanding of the care measures? 1. "I need to keep my child on bedrest for 3 weeks." 2. "I will call the physician if my child is still feeling tired in 1 week." 3. "I need to call the physician if my child complains of abdominal pain or left shoulder pain." 4. "I need to isolate my child so that the respiratory infection is not spread to others."

3

An automatic external defibrillator (AED) interprets that the rhythm of a pulseless client is ventricular fibrillation. The nurse takes which of the following actions next? 1. Charges the machine and immediately pushes the discharge buttons on the console 2. Administers rescue breathing during the defibrillation 3. Orders personnel away from the client, charges the machine, and depresses the discharge buttons 4. Performs cardiopulmonary resuscitation for 1 minute before defibrillating

3

Baclofen (Lioresal) is prescribed for the client with multiple sclerosis. The nurse evaluates that the medication is having the intended effect if which of the following is noted in the client? 1. Increased muscle tone 2. Increased range of motion 3. Decreased muscle spasms 4. Decreased local pain and tenderness

3

Cyclosporine (Sandimmune) is prescribed for a client following an allogenic kidney transplant. The nurse provides instructions to the client regarding the medication and tells the client that: 1. The medication will need to be taken for a period of 6 months. 2. The medication is administered by the intravenous route on a monthly basis. 3. Blood levels of the medication will need to measured periodically. 4. There are no known adverse effects of the medication.

3

Dapsone (DDS) is prescribed for a client with acquired immunodeficiency syndrome for the treatment of toxoplasmosis. The nurse provides medication instructions and determines that the client understands the instructions if the client states she will: 1. Discontinue the medication if nausea develops. 2. Plan to take the medication every 4 hours around the clock. 3. Report a sore throat to the physician. 4. Expect that abdominal pain and jaundice will occur as a normal side effect.

3

During the intrapartum period, a nurse is caring for a laboring client with sickle cell disease. The nurse ensures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily: 1. Stimulate the labor process. 2. Avoid the necessity of a cesarean delivery. 3. Prevent dehydration and hypoxemia. 4. Eliminate the need for analgesic administration.

3

Oral iron is prescribed for a child with an iron deficiency anemia, and the nurse provides instructions to the mother regarding the administration of the iron. The nurse instructs the mother to administer the iron: 1. Just before a meal 2. Just after a meal 3. Between meals 4. With a fruit low in vitamin C

3

The mother of a newborn calls the clinic and reports to the nurse that when she was cleansing the newborn's umbilical cord, the cord was moist and discharge was noted. The appropriate nursing instruction to the mother is which of the following? 1. To increase the number of times that the cord is cleansed per day 2. To monitor the cord for another 24 to 48 hours and to call the clinic if the discharge continues 3. To bring the infant to the clinic 4. That this is a normal occurrence

3

The nurse administering medications to a group of clients notes an order to give a subcutaneous dose of heparin sodium. The nurse should do which of the following to give this medication safely? 1. Aspirate with the plunger before injecting. 2. Massage the site after injection. 3. Give the injection using a 25- to 27-gauge, 5/8-inch needle. 4. Withdraw medication using a 5/8-inch needle and then change to a 1-inch needle.

3

The wife of a client who abuses alcohol tells the nurse she cannot "go it alone" any longer and asks the nurse about the availability of any free support services for "people like me." The nurse refers the client's wife to which of the following community groups? 1. Families Anonymous 2. Fresh Start 3. Al-Anon 4. Alcoholics Anonymous

3

e (Mucomyst) 20% solution diluted in 0.9% normal saline by nebulizer. The nurse checks the client's room to ensure that which of the following equipment is available for use as needed following administration of this medication? 1. Intubation tray 2. Ambu bag 3. Suction equipment 4. Nasogastric tube

3

A physician prescribes atenolol (Tenormin) 0.05 g by mouth daily. The label on the medication bottle states atenolol 25-mg tablets. How many tablets will the nurse administer to the client? 1. 0.5 tablet 2. 1 tablet 3. 2 tablets 4. 3 tablets

3 Rationale: Formula: Convert 0.05 g to mg. In the metric system, to convert the larger unit of measure to the smaller unit of measure, multiply by 1000 or move the decimal three places to the right. Therefore, 0.05 g = 50 mg. The nurse will administer two tablets.

A client is to receive 1000 mL of 5% dextrose in water (D5W) at a rate of 100 mL/hour. The drop (gt) factor is 10 drops (gtt) per mL. The nurse adjusts the flow rate to deliver how many gtt per minute? 1. 10 gtt 2. 13 gtt 3. 17 gtt 4. 20 gtt

3 Rationale: The first step is to determine how many hours the intravenous (IV) infusion will last. This requires simple division of the total volume of mL to be infused (1000 mL) by the total mL per hour (100 mL), which is 10 hours. Then convert hours to minutes, which is 600 minutes. Next, use the formula to calculate the flow rate. Formula: Total volume in mL × gt factor = Flow rate in gtt per minute Time in minutes 1000 mL × 10 gtt = 10,000 = 16.6 or 17 gtt/minute 600 minutes 600

A physician orders 1000 mL of 0.9% normal saline (NS) to run over 8 hours. The drop (gt) factor is 10 drops (gtt) per 1 mL. The nurse adjusts the flow rate to run at how many gtt per minute? 1. 15 gtt/minute 2. 17 gtt/minute 3. 21 gtt/minute 4. 23 gtt/minute

3 Rationale: The prescribed 1000 mL is to be infused over 8 hours. Follow the formula and multiply 1000 mL by 10 (gt factor). Then divide the result by 480 minutes (8 hours × 60 minutes). The infusion is to run at 20.8 or 21 gtt/minute. Formula: Total volume in mL × gt factor = Flow rate in gtt per minute Time in minutes 1000 mL ×10 gtt = 10,000 = 20.8 or 21 gtt/minute 480 minutes 480

A physician prescribes meperidine hydrochloride (Demerol), 40 mg intramuscularly stat, for a postoperative client in pain. The medication label states meperidine hydrochloride, 50 mg/mL. How many mL will the nurse prepare to administer to the client? 1. 0.5 mL 2. 0.6 mL 3. 0.8 mL 4. 1 mL

3 Rationale: Use the formula for calculating the medication dosage. In this question, it is not necessary to perform a conversion. Formula: Desired × mL = mL per dose Available 40 mg × 1 mL = 0.8 mL

A physician orders 3000 mL of 5% dextrose in water (D5W) to run over a 24-hour period. The drop (gt) factor is 15 drops (gtt) per 1 mL. The nurse adjusts the flow rate to run at how many gtt per minute? (Round answer to the nearest whole number.)

