final exam - part 2.1

160) A nurse is preparing to administer morphine 30 mg PO to a client who reports pain. available is morphine solution 20 mg/mL. How many mL should the nurse administer?

1.5 ML

170) A nurse is reinforcing teaching with a client who has primary open-angle glaucoma and a new prescription for timolol eye drops. Which of the following statements indicates an understanding of the teaching? A) " I should check my heart rate while taking this medication." B) "This medication will dilate my eyes." C) "I should take a zinc supplement while taking this medication." D) "This medication will darken the color of my eyes."

A) " I should check my heart rate while taking this medication."

6) A nurse is reinforcing discharge teaching with a client who has a prescription for home oxygen therapy. Which of the following statements by the client indicates an understanding of the teaching? A) " I will check my oxygen equipment at least once daily." B) " I will increase the flow rate if I feel short of breath." C) " I can use synthetic blankets in my bed." D) " I can use isopropyl alcohol to clean the nasal cannula when necessary.

A) " I will check my oxygen equipment at least once daily."

5) A nurse is reinforcing teaching about ADLs with a client who has multiple sclerosis. Which of the following client statements should indicate to the nurse an understanding of the teaching? A) " I will take rest periods throughout the day." B) " I will take tub baths rather than showers." C) " I will eliminate vitamin D from my diet." D) " I will decrease my fiber intake."

A) " I will take rest periods throughout the day."

65) A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching? A) "I should decrease my salt intake to 2 grams per day."* B) "I can have two glasses of wine with dinner." C) "I will set my blood pressure goal at 130 over 84." D) "I should exercise for 15 minutes two times per week."

A) "I should decrease my salt intake to 2 grams per day."*

63) A nurse is reinforcing teaching with a client about monitoring her blood pressure at home with a digital device. Which of the following statements by the client indicates an understanding of the teaching? A) "I will know my blood pressure is too high if I get a reading of 140 over 90 or higher." B) "I will loosely wrap the blood pressure cuff around my upper arm." C) "I will check my blood pressure at a different time of the day." D) "I will make sure my hand is about 6 inches below my heart when I use the device."

A) "I will know my blood pressure is too high if I get a reading of 140 over 90 or higher."

146) A nurse is assisting with the care of a client who has schizophrenia and auditory hallucinations. Which of the following responses should the nurse make? A) "Let's talk about what the voices are saying to you." B) "I'm sure the voices wil go away soon." C) "You should talk to your counselor about the voices." D) "Tell me what medications you are taking."

A) "Let's talk about what the voices are saying to you."

12) A nurse is assisting with the admission of a client who states, "The last time I was at the hospital, the nurses took forever to answer my call light." Which of the following is an appropriate response by the nurse? A) "That must have been a difficult experience for you." B) "It will not happen this time because we have more staff." C) "I am sure no one meant to ignore you." D) "Let's discuss what brought you to the hospital this time."

A) "That must have been a difficult experience for you."

22) a nurse is reinforcing teaching with a client who is about to start using an albuterol metered dose inhaler which of the following instruction should the nurse include in the teaching? A) "close your mouth around the mouthpiece" B) "take 3 quick breaths while depressing the canister" C) " tilt your head forward while inhaling" D) " Exhale immediately after inhaling"

A) "close your mouth around the mouthpiece"

98) A nurse is preparing to administer 0.9% sodium chloride 1,000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? ( Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A) 125 mL / hr

64) A nurse on a medical-surgical unit is preparing to assist with the admission of clients who were injured in a tornado. Which of the following clients should the nurse recommend for discharge to make room for the new admissions? A) A client who had a radical mastectomy 36 hr ago and has a surgical drain.* B) A client who had a lobectomy and has a chest tube drainage system C) A client who had a cerebrovascular accident 8 hr ago and received thrombolytic therapy D) A client who has cervical cancer and an internal radioactive implant.

A) A client who had a radical mastectomy 36 hr ago and has a surgical drain.*

151) A nurse is reviewing client confidentiality with a group of newly licensed nurses. Which of the following situations should the nurse include as an example of a breach in confidentiality? A) A nurse tells the chaplain that a client has a new diagnosis of cancer. B) A nurse discusses a client's postoperative complications during shift report. C) A social worker reads a client's chart as a follow-up to a requested consultation. D) A facility risk manager includes information from a client's medical record in a written report.

A) A nurse tells the chaplain that a client has a new diagnosis of cancer.

56) A nurse is caring for a child who has terminal cancer. Which of the following responses by the child's school-age brother should the nurse expect? A) Believes his bad behavior is causing his brother's death B) Alienates himself from his peers C) Belives that his brother's death will be reversible D) Regresses to an earlier development level

A) Believes his bad behavior is causing his brother's death

156) A nurse is assisting with the care of a client who has hearing loss and has questions regarding their medication. Which of the following actions should the nurse take? A) Choose a room that is well lit. B) Sit on the client's right side. C) Ask a few questions at a time. D) Exaggerate lip movement while speaking.

A) Choose a room that is well lit.

53) A nurse is assisting with the plan of care for a client who has burns to his lower extremities. Which of the following actions should the nurse include in the plan? A) Cleanse the most contaminated wounds first. B) Apply dressings with sterile gloves. C) Use hydrogen peroxide for wound cleaning. D) Perform dressing changes every other day.

A) Cleanse the most contaminated wounds first.

26) a nurse is collecting data from a client who received oxytocin 10 units IM 30 minutes ago for excessive vaginal bleeding. which of the following findings should the nurse expect? A) Client report of uterine cramping B) Client report of burning with urination C) saturation of perineal pad in 15 min D) boggy fundus 3 fingerprints above the umbilicus

A) Client report of uterine cramping

116) A nurse is reinforcing teaching with a client who is postoperative following a partial gastrectomy.Which of the following instructions should the nurse include to prevent dumping syndrome? A) Consume high-fiber foods at each meal. B) Include one serving of protein with each meal. C) Ambulate for 15 min after each meal. D) Drink at least 240 mL (8oz)of liquid with each meal.

A) Consume high-fiber foods at each meal.

167) A nurse is contributing to the plan of care for a client who has herpes simplex. The nurse should plan to initiate which of the following isolation procedures when caring for this client? A) Contact precautions B) Airborne precautions C) Droplet precautions D) Protective environment

A) Contact precautions

94) A nurse is caring for an older adult who has acute delirium. Which of the following actions should the nurse take first? A) Determine the client's level of consciousness B) Administer an anxiolytic medication. C) Encourage visits from family members. D) Keep lights on in the clients room.

