HESI EXAM 1 2022, HESI EXAM 2, HESI EXAM 3, HESI EXAM 4, HESI EXAM 5

An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? a. Urine specific gravity is 1.040b. b. Systolic blood pressure decreases 10 points when standing. c. The client denies being thirsty. d. Skin tenting occurs when the client's forearm is pinched.

.d. Skin tenting occurs when the client's forearm is pinched

Penicillin G procaine 240,000 units intramuscularly is prescribed for four-year-old child who has a streptococcal respiratory infection. The medication bio is labeled 1,200,000 units/2 ml. How many ml should the nurse administer?

0.4

Methylprednisone 100 mg IV is prescribed for a client. The medication comes in a vial labeled "125 mg per ml." How many ml should the nurse administer?

0.8

A child with Cellulitis receives a prescription for nafcillin 250 mg IM STAT. The available vial is labeled "add 3.4 ml of dilution to provide a solution of 1 gram/4 ml." How many milliliters should the nurse administer?

1

After receiving chemotherapy, a client who weighs 154 pound develops febrile neutropenia. The healthcare provider prescribes filgrastim 5 mcg/kg SUBQ every 12 hours. The available vial labeled, filgrastim 300 mcg/ml. Based on the client's weigh, how many milliliters should the nurse administer?

1.2

The nurse is preparing to give fentanyl 0.075 mg IM to a client who is scheduled for a colonoscopy. The medication is labeled 50 mcg/ml. How many ml Should the nurse administer?

1.5

The healthcare provider prescribes ceftazidime 1 gram every 8 hours. The label on the 1 gram vial reads, "reconstitute with 100ml sterile water." This dilution provides a concentration of how many mg/ml?

10

Heparin 0.4 units/kg/minute IV is prescribed for a client who weighs 110 pounds. The available solution is labeled heparin sodium 25,000 units in 5% dextrose injection 250 mL. The nurse should program the infusion pump to deliver how many ml/hour?

12

The health care provider prescribes a low dose heparin protocol at 18 units/kg/hr for a client with a possible pulmonary embolism. This client weighs 144 pounds. The available solution is labeled, heparin sodium two 25,000 units in 5% dextrose injection 250 ml. The nurse should program the pump to deliver how many ml/hr?

12

A client with human immunodeficiency virus begins active labor at 38 weeks gestation and receives a prescription for zidovudine 2 mg/kg IV To be administered over one hour period the client weighs 185 pounds. Based on the clients wait, how many mg should the nurse prepare to administer?

168

A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution at 18 units/kg/hr. The available solution is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the infusion pump to deliver how many mL/hour?

18

The health care provider prescribes digoxin elixir 125 mcg PO daily. The drug is available in a 60 ml bottle labeled "Digoxin elixir 0.05 mg/ml." How many ml should the nurse administer?

2.5

A client with a gram-positive bacterial skin infection is receiving daptomycin 500 mg IV every 24 hours. The pharmacy delivers a secondary infusion of 0.9% Sodium Chloride with daptomycin 500mg/100 ml to be infused in 30 minutes. How many ml/hour should the nurse program the infusion pump?

200

The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 mL to be infused intravenously (IV) over 4 hours. The IV administrations delivers 10 get/mL. How many get/minute should the nurse regulate the infusion?

21

The healthcare provider prescribes penicillin G benzathine 2,400,000 units intramuscularly for a client who has postoperative wound infection. The pre-filled syringe is labeled, penicillin G benzathine 1,200,000 units/2 mL. How many mL should the nurse administer to this client?

4

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In what order should the unit manager implement these interventions to address the UAP's behavior? 1. Evaluate the UAP for signs of improvement 2. Plan for scheduled break times 3. Discuss the issue privately with the UAP 4. Note date and time of the behavior

4. Note date and time of the behavior 3. Discuss the issue privately with the UAP 2. Plan for scheduled break times 1. Evaluate the UAP for signs of improvement

The nurse is preparing to administer a suspension ampicillin labeled, 250 mg/5 mL, to a child with impetigo. The prescription is for 500 mg four times a day. How many mL should the child receive per day?

40

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin that is initiated. In what order should the nurse implement these interventions? (arrange the actions in order of priority, with highest priority first, and least priority last or at the bottom.) 1. Document reaction to the drug 2. Initiate an adverse event report 3. Contact the health care provider 4. Assess vital signs 5. Stop the infusion

5. Stop the infusion 4. Assess vital signs 3. Contact the health care provider 1. Document reaction to the drug 2. Initiate an adverse event report

Dopamine 5 mcg/kg/minute IV is prescribed for a client who weighs 132 pounds. The pharmacy dispenses of 500 ml IV solution of 0.9% normal saline with dopamine 1600 mg. The nurse should program the infusion pump to deliver how many ml/hr?

5.6

A 154-pound client with diabetic ketoacidosis is receiving an IV abnormal saline 100 ml with regular insulin 100 units. The health care provider prescribes a rate of 0.1 units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump to infuse how many ml/hour?

7

The healthcare provider prescribes cephalexin 125 mg/5 mL oral suspension for a client who weighs 77 pounds. The recommended safe dose is 25 mg/kg/24 hours in 4 divided doses. Based on the client's weight, how many mL should the nurse administer?

9

The nurse plans to administer a bolus dose of IV Heparin based on the clients weight. The prescribed bolus dose is 100 units/kg. The client weighs 198 pounds. How many units of heparin should the nurse administer?

9000

A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? A) A 79 year-old malnourished client on bed rest B) An obese client who uses a wheelchair C) A client who had 3 incontinent diarrhea stools D) An 80 year-old ambulatory diabetic client

A) A 79 year-old malnourished client on bed rest

After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is A) Abdominal x-ray B) Auscultation C) Flushing tube with saline D) Aspiration for gastric contents

A) Abdominal x-ray

An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply) A) Administer a daily dose of lisinopril as scheduled. B) Assess the client for postural hypotension. C) Notify the healthcare provider immediately D) Provide a PRN dose of acetaminophen for headache E) Withhold the next scheduled daily dose of warfarin

A) Administer a daily dose of lisinopril as scheduled. D) Provide a PRN dose of acetaminophen for headache

A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? A) An infant who has been identified to have botulism B) A toddler who ate a number of ibuprofen tablets C) A preschooler who swallowed powdered plant food D) A school aged child who took a handful of vitamins

A) An infant who has been identified to have botulism

To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must A) Apply suction for no more than 10 seconds B) Maintain sterile technique C) Lubricate 3 to 4 inches of the catheter tip D) Withdraw catheter in a circular motion

A) Apply suction for no more than 10 seconds

The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important? A) Avoid chocolate and cheese B) Take frequent naps C) Take the medication with milk D) Avoid walking without assistance

A) Avoid chocolate and cheese

The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to A) Exercise doing weight bearing activities B) Exercise to reduce weight C) Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones

A) Exercise doing weight bearing activities

A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which interventions should the nurse implement? (Select all that apply) A) Give the client 4 ounces of orange juice B) Obtain blood pressure and pulse rate C) Provide the client with 1⁄2 cup diet carbonated soda D) Administer a PRN dose of regular insulin E) Check the client's current finger stick blood glucose

A) Give the client 4 ounces of orange juice B) Obtain blood pressure and pulse rate E) Check the client's current finger stick blood glucose

The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should thenurse take?A) Hold the tube feeding and notify the provider B) Administer the tube feeding as scheduled C) Irrigate the tube with diet cola soda D) Apply intermittent suction to the feeding tube

A) Hold the tube feeding and notify the provider

A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include during the instructions to the client is which of these statements? A) In the initial 48 hours avoid contact with children and pregnant women, and after urination and defecation flush the commode twice. B) Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose, do so in the toilet and flush it twice. C) Your family can use the same bathroom that you use without any special precautions. D) Drink plenty of water and empty your bladder often during the initial 3 days of therapy.

A) In the initial 48 hours avoid contact with children and pregnant women, and after urination and defecation flush the commode twice.