31 gtt per minute Rationale: The prescribed 3000 mL is to be infused over 24 hours. Follow the formula and multiply 3000 mL by 15 (gt factor). Then divide the result by 1440 minutes (24 hours × 60 minutes). The infusion is to run at 31 gtt/minute. Formula: Total volume in mL × gt factor = Flow rate in gtt per minute Time in minutes 3000 mL × 15 gtt = 45,000 = 31.2 or 31 gtt/minute 1440 minutes 1440

A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions would the nurse initiate? Select all that apply. 1. Restrict all visitors. 2. Place the child on a low-bacteria diet. 3. Change dressings using sterile technique. 4. Encourage the consumption of fresh fruits and vegetables. 5. Perform meticulous handwashing before caring for the child. 6. Allow fresh-cut flowers in the room as long as they are kept in a vase with fresh water.

4

A 6-year-old is hospitalized with a fracture of the femur and is placed in traction. In meeting the psychosocial needs of the child, the nurse most appropriately selects which of the following play activities for the child? 1. A coloring book with crayons 2. A finger-painting set 3. A large puzzle 4. A board game

4

A 9-year-old child is diagnosed with chlamydial conjunctivitis. The nurse consults with the primary health care provider regarding necessary follow-up because this infection can be associated with: 1. The presence of systemic allergies 2. The cleanliness of the home environment 3. The presence of otitis media 4. Possible sexual abuse

4

A child is brought to the emergency department, and a fracture of the left lower arm is suspected. The mother states that the child was Rollerblading and attempted to break a fall with an outstretched arm. The child receives diagnostic x-rays, from which it has been determined that a fracture is present. A plaster of paris cast is applied to the arm, and the nurse provides instructions to the mother regarding cast care at home. Which of the following instructions would the nurse provide to the mother? 1. The cast should be dry in about 6 hours. 2. The cast is water resistant, so the child is able to take a bath or a shower. 3. The cast will not mold to the body and should heal the fracture in no time at all. 4. The cast needs to be kept dry, because when wet it will begin to disintegrate.

4

A child is diagnosed with tinea capitis of the scalp. Oral griseofulvin (Gris-PEG) has been prescribed for the child, and the nurse provides instructions regarding the administration of the medication. Which of the following instructions would the nurse provide to the mother? 1. Administer the medication with water. 2. Administer the medication on an empty stomach. 3. Administer the medication at bedtime. 4. Administer the medication with milk.

4

A child is seen in the health care clinic and received an immunization of DPT (diphtheria, pertussis, tetanus vaccine). One hour later, the mother calls the clinic and tells the nurse that the injection site is painful and red. Which of the following instructions would the nurse provide to the mother? 1. To return to the health care clinic immediately 2. To call the physician 3. To apply warm compresses on the site 4. To apply cold compresses for 24 hours following the injection

4

A child with a right-to-left cardiac shunt is receiving propranolol (Inderal). The physician visits the child and writes orders in the child's record. The licensed practical nurse (LPN) reviews the orders and notes that the child is placed on a nothing-by-mouth (NPO) status. The LPN consults with the registered nurse and prepares to monitor which of the following most closely? 1. Blood urea nitrogen 2. White blood cell count 3. Sodium level 4. Glucose level

4

A client diagnosed with depression is starting therapy with imipramine hydrochloride (Tofranil). The nurse is concerned that the client will not comply with the medication regimen. To encourage the client to continue taking the medication, the nurse tells the client that it is normal not to feel beneficial effects of the medication for: 1. 3 to 5 days 2. 5 to 7 days 3. 1 to 2 weeks 4. 2 to 3 weeks

4

A client diagnosed with gout has been started on medication therapy with allopurinol (Zyloprim). The nurse teaches the client which of the following points about this medication? 1. Take the medication on an empty stomach. 2. Development of a rash frequently occurs with this medication. 3. The medication takes effect immediately. 4. It is important to drink 3 L of fluid per day.

4

A client diagnosed with hyperthyroidism will be taking propylthiouracil (PTU). The nurse provides medication instructions and determines that the client understands the information if the client states that it is most important to report which of the following symptoms to the physician? 1. Muscle aches 2. Weight loss 3. Excitability 4. Sore throat

4

A client has an order for sucralfate (Carafate) 1 g by mouth four times daily. The nurse writes in the medication record to administer the medication at which of the following times? 1. Every 6 hours around the clock 2. One hour after meals and at bedtime 3. With meals and at bedtime 4. One hour before meals and at bedtime

4

A client has an order to receive albuterol (Proventil) two puffs and beclomethasone bipropionate (Qvar) two puffs by metered-dose inhaler. The nurse plans to give these medications most effectively by: 1. Alternating a single puff of each hourly, beginning with the beclomethasone bipropionate. 2. Alternating a single puff of each hourly, beginning with the albuterol. 3. Administering the beclomethasone bipropionate before the albuterol. 4. Administering the albuterol before the beclomethasone bipropionate

4

A client has been diagnosed with glaucoma. The nurse who is teaching the client principles of self-care would encourage the client to limit or refrain from which of the following usual activities on a repeated basis? 1. Ironing 2. Folding clothes on a laundry table 3. Peeling vegetables 4. Picking objects up off the floor

4

A client has begun taking phenelzine (Nardil). At the initiation of therapy, the nurse teaches the client that which of the following items are allowed in the diet? 1. Red wines such as Chianti or sherry 2. Avocados, figs, and raisins 3. Lunchmeats such as bologna or salami 4. Carrots, sweet potatoes, and squash

4

A client has just been given a prescription for methocarbamol (Robaxin), and the nurse provides instructions to the client. Which statement by the client indicates the need for further instructions? 1. "This medication can cause nasal congestion." 2. "This mediation is intended to relieve muscle spasms." 3. "The medication may turn the urine brown or green." 4. "Blurred vision is a common but unimportant effect.

4

A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and collecting initial data, the nurse places a sign above the bed stating that the client should remain on bedrest: 1. With the foot of the bed elevated as much as tolerated by the client 2. In semi-Fowler's position 3. With the head of the bed elevated 45 degrees 4. With the head of the bed elevated no more than 15 degrees

4

A client has just undergone lumbar puncture (LP). The nurse assists the client into which most optimal position if tolerated by the client? 1. Supine, with the head of the bed elevated 15 degrees 2. Side-lying, with a pillow under the hip 3. Prone, in slight Trendelenburg's position 4. Prone, with a pillow under the abdomen

4

A client is admitted with an arterial ischemic leg ulcer. The nurse expects to note that this ulcer has which of the following typical characteristics? 1. Accompanied by very slight pain 2. Brown pigmentation of surrounding skin 3. Dark, pink base 4. Deep and painful

4

A client is determined to be in respiratory alkalosis by blood gas analysis. The nurse would monitor this client for signs of which of the following electrolyte disorders that could accompany the acid-base imbalance? 1. Hypercalcemia 2. Hypochloremia 3. Hypernatremia 4. Hypokalemia

4

A client is diagnosed with an immune deficiency. The nurse focuses on which of the following as the highest priority when providing care to this client? 1. Encouraging discussion about emotional impact of the disorder 2. Identifying historical factors that placed the client at risk 3. Providing emotional support to decrease fear 4. Protecting the client from infection