A) Determine the client's level of consciousness

148) A nurse is assisting with the care of a client who is receiving a continuous IV infusion. Which of the following findings indicates fluid volume excess? A) Distended neck veins B) Decreased bowel sounds C) Urine output of 360 mL?12 hr D) BLood pressure of 100/74 mm Hg

A) Distended neck veins

136) A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the following findings should the nurse expect? A) Fruity breath odor B) Bounding pulse C) Elevated blood pressure D) Clammy skin

A) Fruity breath odor

154) A nurse is reviewing laboratory data from a client who has diabetes mellitus. Which of the following laboratory tests is the most accurate indicator of long-term disease managment? A) Glycosylated hemoglobin B) Glucose tolerance test C) Urine ketones D) Fasting blood glucose

A) Glycosylated hemoglobin

82) A nurse is reviewing the medical record of a client who is taking acetaminophen to relieve headache pain. Which of the following conditions in the client's history should the nurse identify as a contraindication? A) Hepatitis C B) Cystitis C) Diabetes mellitus D) Hypotension

A) Hepatitis C

92) A nurse is reinforcing teaching with a client who has GERD and a prescription for pantoprazole. Which of the following statements indicates an understanding of teaching? A) I have to take this medication on an empty stomach B) I will need to remain upright for 1 hour after taking the medication C) I can take antacids at the same time as this medication D) I should expect to have diarrhea while taking this medication

A) I have to take this medication on an empty stomach B) I will need to remain upright for 1 hour after taking the medication

168) A nurse is assisting with the care of a group of clients. Which of the following actions should the nurse take to manage her time effectively? (Select all that apply.) A) Keep track of how long it takes to complete certain tasks. B) COmplete activities with one client before moving to another client. C) Plan a time at the end of the shift to document nursing interventions. D) Delegate collecting of vital signs to the assistive personnel on the team. E) Make a priority to-do-list at the beginning of the shift.

A) Keep track of how long it takes to complete certain tasks. B) COmplete activities with one client before moving to another client. D) Delegate collecting of vital signs to the assistive personnel on the team. E) Make a priority to-do-list at the beginning of the shift.

119) A nurse is preparing to apply a thin-length sequential compression device for a client who is postoperative. Which of the following actions should the nurse take? A) Measure the circumference of the client's upper leg. B) Turn on the mechanical unit prior to applying the sleeve C) Wrap the sleeve loose around the client's lower leg. D) Position the client prone to apply the device.

A) Measure the circumference of the client's upper leg.

31) A nurse is assisting with the admission of an adolescent client who is supposed to have bacterial meningitis. Which of the following findings should the nurse expect? A) Nuchal rigidity B) Jaundice C) 2+ pedal edema D) hematuria

A) Nuchal rigidity

66) A nurse is preparing to complete a sterile dressing change for a client's wound. Which of the following actions should the nurse take first? A) Open the outermost flap of the sterile kit away from the nurse's body. B) Open the side flap of the sterile kit, allowing it to lie flat on the work surface. C) Apply sterile gloves. D) Open the flap on the sterile kit nearest to the nurse and place the flap on the work surface.

A) Open the outermost flap of the sterile kit away from the nurse's body.

123) A nurse is collecting data from a client who has an acute cholecystitis. Which of the followings findings should the nurse expect? A) Pain in the right upper abdomen. B) Increased abdominal discomfort prior meals C) Discomfort with urination D) Pain radiating to the jaw

A) Pain in the right upper abdomen.

122) A nurse in acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the followings informations should the nurse plan to include? A) Physical assessments findings B) Medical health insurance claims C) Family medical history D) Medications taken prior to admission

A) Physical assessments findings

78) A nurse is collecting data from a client who has left sided heart failure. Which of the following findings should the nurse notify the provider? A) Productive cough with pink, frothy sputum B) Pale, clammy skin C) Weight loss of 1kg (2.2 lb) in the past 24 hr. D) Fatigue when ambulating 152 m (500 ft)

A) Productive cough with pink, frothy sputum

41) A nurse is contributing to the plan of care for a client who is scheduled to receive electroconvulsive therapy (ECT) for the treatment of depression. Which of the following actions should the nurse recommend to include in the plan? A) Provide frequent reorientation after ECT B) Schedule follow-up ECT treatments 1 month apart C) Instruct the client to notify the provider if discomfort felt duringECT D) Initiate NPO status 1 hr prior to ECT

A) Provide frequent reorientation after ECT

51) A nurse is caring for a client who is taking warfarin and has an INR of 5.5. The nurse should expect which of the following instructions from the provider? A) Reduce the dosage of the medication. B) Administer protamine sulfate. C) Change the medication to heparin IV. D) Obtain an aPTT level.

A) Reduce the dosage of the medication.

147) A nurse is contributing to the plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. The client reports hearing voices. Which of the following interventions should the nurse plan to take? A) Reinforce that, although the voices are real to the client, the nurse does not hear them. B) Discourage the client from discussing the hallucinations. C) Ensure that the client avoids other forms of auditory stimulation, such as music or television. D) Provide extended periods of alone time for the client.

A) Reinforce that, although the voices are real to the client, the nurse does not hear them.

135) A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include in the tray? A) Roasted salmon B) Shrimp salad C) Pulled-pork sandwich D) Clam chowder

A) Roasted salmon

159) A nurse on a mental health unit observes a client yelling at another client. Which of the following actions should the nurse take first? A) State expectations for the client's behavior. B) Request security personnel restrain the client. C) Debrief staff members about the conflict. D) Place the client in seclusion.

A) State expectations for the client's behavior.

13) A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take? A) Tell the APs to stop the conversation. B) Document the event in the client's progress notes. C) Inform the client of the AP's actions. D) Submit an incident report to the risk manager.

A) Tell the APs to stop the conversation.

128) A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include? A) The discovers the electronic IV pump deliver twice the prescribed amount of fluid to a client B) A nurse observes the client's vomiting after receiving an oral pain medication. C) A nurse observes another nurse removing wrist restraints one at time in front the clients who are currently calm. D) A nurse discovers that a client's family member has administered a PCA dose.

A) The discovers the electronic IV pump deliver twice the prescribed amount of fluid to a client

72) A nurse determines that clients who receive zolpidem postoperatively have an increase fall rate compared to other postoperative clients. To which of the following members of the health care team should the nurse report these findings? A) The risk manager B) The pharmacist C) The case manager D) The surgeon

A) The risk manager

50) A nurse is preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report? A) Time of last pain medication B) Steps required for dressing change C) Preferred bath time D) Admission vital signs

A) Time of last pain medication

124) A nurse is caring for a client who has been admitted to the mental health unit.while reinforcing teaching about the clients prescribing medications, the nurse communicates truthfully about the adverse effect of the medications. Which of the following ethical concepts is the nurse exhibiting? A) Veracity B) Justice C) Beneficence D) Autonomy

A) Veracity

28) A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg. one tablet every 3 to 4 hours PRN for pain. the nurse inadvertently administers to tablets to the client. in which of the following location should the nurse document this client care incident? A) incident report B) providers progress notes C) controlled substance inventory record D) nursing care plan

A) incident report

17) The nurse is assisting with preparing a client who is to have central venous catheter inserted for the administration of Total parenteral Nutrition. Which of the following actions should the nurse take? A) verify the amount of tpn solution the client is receiving every 4 hours* B) prepare the client for a chest x-ray to verify catheter placement C) use clean technique when changing the catheter dressing D) place a client in Sims position for catheter insertion

A) verify the amount of tpn solution the client is receiving every 4 hours*

30) a nurse is reinforcing teaching with a support person of a client who is in the first stage of Labor. which of the following instructions should the nurse include regarding effleurage? A) " assist her to breathe in deeply at the beginning of each contraction" B) " Gently stroke her abdomen during contractions." C) "Apply steady pressure with the tennis ball to her sacral area" D) Help her to focus on an object in the room."