The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective sign of depression? (Select all that apply) A) Interacts with a flat affect B) Avoids eye contact C) Has a disheveled appearance D) Report feeling sad E) Expresses suicidal thoughts

A) Interacts with a flat affect B) Avoids eye contact C) Has a disheveled appearance

A client who is hospitalized and recently diagnosed with Addison's disease is now confused and lethargic. Which actions should the nurse implement? (Select all that apply) A) Measure capillary glucose level B) Monitor cardiac rhythm C) Reduce rate of intravenous fluid infusion D) Withhold next dose of corticosteroid E) Initiate fall risk precautions

A) Measure capillary glucose level B) Monitor cardiac rhythm E) Initiate fall risk precautions

An older adult client admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.) A) Measure neurological vital signs every 4 hours B) Place a bedside commode next to the bed C) Suction oral cavity every 4 hours D) Encourage family to participate in the client's care E) Play classical music in room while client is awake

A) Measure neurological vital signs every 4 hours B) Place a bedside commode next to the bed D) Encourage family to participate in the client's care

When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because A) Normal patterns of behavior may be labeled as deviant, immoral, or insane B) The meaning of the client's behavior can be derived from conventional wisdom C) Personal values will guide the interaction between persons from 2 cultures D) The nurse should rely on her knowledge of different developmental mental stages

A) Normal patterns of behavior may be labeled as deviant, immoral, or insane

A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the rightfoot is pale with the absence of a pulse. What should the nurse do first? A) Notify the health care provider B) Readjust the traction C) Administer the ordered PRN medication D) Reassess the foot in fifteen minutes

A) Notify the health care provider

136. A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why the healthcare provider has prescribed all these medications. Which information should the nurse included when responding to this client? (Select all that apply.) A) One of the medications is used to anesthetize the corneal surface B) Pupillary dilation is necessary to access the eye chamber for lens removal C) The iris must be paralyzed during surgery to prevent it from reacting to light D) A medication is used to induce sleep during the procedureE) These medications assist in obstructing client ́s vision during the surgery Encourage family participate in the client's care E) Play classical music in room while client is awake

A) One of the medications is used to anesthetize the corneal surface B) Pupillary dilation is necessary to access the eye chamber for lens removal C) The iris must be paralyzed during surgery to prevent it from reacting to light

Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? A) Orthostatic hypotension is a common side effect B) Most antipsychotic drugs cause elevated blood pressure C) This provides information on the amount of sodium allowed in the diet D) It will indicate the need to institute anti parkinsonian drugs

A) Orthostatic hypotension is a common side effect

To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client's discharge plan? (Select all that apply). A) Practice relaxation exercises B) Limit fluids to avoid bladder distention C) Space activities to allow for rest periods D) Avoid persons with infections E) Take warm baths before starting exercise

A) Practice relaxation exercises C) Space activities to allow for rest periods D) Avoid persons with infections

A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin? A) Protamine B) Amicar C) Imferon D) Diltiazem

A) Protamine

While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? (Select all that apply). A) Provide supplemental oxygen B) Auscultate bilateral lung fields C) Administer a nebulizer treatment D) Reinforce occlusive CT dressing E) Give PRN dose of pain medication

A) Provide supplemental oxygen B) Auscultate bilateral lung fields D) Reinforce occlusive CT dressing

The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse shouldtake? A) Stop the infusion B) Slow the rate of infusion C) Take vital signs and observe for further deterioration D) Administer Benadryl and continue the infusion

A) Stop the infusion

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? (Select all that apply) A) Teach client to use incentive spirometer q2 hours while awake B) Remove urinary catheter as soon as possible and encourage voiding C) Maintain sequential compression devices while in bed D) Administer low molecular weight heparin as prescribed E) Assess pain level and medicate PRN as prescribed

A) Teach client to use incentive spirometer q2 hours while awake B) Remove urinary catheter as soon as possible and encourage voiding

An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to A) administer the medication in 2 separate injections B) give the medication in the dorsal gluteal site C) call to get a smaller volume ordered D) check with pharmacy for a liquid form of the medication skip

A) administer the medication in 2 separate injections

A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The health care provider knows the client has a good prognosis and refuses to write a "do not resuscitate" (DNR) prescription. Which action should the nurse take? A. Initiate an Ethics Committee review of the case B. Place a DNR bracelet on the client's arm C. Ensure resuscitation equipment is available D. Ask the family to review options with the client

A. Initiate an Ethics Committee review of the case

A postoperative client has a large amount of serosanguineous drainage on the surgical dressing and the nurse notes that the operative report indicates the client has a Penrose drain near the incision. What intervention should the nurse implement when changing the clients dressing? A. Place sterile gauze dressings under the Penrose drain B. Apply sterile gloves before removing the soiled dressing C. Cover the Penrose drain with a saline moistened gauze D. Wear a face mask or shield during the dressing change

A. Place sterile gauze dressings under the Penrose drain

A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first? A. Place the client in Trendelenburg B. Administer oxygen via face mask C. Notify the operating room team D. Administer a fluid bolus of 500 mL

A. Place the client in Trendelenburg

A client who was recently diagnosed with anorexia nervosa collapses at an outpatient clinic. While taking the blood pressure, the client begins to demonstrate cloudy consciousness, stupor, and has slurred speech. The nurse obtains a blood glucose 50 mg/dL, heart rate of 116 beats/minute, and blood pressure of 88/50 mmHg. Which intervention is most important for the nurse to implement? A. Position client with head flat and feet elevated B. Suggest obtaining a medical alert bracelet to be always worn C. Encourage the client to eat low carbohydrate and high protein meals D. Reinforced the need to continue the outpatient clinic therapy

A. Position client with head flat and feet elevated

An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide? A. Tell the client to discuss the medication side effects with the health care provider B. Inform the client that gradual tapering must be used to discontinue the medication C. Remind the client that feeling better is the therapeutic side effect of the medication D. Tell the client that the medication side effects will most likely dissipate overtime

A. Tell the client to discuss the medication side effects with the health care provider

The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective? A) "We will call the health care provider if the child develops acne." B) "Our child should brush and floss carefully after every meal." C) "We will skip the next dose if vomiting or fever occur." D) "When our child is seizure-free for 6 months, we can stop the medication."

B) "Our child should brush and floss carefully after every meal."

The mother of a toddler who is being treated for pesticide poisoning asks: "Why is activated charcoal used? What does it do?" What is the nurse's best response? A) "Activated charcoal decreases the systemic absorption of the poison from the stomach." B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child." C) "This substance helps to get the poison out of the body by the gastrointestinal system." D) "The action may bind or inactivate the toxins or irritants that are ingested by childrenor adults."

B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child."

The nurse is to administer a new medication to a client. Which actions are in the best interest of the client? Verify the order for the medication. Prior to giving the medication the nurse should say A) "Please state your name?" Upon entering the room the nurse should ask: B) "What is your name? What allergies do you have?" then check the client''s name band and allergy band C) "What is your name?" then check the client's name band Verify the client's allergies on the admission sheet and order. D) "Verify the client's name on the name plate outside the room then as the nurse enters the room ask the client "What is your first, middle and last name?"

B) "What is your name? What allergies do you have?" then check the client''s name band and allergy band

Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition?A) Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV) B) A positive purified protein derivative with an abnormal chest x-ray C) A tentative diagnosis of viral pneumonia with productive brown sputum D) Advanced carcinoma of the lung with hemoptasis

B) A positive purified protein derivative with an abnormal chest x-ray

Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? A) An infant with a positive culture of stool for Shigella B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear C) A young adult commercial pilot with a positive histopathological examination from aninduced sputum for Pneumocystis carinii D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicleson an erythematous base that appear on the skin

B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear

The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? A) Blanch nail beds for color and refill B) Assess for post operative arrhythmias C) Auscultate for pulmonary congestion D) Monitor equality of peripheral pulses

B) Assess for post operative arrhythmias

The most effective nursing intervention to prevent atelectasis from developing in a post operative client is to A) Maintain adequate hydration B) Assist client to turn, deep breathe, and cough C) Ambulate client within 12 hours D) Splint incision

B) Assist client to turn, deep breathe, and cough

The nurse is interacting with a female client who is diagnosed with postpartum depression. Which findings should the nurse document as an objective signs of depression? (Select all that apply) A) Expresses suicidal thoughts B) Avoid eyes contact C) Reports feeling sad D) Has a disheveled appearance E) Interacts with flat affect

B) Avoid eyes contact D) Has a disheveled appearance E) Interacts with flat affect

An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? A) Add a thickening agent to the fluids B) Check the client's gag reflex C) Feed the client only solid foods D) Increase the rate of intravenous fluids

B) Check the client's gag reflex

When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula A) Every four to six hours B) Continuously C) In a bolus D) Every hour

B) Continuously

The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate? A) Decreased carbohydrates and fat B) Decreased sodium and potassium C) Increased potassium and protein D) Increased sodium and fluids

B) Decreased sodium and potassium

83. When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote A) Relaxation and sleep B) Deep breathing and coughing C) Incisional healing D) Range of motion exercises

B) Deep breathing and coughing

A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely? A) Bleeding time B) Hemoglobin and hematocrit C) White blood cells D) Platelets

B) Hemoglobin and hematocrit

A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care? A) Esophagitis B) Leukopenia C) Fatigue D) Skin irritation

B) Leukopenia

A nurse is administering diazepam, a benzodiazepine, 10 mg IV push PRN, as prescribed to a client with alcohol withdrawal symptoms. Which actions should the nurse implement when administering the medication? (Select all that apply) A) Protect medication from exposure to light B) Monitor for changes in level of consciousness C) Observe for onset of generalized bruising or bleeding D) Perform ongoing assessment of respiratory status E) Administer slowly over at least two minutes

B) Monitor for changes in level of consciousness D) Perform ongoing assessment of respiratory status E) Administer slowly over at least two minutes

What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? A) Presence of blood in stools B) Oozing liquid stool C) Continuous rumbling flatulence D) Absence of bowel movements

B) Oozing liquid stool

The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A) Disconnect the client from the ventilator and use a manual resuscitation bag B) Perform a quick assessment of the client's condition C) Call the respiratory therapist for help D) Press the alarm re-set button on the ventilator

B) Perform a quick assessment of the client's condition

A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element? A) Sodium B) Potassium C) Phosphate D) Albumin

B) Potassium

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.) A) Take an additional dose for signs of hyperglycemia B) Recognize signs and symptoms of hypoglycemia C) Report persist polyuria to the healthcare provider D) Use sliding scale insulin for finger stick glucose elevation E) Take Glucophage with the morning and evening meal.