4

A client is diagnosed with hyphema after experiencing a traumatic blow to the eye. The nurse explains to the client that which activity limitations need to be implemented following this type of injury? 1. Bathroom privileges only 2. Ambulation within the room only 3. Bedrest with the head of the bed flat 4. Bedrest with the head in semi-Fowler's position

4

A client is newly diagnosed with hypothyroidism. Levothyroxine (Synthroid) is prescribed. The nurse who plans to teach this client about the medication should include that the appropriate method for taking the medication is: 1. With milk 2. With fruit juice 3. With food 4. On an empty stomach

4

A client is receiving a daily dose of oral fluphenazine (Prolixin). The nurse would teach the client to do which of the following to minimize common side effects of this medication? 1. Have blood pressure checked once a week. 2. Monitor pulse daily. 3. Eat snacks at midmorning and bedtime. 4. Use hard, sour candy or sugarless gum

4

A client is receiving bolus feedings via a nasogastric tube. The nurse plans to place the client in which most optimal position once the feeding is completed? 1. Head of bed (HOB) elevated 45 to 60 degrees with the client supine for 15 minutes 2. HOB in semi-Fowler's with the client in the left lateral position for 10 minutes 3. HOB flat with the client supine for at least 60 minutes 4. HOB elevated 30 to 45 degrees with the client in the right lateral position for 60 minutes

4

A client is resuming a diet after hemigastrectomy. To minimize complications, the nurse would tell the client to avoid doing which of the following? 1. Eating six small meals per day 2. Excluding concentrated sweets in the diet 3. Lying down after eating 4. Drinking liquids with meals

4

A client is scheduled for insertion of a peripherally inserted central catheter (PICC), and the nurse explains the advantages of this catheter. Which statement by the client indicates a lack of understanding about this type of catheter? 1. There is less pain and discomfort. 2. This type of catheter is very reliable. 3. It is reasonable in cost. 4. It is specifically designed for short-term use.

4

A client is scheduled to receive chemotherapy with a group of medications, one of which is asparaginase (Elspar). The nurse anticipates that this medication will be removed from the regimen after noting which of the following disorders in the client's medical record? 1. Heart failure 2. Chronic airflow limitation 3. Hypothyroidism 4. Pancreatitis

4

A client is scheduled to receive digoxin (Lanoxin), 0.125 mg by mouth. The licensed practical nurse (LPN) reads the medication label and notes that each tablet contains 0.25 mg. The LPN should do which of the following? 1. Withhold the medication and notify the registered nurse regarding the medication. 2. Administer two tablets of the medication. 3. Withhold the medication and call the pharmacy regarding the medication. 4. Administer half of a medication tablet.

4

A client is taking brompheniramine (BroveX). The nurse teaches the client to expect which of the following side effects of this medication? 1. Excess salivation 2. Diarrhea 3. Excitability 4. Drowsiness

4

A client receiving a high cleansing enema complains of pain and cramping. The nurse would take which corrective action? 1. Reassure the client and continue the flow. 2. Discontinue the enema and notify the registered nurse (RN). 3. Raise the enema bag so that the solution can be completed quickly. 4. Clamp the tubing for 30 seconds and restart the flow at a slower rat

4

A client receiving long-term therapy with lithium carbonate (Eskalith) exhibits muscle tremors, confusion, vomiting, and diarrhea. The nurse anticipates that the results of the latest serum lithium level will be between: 1. 0 and 0.5 mEq/L 2. 0.6 and 1 mEq/L 3. 1 and 1.3 mEq/L 4. 1.5 and 2 mEq/L

4

A client recently began medication therapy with propranolol (Inderal). The nurse would be most concerned after noting the presence of which of the following in this client? 1. Blood pressure of 136/84 from 162/90 mm Hg 2. Heart rate of 86 beats per minute decreased to 78 3. Complaints of insomnia 4. Audible expiratory wheezes

4

A client who has developed atrial fibrillation that is not responding to medication therapy has begun taking warfarin (Coumadin). The nurse is doing discharge dietary teaching with the client. The nurse would plan to teach the client to avoid which of the following foods while taking this medication? 1. Cherries 2. Potatoes 3. Spaghetti 4. Broccoli

4

A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. The nurse should wear which of the following to perform these tasks? 1. Gloves 2. Gloves and mask 3. Gown, gloves, and a mask 4. Gown and gloves

4

A client who is human immunodeficiency virus (HIV) seropositive has been taking stavudine (d4T, Zerit XR). The nurse assesses which of the following most closely while the client is taking this medication? 1. Appetite 2. Level of consciousness 3. Gastrointestinal function 4. Presence of paresthesias

4

A client who is human immunodeficiency virus (HIV) seropositive has been taking zalcitabine (ddC, Hivid) as a component of treatment. The nurse tells the client that which laboratory test will need to be monitored while taking this medication? 1. Glucose level 2. Platelet count 3. Red blood cell count 4. Liver function studies

4

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client's respiratory status would avoid doing which of the following? 1. Keeping the head of the bed elevated 2. Monitoring the flow rate of supplemental oxygen 3. Assisting the client to turn, cough, and deep breathe 4. Encouraging the client to breathe slowly and shallowly

4

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse gives the client suggestions for foods to aid in symptom management that are on which of the following diets? 1. A high-carbohydrate diet 2. A low-fat diet 3. A high-fat diet 4. A low-fiber diet

4

A client with a history of spinal cord injury is beginning medication therapy with baclofen (Lioresal). The nurse who is providing medication information should caution the client about which side effect of this medication? 1. High blood pressure 2. Muscle pain 3. Sensitivity to bright light 4. Drowsiness

4

A client with a leg ulcer has sutilains (Travase) prescribed for its treatment. The nurse should avoid doing which of the following when using this product in wound care? 1. Moistening the wound with sterile normal saline and then applying the sutilains. 2. Placing the sutilains in the refrigerator following use. 3. Ensuring that sterile technique is maintained. 4. Rinsing off the sutilains after 3 minutes with sterile water.

4

A client with a urinary tract infection is beginning medication therapy with nitrofurantoin (Macrodantin). The nurse reminds the client to avoid which food item while taking this medication to maintain an acid-ash diet? 1. Oranges 2. Cranberries 3. Prunes 4. Rhubarb

4

A client with acquired immunodeficiency syndrome has been started on therapy with zidovudine (AZT, Retrovir). The nurse reviews the physician's orders, expecting to note that which laboratory test has been prescribed? 1. Blood glucose level 2. Blood urea nitrogen 3. Blood culture 4. Complete blood count (CBC)

4

A client with acute glomerulonephritis is admitted to the nursing unit. The nurse should plan to do which of the following immediately on admission? 1. Ambulate the client frequently. 2. Encourage a diet that is high in protein. 3. Monitor the temperature every 2 hours. 4. Remove the water pitcher from the bedside.