B) " Gently stroke her abdomen during contractions."

20) a nurse is reinforcing teaching with a client about collecting a stool specimen to check for adult blood. Which of the following statements by the client indicates an understanding of the teaching? A) " having urine Mix end with a stool will not affect the results" B) " I should have weight eating red meat for 3 days before my test"* C) " Eating pasteurised dairy products will affect my test results." D) "I should collect a specimen once each week for 4 weeks

B) " I should have weight eating red meat for 3 days before my test"*

7) A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report? A) " The client's mother died 4 years ago from breast cancer." B) " The client reports pain is reduced when he is positioned on his side." C) " The client's partner visited earlier today for 2 hours." D) " The client received the prescribed antibiotic every 8 hours."

B) " The client reports pain is reduced when he is positioned on his side."

3) A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make? A) " The psychiatric staff is not FBI. They are here to help you." B) " This must be very frightening for you. Let's talk more about it." C) " Why do you feel the staff is the FBI?" D) " What makes you think the staff is following you?

B) " This must be very frightening for you. Let's talk more about it."

11) A nurse is reinforcing teaching with a client who is at 16 weeks of gestation and has a prescription for ferrous sulfate to treat iron-deficiency anemia. Which of the following recommendations should the nurse make to improve the absorption of the medication? A) "Increase your dietary fiber intake." B) "Avoid drinking milk with the iron supplement"* C) "Eliminate berries and citrus fruits from your diet." D) "Take the iron supplement with green tea."

B) "Avoid drinking milk with the iron supplement"*

164) A male nurse is assigned to care for an older adult female client. The client tells the nurse that she wants a female nurse to care for her. Which of the following statements should the nurse make? A) "You will need to speak with the nurse manager about this." B) "I will ask to have you assigned to a female nurse." C) "I will get a female assistive personnel to provide your bath." D) "I care for other female clients and they do not mind having a male nurse."

B) "I will ask to have you assigned to a female nurse."

139) A nurse is reinforcing teaching with a parent of a newborn about home safety precautions. Which of the following statements by the parent indicates an understanding of the teaching? A) "I will attach the pacifier to my newborn's clothing with a string at bedtime." B) "I will make sure that I can fit one finger between the mattress and the side of my newborn's crib." C) "I will place my newborn's crib near a heat vent during cold weather." D) "I will place my newborn face up on a pillow when sleeping."

B) "I will make sure that I can fit one finger between the mattress and the side of my newborn's crib."

138) A nurse is reinforcing teaching with a parent of a newborn about home safety precautions. Which of the following statements by the parent indicates an understanding of the teaching? A) "I will attach the pacifier to my newborn's clothing with a string at bedtime." B) "I will make sure that i can fit one finger between the mattress and the side of my newborn's crib." C) "I will place my newborn's crib near a heat vent during cold weather." D) "I will place my newborn face up on a pillow when sleeping."

B) "I will make sure that i can fit one finger between the mattress and the side of my newborn's crib."

144) A nurse is reinforcing teaching with a client who is at 12 weeks of gestation and has hyperemesis gravidarum. Which of the following client statements indicates an understanding of the nurse's instructions? A) "I will eat or drink something every 2 to 3 hours throughout the day." B) "I will try to eat balanced meals instead of only foods that appeal to my taste." C) "I will wait 1 hour after getting up in the morning to have breakfast." D) "I will eat a low-protein snack 30 minutes before going to bed each night."

B) "I will try to eat balanced meals instead of only foods that appeal to my taste."

33) A nurse working in a clinic is reinforcing teaching with a client who has hepatitis A. Which of the following client statements indicates an understanding of the teaching? A) "I will wash my hands using alcohol-based cleanser" B) "I will use different hand towels than others in the home"* C) I know that this virus is transmitted by contact with my blood" D) "I can continue to prepare meals for my family"

B) "I will use different hand towels than others in the home"*

140) A charge nurse is reinforcing teaching with a newly licensed nurse about the nurse's role in obtaining informed consent. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A) "I will sign the consent form to indicate that the client has received written materials explaining the procedure." B) "It is my responsibility to obtain informed consent from the client prior to the procedure." C) "When I sign the consent for, I am stating that the client appears to be competent to give consent. D) "I will provide the client with an explanation of the procedure before I sign the consent form."

B) "It is my responsibility to obtain informed consent from the client prior to the procedure."

49) A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states, I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make? A) "If i turn him on his side, maybe he'll go back to sleep." B) "Let me show you how to swaddle and cuddle him, then you try." C) "I'll take him back to the nursery, so you can get some rest." D) "Babies need to cry soon after they are born to develop their lungs."

B) "Let me show you how to swaddle and cuddle him, then you try."

57) A charge nurse is reinforcing teaching with a newly licensed nurse about infection control measures. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A) "Droplet precautions require that I wear a gown and gloves when providing client care." B) "Soiled dressings should be placed in a biohazard trash receptacle." C) "For a client who has clostridium difficile, I will cleanse my hands wirth an alcohol-based rub." D) "Following a blood spill, I should use a bleach solution with a ratio of 1 to 20."

B) "Soiled dressings should be placed in a biohazard trash receptacle."

42) A charge nurse is discussing confidentiality requirements with a newly licensed nurse when sharing a client's medical information. Which of the following individuals should the charge nurse identify as appropriate with whom to share client information? A) A client's partner after the client reports intimate partner abuse B) A social worker who is assigned to an involuntarily committed school-age client C) A nurse from another unit after a client commits suicide D) A client's employer who is concerned about safety due to substance use

B) A social worker who is assigned to an involuntarily committed school-age client

155) A nurse is caring for an older adult client who reports dry, itchy skin. Which of the following actions should the nurse take? A) Apply powder to the client's skin. B) Add moisturizing oil to the client's bath water. C) Place a humidifier in the client's room. D) Encourage the client to bathe frequently.

B) Add moisturizing oil to the client's bath water.

145) A nurse on a hospice unit is caring for a client who has cancer and is in the active phase of dying. Which of the following findings requires intervention by the nurse? A) Benzodiazepines are administered every 4 hr. B) An assistive personnel is encouraging intake of oral fluids. C) Supplemental oxygen is in use. D) A family member remains at the client's bedside 24 hr each day.

B) An assistive personnel is encouraging intake of oral fluids.

86) A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use? A) Wait 1 min between suctioning attempts B) Apply intermittent suction for 30 seconds C) Apply suction while inserting the catheter D) Insert the catheter 10 cm (4 in.)

B) Apply intermittent suction for 30 seconds

99) A nurse at a long term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel ? A) Evaluate the need for the client to remain in mitten restraints. B) Assist the client with range of motion exercises of the hands C) Determine the circulation status of the affected extremities every 2 hr. D) Instruct the client's family about the purpose of mitten restraints.