B) Recognize signs and symptoms of hypoglycemia C) Report persist polyuria to the healthcare provider E) Take Glucophage with the morning and evening meal.

A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? A) Change in libido, breast enlargement B) Sore throat, fever C) Abdominal pain, nausea, diarrhea D) Dsypnea, nasal congestion

B) Sore throat, fever

Discharge instructions for a client taking alprazolam (Xanax) should include which of the following? A) Sedative hypnotics are effective analgesics B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares C) Caffeine beverages can increase the effect of sedative hypnotics D) Avoidance of excessive exercise and high temperature is recommended

B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares

A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that A) A referral is needed to the psychiatrist who is to provide the client with answers B) The client has a right to know about the prescribed medications C) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications D) Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects

B) The client has a right to know about the prescribed medications

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays in normal sinus rhythm, but he has no spontaneous respirations, and his carotid pulse is not palpable. Which intervention should the nurse implement? A. Observed for swelling at the fracture site B. Begin chest compressions at 100/minute C. Analyze the cardiac rhythm in another lead D. Obtain a 12-lead electrocardiogram

B. Begin chest compressions at 100/minute

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty in concentrating at work. Which coping strategy should the nurse include in the plan of care? A. Analyze past hurts and resentments to identify the source B. Focus on small achievable tasks, not taxing problems C. Concentrate on and ventilate emotions when distressed D. Relax and reduce the amount of effort to solve the problem

B. Focus on small achievable tasks, not taxing problems

An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sounds. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are temperature of 96 degrees Fahrenheit, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure 64 mmHg, and central venous pressure 7 mmHg. Serum laboratory findings include hemoglobin 6.6 grams/dl, platelets 60,000/mm^3, and white blood cell count 30,000mm^3. Based on these findings the client is that greatest risk for which pathophysiological condition? A. Chronic obstructive pulmonary disease (COPD) B. Multiple organ dysfunction syndrome (MODS) C. Disseminated intravascular coagulation (DIC) D. Acquired immune deficiency syndrome (AIDS)

B. Multiple organ dysfunction syndrome (MODS)

A client who is admitted to the intensive care unit with the right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complaints of difficulty breathing. The nurse determines that the client is tachypneic with absent breath sounds in the client's right lung fields. Which additional finding indicates that the client has developed a tension pneumothorax? A. Continuous bubbling in the water seal chamber B. Tracheal deviation toward the left lung C. Decreased bright red bloody drainage D. Tachypnea with difficulty breathing

B. Tracheal deviation toward the left lung

An infant is unresponsive and gasping for breath period prior to starting CPR, which site should the nurse palpate for a pulse?

Brachial

After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond by saying A) "He has a lot of problems. You need to have patience with him." B) "I will talk with him and try to figure out what to do." C) "He is scared and taking it out on you. Let's talk to figure out what to do." D) "Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day."

C) "He is scared and taking it out on you. Let's talk to figure out what to do."

While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response? A) "As you urinate more, you will need less medication to control fluid." B) "You will have to take this medication for about a year." C) "The medication must be continued so the fluid problem is controlled." D) "Please talk to your health care provider about medications and treatments."

C) "The medication must be continued so the fluid problem is controlled."

A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values? A) Bleeding time B) Platelet count C) Activated PTT D) Clotting time

C) Activated PTT

60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? A) Have him drink several glasses of water B) Crede' the bladder from the bottom to the top C) Assist him to stand by the side of the bed to void D) Wait 2 hours and have him try to void again

C) Assist him to stand by the side of the bed to void

The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? A) "The treatment requires reapplication in 8 to 10 days." B) "Bedding and clothing can be boiled or steamed." C) Children are not to share hats, scarves and combs. D) Nit combs are necessary to comb out nits.

C) Children are not to share hats, scarves and combs.

The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN?A) Test a stool specimen for occult blood B) Assist with the ambulation of a client with a chest tube C) Irrigate and redress a leg wound D) Admit a client from the emergency room

C) Irrigate and redress a leg wound

A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client's comfort? A) Increase oral fluid intake B) Encourage visits from family and friends C) Keep conversations short D) Monitor vital signs frequently

C) Keep conversations short

The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID A) Glycerine suppositories B) Fiber supplements C) Laxatives D) Stool softeners

C) Laxatives

A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? A) Increased blood pressure B) Increased heart rate C) Loss of pulse in the extremity D) Decreased urine output

C) Loss of pulse in the extremity

A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first? A) Obtain a 12-lead EKG B) Place client in high Fowler's position C) Lower the oxygen rate D) Take baseline vital signs

C) Lower the oxygen rate

After an explosion at a factory one of the workers approaches the nurse and says "I am an unlicensed assistive personnel (UAP) at the local hospital." Which of these tasks should the nurse assign to this worker who wants to help during the care of the wounded workers? A) Get temperatures B) Take blood pressure C) Palpate pulses D) Check alertness

C) Palpate pulses

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply) A) Take out dentures and place in a labeled cup B) Apply a body shroud C) Place a small pillow under the head D) Remove resuscitation equipment from the room E) Gently close the eyes

C) Place a small pillow under the head D) Remove resuscitation equipment from the room E) Gently close the eyes

A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? A) Institute seizure precautions B) Monitor neurologic status every hour C) Place in respiratory/secretion precautions D) Cefotaxime IV 50 mg/kg/day divided q6h

C) Place in respiratory/secretion precautions

The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to A) Wrap the leg with elastic bandages B) Apply pressure at the bleeding site C) Reinforce the dressing and elevate the leg D) Remove the dressings and re-dress the incision

C) Reinforce the dressing and elevate the leg

The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? A) Place client in the wheelchair for four hours each day B) Pad the bony prominence C) Reposition every two hours D) Massage reddened bony prominence

C) Reposition every two hours

A 20 year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: A) Visitors must wear a mask and a gown B) There are no special requirements for visitors of clients on contact precautions C) Visitors should wash their hands before and after touching the client D) Visitors should wear gloves if they touch the client

C) Visitors should wash their hands before and after touching the client

A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? A) diaphoresis with decreased urinary output B) increased heart rate with increase respirations C) improved respiratory status and increased urinary output D) decreased chest pain and decreased blood pressure

C) improved respiratory status and increased urinary output

A client with cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescriptions include radiation therapy. What action should the nurse implement? A. Notify the radiation department to withhold the treatments for now B. Determine if the client wishes to cancel further radiation treatments C. Ask the client about his expected goals for this hospitalization D. Explain that palliative care measures can be provided at home

C. Ask the client about his expected goals for this hospitalization

A preschool aged boy is admitted to the pediatric unit following successful resuscitation from a near drowning accident. While providing care to the child, the nurse begins talking with his pre-adolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. Which action should the nurse take? A. Develop a water safety teaching plan for the family B. Tell the older brother that he seems depressed C. Ask the older brother how he felt during the incident D. Commend the older brother for his heroic actions

C. Ask the older brother how he felt during the incident

A client in the third trimester of pregnancy complaints of frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated, and she has an increased costal angle. Which intervention should the nurse implement? A. Ask a nurse with more experience to validate the costal angle finding B. Ask the health care provider to evaluate the client's respiratory status C. Examine the client for signs of tissue and anoxia, such as pallor D. Record the respiratory finding in the client's record as normal