4

A client with breast cancer has been given a prescription for cyclophosphamide (Cytoxan). The nurse determines that the client understands the proper use of the medication if the client states that she needs to: 1. Decrease dietary intake of magnesium. 2. Increase dietary intake of potassium. 3. Take the medication with large meals. 4. Increase fluid intake to 2 to 3 L/day.

4

A client with cancer develops white patches on the mucous membranes of the oral cavity. The nurse noting this would: 1. Encourage the client to use better oral hygiene. 2. Check the client's most recent electrolyte results. 3. Do nothing, because this is a normal finding. 4. Report these symptoms, which are consistent with candidiasis.

4

A client with eczema has a prescription for a topical corticosteroid. The nurse cautions the client to use the product carefully in which of the following areas where the risk of systemic absorption is greater? 1. Palms of the hands 2. Soles of the feet 3. Back 4. Face

4

A client with psoriasis has been prescribed coal tar for use in the treatment of the disorder. In teaching the client about the medication, the nurse incorporates the understanding that this medication: 1. Can cause systemic effects 2. Carries no risk of phototoxicity 3. Has a very agreeable odor 4. Can stain the skin and hair

4

A client with recurrent constipation has begun using psyllium (Metamucil). The nurse tells this client that this medication should be taken with: 1. Any cold beverage 2. Any hot beverage 3. Any type of gelatin 4. A full glass of liquid, followed by a second glass of liquid

4

A client with right pleural effusion by chest x-ray is being prepared for a thoracentesis. The client experiences dizziness when sitting upright. The nurse assists the client to which of the following positions for the procedure? 1. Prone with the head turned to the side supported by a pillow 2. Sims' position with the head of the bed flat 3. Right side-lying with the head of the bed elevated 45 degrees 4. Left side-lying with the head of the bed elevated 45 degrees

4

A client with schizophrenia has been started on medication therapy with loxapine (Loxitane). The nurse determines that the client is experiencing the intended effects of the medication if which of the following client behaviors is observed? 1. Decreased appetite and food intake 2. Taking sips of water for dry mouth 3. Presence of fixed stare 4. Absence of delusional statements

4

A glucocorticoid is prescribed for a client with adrenal insufficiency, and the nurse provides medication instructions to the client. The nurse determines that the client needs additional instructions if the client states to: 1. Limit intake of sodium. 2. Stay away from people with infections. 3. Eat breakfast each day. 4. Discontinue the medication when symptoms subside.

4

A licensed practical nurse (LPN) employed in a long-term care facility is asked to assist in planning implementation of a change in the method of documentation system in the nursing unit. Many problems have occurred as a result of the present documentation system, and the nurse manager determines that a change is required. The LPN understands that the initial step in the process of change is which of the following? 1. Plan strategies to implement the change. 2. Identify potential solutions and strategies for the change process. 3. Set goals and priorities regarding the change process. 4. Identify the inefficiency that needs improvement or correction.

4

A licensed practical nurse (LPN) employed in a long-term care facility is planning assignments for the clients on a nursing unit. The LPN needs to assign four clients and has another LPN and three nursing assistants on a nursing team. Which of the following clients should the nurse assign the LPN? 1. The client requiring a 24-hour urine collection 2. An older adult client requiring assistance with a bed bath 3. A client requiring frequent ambulation 4. A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours

4

A licensed practical nurse (LPN) is a certified basic life support (BLS) instructor. The LPN is conducting a BLS recertification class and is discussing automated external defibrillation. A member of the class asks the LPN to identify the correct location for the placement of conductive gel pads to treat ventricular fibrillation. The LPN tells the class that the conductive gel pads are placed in which of the following locations on the client's chest? 1. Bilaterally under the right and left clavicles 2. Parallel between the umbilicus and the left nipple 3. Centered on the upper and lower half of the sternum 4. Under the right clavicle and to the left of the precordium

4

A licensed practical nurse (LPN) is asked to prepare an intravenous (IV) infusion of 1000 mL 5% dextrose in lactated Ringer's at 80 mL/hour to be administered to an assigned client. The LPN time-tapes the bag with a start time of 09:00. After making hourly marks on the time-tape, the LPN notes that the completion time for the bag is: 1. 15:30 2. 17:30 3. 19:30 4. 21:30

4

A licensed practical nurse (LPN) is assisting in the care of a client in preterm labor who is being started on intravenous magnesium sulfate to stop the contractions. The LPN checks to see that which of the following is available on the unit as an antidote to magnesium sulfate? 1. Magnesium oxide 2. Vitamin K 3. Aluminum hydroxide 4. Calcium gluconate

4

A licensed practical nurse (LPN) is assisting in the care of a client who is receiving oxytocin (Pitocin) to induce labor. The LPN plans to notify the registered nurse immediately if which of the following is noted? 1. The client complains of fatigue. 2. The client becomes drowsy. 3. There are early decelerations of fetal heart rate. 4. The uterus becomes hyperstimulated.

4

A licensed practical nurse (LPN) is caring for a client with a diagnosis of schizophrenia. The LPN observes behaviors indicative of paranoia and reports these observations to the registered nurse (RN). The LPN assists the RN in developing a plan of care for the client and suggests inclusion of which intervention in the plan of care? 1. Encourage the client to socialize with other clients. 2. Inform the client about support groups that are available in the community. 3. Encourage the client to lead a support group. 4. Avoid joking or laughing in the presence of the client.

4

A licensed practical nurse (LPN) is providing instructions to a nursing assistant who is preparing to care for a deceased client whose eyes will be donated. The nurse intervenes if the nursing assistant does which of the following? 1. Elevates the head of the bed 2. Closes the client's eyes 3. Places wet saline gauze pads and an ice pack on the eyes 4. Closes the client's eyes and places a dry sterile dressing over the eyes

4

A mental health nurse is assigned to care for a client with a diagnosis of schizophrenia, acute phase. The nurse uses which of the following approaches when planning care for this client? 1. Repeatedly points out inconsistencies in the client's communication during initial treatment 2. Lets the client act out initially and uses the quiet room and restraints as needed 3. Allows the client to set the goals for the plan of care 4. Provides assistance with grooming and nutrition until the client's thinking is cleared

4

A mother brings her child to the health care clinic because the child has developed lesions located around the mouth and nose, and mild impetigo is diagnosed. The nurse provides instructions to the mother regarding care of the child. Which statement by the mother indicates the need for further instructions? 1. "The impetigo is extremely contagious." 2. "The lesions should be washed gently three times a day with a warm, soapy washcloth." 3. "The crusts on the lesions need to be soaked and carefully removed." 4. "My child will need to be treated with oral antibiotics."

4

A nurse caring for a child with nephrotic syndrome reviews the medication record. The nurse notes that prazosin hydrochloride (Minipress) is prescribed for the child. The nurse determines that this medication has been prescribed to: 1. Reduce proteinuria 2. Decrease inflammation 3. Suppress the autoimmune response 4. Control hypertension

4

A nurse employed in an emergency department is instructed to monitor a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this finding as indicating: 1. The presence of dehydration 2. The presence of pain 3. Extreme fatigue 4. An airway obstruction

4

A nurse has a routine order to instill erythromycin ointment (Ilotycin) into the eyes of a newborn. The nurse explains to the parents that the purpose of the medication is to: 1. Help the newborn to see more clearly. 2. Guard against infection acquired during intrauterine life. 3. Ensure the sterility of the conjunctiva in the newborn. 4. Protect the newborn from contracting an eye infection from the birth process.