B) Assist the client with range of motion exercises of the hands

149) A nurse is caring for a client who has a femur fracture with the leg in Buck's traction. Which of the following actions should the nurse take? A) Apply 6.8 kg (15 lb) of weight for use in traction. B) Compare bilateral pedal pulses. C) Position the knot of the rope at the top of the pulley. D) Remove the weights for 20 min for the client's report of severe pain.

B) Compare bilateral pedal pulses.

134) A nurse is reinforcing teaching with a client who has stomatitis. Which of the following instructions should the nurse include in the teaching? A) Use lemon glycerin swabs. B) Consume soft, bland foods. C) Eat foods high in vitamin B12. D) Rinse the mouth with an alcohol-based mouthwash.

B) Consume soft, bland foods.

54) A nurse is completing post mortem documentation for a client. Which of the following information should the nurse include in the documentation? A) Location of the identification tag on the client's body. B) Copy of the client's advance directives. C) Last set of the client's vital signs D) Cause of the client's death.

B) Copy of the client's advance directives.

81) A nurse caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take? A) Raise the head of the bed to a 45-degree angle. B) Cover the wound with sterile, saline-soaked gauze. C) Place the client's knees in an extended position. D) Hold gentle, direct pressure on the protruding organ.

B) Cover the wound with sterile, saline-soaked gauze.

10) A nurse is assisting with the development of an education program for a group of older adults. Which of the following actions should the nurse take first? A) Create handouts for participants. B) Determine the literacy level of participants. C) Schedule a time to implement the program. D) Establish learning outcomes.

B) Determine the literacy level of participants.

143) A nurse is collecting data from the caregiver of a client who has alzheimer's disease. The caregiver reports the client has difficulty sleeping at night and wanders throughout the house. Which of the following interventions should the nurse recommend? A) Give the client a carbituate medication at bedtime. B) Encourage the client to take frequent walks during the day. C) Put a simple lock on the client's bedroom door. D) Allow the client to nap for at least 1 hr during the day.

B) Encourage the client to take frequent walks during the day.

75) A nurse is caring for a client who is in isolation precautions. Which of the following pieces of personal protective equipment should the nurse remove first? A) Mask B) Gloves C) Gown D) Eyewear

B) Gloves

107) A nurse is collecting data from a 6 month old infant during a well child visit. Which of the following findings should the nurse report to the provider? A) Feeding Habits B) Gross Motor Skills C) Weight D) Temperature

B) Gross Motor Skills

37) a nurse is reinforcing teaching with a new mother about facility security measures. which of the following statements by the mother and the case an understanding of the teaching? A) I can take my baby to the lobby to visit family B) I will have an identification band the matches the one my baby wears C) I can remove my security band to give it to a family member D) I will carry my baby to the nursery

B) I will have an identification band the matches the one my baby wears

104) A nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches. Which of the following statements indicates an understanding of the teaching? A) I will replace the patch every 12 hours B) I will place the patch on a hairless area of skin C) I will apply the patch in the same place every day D) I will remove the patch if I develop a headache.

B) I will place the patch on a hairless area of skin

96) A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy in 1 week. Which of the following client statements indicates an understanding of the teaching? A) This procedure will take place while I'm under general anesthesia B) I'll have my friend drive me home after the procedure C) I can expect rectal bleeding for a week after the procedure D) I will follow a full-liquid diet the day before the procedure

B) I'll have my friend drive me home after the procedure

127)A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement? A) Have visitors remain at least 0.91 m (3 feets) away from the client. B) Initiate contact precaution for the client. C) Assign the client to a negative pressure airflow room. D) Administer aspirin if the client develops a fever.

B) Initiate contact precaution for the client.

48) A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial. Which of the following actions should the nurse take next? A) Place the cap over the needle. B) Inject 15 units of air into the regular insulin vial. C) Verify the dosage with another nurse. D) Withdraw 10 units of NPH insulin.

B) Inject 15 units of air into the regular insulin vial.

163) A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures? A) Irrigation of a wound with antibiotic solution B) Insertion of a nasogastric tube C) Placement of a central venous catheter D) Administration of an iron injection using Z-track technique

B) Insertion of a nasogastric tube

172) A nurse is positioning a client in preparation for a lumbar puncture. In which of the following position should the nurse place the client? A) Semi-Fowler's B) Lateral recumbent C) Prone D) Lithotomy

B) Lateral recumbent

47) A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan? A) Keep the client's daily protein intake below 0.8g/kg. B) Measure the client's abdominal girth daily. C) Position the client supine with legs elevated. D) Restrict the client's sodium intake to 3 g per day.

B) Measure the client's abdominal girth daily.

39) a nurse in an acute mental health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client? A) Offer the client a nutritious snack every 4 hr B) Monitor the client's range of motion every 60 min C) Plan to remove the restraints as soon as the client is calm D) Ensure that the provider has signed prescription for restraints within 48 hr

B) Monitor the client's range of motion every 60 min

43) A nurse is reviewing the home medications of a client who recently had transient ischemic attacks and is to begin taking clopidogrel. The nurse should instruct the client that which of the following over-the-counter medications interacts adversely with clopidogrel? A) Vitamin d3 B) Naproxen C) Ranitidine D) Docusate Sodium

B) Naproxen

174) A nurse is collecting data from a client who is 12 hr postoperative following intestinal surgery. Which of the following findings should the nurse report to the charge nurse prior to client ambulation? A) Oral temperature 37.6C (99.7 F) B) Oxygen saturation 90% C) Apical pulse rate 88/min D) Respiratory rate 20/min

B) Oxygen saturation 90%

166) A nurse is caring for a client who has recently died. Which of the following actions should the nurse take? A) Remove the client's dentures. B) Place a pillow under the client's head. C) Remove the absorbent pads from underneath the client. D) Place the client in high fowler's position.

B) Place a pillow under the client's head.

85) A nurse is caring for a client who is unable to perform ADLs and wears dentures. Which of the following actions should the nurse take when providing denture care A) Remove the lower dentures before the upper dentures B) Place a towel in the sink when cleaning the dentures C) Store the dentures in a dry denture cup on the bedside table after cleaning D) Use a circular motion to cleanse the biting surface of the dentures

B) Place a towel in the sink when cleaning the dentures

101) A nurse is reviewing the medical record of a client who has COPD. Which of the following laboratory findings indicates a need to request a dietary referral for the client ? A) Potassium 3.5 mEq/L B) Prealbumin 13 mg/dL C) Sodium 138 mEq/L D) Total Calcium 10 mg/dL

B) Prealbumin 13 mg/dL

102) A community health nurse is developing a brochure about hypertension. Which of the following actions should the nurse take? A) Use a 12 point font size B) Present information from complex to simple C) Explain medical terminology using basic , one syllable words D) Write the information at an 8th grade reading level.

B) Present information from complex to simple

142) A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm. The nurse places wrist restrains on the client. Which of the following actions should the nurse take? A) Contact the provider within 48 hr to obtain a prescription for the restrains. B) Remove the restrains from the client's wrists every 2hr. C) Fasten the restriains' ties to the bed's side rails. D) Check that one finger will fit between the client's wrists and the restraints.