C. Examine the client for signs of tissue and anoxia, such as pallor

A male client being treated for testicular cancer with chemotherapy has a decreased alpha fetoprotein radioimmunoassay (AFP). Which nursing intervention should the nurse implement? A. Advise the client that the treatment is having a beneficial effect B. Instruct the client to obtain prostate specific antigen (PSA) testing C. Inform the client that his chemotherapy dose will probably be increased D. Discuss options for Hospice care with the client and family members

C. Inform the client that his chemotherapy dose will probably be increased

A client with acute renal failure (ARF) is admitted for uncontrolled type one diabetes mellitus and hyperkalemia. The nurse administers and IV dose of regular insulin per sliding scale. Which intervention is most important for the nurse to include in this clients plan of care? A. Evaluate hourly urine output for return of normal renal function B. Assess glucose via fingerstick every four to six hours C. Monitor the client's cardiac activity via telemetry D. Maintain venous access with an infusion of normal saline

C. Monitor the client's cardiac activity via telemetry

A terminally ill male hospice client who is at home is showing decreased awareness of his surroundings. His appetite is poor, and he often uses oral intake of solids and liquids. For the past several days he has been unable to get out of bed. Which action should the hospice nurse implement? A. Ask family to remain nearby, but in another room B. Encourage family to speak often with the client C. Teach family how to assist the client to a wheelchair D. Instruct family to offer client only soft bland foods

C. Teach family how to assist the client to a wheelchair

An older client returns to the clinic and received refills on several medications. The client shares concerns with the nurse about having to take so many medications and asks if one pill can be substituted for many of the others. Which instruction should the nurse implement to address the clients concerns? A. Do not take any over the counter drugs while taking medications prescribed by the health care provider B. Make certain a family member knows the name and use of all medications currently being taken C. Use a medication reminder system to prevent forgetting to take the right medications at the right time D. Bring all medications, supplements, and herbs currently being taken to the next clinic appointment

C. Use a medication reminder system to prevent forgetting to take the right medications at the right time

A preschool age child who is being treated for streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the earliest indication to the nurse that the child is experiencing a reaction to the toxins that are created by the streptococcus bacteria? A. High, protracted fever B. Flaky, peeling skin C. White coating on the tongue D. Red bumps across chest

C. White coating on the tongue

The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching? A) "I use a sliding scale to adjust regular insulin to my sugar level." B) "Since my eyesight is so bad, I ask the nurse to fill several syringes." C) "I keep my regular insulin bottle in the refrigerator." D) "I always make sure to shake the NPH bottle hard to mix it well."

D) "I always make sure to shake the NPH bottle hard to mix it well."

Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency? A) An adolescent diagnosed with sepsis 7 days ago with vital signs maintained withinlow normal B) A middle-aged woman documented to have had an uncomplicated myocardialinfarction 4 days ago C) An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis D) A young adult in the second day of treatment for an overdose of acetometaphen

D) A young adult in the second day of treatment for an overdose of acetometaphen

Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls? A) Sensory perceptual alterations related to decreased vision B) Alteration in mobility related to fatigue C) Impaired gas exchange related to retained secretions D) Altered patterns of urinary elimination related to nocturia

D) Altered patterns of urinary elimination related to nocturia

A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse? A) Cut the child's hair short to remove the nits B) Apply warm soaks to the head twice daily C) Wash the child's linen and clothing in a bleach solution D) Application of pediculicides

D) Application of pediculicides

A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? A) Ask client to cough sputum into container B) Have the client take several deep breaths C) Provide a appropriate specimen container D) Assist with oral hygiene

D) Assist with oral hygiene

The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? A) Three apricots B) Medium banana C) Naval orange D) Baked potato

D) Baked potato

Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? A) All 4 side rails up, wheels locked, bed closest to door B) Lower side rails up, bed facing doorway C) Knees bent, head slightly elevated, bed in lowest position D) Bed in lowest position, wheels locked, place bed against wall

D) Bed in lowest position, wheels locked, place bed against wall

A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? A) Reverse B) Airborne C) Standard precautions D) Contact

D) Contact

A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Prepare for blood transfusion D) Continue to monitor the rate of drainage

D) Continue to monitor the rate of drainage

A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate? A) Pulverize all medications to a powdery condition B) Squeeze the tube before using it to break up stagnant liquids C) Cleanse the skin around the tube daily with hydrogen peroxide D) Flush adequately with water before and after using the tube

D) Flush adequately with water before and after using the tube

A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy ,in addition to hand washing, to be implemented is which of these? A) Apply appropriate signs outside and inside the room B) Apply a mask with a shield if there is a risk of fluid splash C) Wear a gown to change soiled linens from incontinence D) Have gloves on while handling bedpans with feces

D) Have gloves on while handling bedpans with feces

A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response ofthe nurse should be which of these statements? A) I am sorry. Referral information can only be provided by the client's health care providers. B) "I can never give any information out by telephone. How do I know who you are?" C) Since this is a referral, I can give you the this information. D) I need to get the client's written consent before I release any information to you.

D) I need to get the client's written consent before I release any information to you.

A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic? A) Bruising at the operative site B) Elevated heart rate C) Decreased platelet count D) No bowel movement for 3 days

D) No bowel movement for 3 days

The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement? A) Have the client cough into a tissue and dispose in a separate bag B) Instruct the client to cover the mouth with a tissue when coughing C) Reinforce for all to wash their hands before and after entering the room D) Place client in a negative pressure private room and have all who enter the room use masks with shields

D) Place client in a negative pressure private room and have all who enter the room use masks with shields

A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? A) Drowsiness B) Complaint of nausea C) Pulse rate of 92 D) Restlessness

D) Restlessness

The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to A) enhance absorption of the medication B) ensure that the entire dose of medication is given C) provide more even distribution of the drug D) prevent the drug from tissue irritation

D) prevent the drug from tissue irritation

A young adult female client with recurrent pelvic pain for 3 years returns to the clinic for relief of severe dysmenorrhea. The nurse views her medical record which indicates that the client has endometriosis. Based on this finding, what information should the nurse provide this client? A. An option to diagnose disease extent and provide therapeutic treatment is laparoscopy B. Infertility is successfully treated with removal of intra-abdominal endometrial lesions C. The symptoms of endometriosis can increase with menopause D. Oral contraceptives increase the symptoms of endometriosis

D. Oral contraceptives increase the symptoms of endometriosis

Following a gunshot wound, an adult client has a hemoglobin level of 4 grams/dl. The nurse prepares to administer a unit of blood for an emergency transfusion. That client has an AB negative blood type and the blood bank sends a unit of Type A RH negative, reporting that there is no Type AB negative blood currently available. Which intervention should the nurse implement? A. Recheck the clients hemoglobin, blood type, and RH factor B. Administer normal saline until Type AB negative is available C. Obtain additional consent for administration of Type A negative blood D. Transfuse Type A negative blood until Type AB negative is available

D. Transfuse Type A negative blood until Type AB negative is available

A client who is hospitalized and recently is now confused and lethargic. Which actions should the nurse implement? (Select all that apply) A) Measure capillary glucose level B) Monitor cardiac telemetry pattern C) Reduce rate of intravenous fluid infusion D)Withhold next dose of corticosteroid E) Initiate fall risk

E) Initiate fall risk

1. Which laboratory finding for an adult client is most critical for the nurse to report to the health care provider? (CHART)

Serum glucose

Which needles should the nurse administer intravenous fluids via our clients implanted port?

The one with the little lock on the end

Which statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? a. "When I get out of bed quickly, I feel a little dizzy." b. "The dressing over my incision feels like it is too tight." c. "I'm most comfortable when the head of the bed is raised." d. "This IV infusion makes me urinate more often than usual."

a. "When I get out of bed quickly, I feel a little dizzy."