4

A nurse has an order to collect a 24-hour urine specimen from a client. The nurse should avoid which of the following errors in technique while completing this procedure? 1. Discard a urine specimen collected at the start time. 2. Place the specimen on ice. 3. Ask the client to save a sample voided at the end of the collection time. 4. Ask the client to void, save the specimen, and note the start time.

4

A nurse has an order to give 30 mL of an antacid to a client through a nasogastric (NG) tube that is connected to wall suction. The nurse would do which of the following to perform this procedure correctly? 1. Adjust the suction to low-intermittent setting for an hour after medication administration. 2. Aspirate the NG tube following medication administration to maintain patency. 3. Position the client supine to assist in medication absorption. 4. Clamp the NG tube for 30 minutes following administration of the medication.

4

A nurse has an order to give a client a scheduled dose of digoxin (Lanoxin). Before administering the medication, the nurse routinely screens for which manifestations that could indicate early signs of digoxin toxicity? 1. Dyspnea, edema, and palpitations 2. Chest pain, hypotension, and paresthesias 3. Constipation, dry mouth, and sleep disorder 4. Loss of appetite and nausea

4

A nurse has an order to give a first dose of hydrochlorothiazide (HydroDIURIL) to an assigned client. The nurse would question the order if the client had a history of allergy to: 1. Iodine 2. Shellfish 3. Penicillin 4. Sulfa drugs

4

A nurse in a newborn nursery is told that a newborn with spina bifida (myelomeningocele type) will be transported from the delivery room. The nurse is asked to prepare for the arrival of the newborn. The nurse places which of the following priority items at the newborn's bedside? 1. A blood pressure cuff 2. A rectal thermometer 3. A specific gravity urinometer 4. A bottle of sterile normal saline

4

A nurse in the delivery room is assisting with the delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction by: 1. Wrapping the newborn in a blanket 2. Closing the doors to the delivery room 3. Drying the newborn with a warm blanket 4. Warming the crib pad before placing the newborn in the crib

4

A nurse in the psychiatric unit is reviewing the records of the clients admitted to the nursing unit. A client with a history of violent behavior approaches the nurse and demands immediate discharge from the hospital. The nurse notes that the client was voluntarily admitted to the psychiatric unit. Which of the following is the appropriate nursing action? 1. Allow the client to leave. 2. Attempt to persuade the client to stay. 3. Call security to assist in restraining the client. 4. Tell the client that the physician will be contacted regarding discharge

4

A nurse is admitting a 10-month-old infant who is being hospitalized for a respiratory infection. The nurse develops a plan of care for the infant and includes which of the following? 1. Keeping the infant as quiet as possible 2. Placing small toys in the crib to provide stimulation for the infant 3. Restraining the infant to prevent tubes from being dislodged 4. Providing a consistent routine such as touching, rocking, and cuddling throughout the hospitalization

4

A nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. The initial nursing action is to: 1. Call a code. 2. Contact the respiratory therapy department. 3. Place the infant in a prone position. 4. Place the infant in a knee-chest position.

4

A nurse is assisting in admitting a child who arrived from the emergency department after treatment for acetaminophen (Tylenol) overdose. The nurse reviews the child's record and expects to note that the child received which of the following for the acetaminophen overdose? 1. Calcium disodium edetate (EDTA) 2. Protamine sulfate 3. Epoetin alfa (Epogen) 4. Acetylcysteine (Mucomyst)

4

A nurse is assisting in caring for a client with an endotracheal tube attached to a ventilator when the high-pressure alarm sounds. The nurse checks the client and system for which most likely cause? 1. Disconnection from the ventilator 2. Endotracheal tube cuff leak 3. Loose connection in the system 4. Accumulation of secretions in the client's lungs

4

A nurse is assisting in conducting a group therapy session. During the session a male client threatens to act out physically and states that he will punch another member of the group. Which of the following is the appropriate initial nursing action? 1. Tell the client that he must leave immediately. 2. Call security to come to the session immediately. 3. Tell the client that if he hits another client, he will be restrained and placed in seclusion. 4. Tell the client that he may talk about his anger but cannot act on it during the group session.

4

A nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells. Before leaving the room, the nurse tells the client that it is most important to immediately report which of the following signs if they occur? 1. Fatigue 2. Nausea 3. Headache 4. Backache

4

A nurse is assisting in planning care to meet the emotional needs of a pregnant woman. Which of the following nursing interventions would be least likely to assist in meeting her emotional needs? 1. Providing an opportunity for the pregnant woman to discuss the aspects of pregnancy 2. Using a caring and supportive approach when dealing with a pregnant woman 3. Offering praise and reinforcement for compliance with treatment therapies 4. Providing the mother with pamphlets and booklets to read about the pregnancy

4

A nurse is assisting in preparing a plan of care for a client who just delivered a dead fetus. The appropriate initial intervention in meeting the emotional needs of the client and her spouse is which of the following? 1. Encourage the client to talk about the dead fetus. 2. Allow the client and the spouse to hold the baby. 3. Allow family members to name the baby. 4. Gather data from the client and spouse about the perception of the event

4

A nurse is assisting in preparing a plan of care for the client who will be seen in the mental health clinic for the first time. In preparing for the orientation phase of the therapeutic relationship, the nurse suggests addressing which of the following issues? 1. Facilitating behavioral change 2. Promoting problem-solving skills in the client 3. Promoting self-esteem in the client 4. The parameters of the relationship

4

A nurse is assisting in the care of a client who is at risk for hyponatremia. The nurse would monitor this client for which of the following manifestations of this electrolyte imbalance? 1. Slow pulse rate 2. High blood pressure 3. Flaccid muscles 4. Abdominal cramping

4

A nurse is assisting in the care of a client with Parkinson's disease who is receiving carbidopa/levodopa (Sinemet). The nurse plans to monitor the client for which of the following adverse effects, which could appear with elevated serum levels of this medication? 1. Pruritus 2. Hypertension 3. Tachycardia 4. Impaired voluntary movements

4

A nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding preventing the transmission of the infection to the other children in the family and the other household members and tells the mother which of the following? 1. Isolate the child from others because the virus is transmitted by breathing and coughing. 2. Wash sheets and towels used by the child separately in bleach to prevent the spread of the infection to the others. 3. Have the child use a separate bathroom for urination and bowel movements to prevent the spread of infection through the urine and feces. 4. Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through the saliva.