B) Remove the restrains from the client's wrists every 2hr.

9) A nurse is participating in a performance improvement program. Which of the following actions should the nurse take to evaluate the effectiveness of the program? A) Define the problem. B) Review the facility's policy and procedure manual. C) Perform chart audits. D) Identify data collection methods.

B) Review the facility's policy and procedure manual.

105) A nurse overhears two assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first? A) Speak to the staff members in private about client confidentiality B) Tell the staff members to stop their discussions C) Report the incident to the charge nurse D) Participate in an in service about client confidentiality

B) Tell the staff members to stop their discussions

179) A nurse is preparing to delegate client care to an assistive personnel (AP). Which of the following information should the nurse verify prior to delegation? A) The AP's years of experience B) The AP's job description C) The client's age D) The client's length of facility stay

B) The AP's job description

95) A nurse is assisting in developing a list of internet sites for clients to obtain valid health information. When evaluating internet resources. Which of the following findings indicates the information likely contains credible medical information? A) The website URL is listed as .com B) The authors name is listed without credentials C) The author cites references to statements made D) The website was last updated 3 years ago

B) The authors name is listed without credentials

16) a nurse is planning to obtain at 12- lead ECG for a client who has history of cardiac dysrhythmias. which of the following actions should the nurse plan to take? A) tell the client to expect a mild stinging sensation during the test B) instruct the client to remain as still as possible during the recording C) assisted client to the orthopneic position D) attach a blood pressure cuff to the clients upper arm

B) instruct the client to remain as still as possible during the recording

25) a home health nurse is conducting a home inspection for a client who is at risk for Falls. which of the following instruction should the nurse provide for the client? A) keep Lighting in the home dim B) move the clients bed to the main floor of the house C) Place area rugs on slick floor surfaces D) place a bet site table 2 feet away from the bed

B) move the clients bed to the main floor of the house

14) A nurse is collecting a health history from the guardian of a four-year-old child. Which of the following statements by the guardian is the priority for the nurse to address? A) "My child continually asking the same questions." B) " I have a difficult time getting my child to eat green vegetables." C) " I have noticed that my child is withdrawn since we switched daycare providers."* D) " my child still wets the bed at least two times per week."

C) " I have noticed that my child is withdrawn since we switched daycare providers."*

152) A nurse is reinforcing teaching with the guardian of a 2-month-old infant about immunization. Which of the following statements by a guardian indicates an understanding of the teaching? A) "I should not feed my baby anything for 2 hours prior to an immunization." B) " My baby will receive the rotavirus immunization orally." C) " I should expect my baby to have a high fever for 24 hours after an immunization." D) "My baby will receive three doses of the meningococcal immunization before kindergarten."

C) " I should expect my baby to have a high fever for 24 hours after an immunization."

173) A nurse is reinforcing teaching with a client who has a new prescription for ciprofloxacin. Which of the following information should the nurse include in the teaching? A) "Restrict your daily fluid intake while taking this medication." B) "This medication can increase your risk for sunburn." C) "Expect to experience diarrhea while taking this medication." D) "Take an antacid if the medication causes gastrointestinal upset."

C) "Expect to experience diarrhea while taking this medication."

24) A nurse is reviewing information about advance directives with a newly admitted client. which of the following statements by the client indicates an understanding of the information? A) " advance directives include instructions for resolving financial matters after my death B) "Federal legislation dictates the legal guidelines for advance directives" C) "advance directives include a living will" D) " my medical records should not include my advance directives"

C) "advance directives include a living will"

93) A nurse is caring for a client who has terminal cancer. Which of the following actions should the nurse take to promote the clients autonomy? A) Be honest with the client about the prognosis B) Provide privacy during client care procedures C) Allow the client to choose treatment times D) Administer pain medication on a routine schedule

C) Allow the client to choose treatment times

114) A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicate the client is experiencing a transfusion reaction? A)temperature 38.8 (101.8 F) B) blood pressure of 158/92 mm Hg C) Apical pulse rate 58/min D) Straw-colored urine

C) Apical pulse rate 58/min

8) A nurse is assisting with the plan of care for a client who is in the third trimester of pregnancy and has ankle edema. Which of the following interventions should the nurse include in the client's plan of care? A) Limit fluid intake. B) Administer diuretics. C) Apply support stockings. D) Place on bedrest.

C) Apply support stockings.

84) A nurse is reinforcing teaching a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching ? A) Limit fluid intake to 750mL per day B) Cleanse the neck by rubbing with a washcloth C) Avoid exposing the neck to the cold D) Eat three large meals each day

C) Avoid exposing the neck to the cold

106) A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group? A) Express curiosity about the funeral service B) Understands that everyone dies eventually C) Believes the death is punishment for bad behavior D) Recognizes the parent will never wake up

C) Believes the death is punishment for bad behavior

178) A nurse is caring for a 3-year-old child immediately following a tonic-clonic- seizure. Which of the following actions should the nurse take? A) Place the child in a supine position. B) Offer the child sips of clear liquids C) Check the child for oral injuries. D) Administer an oral antiepileptic medication.

C) Check the child for oral injuries.

4) A nurse is reinforcing discharge teaching with the caregiver of a client who has a dependent personality disorder. Which of the following instructions should the nurse include in the teaching? A) Assume responsibility for making the client's decisions. B) Limit the client's social interactions. C) Encourage the client to be assertive. D) Maintain a verbal no-harm contract with the client.

C) Encourage the client to be assertive.

150) A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take to promote progression toward independence and mobility for the client? A) Keep a loose, absorbent dressing over the client's surgical site. B) Maintain abduction of the client's residual limb with a pillow. C) Encourage the client to use the overbed trapeze. D) Caution the client to avoid prone position while in bed.

C) Encourage the client to use the overbed trapeze.

87) A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure? A) Inform the client the procedure will take 60 min B) Administer an oral contrast solution C) Ensure that the client gave informed consent D) Ensure that the clients bladder is full

C) Ensure that the client gave informed consent

62) A nurse is collecting data from a client who is in the manic phase of bipolar disorder. Which of the following findings should the nurse expect? A) Hypersomnia B) Slurred speech C) Grandiose thinking* D) Blunted affect

C) Grandiose thinking*

157) A community health nurse is assisting with the development of a pamphlet regardingchoking hazards for toddlers. Which of the following foods should the nurse include? A) Potatoes B) Corn C) Grapes D) Oranges

C) Grapes

108) A nurse is caring for a client who has toxoplasmosis and asks about the cause of the infection. Which of the following responses should the nurse make? A) Touching Body Fluids B) Drinking contaminated water C) Handling cat feces D) Eating shellfish

C) Handling cat feces

27) a nurse in a provider's office is reinforcing teaching about skin care with a client who has a new diagnosis of systemic lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching? A) I will dry my skin by patting it with a towel" B) I will limit my time in the tanning bed for 15 minutes C) I will cleanse my skin using antibacterial soap D) I will use an astringent on my face

