Final Review Practice

Every morning, a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain? 70% regular insulin and 30% NPH insulin 70 units of neutral protamine Hagedorn (NPH) insulin and 30 units of regular insulin 70 units of regular insulin and 30 units of NPH insulin 70% NPH insulin and 30% regular insulin

70% NPH insulin and 30% regular insulin

The health care provider orders documentation of a client's intake and output. Using the following information, calculate this client's intake in milliliters. Record your answer to the nearest tenth. 250 ml decaffeinated coffee 125 ml green gelatin 62.5 ml apple juice 125 ml lemon-lime soda 250 ml beef broth 300 ml of urine output

812.5

Client is a 13-year-old who presented to the emergency department after suffering a sports related injury. Client's left forearm is significantly larger than left due to swelling and tissue damage. Bone is protruding through skin with bleeding. Capillary refill: 1 second in affected extremity. Client rates pain as a 10 (1 = no pain, 10 = worst pain). Which nursing interventions are appropriate for this client? Select all that apply. Administer fluid replacement Apply splint below suspected fracture Elevate affected limb Apply a sterile wound dressing Apply direct pressure to wound Prepare for aspirin therapy to prevent clotting Apply cold pack to affected area Administer analgesics Educate on possible need for tetanus prophylaxis

Administer analgesics Elevate affected limb Apply direct pressure to wound Administer fluid replacement Apply a sterile wound dressing Educate on possible need for tetanus prophylaxis

A nurse is assessing a client with schizophrenia. Which assessment data would be priority for the nurse to follow up on? After checking the blood pressure, the client's arm stays in the air. The client reports 9 hours of sleep every night. The client reports being scared of needles, and the lab is going to draw blood. The client demonstrates lack of expression and flat affect during the conversation.

After checking the blood pressure, the client's arm stays in the air.

Which statement is correct regarding the Omnibus Reconciliation Act of 1986? The facility may not release the donor's name without the family's permission. The medical examiner should be notified whenever donated organs or tissues may be available. All families of clients who are nearing death, or who have died, must be asked about organ and tissue donation. Hospitals need not have designated requesters who approach families for organ and tissue donation.

All families of clients who are nearing death, or who have died, must be asked about organ and tissue donation.

A client has had a cardiac catheterization. The femoral dressing has a bright bloody drainage. What should the nurse do first? Assess the pulse in the left extremity. Apply pressure to the site. Assess the airway. Administer oxygen.

Apply pressure to the site.

A staff nurse receives a phone call and is told there is a bomb in a client's room. What is the nurse's priority action? Ask the caller for details about the bomb placement. Put the call on hold and find the charge nurse. Signal to staff to close the client's doors. Transfer the call to security.

Ask the caller for details about the bomb placement.

A home care nurse assesses a 4-day-old infant. The infant has developed a yellowish tinge to the face extending to the mid-chest. Which of the following is the priority nursing intervention? Notify the baby's health care provider as soon as possible. Monitor the jaundice over the next 24 hours. Advise the parent to stop breastfeeding and offer formula instead. Assess the jaundice using a transcutaneous monitor.

Assess the jaundice using a transcutaneous monitor.

Which action should the nurse take first when admitting an 11-year-old child in sickle cell crisis? Start oxygen therapy as soon as the child's vital signs are taken. Instruct the parents about what to expect during this hospitalization. Administer oral pain medication while obtaining the child's history. Begin IV fluids after obtaining the child's history.

Begin IV fluids after obtaining the child's history

A client is to start on enteral tube feedings. What intervention will the nurse implement to best promote the client's ability to adequately digest the feeding and reduce residual gastric volumes? Begin with a slow, continuous rate of feeding and adjust based on client response. Elevate the head of the bed to at least 30 degrees during feedings and for 30 minutes after. Use four smaller bolus feedings per 24-hours instead of three larger feedings. Aspirate stomach contents every 4 hours to check for residual volume.

Begin with a slow, continuous rate of feeding and adjust based on client response.

The nurse notices some new electrical equipment has been brought to the operating suite. Which action should the nurse prioritize when preparing to use this new equipment? Disinfect the equipment before taking it into the operative suite. Check the client's records for an order to use it. Plug the equipment in, and check that it works. Check that a safety label has been applied.

Check that a safety label has been applied.

When cleaning the skin around an incision and drain site, what should the nurse do? Clean the incision and drain site separately. Clean from the drain site to the incision. Clean from the incision to the drain site. Clean the incision and drain site simultaneously.

Clean the incision and drain site separately.

The nurse reads the new medication prescriptions for a 4-year-old child with nephrotic syndrome (see exhibit). What action should the nurse take? Start the 30-mg dose tomorrow. Discontinue the prednisolone 40 mg, and give the 30-mg dose today. Check the medication record first to see when the last dose of prednisolone was given. Contact the prescriber for clarification.