4

A nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the mother regarding care related to the infection. Which statement by the mother indicates the need for further instructions? 1. "I need to take the antibiotics as prescribed." 2. "I need to apply warm compresses to provide comfort." 3. "I need to take warm sitz baths to promote healing." 4. "I need to isolate my infant for 48 hours after starting the antibiotics."

4

A nurse is caring for a client who is on airborne precautions. The nurse notes that the client is scheduled for a magnetic resonance imaging (MRI) test. Which of the following nursing actions would be most appropriate in preparing the client for the test? 1. Ask that the MRI department be called to tell the technician that the test will have to be delayed until the airborne precautions are discontinued. 2. Plan to have the MRI performed at the bedside. 3. Ask that the MRI department be called to tell technicians in the department to wear masks. 4. Place a surgical mask on the client for transport and for contact with other individuals.

4

A nurse is caring for a client with a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse should take which action first? 1. Replace the chest tube system. 2. Place a sterile dressing over the end of the chest tube. 3. Place the client in a prone position. 4. Immerse the end of the tube in sterile saline.

4

A nurse is caring for a client with esophageal varices who is going to have a Sengstaken-Blakemore tube inserted. The nurse brings which priority item to the bedside so that it is available at all times? 1. A Kelly clamp 2. An obturator 3. An irrigation set 4. A pair of scissors

4

A nurse is caring for a pregnant client who has herpes genitalis. The nurse provides instructions to the mother about modalities that may be necessary to treat this condition. Which statement by the mother indicates an understanding of these treatment measures? 1. "I do not need to abstain from sexual intercourse." 2. "I need to use vaginal creams after the douche every day." 3. "I need to douche and perform a sitz bath three times a day." 4. "It may be necessary to have a cesarean section for delivery."

4

A nurse is caring for an infant with congenital heart disease. Which of the following signs, if noted in the infant, would alert the nurse to the early development of congestive heart failure (CHF)? 1. Strong sucking reflex 2. Slow and shallow breathing 3. Pallor 4. Diaphoresis during feeding

4

A nurse is caring for the client who is at risk for lung cancer due to an extremely long history of heavy cigarette smoking. The nurse tells the client to report which most frequent early symptom of lung cancer? 1. Hoarseness 2. Pleuritic pain 3. Hemoptysis 4. Nonproductive hacking cough

4

A nurse is collecting data on a child with a diagnosis of rheumatic fever. Which of the following questions would the nurse initially ask the mother of the child? 1. "Has the child had any diarrhea?" 2. "Has the child been vomiting?" 3. "Does the child complain of chest pain?" 4. "Has the child complained of a sore throat within the past few months?"

4

A nurse is collecting data on a client diagnosed with mild depression. The client says to the nurse, "I haven't had an appetite at all for the last few weeks." Which of the following responses by the nurse would be therapeutic? 1. "Once the medication begins to work, you will begin to feel better." 2. "Think about everything that you have been through. It will take time for your appetite to improve." 3. "The last few weeks?" 4. "You haven't had an appetite at all?"

4

A nurse is concerned that a client may experience systemic effects from carteolol hydrochloride (Ocupress) ophthalmic solution. The nurse observes the client self-administer the medication to be sure that the client: 1. Instills the eye drops after a meal 2. Swallows at least five times after instillation 3. Blinks quickly to form tears after instillation 4. Applies digital pressure to the lacrimal sac for 1 to 2 minutes after instillation

4

A nurse is developing a poster to use in teaching clients about the prevention of hearing loss. The nurse would diagram which of the following structures as part of the inner ear? 1. Malleus 2. Incus 3. Stapes 4. Cochlea

4

A nurse is instructing a Native-American client regarding the procedure for collecting a urine sample. The nurse observes that the client continually stares at the floor during the instructional session. The nurse interprets this behavior as: 1. Rude 2. Disinterest 3. Embarrassment 4. Indicative that the client is paying close attention

4

A nurse is instructing a pregnant client in her first trimester about nutrition. The nurse would correct which of the following misunderstandings on the part of the client about nutrition during pregnancy? 1. Calcium intake should be increased for the duration of the pregnancy. 2. Iron supplements should be taken throughout pregnancy. 3. The maternal diet significantly influences fetal growth and development. 4. Pregnancy greatly increases the risk of malnourishment for the mother.

4

A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which of the following nursing actions is appropriate? 1. Encourage the client's coach to continue breathing techniques. 2. Encourage the client to continue pushing with each contraction. 3. Continue monitoring the fetal heart rate. 4. Notify the registered nurse (RN).

4

A nurse is monitoring a client in labor whose membranes rupture spontaneously. The initial nursing action is to: 1. Take the client's blood pressure. 2. Provide peripads to the client. 3. Note the amount, color, and odor of the amniotic fluid. 4. Determine the fetal heart rate.

4

A nurse is monitoring the child with a cast on the forearm for signs of compartment syndrome. The nurse understands that which data collection technique is unlikely to provide information about this complication? 1. Checking the quality of the radial pulse 2. Checking the child's ability to extend the fingers 3. Checking for effectiveness of analgesics administered for pain 4. Checking the child's ability to perform range of motion to the shoulder area of the affected extremity

4

A nurse is orienting a new nurse to the care of a client who has an internal radiation implant. The nurse includes which of the following instructions in discussions with the orientee? 1. Visitors who are less than 16 years of age are allowed but must stay 6 feet away from the client. 2. The dosimeter badge is removed when entering the client's room. 3. There is a 1 hour per 8-hour shift time limit for contact with the client. 4. Pregnant women are not allowed in the client's room.

4

A nurse is performing a safety assessment in the home of a mother with two children. The ages of the children are 1 and 3 years. Which of the following, if noted during the assessment, would present the greatest hazard to the children? 1. The water heater set above 120° F 2. A small dog as a house pet 3. A gate placed at the stairs of the second floor 4. Toys with small loose parts in the playroom

4

A nurse is planning to instruct the Hispanic-American client about nutrition and dietary restrictions. When developing the plan for the instructions, the nurse is aware that this ethnic group: 1. Enjoys foods that lack color, flavor, and texture 2. Primarily eats raw fish 3. Enjoys eating red meat 4. Views food as a primary form of socialization

4

A nurse is planning to reinforce dietary teaching about foods that are low in potassium to a client receiving a potassium-sparing diuretic. The nurse would be sure to include which of the following on a list of foods that have a low potassium content? 1. Spinach 2. Avocado 3. Fresh pork 4. White bread

4

A nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which of the following is the appropriate action by the nurse? 1. Wipe the tubing port with povidone-iodine. 2. Scrub the needleless device with an alcohol swab. 3. Attach a new needleless device. 4. Change the IV tubing.

4

A nurse is preparing the client who is scheduled for an intravenous pyelogram (IVP). The nurse would take which most important action before the test? 1. Administer a sedative. 2. Encourage fluid intake. 3. Administer an oral preparation of radiopaque dye. 4. Question about allergies to iodine or shellfish.