C) I will cleanse my skin using antibacterial soap

34) A nurse is reinforcing teaching with a client who has a prescription for ferrous sulfate elixir. which of the following statements by the client indicates an understanding of the teaching? A) I can prevent nausea if I take the medication on an empty stomach B) I can prevent constipation if I drink more milk while taking this medication C) I will mix the medication with a full glass of water D) I will report black stools to my doctor

C) I will mix the medication with a full glass of water

129) a nurse is collecting data from a client who is 12 weeks of gestation. The client states, " we have been trying to get pregnant for several months", but now I'm not sure I'm ready. Which of the following responses should the nurse make? A) You need to talk to the therapist about how you feeling. B) Why do you feel the way if youve been trying to get pregnant C) Many womens experience feelings of ambivalence during pregnancy D) I wouldnt worry about it if i were you. Youll be a good mother

C) Many womens experience feelings of ambivalence during pregnancy

52) A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first? A) Administer an anti-anxiety medication. B) Explore behaviors that have helpful to reduce the client's anxiety in the past. C) Minimize environmental stimuli in the client's surroundings. D) Explain to the client that anxiety causes physical manifestations.

C) Minimize environmental stimuli in the client's surroundings.

176) A nurse in a provider's office is caring for a group of clients who has communicable diseases. Which of the following infections should the nurse report to the state health department? A) Impetigo contagiosa B) Human Papillornavirus C) Neisseria gonorrhoeae D) Sarcoptes Scabiei

C) Neisseria gonorrhoeae

115) A nurse is monitoring a client who is postoperative. Which of the following action should the nurse take when collecting data about the client's respirations? A)place the client in a supine position B) Inform the client when beginning to observe his respirations C) Observe the movements of the client's chest wall D) Counts the client's respirations for 15 seconds.

C) Observe the movements of the client's chest wall

121) A nurse is collecting data from a client during a routine prenatal visit. The client is in the second trimester of pregnancy and reports feeling dizzy. Has a racing heart, and becomes pale while lying on their back. Which of the followings actions should the nurse take? A) Check the clients temperature. B) Instruct the client to take a brisk walk. C) Position the client on their left side D) Provide the client a glass of orange juice

C) Position the client on their left side

100) A nurse is caring for a client who has anorexia nervosa and a behavioral management plan in place. Which of the following findings should the nurse identify as an indication that the behavioral plan is effective? A) Sodium 130 mEq/L B) Hgb 10 g/dL C) Potassium 3.5 mEq/L D) BMI 14.5

C) Potassium 3.5 mEq/L

120) A nurse is contacting an occupational therapist for a client who had a stroke with right-sided weakness and has difficulty eating. Which of the following roles should the nurse expect the occupational therapist to perform? A) Promotes health by ensuring the clients nutritional needs are met. B) Uses heat,massage and water to treat a client's strength and movement C) Provides and adjust devices to assist the client with daily living activities D) Assists in findings an economics living arrangements for the clients

C) Provides and adjust devices to assist the client with daily living activities

83) A nurse is reinforcing teaching about passive range-of-motion exercises with the family of a client who has had a stroke. Which of the following instructions should the nurse include in the teaching? A) Move each joint just past the point of resistance. B) Position the bed at mid-thigh level. C) Support the extremity above and below each joint during the exercise. D) Repeat each exercise movement 10 times.

C) Support the extremity above and below each joint during the exercise.

32) A nurse is about to administer an intermittent enteral feeding to a client who has an NG tube in place. Besides obtaining an x-ray. Which of the following methods should the nurse use to verify the placement? A) Inject air and listen to the bubbling. B) Measure the gastric residual C) Test the pH of the gastric aspirate D) Add food coloring to the formula

C) Test the pH of the gastric aspirate

45) A nurse is participating in an interprofessional client care conference for a client who has experienced a stroke. The nurse should identify that which of the following client care issues requires reporting to the interprofessional team? A) The client is unable to grasp eating utensils. B) The client requests to perform ADLs later in the day. C) The client requires reinforcement of teaching about the purpose of his medications. D) The client tells the nurse he prefers a snack before bedtime.

C) The client requires reinforcement of teaching about the purpose of his medications.

90) A nurse on a mental health unit is reinforcing teaching with a client who has anorexia nervosa. Which of the following statements by the client indicates an understanding of the teaching? A) I should gain half of a pound per week to meet my treatment goal. B) The staff will weigh me every night before i got to bed C) The staff will watch me closely for 1 hour after each meal D) The treatment goal is to be within 60 percent of my ideal body weight.

C) The staff will watch me closely for 1 hour after each meal

2) A nurse is collecting data from a client who uses a continuous positive airway pressure(CPAP) machine at night for sleep apnea. The nurse should identify which of the following findings as an indication of proper cpap use? A) The mask is secured over the client's mouth and the client's nose is uncovered. B) The therapeutic dose of albuterol is being inhaled. C) There is one finger width between the strap on the mask and the client's face. D) The mask fits loosely so air can escape from underneath.

C) There is one finger width between the strap on the mask and the client's face.

112) A nurse is assisting in providing postmortem care for a client who was a devout follower of Hinduism. Which of the following requests should the nurse anticipate from the client's family? A) To stay with the client's body for 8 hr following their death B) To bury the client's body within 24 hr of their death C) To prohibit medical personnel from touching the client's body D) To cremate the client's body

C) To prohibit medical personnel from touching the client's body

111) A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider? A) Urine specific gravity 1.020 B) Serum creatinine 1.0 mg/dL C) Urine Output 12ml/hr D) BUN 18 mg/dL

C) Urine Output 12ml/hr

91) A nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of the following findings should the nurse report to the provider? A) BUN 15 mg/dL B) Hgb 13.2 g/dL C) Urine protein 3+ D) Fasting blood glucose 72 mg/dL

C) Urine protein 3+

70) A nurse is supervising an assistive personnel (AP) who is providing client care. The nurse should identify that which of the following actions by the AP demonstrates effective use of supplies? A) Wears an N95 mask when bathing a client who has Clostridium difficile B) Disposes of contaminated sheets in a linen bag C) Wears clean gloves when performing oral hygiene D) Empties the sharps contained when it is full

C) Wears clean gloves when performing oral hygiene

19) A nurse in an acute care setting is preparing to administer medications to a client. which of the following information should the nurse obtain to identify the client? A) name of the client's provider B) room number of the client C) clients telephone number D) clients for medical diagnosis

C) clients telephone number

38) a nurse is providing a client with IV fluids and finds that the IV pump screen is malfunctioning. Which of the following actions should the nurse take? A) replace the IV pump's tubing B) plug the IV pumps cord into a different Outlet C) discontinue use and tag the IV pump D) clear the settings and reset the IV pump

C) discontinue use and tag the IV pump

21) a nurse is assisting with the planning of an in-service about updates in wound care for nursing staff. which of the following sources should the nurse identify as providing the best evidence-based information? A) first-hand experience with wound care products B) a peer-reviewed journal article C) information from a wound care product vendor D) an entry on a nursing block the dressing wound healing