Contact the prescriber for clarification.

A client is a 43-year-old G2 P1 at 16 weeks' gestation that has completed prenatal testing for chromosomal abnormalities. The results reveal the infant has Down syndrome. The parents are seeking information about this syndrome. What should the nurse tell the parents? Select all that apply. Down syndrome results from a trisomy of chromosome 21. Down syndrome can occur in birth parents of any age. Down syndrome is correlated with autosomal dominant traits carried by the parents. Down syndrome occurs more frequently with advanced maternal age. Down syndrome depends upon maternal prenatal care since pregnancy began. Down syndrome is a result of autosomal recessive traits carried by the parents.

Down syndrome can occur in birth parents of any age. Down syndrome occurs more frequently with advanced maternal age. Down syndrome results from a trisomy of chromosome 21.

A client with rheumatoid arthritis has increasing fatigue and is unable to manage daily activities. What should the nurse do to help the client manage their activity? Encourage the client to alternate periods of rest and activity throughout the day. Instruct the client to not perform daily hygienic care until activity tolerance improves. Tell the client to perform all tasks early in the day. Administer opioids to promote pain relief and rest.

Encourage the client to alternate periods of rest and activity throughout the day

The nurse is caring for a young child on the oncology unit who has developed thrombocytopenia after cancer treatment. What is the priority action for the nurse to implement when caring for this client? Plan for extra nap times. Encourage high-protein foods. Assess for signs of infection. Ensure a safe environment.

Ensure a safe environment.

Which action(s) should the nurse take prior to administering an oral medication to an infant? Select all that apply. Verify that it is the correct dose. Check the infant's pulse. Have the parent hold the infant. Ensure that it is the correct medication. Verify the infant's name.

Ensure that it is the correct medication. Verify that it is the correct dose. Verify the infant's name.

The nurse is caring for a young adult with end stage leukemia. The client asks the nurse to "help end my suffering in this life because it has gotten to be too much to endure." Based on the ANA Code of Ethics for nurses, what would the nurse do next? Select all that apply. Explain to the client that nurses cannot participate in assisted suicide. Ask the family members to talk to the client about their desires to end their life. Administer the client's next scheduled morphine sulfate dose early. Tell the client they are just depressed and ask the health care provider for an antidepressant. Allow the client to discuss their feelings and explore other options for comfort.

Explain to the client that nurses cannot participate in assisted suicide. Allow the client to discuss their feelings and explore other options for comfort.

A public health nurse has been asked to teach the importance of hand washing to older adult clients. Which statement by a client indicates that the teaching has been effective? Warm water is best for all infections. Friction while washing hands decreases transmission of bacteria. Soap is the only product that can control spread of infections. Wash the hands for at least 15 seconds

Friction while washing hands decreases transmission of bacteria.

A nurse is caring for a client with obsessive-compulsive disorder (OCD) with rituals of washing hands, folding and unfolding towels, and switching the bathroom light on and off multiple times prior to meals. What action should the nurse take? Interrupt the client's ability to complete the rituals. Gradually limit the time allowed for the client to complete the rituals. Allow ample time for the client to complete the rituals. Assist the client in completing the rituals.

Gradually limit the time allowed for the client to complete the rituals.

A child with type 1 diabetes mellitus reports feeling shaky. The child's skin is pale and sweaty. What is the nurse's priority intervention? Offer the child a complex carbohydrate snack. Give supplemental insulin per order. Administer intravenous dextrose. Have the child eat a glucose tablet.

Have the child eat a glucose tablet. These symptoms are indicative of hypoglycemia. If a client is fully conscious and able to drink and swallow safely, a rapidly absorbed carbohydrate such as glucose tablets, glucose gel, table sugar, or fruit juice should be given by mouth. This will result in a rapid increase in blood glucose. Giving supplemental insulin would lower the blood glucose. Dextrose should be given only if there is a risk of aspiration with oral glucose. Complex carbohydrates should not be the initial treatment, because these take too long to be absorbed. After the symptoms of hypoglycemia have resolved, the child should be given a snack of complex carbohydrates and protein to prevent recurrence. Ideally, the nurse monitors treatment with a glucometer.

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

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

The nurse is performing a complete neurological assessment on an older adult client. Which question by the nurse would best assess cerebral function? "Have you noticed a change in your memory?" "Have you noticed a change in your muscle strength?" "Have you had any problems with walking or coordination?" "Have you had any problems with blurry vision?"

Have you noticed a change in your memory?"