4

A nurse is providing general information to a group of high school students about preventing human immunodeficiency virus (HIV) transmission. The nurse would inform the students that which of the following is an unsafe behavior? 1. Abstinence 2. Mutual monogamy 3. Use of latex condoms 4. Use of natural skin condoms

4

A nurse is providing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to: 1. Keep the ice pack on the eye continuously for 24 hours. 2. Place the ice pack directly on the eye. 3. Avoid the use of commercially prepared ice bags. 4. Wrap a plastic bag filled with ice with a pillowcase and place it on the eye

4

A nurse is providing instructions to the parents of an infant with a ventricular-peritoneal shunt. The nurse plans to include which of the following instructions? 1. Call the physician if the infant is fussy. 2. Position the infant on the side of the shunt when the infant is put to bed. 3. Expect an increased urine output from the shunt. 4. Call the physician if the infant has a high-pitched cry.

4

A nurse is providing vaccine information to a second-day postpartum client who received a rubella vaccine. The nurse reminds the client to avoid which of the following after receiving this vaccine? 1. Eating highly acidic foods for a week 2. Sustaining injury to the injection site 3. Having sexual relations for 2 to 3 months 4. Becoming pregnant for 2 to 3 months

4

A nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who underwent lumbar puncture. The nurse knows that a reported value of 0 is normal for which of the following substances in CSF? 1. Protein 2. Glucose 3. White blood cells 4. Red blood cells

4

A nurse is reviewing the list of discharge instructions for a client who underwent left total knee replacement (TKR) with insertion of a metal prosthesis. Which statement by the client indicates the need for further instructions? 1. "I need to report bleeding gums or tarry stools." 2. "I need to tell my other doctors about the metal implant." 3. "I need to report fever, redness, or increased pain." 4. "I don't need to be worried if the shape of my knee changes."

4

A nurse is reviewing the medication list for an assigned client. The nurse becomes concerned because which of the following medications is the only one on the client's order sheet that does not have an ototoxic effect? 1. Furosemide (Lasix) 2. Vancomycin hydrochloride (Vancocin) 3. Acetylsalicylic acid (aspirin) 4. Acetaminophen (Tylenol)

4

A nurse is speaking with a client with a hearing impairment. The nurse refrains from doing which of the following, which is least helpful when communicating with this client? 1. Standing directly in front of the client while speaking 2. Speaking slowly and clearly 3. Turning down the volume on the radio or TV 4. Using many exaggerated hand gestures while talking

4

A nurse is teaching a client about foods in the diet that could minimize the risk of osteoporosis. The nurse would encourage the client to increase intake of which of these foods? 1. Fish 2. Turkey 3. Sweet potatoes 4. Cheese

4

A nurse is teaching a client about the use of an incentive spirometer in the postoperative period. The nurse should include which of the following pieces of information in discussions with the client? 1. Keep a loose seal between the lips and the mouthpiece. 2. Inhale as rapidly as possible. 3. After maximum inspiration, hold the breath for 10 seconds and exhale. 4. The best results are achieved when sitting at least halfway or fully upright.

4

A nurse is teaching a group of high school males in a health class about how to perform a testicular self-examination (TSE). The nurse would make which of the following statements during the class? 1. "Gently push on the testicle with one or two fingers to feel for a lump." 2. "Perform TSE at least every 3 months." 3. "Examine the testicles while lying down." 4. "Do the examination after a warm bath or shower

4

A nurse is told that a client will be admitted to the hospital for a radiation implant for bladder cancer. The nurse is asked to prepare for the admission of the client and plans which of the following as a priority measure for this client? 1. Encourage the family to visit. 2. Place the client on reverse isolation. 3. Place the client in a room near the nurse's station. 4. Admit the client to a private room.

4

A nurse overhears that a client is having occasional ventricular dysrhythmias. The nurse reviews the client's laboratory results, recalling that which electrolyte imbalance could be responsible for this development? 1. Hypernatremia 2. Hypochloremia 3. Hypercalcemia 4. Hypokalemia

4

A nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement, if made by one of the parents, indicates an understanding of the use of the harness? 1. "I need to remove the harness to feed my infant." 2. "I need to remove the harness to change the diaper." 3. "My infant needs to remain in the harness at all times." 4. "I can remove the harness to bathe my infant."

4

A nurse tells the client with leukemia that allopurinol (Zyloprim) has been added to the medication list. The client is currently receiving busulfan (Myleran). When the client asks the purpose of the new medication, the nurse responds that the allopurinol is intended to prevent: 1. Alopecia 2. Diabetes 3. Arthritis 4. Hyperuricemia

4

A nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The appropriate initial action by the nurse is which of the following? 1. Call the police. 2. Call security. 3. Lock the co-worker in the medication room until help is obtained. 4. Call the nursing supervisor.

4

A nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which of the following would be the therapeutic response by the nurse? 1. "What would your spouse think about your decision?" 2. "This is not a good time to make that decision." 3. "You seem to have a good grip of this situation . . . you probably should get out." 4. "What aspects of this situation are the most difficult for you?"

4

A nurse working in an obstetrical-gynecological physician's office is instructing a small group of female clients about breast self-examination (BSE). The nurse teaches the clients to perform the exam: 1. Every month during ovulation 2. At the same time of day each week 3. At the onset on menstruation 4. One week after menstruation begins

4

A nursing instructor asks a nursing student to define a critical path. Which of the following statements, if made by the student, indicates a need for further understanding regarding critical paths? 1. "They are developed through the collaborative efforts of all members of the health care team." 2. "They provide an effective way to monitor care and for reducing or controlling the length of hospital stay for the client." 3. "They are developed based on appropriate standards of care." 4. "They are nursing care plans and use the steps of the nursing process."

4

A nursing instructor is observing a nursing student caring for an infant with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by: 1. Covering the bladder with a dry sterile dressing 2. Covering the bladder with a wet-to-dry dressing 3. Applying sterile water soaks to the bladder mucosa 4. Covering the bladder with a nonadhering plastic wrap

4

A nursing student is assigned to care for an infant with a diagnosis of congestive heart failure (CHF). The student develops a plan of care for the child that is focused on monitoring for fluid overload. The student plans to best assess the urine output of the infant by: 1. Asking the physician for permission to insert a Foley catheter 2. Monitoring the intake closely 3. Comparing the intake with the output 4. Weighing the diapers

4

A nursing student is discussing cultural issues in a clinical conference. The nursing instructor asks the student to describe ethnocentrism. Which of the following if stated by the student indicates a lack of understanding of the issue of ethnocentrism? 1. "It is a tendency to view one's own ways as best." 2. "It is acting in a manner that is superior to other cultures." 3. "It is believing that one's own ways are the only acceptable way." 4. "It is imposing one's beliefs on individuals from another culture."

4

A nursing student prepares to instruct a client to expectorate a sample of sputum that will be sent to the laboratory for Gram stain, culture, and sensitivity and describes the procedure to the licensed practical nurse (LPN), who is the primary nurse. The LPN corrects the student if which incorrect description is provided? 1. "I will use a sterile container from the supply area." 2. "I will send the specimen immediately to the laboratory." 3. "I will ask the client to brush the teeth and rinse the mouth before expectorating." 4. "I will have the client take a shallow breath before coughing."