An IV antibiotic is prescribed for a client with a post operative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription? a. 1000, 1600, 2200, 0400 b. 0800, 1200, 1600, 2000 c. Administer with meals and a bedtime snack d. Given equally divided doses during waking hours

a. 1000, 1600, 2200, 0400

The nurse is teaching the parents of a child newly diagnosed with a latex allergy. Which information by the parents indicates the need for further teaching? a. A diet of healthy fruits, such as bananas and Kiwis, are best for the child b. Only foil balloons will be used for the child's birthday party c. Rubber-free toys, such as wooden building blocks, are good choices for the child d. An epinephrine auto-injector will be on hand to treat allergic reactions

a. A diet of healthy fruits, such as bananas and Kiwis, are best for the child

The nurse has completed a diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective? a. A tuna fish sandwich with chips and ice cream b. A salad with three kinds of lettuce and fruit c. A peanut butter sandwich with soda and cookies d. Vegetable soup, crackers, and milk

a. A tuna fish sandwich with chips and ice cream

A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum amylase. Which additional information is the client most likely to report to the nurse? a. Abdominal pain decreases when lying supine b. Pain lasts and hour and leaves the abdomen tender c. Right upper quadrant pain refers to right scapula d. Drinks alcohol until intoxicated at least twice weekly

a. Abdominal pain decreases when lying supine

The nurse is caring for a client who reports experiencing pain. The client reads the pain as two out of 10 on the numeric 1-10 pain scale. Which prescription should the nurse administer? a. Acetaminophen b. Hydrocodone c. Ketorolac d. Morphine sulfate

a. Acetaminophen

The nurse is caring for a group of clients with the help of a practical nurse. Which nursing action should the nurse assign to the practical nurse? Select all that apply. a. Administer of dose of insulin per sliding scale for a client with type 2 diabetes mellitus b. Start the second blood transfusion for a client 12 hours following a below knee amputation c. Initiate patient-controlled analgesia pumps for two clients immediately postoperatively d. Perform daily surgical dressing change for a client who had an abdominal hysterectomy e. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty

a. Administer of dose of insulin per sliding scale for a client with type 2 diabetes mellitus d. Perform daily surgical dressing change for a client who had an abdominal hysterectomy e. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty

Four hours after the nurse administers interferon alpha subcutaneously into a client, the client develops a headache, muscle aches and a fever of 101.8 degrees Fahrenheit. What action should the nurse implement? a. Administer prescribed PRN dose of acetaminophen for these side effects b. Explain that an antihistamine may be needed in response to this allergic reaction c. Document these findings as an idiosyncratic response to this medication d. Observed the site where the medication was injected for signs of local reaction

a. Administer prescribed PRN dose of acetaminophen for these side effects

A female client with a history of heart failure arrives to the clinic after what she describes as a very long trip. Following the initial physical assessment and chart review, which priority action should the nurse implement? a. Administer the prescribed diuretic b. Give a potassium supplement c. Reteach medication regimen d. Auscultate lung and heart sounds

a. Administer the prescribed diuretic

The healthcare provider prescribes a sedative for a client with severe hypothyroidism. The nurse plans to contact the provider to review the safety of the prescription for the client and consultS first with the charge nurse. The charge nurse notes that the prescription is written legally and completely. How should the charge nurse respond? a. Affirm the nurses plan to review the prescription with the provider b. Advise the nurse to administer the medication as prescribed c. Assume responsibility for discussing the concern with the provider d. Offer to administer the prescription since the nurse has concerns

a. Affirm the nurses plan to review the prescription with the provider

A client diagnosed with calcium kidney stones has a history of gout. The new prescription for aluminum hydroxide is scheduled to begin at 0730. Which medication should the nurse bring to the health care providers attention? a. Allopurinol b. Furosemide c. Aspirin, low dose d. Enalapril

a. Allopurinol

After reviewing the Braden scale findings of residents in a long term facility, the charge nurse should tell the unlicensed assistive personnel (UAP) to prioritize skin care for which client? a. An older man who sheets are damp each time he is turned b. A woman with osteoporosis who is unable to bear weight c. An older adult who is unstable to communicate elimination needs d. A poorly nourished client who requires liquid supplements

a. An older man who sheets are damp each time he is turned

A client who gave birth 48 hours ago has decided to bottle feed the infant. During the assessment the nurse observes that both breasts are swollen, warm, and tender on palpation. Which instructions should the nurse provide? a. Apply ice to the breasts for comfort b. Wear a loose fitting bra during the day to prevent nipple irritation c. Run warm water over breasts d. Express small amounts of milk from the breast to relieve pressure

a. Apply ice to the breasts for comfort

After years of struggling with weight management, a middle-aged man is evaluated for gastroplasty. He has experienced difficulty with managing his diabetes mellitus and hypertension, but he is approved for surgery. Which intervention is most important for the nurse to include in this client's plan of care? a. Apply sequential compression stockings b. Monitor for urinary incontinence c. Observe for signs of depression d. Provide a wide variety of meal choices

a. Apply sequential compression stockings

The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After administering surfactant which assessment is most important for the nurse to monitor? a. Arterial blood gases b. Breath sounds c. Oxygen saturation d. Respiratory rate

a. Arterial blood gases

An older client's daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. The daughter states that her mother's behavior changed suddenly a few days ago and is now getting worse. Which action should the nurse take? Select all that apply. a. Ask if the mother is experiencing any pain with urination b. Encourage increased intake of high protein foods c. Instruct the daughter to check her mother's temperature d. Review the client's current food and medication allergies e. Determine if the mother has recently experienced a fall

a. Ask if the mother is experiencing any pain with urination c. Instruct the daughter to check her mother's temperature e. Determine if the mother has recently experienced a fall

A male client who arrives at the emergency department after a motor vehicle collision (MVC) tells the nurse "The car started to slide, and I just decided to let it go. Everyone would be better off if I was no longer was around." How should the nurse respond? a. Ask the client if the MVC was a suicide attempt b. Assess the client for other symptoms of depression c. Report to the health care provider that the client may need an antidepressant d. Determine what is going on in the clients life to make him feel depressed

a. Ask the client if the MVC was a suicide attempt

A client presses the call bell and requests pain medication for severe headache. To assess the quality of the clients pain, which approach should the nurse use? a. Ask the client to describe the pain b. Observe body language and movement c. Identify effective pain relief measures d. Provided numeric pain scale

a. Ask the client to describe the pain

An older male client is admitted with a medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take? a. Ask the wife to stop and assess the client swallowing reflex b. Give the wife a straw to help facilitate the clients drinking c. Assist the wife and carefully give the client small sips of water d. Obtain thickening powder before providing any more fluids

a. Ask the wife to stop and assess the client swallowing reflex

The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignment is best for the charge nurse to give to this nurse? a. Assist cardiac nurses with their assignments b. Monitor the central telemetry c. Perform the admission of a new client d. Transfer client to another unit

a. Assist cardiac nurses with their assignments

A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? a. Auscultate bilateral breath sounds b. Review the heart rhythm on cardiac monitor c. Administer PRN dose of lorazepam d. Check urinary catheter for obstruction

a. Auscultate bilateral breath sounds

The nurse identifies an electrolyte imbalance, a weight gain of 4.4 lbs in 24 hours and an elevated central venous pressure for a client with full thickness burns. Which intervention should the nurse implement? a. Auscultate for irregular heart rate b. Review arterial blood gases results c. Measure ankle circumference d. Document abdominal girth

a. Auscultate for irregular heart rate

A client with chronic kidney disease is admitted in heart failure and is complaining of shortness of breath and a headache. Assessment findings include blood pressure 180/90 mmHg, heart rate 130 beats/minute, oxygen saturation 89%, and a temperature of 100 degrees Fahrenheit. A temporary dialysis catheter is inserted for immediate hemodialysis and the client is scheduled for replacement of an arterial venous fistula in the left arm. Which action should the nurse implement? a. Avoid using the left arm for IV access b. Initiate oxygen at 110% per face mask c. Give the PRN dose of enalapril d. Administer PRN antipyretic prescription

a. Avoid using the left arm for IV access

The nurse is interacting with a client who is diagnosed with postpartum depression. Which finding should the nurse document as objective signs of depression? Select all that apply. a. Avoids eye contact b. Interacts with a flat affect c. Expresses suicidal thoughts d. Has a disheveled appearance e. Reports feeling sad

a. Avoids eye contact b. Interacts with a flat affect d. Has a disheveled appearance

A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? a. Blood transfusion b. Bone marrow transplantation c. Immunosuppressive therapy d. Chemotherapy

a. Blood transfusions

The nurse is teaching a primigravida about preeclampsia. Which finding are indicators of preeclampsia and should be reported to the healthcare provider? (select all that apply.) a. Blurred vision b. Headache c. Lack of appetite. d. Urinary frequency. e. Chills and fever. f. Swollen hands.

a. Blurred vision b. Headache f. Swollen hands.

A pediatric client taking the beta-adrenergic blocking agent propranolol. In developing a teaching plan, the nurse should teach the parents to report which sign of overdose? a. Bradycardia b. Tachypnea c. Hypertension d. Coughing

a. Bradycardia

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? (Select all that apply) a. Brings a heavy can close to body before lifting b. Locks knees while preparing food on the counter c. Widens stance while working near the sink. d. Bends from the waist to pick trash off the floor. e. Leans forward to pull a pan from a high shelf.

a. Brings a heavy can close to body before lifting b. Locks knees while preparing food on the counter

A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication a. Can predispose to dysrhythmias b. May lead to oliguria c. May cause irritability and anxiety d. Sometimes alters consciousness

a. Can predispose to dysrhythmias

A female client with chronic kidney disease and renal failure has an indwelling peritoneal catheter in ..... used for peritoneal dialysis. While bathing, the her abdominal dressing becomes wet. What action should the nurse take? a. Change the dressing. b. Reinforce the dressing. c. Flush the peritoneal dialysis catheter. d. Scrub the catheter with povidone-iodine.

a. Change the dressing.