The nurse has been assigned to a client who has had diabetes for 10 years. The nurse gives the client's usual dose of regular insulin at 7 a.m. At 10:30 a.m., the client has light-headedness and sweating. The nurse should contact the health care provider, report the situation, background, and assessment, and recommend intervention for: Metabolic acidosis. Hyperglycemia. Hypoglycemia. Ketoacidosis.

Hypoglycemia.

During initial rounds, a nurse notes that a norepinephrine infusion has extravasated into the forearm of a client. After stopping the infusion, the nurse follows standing orders and prepares to administer phentolamine. Which action by the nurse is appropriate when administering this drug? Dilute in saline and administer intravenously. Mix the oral form with soda or juice and have the client drink through a straw. Massage topically in a circular fashion around the extravasation site. Inject subcutaneously in a circular fashion around the extravasation site.

Inject subcutaneously in a circular fashion around the extravasation site.

One day after a subtotal thyroidectomy, a client begins to have tingling in the fingers and toes. What should the nurse do first? Notify the health care provider (HCP). Ask the client to speak. Encourage the client to flex and extend the fingers and toes. Assess the client for thrombophlebitis.

Notify the health care provider (HCP).

The nurse assesses an infant born 28 hours earlier and finds a yellowish tinge to the face and chest when the skin is balanced. The nurse screens with a transcutaneous bilirubin monitor, which shows increased bilirubinemia. Which intervention should the nurse do next? Screen the bilirubin level using transcutaneous bilirubin again in 2 hours. Discharge the client with home care follow-up within 24 hours. Obtain a total serum bilirubin measurement. Notify the health care provider.

Obtain a total serum bilirubin measurement.

The nurse is developing a teaching plan for a client with viral hepatitis. What information should the nurse include in the plan? Take antibiotic therapy as prescribed. Obtain adequate bed rest. Increase fluid intake. Drink 8 oz (240 mL) of an electrolyte solution every day.

Obtain adequate bed rest.

The nurse is providing care for an adult client who presented to the emergency department with symptoms of agitation, tachycardia, diaphoresis, and dilated pupils. The client admits to using methamphetamine several hours ago. Which intervention should the nurse implement first? Obtain a urine sample for toxicology screening to confirm substance use. Provide a calm and quiet environment to reduce stimulation. Start an IV line, and administer fluids to promote hydration. Administer activated charcoal to prevent further absorption of the substance.

Provide a calm and quiet environment to reduce stimulation.

A client has been taking 30 mg of duloxetine hydrochloride twice daily for 2 months because of depression and vague aches and pains. While interacting with the nurse, the client discloses a pattern of drinking a 6-pack of beer daily for the past 10 years to help with sleep. What should the nurse do first? Share the information at the next interdisciplinary treatment conference. Report the client's beer consumption to the health care provider (HCP). Refer the client to the concurrent disorders program at the clinic. Teach the client relaxation exercises to perform before bedtime

Report the client's beer consumption to the health care provider (HCP)

A nurse is caring for a client with bulimia nervosa. Strict management of the client's dietary intake is necessary. Which intervention is the most important? Let the client eat meals in private. Engage the client in social activities for at least 2 hours after each meal. Let the client eat food brought by family, but have the client keep a strict calorie count. Fill out the client's menu and make sure the client eats at least half of what is on the tray. Serve the client's menu choices in a supervised area and observe the client 1 hour after each meal.

Serve the client's menu choices in a supervised area and observe the client 1 hour after each meal.

A nurse assigned to a client with emphysema is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply. Maintain fluid intake at fluid maintenance standards. Maintain the client in a supine position as much as possible. Teach the use of postural drainage and chest physiotherapy. Encourage alternating client activity with rest periods. Administer low-flow oxygen as needed. Teach diaphragmatic, pursed-lip breathing.

Teach diaphragmatic, pursed-lip breathing. Administer low-flow oxygen as needed. Encourage alternating client activity with rest periods. Teach the use of postural drainage and chest physiotherapy.

A nurse is assigned a client with an acute exacerbation of rheumatoid arthritis (RA). Which medical facts about RA are essential in developing a plan of care? Select all that apply. Onset is acute and usually occurs between ages 20 and 40. Erythrocyte sedimentation rate (ESR) is elevated, and x-rays show erosions and decalcification of involved joints. The client may not exercise once the disease is diagnosed. Inflamed cartilage triggers complement activation, which stimulates the release of additional inflammatory mediators. The client experiences stiff, swollen joints bilaterally. The first-line treatment is gold salts and methotrexate.

The client experiences stiff, swollen joints bilaterally. Erythrocyte sedimentation rate (ESR) is elevated, and x-rays show erosions and decalcification of involved joints. Inflamed cartilage triggers complement activation, which stimulates the release of additional inflammatory mediators.