4

A physician has prescribed codeine sulfate for a client with a nonproductive cough to suppress the cough reflex. The nurse teaches the client about the medication and tells the client to monitor for: 1. Difficulty swallowing 2. Difficulty coughing 3. Increased urination 4. Constipation

4

A postoperative client has been receiving morphine sulfate every 3 to 4 hours for pain. The nurse should be sure to implement which measure to reduce the risk of adverse effects from this medication? 1. Monitor the client's temperature. 2. Encourage fluids. 3. Maintain the client in a supine position. 4. Encourage coughing and deep breathing.

4

A postpartum nurse is providing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which of the following instructions would the nurse provide to the mother? 1. Switch to bottle-feeding the baby during the period of high bilirubin levels, and feed less frequently. 2. Stop the breast-feedings and switch to bottle-feeding permanently. 3. Provide bottled-water feedings between the breast-feeding sessions. 4. Increase the frequency of the breast-feeding.

4

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted: 1. Between 6 and 8 weeks' gestation 2. Between 8 and 10 weeks' gestation 3. Between 12 and 14 weeks' gestation 4. Between 16 and 20 weeks' gestation

4

A pregnant client who is anemic tells the nurse that she is concerned about what her baby's condition will be following delivery. Which nursing response would best support the client? 1. "You will not have any problems if you follow all the advice the doctor has given you." 2. "Your baby will need to spend a few days in the neonatal intensive care unit following delivery." 3. "Don't worry about your baby; complications are rare." 4. "The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure that you are providing the best nutrition and growth potential."

4

A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which of the following responses by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "I will be happy to explain the entire surgical procedure to you." 2. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate." 3. "If it's any help, everyone is nervous before surgery." 4. "Can you share with me what you've been told about your surgery?"

4

A registered nurse (RN) is discussing the overall fluid balance of an assigned client. The RN calculates that the client's insensible fluid loss is approximately 500 mL/day. The licensed practical nurse (LPN) recalls that the RN is referring to fluid losses occurring through which of the following areas? 1. Nasogastric tube and wound drain 2. Foley catheter and nasogastric tube 3. Wound drain and skin 4. Skin and lungs

4

An adolescent with diabetes mellitus is attending gym class and suddenly becomes flushed and complains of dizziness and a headache. The gym teacher quickly takes the adolescent to the school nurse's office. The nurse obtains a blood glucose level, and the results indicate a level of 65 mg/dL. The appropriate initial nursing intervention is to: 1. Call the child's mother for permission to treat the child. 2. Call the school physician immediately. 3. Let the child rest until the blood glucose has an opportunity to rise. 4. Give the child 6 oz of a regular cola drink

4

An adult client has had serum electrolytes drawn. The nurse receiving the results by telephone from the laboratory would be most concerned with which of the following results? 1. Chloride 103 mEq/L 2. Bicarbonate 24 mEq/L 3. Sodium 142 mEq/L 4. Potassium 5.4 mEq/L

4

An adult client is brought to the emergency department by the emergency medical services team after being hit by a car. The name of the client is not known. The client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. In regard to informed consent for the surgical procedure, which of the following is the best initial action? 1. Call the police to identify the client and locate the family. 2. Obtain a court order for the surgical procedure. 3. Ask the emergency medical services team to sign the informed consent. 4. Transport the victim to the operating room for surgery.

4

An older client is complaining of chronic dry skin and occasional pruritus. The nurse tells the client to avoid which of the following that will aggravate the condition? 1. Applying emollient to the skin after a shower 2. Using a humidifier, especially during the winter months 3. Drinking 8 to 10 glasses of water a day 4. Using astringents to clean the skin

4

Collagenase (Santyl) is prescribed for a client with a severe burn to the hand. The nurse is preparing to provide instructions to the client and spouse regarding the wound treatment. Which of the following should the nurse include in the instructions? 1. Apply twice a day and leave the wound open to the air. 2. Apply twice a day and cover the wound with a sterile dressing. 3. Apply once a day and leave the wound open to the air. 4. Apply once a day and cover the wound with a sterile dressing

4

On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urine sample is collected for urinalysis, and the results indicate the presence of a urinary tract infection. The nurse instructs the new mother regarding measures to take for the treatment of the infection. Which statement by the mother indicates the need for further instructions? 1. "My prescribed medication must be taken until it is completed." 2. "My fluid intake should be increased to at least 3000 mL daily." 3. "I should urinate frequently throughout the day." 4. "Foods and fluids that will increase urine alkalinity should be consumed."

4

Saquinavir (Invirase) is prescribed for the client who is human immunodeficiency virus (HIV) seropositive. The nurse provides medication instructions and determines that the client needs further instructions if the client states he will: 1. Avoid sun exposure. 2. Eat high-calorie foods. 3. Eat foods that are high in fat. 4. Take the medication on an empty stomach.

4

The day nurses in a psychiatric unit are receiving report from the night shift. During report, a client approaches the nurses' station, becomes very loud and angry, and demands to be seen by the physician immediately. The appropriate nursing intervention is which of the following? 1. Tell the client that the physician will be called as soon as report is completed. 2. Tell the client to wait in her room until report is over. 3. Inform the client that the behavior is unacceptable. 4. Offer to assist the client to an examination room until the physician is notified.

4

The mother of a 2-year-old child asks the nurse if it is all right to give the child a bottle at naptime. The appropriate response by the nurse is which of the following? 1. "At this age, the child may have a bottle at any time." 2. "The child may have a bottle at naptime, but it is best not to give a bottle at bedtime." 3. "A bottle may be given if the child isn't taking fluids well during the day." 4. "You may give the child a bottle if necessary, but if you do, it should contain water."

4

When performing a surgical dressing change of a client's abdominal dressing, a nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should plan to do which of the following in the initial care of this wound? 1. Leave the incision open to the air to dry the area. 2. Apply a povidone-iodine-soaked sterile dressing. 3. Irrigate the wound and apply a dry sterile dressing. 4. Apply a sterile dressing soaked with normal saline.

4

A physician orders a bolus of 500 mL of 0.9% normal saline (NS) to run over 4 hours. The drop (gt) factor is 10 drops (gtt) per 1 mL. The nurse plans to adjust the flow rate at how many gtt per minute? 1. 15 gtt 2. 17 gtt 3. 19 gtt 4. 21 gtt

4 Rationale: The prescribed 500 mL is to be infused over 4 hours. Follow the formula and multiply 500 mL by 10 (gt factor). Then, divide the result by 240 minutes (4 hours × 60 minutes). The infusion is to run at 20.8 or 21 gtt/minute. Formula: Total volume in mL × gt factor = Flow rate in gtt per minute Time in minutes 500 mL × 10 gtt = 5000 = 20.8 or 21 gtt/minute 240 minutes 240