C) information from a wound care product vendor

*23) A nurse is collecting data from a client whose partner died 1 year ago which of the following findings indicates that the client is experiencing complicated grief? A) the client attends a grief support group twice each month B) the client keeps a framed picture of his partner on the wall C) the client develops chest pain each time he talks about his partner* D) The client reports he has no interest in dating

C) the client develops chest pain each time he talks about his partner*

29) a nurse is collecting data from a client who has 8 hour post-operative following an appendectomy. which of the following manifestations is the best indication that the client needs a prn analgesic? A) The cleint demonstrates a decrease attention span B) the clients heart rate has increased to 110/min C) the client reports pain as 7 on a scale of zero to ten* D) the client grimaces when changing positions

C) the client reports pain as 7 on a scale of zero to ten*

117) A nurse is reinforcing teaching with a client who has a new prescription for cervical cap as a form of contraception. Which of the following statements by the client indicates an understanding of the teaching? A) " I need to have my provider check the size of the cap every 6 months " B) " I should avoid using spermicide with the cervical cap " C) " I should use the cap on menstrual cycle to prevent pregnancy " D) " I need to keep the cap in place for at least 6 hours after intercourse "

D) " I need to keep the cap in place for at least 6 hours after intercourse "

125) A nurse is reinforcing teaching about newborn care with a new guardian. Which of the following statements by the guardians indicates an understanding of the teaching? A) " I will wash my baby's face warm. Wet washcloth without soap " B) " I will give my baby a bath everyday" C) " I will bathe my baby under a faucet of running water" D) " I will wash my baby's head using a moist towelette"

D) " I will wash my baby's head using a moist towelette"

46) A nurse is reinforcing teaching about preventing dental caries with the parent of a 12-month-old toddler. Which of the following instructions should the nurse provide? A) "Position the bristles of your child's toothbrush against the teeth at a 90-degree angle." B) "Floss between your child's teeth before brushing." C) "Use a 5-inch strip of toothpaste on the toothbrush." D) "Clean the teeth with a small, soft-bristled toothbrush."

D) "Clean the teeth with a small, soft-bristled toothbrush."

153) A nurse is reinforcing teaching about palliative care to a client who has cancer. Which of the following statements should the nurse make? A) "It is for client who have a terminal illness." B) "It includes restriction of nutritional support." C) "It is for clients who are given 6 months or less to live." D) "It enhances quality of life by promoting comfort."

D) "It enhances quality of life by promoting comfort."

73) A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective? A) "Our child has increased his daily caloric intake." B) "Our child has lost some weight since the last appointment." C) "Our child has a better grasp of reality." D) "Our child is able to complete his homework on time."

D) "Our child is able to complete his homework on time."

130) A nurse is assisting with the care of a client who is receiving chemotherapy and radiation for advanced chemotherapy and radiation for advanced breast cancer. The client states, "I am thinking about stopping the treatment." Which of the following responses should the nurse make? A) "You'll be cancer-free after you complete your treatments." B) "Why do you think that would be a good choice?" C) "I would feel the same way if I were you." D) "Tell me more about what you are thinking."

D) "Tell me more about what you are thinking."

79) A nurse is preparing a vitamin K injection to give to a newborn. The newborn's mother question the purpose of the medication. Which of the following responses should the nurse make? A) "This medication will increase the absorption of nutrients in the intestines." B) "This medication will decrease the possibility of your newborn developing jaundice." C) "This medication will increase the immunity of your newborn." D) "This medication will decrease the risk of hemorrhage in your newborn."

D) "This medication will decrease the risk of hemorrhage in your newborn."

44) A nurse is reviewing the medical records of five clients. For which of the following events should the nurse write an incident report? A) A client received an 0900 daily medication at 1000. B) A client who has an infection refused the evening meal. C) A client received the first dose of an antibiotic 1 hr before the collection of blood for culture and sensitivity testing. D) A client fell when ambulating to the bathroom alone. E) An approximate amount of urine was recorded after the urine leaked from the client's catheter bag.

D) A client fell when ambulating to the bathroom alone.

133) A nurse is caring for a group of clients. Which of the following client's should the nurse recognize is experiencing fluid volume excess? A) A client who has COPD and an oxygen saturation of 92% B) A client who has a urinary tract infection with bladder distention two fingerbreadths below the umbilicus C) A client who is 1 day postoperative and has an Hgb level of 16g/dL. D) A client who has heart failure and has had orthopnea for 2 days.

D) A client who has heart failure and has had orthopnea for 2 days.

80) A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions. Which of the following actions should the nurse take? A) Tell the client to push during contractions. B) Instruct the client to change positions frequently. C) Encourage the client to soak in a hot bath. D) Apply fundal pressure during contractions.

D) Apply fundal pressure during contractions.

113) A nurse is providing preoperative care to a client who reports he has no one at home to help him after his outpatient surgery. Which of the following actions should the nurse take? A) Give the client a list of home care assistants to contact B) Contact the next of kin to assist the client at home C) Call the provider about admitting the client to the facility overnight D) Assist with a referral to a home health care agency

D) Assist with a referral to a home health care agency

118) A nurse at the providers office is caring for client who is in the third trimester of pregnancy. Which of the following findings should the nurse report to the provider? A) Shortness of breath when climbing stairs. B) Leukorrhea C) Periodic numbness of the fingers D) Blurred vision

D) Blurred vision

55) A nurse is collecting data from a client who has alcohol use disorder and is experincing withdrawal. Which of the following manifestations should the nurse expect? A) Constipation B) Hypertension C) Polyuria D) Bradycardia

D) Bradycardia

18) A nurse is assisting with a prenatal Examination for a client who is at 8 weeks of gestation. the nurse notes of the clients vagina and vulva are a purplish color. the nurse document the finding as which of the following? A) Hegar's sign B) Chloasma C) Ballottement D) Chadwick's sign

D) Chadwick's sign

109) A nurse is collecting data from a client who is at 20 weeks of gestation and has been taking ferrous sulfate. For which of the following findings should the nurse monitor as a common adverse effect of iron supplementation and report to the provider? A) Hematuria B) Dry Mouth C) Tinnitus D) Constipation

D) Constipation

141) A nurse is collecting data from a 9-year-old during a well-child visit. Which of the following findings should the nurse expect? A) Expresses conflict over the independence and control B) Grasps concept of cause-and-effect C) Displays emotional detachment from parents D) Demonstrates self-centered thinking

D) Demonstrates self-centered thinking

162) A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the following actions should they take first? A) Obtain the client's ABG levels. B) Prepare the client for a ventilation-perfusion scan. C) Place the client on the bedrest. D) Elevate the head of the client's bed.

D) Elevate the head of the client's bed.

171) A nurse on a medical-surgical unit is assisting with the admission of a client who has advanced lung cancer. Which of the following actions regarding advanced directives should the nurse take? A) Tell the client that a family member should serve as a health care surrogate, B) Contact the facility's risk manager to verify if the client has a living will. C) Document the client's decisions about end-of-life carein the medical record. D) Ensure that an attorney has reviewed the client's advanced directives.

D) Ensure that an attorney has reviewed the client's advanced directives.