The nurse working in a critical care unit is assigned the care of two clients, one with pneumonia who is being mechanically ventilated and the other who had a thoracotomy yesterday and is complaining of incisional pain. What should the nurse do first? a. Change the surgical dressing to observe the appearance of the incision b. Assess the level of consciousness and vital signs for both clients c. Review the plan of care and the medications that are due for both clients d. Complete a head-to-toe assessment of the client with pneumonia

a. Change the surgical dressing to observe the appearance of the incision

When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? a. Check for a distended bladder b. Review the hemoglobin to determine hemorrhage c. Massage the uterus to decrease atony d. Increase intravenous infusion

a. Check for a distended bladder

The nurse is assisting the health care provider with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure isn't effective? a. Chest tube insertion tray b. Intubation tray c. Crash cart d. Ventilator

a. Chest tube insertion tray

The nurse request a food tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? Select all that apply. a. Chicken broth b. Apple juice c. Hot chocolate d. Black coffee e. Orange juice

a. Chicken broth b. Apple juice

A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500 milligrams PO every 12 hours. When the client requests an afternoon snack, which dietary choice should the nurse provide? a. Cinnamon applesauce b. Vanilla flavored yogurt c. Calcium fortified juice d. Low fat chocolate milk

a. Cinnamon applesauce

The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900, what nursing action is most important? a. Confirm that the client has been NPO since midnight. b. Review postoperative instructions with the client. c. Offer to assist the client to the restroom to void. d. Determine when the client last had pain medication.

a. Confirm that the client has been NPO since midnight.

A young adult visits the clinic reporting symptoms associated with gastritis which information in the client's history is most important for the nurse to address in the teaching plan? a. Consumes 10 or more drinks of alcohol every weekend b. Snacks on foods with very high salt content on a daily basis c. Exercises vigorously every evening right before going to bed d. Recently became vegetarian eats a lot of high fiber foods

a. Consumes 10 or more drinks of alcohol every weekend

The nurse is assessing a client who reports falling 2 days ago and has a history of gouty arthritis that is controlled with allopurinol. The client states the left knee is swollen and extremely painful to touch. Which instruction should the nurse include in the discharge teaching? a. Decrease consumption of red meat and most seafood b. Substitute natural fruit juices for carbonated drinks c. Limit use of mobility equipment to avoid muscle atrophy d. Use electric heating pad when pain is at its worse

a. Decrease consumption of red meat and most seafood

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. Which effect is the nurse likely to note as a result of this increase in glaucoma surgeries? a. Decrease prevalence of glaucoma in the population b. Increased incidence of glaucoma in the population c. Decrease morbidity in the elderly population d. Increased mortality in the elderly population

a. Decrease prevalence of glaucoma in the population

The client arrives on the surgical floor after a major abdominal surgery. Which intervention should the nurse perform first? a. Determine the client's vital signs b. Assess the surgical site c. Apply warm blankets d. Administer prescribed pain medication

a. Determine the client's vital signs

A client arrives on the surgical floor after major abdominal surgery. Which intervention should the nurse perform first? a. Determine the clients vital signs b. Administer prescribed pain medication c. Apply warm blankets d. Assess the surgical site

a. Determine the clients vital signs

The nurse knows that several complications can occur with the administration of blood. Which finding is an indication of an air emboli? a. Difficulty breathing b. Increased blood pressure c. Chills and tremors d. Nausea and vomiting

a. Difficulty breathing

The healthcare provider prescribes a placebo instead of pain medication. What intervention should the nurse implement? a. Discuss ethical concerns about placebo use with the health care provider b. Administer the placebo as prescribed when the client complaints of pain c. Tell the charge nurse about the prescribed placebo and refuse to administer it d. Inform the client that the provider prescribed a placebo instead of pain medication

a. Discuss ethical concerns about placebo use with the health care provider

Prolonged exposure to high concentrations of supplemental oxygen over several days can cause which pathophysiological effect? a. Disrupted surfactant production b. Metabolic acidosis c. Aphasia and memory loss d. Deep sleep or coma

a. Disrupted surfactant production

An older adult male reporting abdominal pain is admitted to the hospital from a long term care facility. It has been seven days since his last bowel movement, and his abdomen is distended, and he just vomited 150 milliliters of dark brown emesis. In what order should the nurse implement these interventions? a. Elevate the head of bed b. Complete focus assessment c. Offer PRN pain medication d. Send emesis sample to the lab

a. Elevate the head of bed c. Offer PRN pain medication b. Complete focus assessment d. Send emesis sample to the lab

A young male client is admitted to rehab following a right above knee amputation for a severe traumatic injury. He is in the common room and anxiously calls out to the nurse, stating that his right foot is aching. The nurse offers reassurance and support. Which additional intervention is most important for the nurse to implement? a. Encourage discussion of feelings about the loss of his limb b. Administer prescription for gabapentin, and neuroleptic agent c. Teach the client how to wrap the stump with an elastic bandage d. Offer to assist the client to a quieter room so he can relax

a. Encourage discussion of feelings about the loss of his limb

The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cookinh. Which action should the nurse implement? a. Encourage family members to cook meals outdoors and bring the cooked food inside b. Assess the clients mucous membranes and report the findings to the healthcare provider c. Advise the client to replace cooked foods with a variety of different nutritional supplements Instruct the client to take an antiemetic before every meal to prevent excessive vomiting

a. Encourage family members to cook meals outdoors and bring the cooked food inside

The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. What action should the nurse implement? a. Encourage family members to cook meals outdoors and bring the cooked foods inside b. Advise the client to replace cooked foods with a variety of different nutritional supplements c. Assess the clients' mucous membranes and report the findings to the health care provider d. Instruct the client to take an anti-emetic before every meal to prevent excessive vomiting

a. Encourage family members to cook meals outdoors and bring the cooked foods inside

An older adult client is admitted to the stroke unit after recovery from the acute phase of an ischemic cerebral vascular accident (CVA). Which intervention should the nurse include in the plan of care during convalescence and rehabilitation? a. Encourage family to participate in the client's care b. Play classical music in room while client is awake c. Suction oral cavity every four hours d. Place a bedside commode next to bed e. Measure neurological vital signs every four hours

a. Encourage family to participate in the client's care e. Measure neurological vital signs every four hours

A middle-aged client, admitted to the critical care unit several weeks ago because of his serious injuries sustained in a motor vehicle accident, is currently in stable condition. Based on the client's age and recent life-threatening crisis, which intervention should the nurse implement? a. Encourage the client to reflect on personal goals and priorities b. Allow long periods of uninterrupted rest in order to reduce fatigue c. Discuss the cause of the accident with the client and his family d. Provide a routine schedule of activities to facilitate trust

a. Encourage the client to reflect on personal goals and priorities

A male client with psoriasis has jaundice and puritis. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take? a. Encourage the client to use cooler water and apply calamine lotion after soaking b. Obtain a PRN prescription for an analgesic that the client can use for symptom relief c. Suggest that the client take brief showers and apply oil based lotion after showering d. Explain that the symptoms are caused by liver damage and cannot be relieved

a. Encourage the client to use cooler water and apply calamine lotion after soaking

The nurse notes that a depressed female client has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? a. Engage the client in non-threatening conversations b. Encourage the client to participate in group activities c. Encourage the clients family to visit more often d. Schedule a daily conference with the social worker

a. Engage the client in non-threatening conversations

The nurse is caring for a client who is having a sickle cell crisis. What intervention should the nurse include in this client's plan of care? a. Ensure adequate IV and oral fluid intake. b. Provide ice packs to major joint areas. c. Space analgesics to prevent addiction to narcotics. d. Re-enforce the importance of nutritional balance.

a. Ensure adequate IV and oral fluid intake.