A client has been placed on isoniazid (INH) as prophylactic treatment against tuberculosis. What instruction should the nurse give the client about taking isoniazid? The client can double the dosage if a dose is missed. The client should take the drug with antacids to decrease gastric distress. The client should increase fluid intake to 3000 mL (about 12½ cups) per day. The client should limit tyramine-rich foods in the diet.

The client should limit tyramine-rich foods in the diet. When taking isoniazid, the client should limit tyramine-rich foods in the diet because these foods and the drug could interact to cause hypertension. Foods such as cheese, dairy products, alcohol (red wine and beer), bananas, raisins, caffeine, and chocolate should be limited. Antacids can inhibit the absorption of INH and should not be taken with the drug. The client does not need to increase fluids to 3000 mL (about 12½ cups) per day. The client should not double the dose because INH is potentially toxic to the liver.

A nurse is caring for a client who's experiencing septic arthritis. This client has a history of immunosuppressive therapy and the client's immune system is currently depressed. Which assignment is the most appropriate for the nurse caring for this client? The nurse caring for this client is also caring for four other immunosuppressed clients on the medical floor. The nurse caring for this client is also caring for two other immunosuppressed clients on the medical intensive care unit. The nurse is caring for this client on the intensive care unit. The nurse caring for this client is also caring for four clients receiving chemotherapy for cancer treatment on the oncology floor.

The nurse is caring for this client on the intensive care unit.

When preparing a 20-year-old client for a serum pregnancy test, the nurse should include what information? A urine sample is needed to obtain quicker results. A positive result is considered a presumptive sign of pregnancy. The test is identical in nature to an over-the-counter home pregnancy test. The test has a high degree of accuracy within 1 week after ovulation.

The test has a high degree of accuracy within 1 week after ovulation.

A nurse is providing care to several clients who require assistance with ambulation. The nurse determines that a gait belt would be appropriate to use for which client(s)? Select all that apply. a client receiving gastrostomy tube feedings a client with adequate leg strength but who requires some assistance a client who had a cholecystectomy 2 days ago a client who is weak and at risk for falling when walking a client exhibiting behavioral aggression

a client with adequate leg strength but who requires some assistance a client who is weak and at risk for falling when walking

The nurse assesses a 6-month-old child for vaccination readiness. Which finding would most likely indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine? temperature of 101.3°F (38.5°C) following the 4-month vaccinations living with a family member who is immunosuppressed family history of sudden unexplained infant death syndrome (SUIDS) acute bilateral ear infection

acute bilateral ear infection

Alprazolam has been prescribed for a client who has been experiencing panic attacks. The nurse reviews the client's records and determines further intervention is needed when the health history includes seizure disorder. acute-angle glaucoma. intermittent insomnia. tartrazine hypersensitivity.

acute-angle glaucoma.

A nurse takes all of these actions when caring for a client with hypothyroidism. Which intervention is the priority? administering liothyronine increasing room temperature and providing blankets administering acetaminophen for headache assessing for periorbital edema

administering liothyronine Liothyronine is triiodothyronine (T3) and is often administered to a client with hypothyroidism. This is the priority to increase thyroid hormone levels. The other interventions would be lower-level priorities.

A registered nurse (RN) is assigning tasks to a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) on the client care team. Which task is restricted in terms of which care team member it could be delegated to? Select all that apply. assessing a client who just returned from cardiac catheterization administering oral pain medication to a postoperative client assisting a client to the bathroom who uses a walker for mobility providing oral care to a client who had nothing by mouth before surgery taking the health history of a newly admitted client

administering oral pain medication to a postoperative client assessing a client who just returned from cardiac catheterization taking the health history of a newly admitted client

A client arrives from surgery to the postanesthesia care unit. Which respiratory assessment should the nurse complete first? oxygen saturation breath sounds respiratory rate airway flow

airway flow

The nurse can be an important advocate for a client who is considering an alternative method of cancer treatment. Which statement best demonstrates the nurse as a client advocate? The nurse will: monitor blood tests as indicated by the alternative therapy. allow the client to make health care choices but will assist in ensuring the client is fully informed when making those decisions. document the client's desire to try an alternative therapy. provide information about standard therapies.

allow the client to make health care choices but will assist in ensuring the client is fully informed when making those decisions.