69) A nurse is caring for a client who has been given methylergonovine intramuscularly for a post partum hemorrhage. The nurse should monitor for which of the following adverse effects? A) Elevated blood pressure B) Uterine relaxation C) Diarrhea D) Hematuria

D) Hematuria

97) A nurse is reinforcing teaching with a parent of a 4 month old infant during a home visit. Which of the following statements by the parent indicates an understanding of the teaching? A) I will leave my baby's bib on while he is sleeping B) I will leave the plastic covering on the crib mattress C) I will lay my baby's head on a pillow while he is in the crib D) I will use a cool mist vaporizer in my baby's room

D) I will use a cool mist vaporizer in my baby's room

103) A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take? A) Coil the tubing on the bed above the collection bag B) Secure the tubing with adhesive tape to the lower abdomen C) Collect a sterile specimen from the urinary drainage bag D) Instruct the client to hold the drainage bag at waist height when ambulating

D) Instruct the client to hold the drainage bag at waist height when ambulating

67) A nurse is collecting data from a client who is in renal failure. The nurse should identify that which of the following findings is a manifestation of hyperkalemia? A) Trousseau's sign B) Hyperactive reflexes C) Dry mucous membranes D) Irregular heart rate

D) Irregular heart rate

165) A nurse is caring for a client who has admitted for observation following a head injury. Which of the following findings by the nurse indicates the client is experiencing increased intracranial pressure? A) Decreased blood pressure B) Pin-point pupils C) Pallor D) Irritability

D) Irritability

89) A nurse is reinforcing teaching with a parent of a preschooler about immunizations. Which of the following statements by the parent indicates an understanding of the teaching? A)"I understand that immunizations will be withheld if my child has lactose intolerance. B) I can make several office visits , so my child does not get so many immunizations at once. C) My child will need to start the human papillomavirus series when he enters kindergarten D) It is recommended that my child receive his first flu immunization at the age of 6

D) It is recommended that my child receive his first flu immunization at the age of 6

180) A nurse is using a glucometer to measure a client's capillary blood glucose level. Which of the following actions should the nurse take? A) Wears sterile gloves. B) Select the central tip of a finger. C) Test the first drop of blood that forms after the puncture. D) Keep the finger in a dependent position.

D) Keep the finger in a dependent position.

74) A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include? A) Use written signs to assist the client with locating the bathroom. B) Use confrontation to manage the client's behavior. C) Provide a stimulating environment for the client. D) Limit the number of choices for the client.

D) Limit the number of choices for the client.

131) A nurse is reinforcing teaching with a newly licensed nurse about transcribing medication prescriptions. Which of the following prescriptions should the newly licensed nurse identify is an accurate transcription? A) Doxazosin .5 mg PO at bedtime B) Heparin 5000 U subcutaneous every 8 hr C) MgSO4 1g PO daily D) Lorazepam 0.5 mg PO PRN at bedtime

D) Lorazepam 0.5 mg PO PRN at bedtime

88) A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect? A) Loose stools B) Increased appetite C) Bladder infection D) Loss of taste

D) Loss of taste

132) A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? A) Turn the child onto their back. B) Restrain the child's upper extremities. C) Place a padded tongue blade in the child's mouth. D) Place a pillow under the child's head.

D) Place a pillow under the child's head.

35) a nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphasia. which of the following instruction should the nurse include in the teaching? A) give the client a straw to use for drinking B) use a needleless syringe to instill feedings C) provide thin liquids to help the client swallow D) Place oral suction equipment next to the client's bedside

D) Place oral suction equipment next to the client's bedside

126) A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include? A) Position the car seat a 90 angle B) Put a small cushion under the newborn's head for support. C) Keep the airbag on if the car seat is on the front seat D) Place the shoulder harness at the level of the infant's shoulders.

D) Place the shoulder harness at the level of the infant's shoulders.

77) A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment? A) Improved absorption of vitamins B and C B) Decreased sodium excretion C) Improved respiratory function D) Reduced fat in the stools

D) Reduced fat in the stools

137) A charge nurse is monitoring a group of assistive personnel (AP) regarding the use of gloves in contact isolation. For which of the following actions by an AP should the charge nurse intervene? A) CHanges gloves between tasks for the same client B) Washes hands after removing gloves C) Pulls gloves off inside-out when tasks are completed D) Removes gloves last after other personal protective equipment

D) Removes gloves last after other personal protective equipment

76) A home health nurse is caring for an older adult client who lives with a family caregiver who has urinary incontinence. The client states "I guess I will be locked in my room again for wetting the bed." Which of the following actions should the nurse take? A) Contact the client's caregiver to discuss the client's comment. B) Review the medical record to see if the client has reported abuse in the past. C) Restrict family members from visiting with the client. D) Report the suspected abuse to the nurse manager.

D) Report the suspected abuse to the nurse manager.

175) A nurse is caring for a client who speaks a different language than the nurse. The client's partner tells the nurse that the client would like to go home against medical advice(AMA). Which of the following actions should the nurse take? A) Discharge the client and notify the health care provider. B) Have the client's partner sign an AMA form. C) Ask the partner to reinstate the consequences of leaving AMA to the client. D) Request the services of an interpreter to determine the client's wishes.

D) Request the services of an interpreter to determine the client's wishes.

110) A nurse is administering hydromorphone to a client who is experiencing postoperative pain. Which of the following findings is an adverse effect of this medication? A) Hypertension B) Urinary retention C) Dilated Pupils D) Tachypnea

D) Tachypnea

58) A nurse is caring for a client who has major depressive disorder and is taking an antidepressant. The nurse should identify which of the following findings as the priority to report to the provider? A) The client is withdrawn and uncommunicative. B) The client reports a change in sleeping patterns. C) The client neglects personal hygiene. D) The client has a sudden increase in energy.

D) The client has a sudden increase in energy.

71) A nurse is contributing to the plan of care for a client who is experiencing panic-level anxiety and reports visual hallucinations. Which of the following actions should the nurse recommend including in the plan of care? A) Instruct the client to spend quiet time alone in their room. B) Provide the client with a restricted-calorie meal. C) Encourage the client to participate in a game in the day room. D) Use a low-pitched voice when speaking to the client.

D) Use a low-pitched voice when speaking to the client.

36) a nurse is assisting with the care of a client who is 6 hours postoperatively following a right total knee arthroplasty. which of the following actions should the nurse take? A) place an abductor wedge under the client's right knee B) maintain the head of the clients bed in high Fowler's position C) remove the clients dressing when it becomes saturated D) check the clients pedal pulses every hour

D) check the clients pedal pulses every hour

15) a nurse is collecting data from a client who has diabetes mellitus and a blood glucose of 40 mg/dL. which of the following findings should the nurse expect? A) Fruity breath B) increased thirst C) deep respiration D) clammy skin*

D) clammy skin*

40) A nurse is collecting data from a client who is 1 day postoperative following transurethral resection of the prostate. Which of the following findings should the nurse report to the provider? E) Urine output of 300 mL over 8 hr F) Frequent urge to urinate G) Occasional Small clots in the urine H) Dark red urine

H) Dark red urine