An adult woman who has a history of inferior myocardial infarction, esophageal reflux, and type 1 diabetes mellitus is admitted to the telemetry unit for sudden onset of dizziness with palpitations and a burning sensation in her chest. Which intervention should the nurse implement first? a. Evaluate telemetry cardiac rhythm b. Administer an oral antacid c. Assess blood glucose level d. Review clients last meal choices

a. Evaluate telemetry cardiac rhythm

A newly hired unlicensed assisted personnel (UAP) is assigned to a home health care team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients? a. Evaluate the newly hired UAP's level of competency by observing the UAP deliver care b. Assign the newly hired UAP to clients who require the least complex level of care c. Ask the most experienced UAP on the team to partner with the newly hired UAP d. Review the UAP's skills checklist and experience with the person who hired the UAP

a. Evaluate the newly hired UAP's level of competency by observing the UAP deliver care

The nurse is planning care for a 16 year old, who has juvenile idiopathic arthritis. The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? a. Exercise in a swimming pool b. Splint affected joints during activity c. Perform passive range of motion exercises twice daily d. Begin a training program lifting weights and running

a. Exercise in a swimming pool

When performing postural drainage on a client with chronic obstructive pulmonary disease, which approach should the nurse use? a. Explain that the client may be placed in five positions b. Instruct the client to breathe shallow and fast c. Obtain arterial blood gases prior to the procedure d. Perform the drainage immediately after meals

a. Explain that the client may be placed in five positions

An adult female client tells the nurse that though she's afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. Which action should the nurse take first? a. Explore the clients readiness to discuss the situation b. Determine the frequency and type of clients abuse c. Report the finding to the Police Department d. Discuss treatment options for abusive partners

a. Explore the clients readiness to discuss the situation

A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were: T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min.Which assessment findings taken now may be an early indication that the client is developing a complication of labor? a. FHT 168 beats/min b. Temperature 100 degrees Fahrenheit. c. Cervical dilation of 4 d. BP 138/88

a. FHT 168 beats/min

An adult male reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents had heart disease and his father had diabetes. He lives with his male partner, is vegetarian, and takes atenolol which maintains his blood pressure at 130/74 mmHg. Which risk factor should the nurse explore further with the client? Select all that apply. a. Family health history b. Homosexual lifestyle c. History of hypertension d. Vegetarian diet e. Excessive aerobic exercise

a. Family health history c. History of hypertension

After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take? a. File a detailed incident report with the specific hiring facility. b. Warn the colleague that their actions are unprofessional. c. Comment anonymously about the action of a staff discussion board. d. Communicate the colleague's actions to the unit charge nurse.

a. File a detailed incident report with the specific hiring facility.

The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading? Select all that apply. a. Flat affect b. Frequent drooling c. Frequent syncope d. Blurred vision e. Occasional nocturia

a. Flat affect c. Frequent syncope d. Blurred vision ?

An older client is admitted in respiratory distress secondary to heart failure (HF), coronary artery disease (CAD), hypertension (HTN), and atrial fibrillation. Which nursing problem should the nurse include in the client's plan of care? Select all that apply. a. Fluid volume excess b. Decreased cardiac output c. Altered peripheral tissue perfusion d. Fluid volume deficit e. Fatigue

a. Fluid volume excess b. Decreased cardiac output c. Altered peripheral tissue perfusion e. Fatigue

A mother brings her child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain? a. Frequency that the child uses a rescue inhaler during the week b. Type of allergen exposure or trigger for the current episode c. Type of inhaler the child typically uses on a regular basis d. Last dose and type of rescue inhaler used by the child

a. Frequency that the child uses a rescue inhaler during the week

The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading? a. Frequent syncope b. Occasional nocturia c. Flat affect d. Blurred vision e. Frequent drooling

a. Frequent syncope c. Flat affect d. Blurred vision

When conducting diet teaching for a client who was diagnosed with hypertension, which food should the nurse encourage the client to eat? (select all that apply.) a. Fruits without sauce b. Canned soup. c. Fresh or frozen vegetables without sauce. d. Cottage cheese. e. Pickled olives.

a. Fruits without sauce c. Fresh or frozen vegetables without sauce.

The nurse assesses a client being treated for herpes zoster (shingles). Which assessment should the nurse include when evaluating the effectiveness of treatment? Select all that apply. a. Functional ability b. Skin integrity c. Pain scale d. Bowel sounds e. Heart sounds

a. Functional ability b. Skin integrity c. Pain scale

The nurse is wearing personal protective equipment (PPE) while caring for a client, when exiting the room, which PPE should be removed first? a. Gloves b. Mask c. Eyewear d. Gown

a. Gloves

A female client presents in the emergency department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask? a. Has she taken a bath since the rape occurred? b. Is the place where she lives a safe place? c. Does she know the person who raped her? d. Did she report the rape to the police department?

a. Has she taken a bath since the rape occurred?

A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply) a. Headache and tremors b. Irregular heart rate c. Skin hyperpigmentation d. Postural hypotension e. Pallor and diaphoresis

a. Headache and tremors b. Irregular heart rate e. Pallor and diaphoresis

When taking a health history, which information collected by the nurse correlates most directly to a diagnosis of chronic peripheral arterial insufficiency? a. History of intermittent claudication b. A positive Brodie-Trendelenburg test c. Ankle ulceration and edema d. A serum cholesterol level of 250mg/dl (6.47 mmol/L)

a. History of intermittent claudication

During an admission assessment, the client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care? a. History of suicide attempts b. Feelings of disorientation c. Undiagnosed social anxiety symptoms d. Family history of schizophrenia

a. History of suicide attempts

The home health nurse observes an older client with unilateral weakness place the walker in front of the chair for support while rising to a standing position. Which action should the nurse take? a. Hold the Walker securely to prevent slipping when the client rises b. Applied gait belt to assist the client to rise out of the chair c. Instruct the client to use the arms of the chair for support d. Encourage the client to use the weaker leg with the walker when rising

a. Hold the walker securely to prevent slipping when the client rises

The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What findings should indicate to the nurse to withhold the next dose of medication? a. Hypertension b. Difficulty locating the uterine fundus c. Saturation of more than one pad per hour d. Excessive lochia

a. Hypertension

The nurse walks into a client's room and notices bright red blood on the sheets and on the floor by the IV pole. Which action should the nurse take first? a. Identify the source and amount of bleeding b. Apply direct pressure to the client's IV site c. Clean up the spilled blood to reduce infection transmission d. Notify the health care provider that the client appears to be bleeding

a. Identify the source and amount of bleeding

The nurse is caring for a client with the sexually transmitted infection (STI) chlamydia. The client reports having sex with someone who had many partners. Which response should the nurse provide? a. Inform that follow-up may end after treatment is finished b. Reassure that complications will not occur if the infection is treated c. Notify that persons with stis are reported to local health departments d. Explain how the infection is transmitted and the health risks involves

a. Inform that follow-up may end after treatment is finished

After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the X-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? a. Initiate intravenous fluids as prescribed b. Remove the catheter and apply direct pressure for five minutes c. Notify the health care provider of the need to reposition the catheter d. Secure the catheter using aseptic technique

a. Initiate intravenous fluids as prescribed

A client with syndrome of inappropriate antidiuretic hormone secretion (SIDH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury? a. Initiate seizure precautions. b. Assess neurological status every 8 hours. c. Limit oral water intake. d. Administer a hypertonic IV fluids as prescribed.

a. Initiate seizure precautions.

A client with chronic kidney disease (CKD) is discharged with a prescription for epoetin alpha subcutaneously. In teaching the client about the medication, the nurse should emphasize the benefit of increasing which food product in the diet? a. Iron rich foods b. High fiber foods c. Citrus fruits and vegetables d. Dairy products

a. Iron rich foods

A female adult who is undergoing chemotherapy tells the nurse that she plans to volunteer at the elementary school this winter. Which question is best for the nurse to ask this client? a. Is it possible that you will be in direct contact with the children at school? b. Do you realize that you will be exposed to many different types of germs? c. Are you aware that you do not have a fully functioning immune system? d. Have you ever considered that you are putting yourself at risk for developing infections?

a. Is it possible that you will be in direct contact with the children at school?

A client with rheumatoid arthritis (RA) starts a new prescription for etanercept subcutaneously once weekly. The nurse should emphasize the importance of reporting which problem to the healthcare provider? a. Joint stiffness b. Persistent fever c. Headache d. Increased hunger and thirst

a. Joint stiffness

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? a. Keep the nails trimmed short. b. Apply baby lotion to the skin twice daily. c. Bathe the child daily with bath oil. d. Allow the child to wear only 100% cotton clothing.

a. Keep the nails trimmed short.