Which client would be most appropriate for the nurse to assign to an unlicensed assistive personnel (UAP) for morning care? an older adult client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy for mild dyspnea a young client receiving chemotherapy for Hodgkin disease a middle-age client who had a laryngectomy 2 days earlier an older client experiencing chest pain due to suspected pulmonary embolus

an older adult client with chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy for mild dyspnea

A newborn was discharged from the hospital before receiving the newborn metabolic screening (NMS) test. The community health nurse is scheduling the home visit for the infant. Which time would be the most critical time to perform the heel stick on this infant? before the baby has received eight feedings of breast milk or formula at least 24 hours after birth within the 24 hours of age at least 36 hours after birth

at least 24 hours after birth

A client with autoimmune thrombocytopenia and a platelet count of 8,000/μl develops epistaxis and melena. Treatment with corticosteroids and immunoglobulins has been unsuccessful, and the health care provider recommends a splenectomy. The client states, "I don't need surgery — this will go away on its own." In considering their response to the client, the nurse must depend on the ethical principle of: advocacy. beneficence. justice. autonomy.

autonomy

A client with schizophrenia who receives fluphenazine develops pseudoparkinsonism and akinesia. What drug should the nurse administer as ordered to minimize this client's extrapyramidal symptoms? diazepam dantrolene benztropine clonazepam

benztropine

Which method should the nurse use to feed an infant after surgical repair of a cleft lip? IV fluids gastric gavage bottle with a lamb's nipple bottle with a high flow nipple

bottle with a high flow nipple

The nurse caring for a 3-year-old with otitis media notes that the client has an allergy to amoxicillin that causes wheezing. Which prescription should the nurse question? azithromycin cephalexin cefdinir trimethoprim-sulfamethoxazole

cephalexin

A hospital is changing the format for documentation in an attempt to decrease the time the nurses are spending on charting. The new type of charting will require that nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which best defines this type of charting? problem, Intervention, Evaluation (PIE) charting variance charting focus charting charting by exception

charting by exception

In caring for a pregnant client with hyperemesis gravidarum, which is the priority nursing intervention? administering acetaminophen suppositories providing adequate sleep for the client reviewing dietary choices and food intake correcting the fluid-electrolyte imbalance

correcting the fluid-electrolyte imbalance

The nurse teaches the parents of a toddler about commonly aspirated foods. Which food, if identified by the parents as easily aspirated, would indicate the need for additional teaching? round candy popcorn crackers raw vegetables

crackers Crackers, because they crumble and easily dissolve, are not commonly aspirated. Because children commonly eat popcorn hulls or pieces that have not popped, popcorn can be easily aspirated. Toddlers frequently do not chew their food well, making raw vegetables a commonly aspirated food. Round candy is often difficult to chew and comes in large pieces, making it easily aspirated.

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates dysfunction in the brain stem. risk for increased intracranial pressure. dysfunction in the cerebrum. dysfunction in the spinal column.

dysfunction in the brain stem

A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client's care, the nurse should focus on their need for antiretroviral therapy. high-calorie nutrition. fluid replacement. pain management.

fluid replacement.

A client who is taking medication to control schizophrenia asks the nurse to explain the causes of the disorder. The nurse knows that an overactive dopamine system in the brain is one of the leading causes of schizophrenia and tells the client that excessive dopamine activity is responsible for symptoms. Which symptoms is the nurse referring to? Select all that apply. withdrawn behavior delusional thinking suspiciousness hallucinations hypotension excessive tearfulness

hallucinations suspiciousness delusional thinking

Which foods would the nurse teach the parents of a child with phenylketonuria (PKU) to avoid? Select all that apply. hot dog juice cereal ice cream hamburger

hamburger hot dog ice cream

A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position? head of the bed elevated 45 degrees supine with the head lower than the trunk prone supine with feet raised

head of the bed elevated 45 degrees

A client with human immunodeficiency virus (HIV) infection gives birth to a neonate. When assessing the neonate, the nurse is most likely to detect skin vesicles. hepatosplenomegaly. limb dysmorphism. conjunctivitis.

hepatosplenomegaly.

Which finding would lead the nurse to suspect that a neonate born at 34 weeks' gestation receiving intravenous fluids has developed overhydration? increased urine specific gravity polycythemia hypernatremia hypoproteinemia

hypoproteinemia

A client is prescribed a tricyclic antidepressant after other medications were ineffective. The nurse assesses for what outcome as evidence the new medication has been effective? reduction in purposeless movements moderate weight gain decreased daytime sleepiness improved cognitive functioning

improved cognitive functioning

Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need? arranging a visit from a support group member inserting a Foley catheter placing the client in a double room with another client the same age raising the side rails on the client's bed

inserting a Foley catheter

A nurse is assessing a client's abdomen after abdominal surgery. Place the assessment techniques in the order in which the nurse should conduct them. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1percussion 2auscultation 3inspection 4palpation

inspection auscultation percussion palpation

The nurse assesses a client with a 5 inch × 2 inch (12.7 cm x 5 cm) stasis ulcer just above the left malleolus. The wound is open with irregular, reddened, swollen edges, and there is a moderate amount of yellowish-tan drainage coming from the wound. The client verbalizes pressure-type pain and rates the discomfort at 7 on a scale of 0 to 10. What is the primary nursing goal for this client? administering prescribed analgesics applying lanolin lotions to the left ankle stasis ulcer encouraging the client to sit up in a chair four times per day keeping the pressure of bed linens off the area

keeping the pressure of bed linens off the area

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first? dextrose 5% in water (D5W) albumin lactated Ringer's solution normal saline solution with 20 mEq of potassium per 1,000 ml

lactated Ringer's solution

As part of a primary cancer prevention program, an oncology nurse answers questions from the public at a health fair. When someone asks about laryngeal cancer, the nurse should explain that inhaling polluted air isn't a risk factor for laryngeal cancer. laryngeal cancer occurs primarily in females. adenocarcinoma accounts for most cases of laryngeal cancer. laryngeal cancer is one of the most preventable types of cancer.

laryngeal cancer is one of the most preventable types of cancer.

A pregnant client arrives at the health care facility, stating that their bed linens were wet when they woke up this morning. The client says no fluid is leaking but reports mild abdominal cramps and lower back discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive ferning. Based on these findings, the nurse concludes that the client is in which phase of the first stage of labor? transitional phase active phase expulsive phase latent phase

latent phase

A client with colon cancer is having a barium enema. The nurse should instruct the client to take which type of medication after the procedure is completed? anticholinergic demulcent laxative antacid

laxative

A client with breast cancer has abdominal bloating and cramping with no bowel movement for 5 days. The client says they usually have a bowel movement every day after their morning coffee. Bowel sounds are present in all four quadrants. The client received 80 mg of doxorubicin hydrochloride 10 days ago. The nurse should contact the health care provider to request which prescription? ready-to-use enema to stimulate peristalsis mild opioid for abdominal discomfort soapsuds enema until clear oral cathartic until the client has a bowel movement

oral cathartic until the client has a bowel movement

A nurse is caring for a client with agoraphobia. Which signs and symptoms would the nurse anticipate? Select all that apply. inability to leave home. tobacco use. hallucinations. eating disorders. alcohol consumption. panic attacks.

panic attacks. inability to leave home.

The nurse is assessing a client who has a chronic obstructive respiratory disorder. Which finding should be immediately reported to the health care provider? barrel chest clubbing of fingernails decreased tactile fremitus pedal edema

pedal edema

A client with Buerger disease smokes two packs of cigarettes a day. When helping a client change their smoking behavior, the nurse should understand what about the client's needs? ability to attend support groups motivation perception of the negative behavior goals of the treatment

perception of the negative behavior

A client with heart failure is allergic to sulfa-based medications. Which diuretic would the nurse anticipate ordered as an alternate? thiazide and thiazide-like diuretics potassium-sparing diuretics loop diuretics carbonic anhydrase inhibitors

potassium-sparing diuretics

A child, age 4, is hospitalized because of alleged sexual abuse. Which nursing intervention promotes healing for this child? avoiding touching the child asking the child to talk about what happened preventing the suspected abuser from visiting the child providing play situations that allow disclosure

providing play situations that allow disclosure

A client in the manic phase of bipolar disorder arrives at the outpatient psychiatric clinic. To help the client manage a manic episode, the nurse should suggest that the client: reorganize a kitchen cabinet. read a book in a quiet room. play a game with a few friends. go shopping with a friend.

reorganize a kitchen cabinet.

The major goal of therapy in crisis intervention is to: provide documentation of events. resolve the immediate problem. decrease anxiety. withdraw from the stress.

resolve the immediate problem.

The nurse is caring for a client admitted for a herniated nucleus pulposus. The client reports a pain level of 7 out of 10 and is currently using the ordered morphine sulfate patient-controlled analgesia pump for pain management. What is the priority nursing assessment for this client? neurological system gastrointestinal system cardiovascular system respiratory system

respiratory system

A client is brought to the outpatient psychiatric clinic with a suspected diagnosis of obsessive-compulsive disorder (OCD). Which behaviors would the nurse document as congruent with the admitting diagnosis of OCD? Select all that apply. denial of illness ritualistic behaviors and irresistible impulses chronic feelings of boredom and emptiness ruminating thoughts embarrassment over behaviors

ritualistic behaviors and irresistible impulses ruminating thoughts embarrassment over behaviors

An infant, age 8 months, has a tentative diagnosis of congenital heart disease. During physical assessment, the nurse measures a heart rate of 170 beats/minute and a respiratory rate of 70 breaths/minute. How should the nurse position the infant? lying on the abdomen sitting in an infant seat sitting in high Fowler's position lying on the back

sitting in an infant seat

During a home visit, a client states the desire to stop smoking. Which criterion/criteria should the nurse include when creating a smoking cessation goal with the client? Select all that apply. measurable time-limited achievable readiness specific

specific measurable achievable time-limited

A client has been hospitalized for 3 days and is now experiencing symptoms of pneumonia, confirmed by chest X-ray. Which action is a priority for preventing this type of pneumonia? prophylactic antibiotics for all hospitalized clients staff education for prevention of hospital-acquired pneumonia (HAP) staff education for early recognition of community-acquired pneumonia (CAP) on admitted clients pneumovax injection at the first sign of pneumonia in the hospitalized client

staff education for prevention of hospital-acquired pneumonia (HAP)

The parent tells the nurse they will be afraid to allow their child with hemophilia to participate in sports because of the danger of injury and bleeding. After explaining that physical fitness is important for children with hemophilia, which activity should the nurse suggest as ideal? gymnastics snow skiing swimming basketball

swimming

The nurse is preparing the client with a cerebrovascular accident for discharge to home. Which factor will influence the client's continuing progress in rehabilitation at home? the family's ability to provide support to the client availability of a home health aide to care for the client frequency of follow-up visits with the health care provider the client's ability to ambulate

the family's ability to provide support to the client

A group of nurses who work at a large, long-term care facility have become embroiled in controversy over a large number of residents who are refusing a seasonal influenza vaccination. Specifically, there is controversy around the appropriate amount of influence that nurses can exercise when encouraging residents to become immunized. A teleological perspective on this issue would prioritize what consideration? historical precedents the greatest good for the greatest number the "rightness" or "wrongness" of coercion the legal rights of the individual

the greatest good for the greatest number

After a client has surgery for an ileal conduit, the nurse should assess the client for the occurrence of which complication? peritonitis ascites inguinal hernia thrombophlebitis

thrombophlebitis After pelvic surgery, there is an increased chance of thrombophlebitis owing to the pelvic manipulation that can interfere with circulation and promote venous stasis. Peritonitis is a potential complication of any abdominal surgery, not just pelvic surgery. Ascites is most frequently an indication of liver disease. Inguinal hernia may be caused by an increase in intra-abdominal pressure or a congenital weakness of the abdominal wall; ventral hernia occurs at the site of a previous abdominal incision.

The nurse is developing a discharge plan for a client who has had a myocardial infarction and been in the cardiac care unit for 2 days. The client will be transferred to a telemetry unit tomorrow. When can the client begin cardiac rehabilitation? after an EKG shows 2 days of normal sinus rhythm when discharged from the hospital today, with a gradual increase of daily activities when transferred to the telemetry unit

today, with a gradual increase of daily activities

A registered nurse is mentoring a new graduate nurse. Which action by the new graduate demonstrates a need for further teaching? administers adenosine as a rapid I.V. push over 2 seconds to a client with supraventricular tachycardia turns the defibrillator to synchronize before defibrillating a client with ventricular fibrillation administers diltiazem to a client with atrial fibrillation administers lidocaine to a client experiencing frequent premature ventricular contractions (PVCs)

turns the defibrillator to synchronize before defibrillating a client with ventricular fibrillation The synchronizer switch should be turned "off" when defibrillating. All other answers are correct and do not require further teaching.

The nurse assesses a client with a history of heroin use. Which finding should the nurse expect to assess for a client who is exhibiting late signs of heroin withdrawal? lacrimation and rhinorrhea vomiting and diarrhea restlessness and irritability yawning and diaphoresis

vomiting and diarrhea

Before a cancer client receiving total parenteral nutrition resumes a normal diet, the nurse teaches them about dietary sources of minerals. Which foods are good sources of zinc? fruits and yellow vegetables yeast and legumes whole grains and meats fruits and green vegetables

whole grains and meats

A nurse is teaching a client with a left fractured tibia how to walk with crutches. Which instruction is appropriate? "All weight should be on the hands." "Use the axillae to help carry the weight." "Keep feet 12 inches (30 cm) apart to provide stability and a wide base of support." "Take long strides to maintain maximum mobility."

"All weight should be on the hands."

During a psychotic episode, a client with schizophrenia is unable to focus on interactions. The client has cognitive disturbances and poor attention, concentration, and memory. The client also has a history of suicide attempts. The client tells the nurse, "I do not want you to contact my family. I don't even have to talk to you." Which statement is the most appropriate nursing response? "This can just be between us, and I will share your progress only with the doctors and not your family." "It sounds like you are not concerned about your problems and why you are in the hospital." "I need you to trust me and the staff members in the facility." "Anything you say about your feelings is confidential but your care involves the whole team so we can all work together."

"Anything you say about your feelings is confidential but your care involves the whole team so we can all work together."

A hospital uses the SOAP method of charting. Within this model, which of the nurse's statements would appear at the beginning of a charting entry? "Client has a history of recent abdominal pain." "2 mg hydromorphone PO administered with good effect." "Client is guarding abdomen and occasionally moaning." "Client reporting abdominal pain rated at 8/10."

"Client reporting abdominal pain rated at 8/10."

On admission to the inpatient psychiatric unit, a client's facial expression indicates severe panic. The client repeatedly states, "I know the police are going to shoot me. They found out that I'm the child of the devil." What should the nurse say to initiate a therapeutic relationship with this client? "Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?" "You certainly look stressed. Can you tell me about the upsetting events that have occurred in your life recently?" "Hello, ___. I'm going to be caring for you while I'm on duty. You look very frightened, but I'm sure you'll feel better by tomorrow." "You're having very frightening thoughts. I'll help you find ways to cope with this scary thinking.

"Hello, my name is ___. I'm a nurse, and I'll care for you when I'm on duty. Should I call you ___, or do you prefer something else?"

The nurse is caring for a client who developed fluctuating moods related to a recent cerebrovascular accident (stroke). When discussing the client's mood in a family meeting, which statements confirm a family's understanding of how to support the client? Select all that apply. "Sometimes I sit down and cry too then I pick myself up and move on." "I do not take what the my family member says personally and try to address the issue of anger." "All the kids just leave the room if the my family member gets emotional; that provides privacy." "I allow my family member to vent feelings and then find a different topic to discuss." "I tell my family member how I feel and yell back if needed so not to keep all of my frustration inside."

"I do not take what the my family member says personally and try to address the issue of anger." "I allow my family member to vent feelings and then find a different topic to discuss." "Sometimes I sit down and cry too then I pick myself up and move on."

A client has been taking imipramine for depression for 2 days. The client's sibling asks the nurse, "Why is my sibling still so depressed?" Which response by the nurse is most appropriate? "They are experiencing a very serious depression." "It takes 2 to 4 weeks for the drug to reach its full effect." "Perhaps we need to change the medication." "I will be sure to convey your concern to the health care provider (HCP)."

"It takes 2 to 4 weeks for the drug to reach its full effect."

The client becomes upset when the nurse asks if the client has an advance directive and states, "Why do I need an advance directive?" What is the most appropriate explanation for the nurse to give this client about an advance directive? "The advance directive allows your health care team to provide optimal health care under any circumstances that happen to you." "An advance directive is all about living well and having your specified treatment plans followed by your health care provider." "In all situations the advance directive allows you to appoint other people to decide what the best end-of-life care is for you." "Let's talk about how an advance directive enables you to have your health care preferences known to your health care providers."

"Let's talk about how an advance directive enables you to have your health care preferences known to your health care providers."

A graduate nurse is discussing verbal orders with the nurse preceptor. What statement by the graduate nurse requires the nurse preceptor to provide further teaching? "When I receive verbal orders, they must be carried out immediately to ensure clients get prompt care." "The date and time the verbal orders were given during the emergency need to be noted." "The health care provider signs the orders with the name, title, and contact information." "When documenting verbal orders, I need to write down the health care provider's name first and follow it with my name and title." "The verbal orders need to be recorded in the client's medical record."

"When I receive verbal orders, they must be carried out immediately to ensure clients get prompt care."

A mother tells the nurse she understands breastfeeding is the best, but will change to formula feedings when she returns to work in a few weeks. What should the nurse tell this mother about formula feedings? Select all that apply. "All babies on formula should have an iron-fortified formula to ensure healthy brain growth." "When mixing the powdered formula, be sure to follow the manufacturer's directions on the container to ensure proper nutrition." "A brand-name formula should be used because it has the best nutritional value." "Speak to your baby's health care provider about the best formula to use when you plan to change from breast to formula feeding." "All babies should be started on soy-based formulas because of the risk of future allergic reactions."

"When mixing the powdered formula, be sure to follow the manufacturer's directions on the container to ensure proper nutrition." "All babies on formula should have an iron-fortified formula to ensure healthy brain growth." "Speak to your baby's health care provider about the best formula to use when you plan to change from breast to formula feeding."

The nurse is preparing the morning insulin for a diabetic client on the unit. The order is for 20 units of Humulin 70/30. The nurse knows that this dose contains a mixture of intermediate-acting insulin and fast-acting insulin. How many units of intermediate-acting insulin does this dose contain? Record your answer using a whole number.

14

A health care provider prescribes meperidine 0.8 mg/kg every 4 hours PRN for a school-age child weighing 66 lb (30 kg). How many milligrams of meperidine will the nurse calculate as the potential maximum dose of meperidine the child could receive in 24 hours? Record your response as a whole number.

144