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type one diabetes mellitus, the client tells the nurse in a loud voice to leave the room. What action should the nurse take? a. Leave the clients room and return later in the day b. Explain that insulin is a life saving drug for the client c. Encourage client to implement relaxation techniques d. Refer the client to the social worker for support therapy

a. Leave the clients room and return later in the day

A client who's administered with complications related to hypopituitarism is diaphoretic and hypotensive. Which assessment finding warrants immediate intervention by the nurse? a. Lethargy b. Bradycardia c. Cor pulmonale d. Muscle cramp (?)

a. Lethargy

The nurse is reviewing the laboratory values for a client with acute pancreatitis who reports that the abdominal pain is not as severe as it was on admission. Which laboratory test should the nurse review to evaluate the client's clinical recovery? a. Lipase b. Creatinine c. Bilirubin d. Glucose

a. Lipase

The nurse is caring for a seated client who is experiencing a tonic clonic seizure. Which actions should the nurse implement? Select all that apply. a. Loosen restrictive clothing b. Insert a bite block c. Ease the client to the floor d. Note the duration of the seizure e. Restrain the client

a. Loosen restrictive clothing c. Ease the client to the floor d. Note the duration of the seizure

A client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exertion, and is diagnosed with acute infective endocarditis. During the admission assessment, the nurse observes multiple areas of petechiae on the client's skin. Which intervention should the nurse include in the client's plan of care? Select all that apply. a. Monitor cardiac rhythm via telemetry b. Report changes in pre-existing murmurs c. Schedule rest periods between activities d. Maintain record of fluid intake and output e. Initiate contact transmission precautions

a. Monitor cardiac rhythm via telemetry b. Report changes in pre-existing murmurs e. Initiate contact transmission precautions

A client with cancer complains of fever, chills, malaise, and headache following administration of a colony stimulating factor. Which nursing intervention is most beneficial in helping to reduce the flu like symptoms? a. Monitor lab values for an increase in WBCs b. Administer anti emetics before, during, and after therapy c. Administer acetaminophen Q4H d. Monitor vital signs Q4H for 24 hours

a. Monitor lab values for an increase in wbcs ?

The nurse identifies an electrolyte imbalance, an elevated pulse rate, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with chronic kidney disease. What intervention should the nurse include in the plan of care? a. Monitor serum electrolytes daily. b. Provide only distilled water. c. Document abdominal girth. d. Perform range of motion exercises.

a. Monitor serum electrolytes daily.

A client with acute renal failure is admitted for uncontrolled type one diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is most important for the nurse to include in the clients plan of care? a. Monitor the client's cardiac activity via telemetry b. Assess glucose via finger stick every four to six hours c. Maintain venous access with an infusion of normal saline d. Evaluate hourly urine output for return of normal renal function

a. Monitor the client's cardiac activity via telemetry

A client with type one diabetes mellitus and a large draining ulcer of the right foot is admitted with a suspected of Staphylococcus aureus infection. Which intervention should the nurse implement? Select all that apply. a. Monitor the client's white blood cell count b. Explain the purpose of a low bacteria diet c. Send wound drainage for culture and sensitivity d. Institute contact precautions for staff and visitors e. Use standard precautions and wear a mask

a. Monitor the client's white blood cell count c. Send wound drainage for culture and sensitivity d. Institute contact precautions for staff and visitors

During discharge teaching, and overweight client with heart failure is asked to make a grocery list for the nurse to review period which food choices included in the clients less should the nurse encourage? Select all that apply. a. Natural whole almonds b. Cheddar cheese cubes c. Lightly salted potato chips d. Plain, air-popped popcorn e. Canned fruit in heavy syrup

a. Natural whole almonds d. Plain, air-popped popcorn

An adult male is brought into the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? a. Nausea with projectile vomiting b. Rebound abdominal tenderness c. Diminished bilateral breath sounds d. Rib pain with deep inspiration

a. Nausea with projectile vomiting

A client with bacterial meningitis is receiving phenytoin. Which assessment finding indicates to the nurse that the client is experiencing a therapeutic response?

a. Normal electroencephalogram after drug administration

A female client is admitted to the hospital with a diagnosis of right lower quadrant (RLQ) abdominal pain in a possible ectopic pregnancy. She tells the nurse that her pain is gone, but she is now experiencing a generalized abdominal aching. Her blood pressure has decreased in her pulse has increased over the past two hours. While waiting for the health care provider to arrive, which intravenous solution is best for the nurse to initiate? a. Normal saline at 20 ml/hr b. Lactated ringer's at 150 ml/hr c. D5W/ 0.45 NS at 125 ml/hr d. Dextrose 10% at 83 ml/hr

a. Normal saline at 20 ml/hr

A client admitted with a liver abscess is scheduled for surgical evacuation and drainage of the abscess tomorrow morning. Nursing assess .... Client's abdominal pain has increased from 4 to 8 on a 10-point scale in the last four hours. What is priority nursing action? a. Notify the surgeon of increasing abdominal pain. b. Administer the next scheduled dose of antibiotic. c. Encourage the client to cough and deep breath. d. Assess for a change in the client's bowel sounds.

a. Notify the surgeon of increasing abdominal pain.

A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate that the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? a. Observe aspiration site b. Monitor skin elasticity c. Measure urinary output d. Assess body temperature

a. Observe aspiration site

A client was admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions? a. Observe breathing patterns b. Assess blood pressure c. Measure body temperature d. Palpate for pedal edema

a. Observe breathing patterns b. Assess blood pressure c. Measure body temperature d. Palpate for pedal edema

1. Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects up from the medication, which assessment is most important for the nurse to include in the client's plan of care? a. Observe color of urine b. Measure body temperature c. Assess skin turgor d. Check for pedal edema

a. Observe color of urine

A client taking clopidogrel reports the onset of diarrhea. Which nursing actions should the nurse implement first? a. Observe the appearance of the stool b. Assess the elasticity of the client skin c. Review the client's laboratory values d. Auscultate the clients bowel sounds

a. Observe the appearance of the stool

A client is admitted with possible urosepsis. Which intervention should the nurse perform as soon as possible? a. Obtain a urine specimen for a prescribed culture and sensitivity test b. Teach the client about the side effects of the prescribed anti-infective drug c. Administer the initial dose of the anti-infective drug as prescribed d. Assess the last 24 hour oral and intravenous fluid intake and urine output

a. Obtain a urine specimen for a prescribed culture and sensitivity test

While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, and irregular heart rate, and persistent cough that pink produces blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement? a. Obtain sputum sample b. Document degree of edema c. Initiate hourly urine output measurement d. Administer intravenous diuretics

a. Obtain sputum sample

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the health care provider? a. Ortolani maneuver causing a click at the hip joint b. Babinski test that reveals fanning out of the toes c. Plum line test indicates fetal position curvature d. Moro test precipitating the startle response

a. Ortolani maneuver causing a click at the hip joint

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the health care provider? a. Ortolani maneuver causing a click at the hip joint b. Plumb line test indicates fetal position curvature c. Babinski tests that reveals fanning out of toes d. Moro test precipitating a startle response

a. Ortolani maneuver causing a click at the hip joint

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take? a. Place a nasal swab specimen for COVID-19 directly into a biohazard bag b. Move the client to a private room, keep the door closed, and initiate droplet precautions c. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus d. Explain to the client to inform others that they may have been potentially exposed in the last 14 days

a. Place a nasal swab specimen for COVID-19 directly into a biohazard bag

A mother of a one-month-old infant calls the clinic to report that the back of her infant's head is flat. How should the nurse respond? a. Position the infant on the stomach occasionally when awake and active b. Turn the infant on the left side braced against the crib when sleeping c. Prop the infant in a sitting position with a cushion when not sleeping d. Place a small pillow under the infants head while lying on the back

a. Position the infant on the stomach occasionally when awake and active

While administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential for the nurse to monitor which serum lab value? a. Potassium b. Calcium c. Protein d. Hemoglobin

a. Potassium

A client with chronic obstructive pulmonary disease (COPD) is experiencing worsening dyspnea and low oxygen levels. Vital signs are: temperature 99.6 degrees F, Heart rate 98 beats/minute, respirations 28 breaths/minute, blood pressure 140/82 mmHg and oxygen saturation 88%. Which action should the nurse implement? a. Prepare client for endotracheal intubation b. Place the client in a forward-leaning position c. Apply a non-rebreather mask at 100% oxygen d. Obtain a sputum sample for culture and sensitivity

a. Prepare client for endotracheal intubation

A female child is brought into the emergency department after awakening with a bark-like cough and stridor. Upon arrival to the hospital, her respirations are labored, and she is drooling. What action should the nurse implement? a. Prepare for emergency tracheostomy b. Assess the child for dehydration c. Collect midstream urine specimen for culture d. Examine oropharyngeal area for foreign body

a. Prepare for emergency tracheostomy

A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cataracts ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Prepare skin for procedure b. Identify clients pulse points c. Check telemetry monitoring d. Witness consent for procedure

a. Prepare skin for procedure

The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child anxiety, what action is best for the nurse to implement? a. Provide dolls and equipment to re-enact feelings associated with painful procedures b. Give the child syringes or hospital masks to play with at home prior to hospitalization c. Provide a family tour of the preoperative unit one week before the surgery is scheduled d. Include the child and play therapy with children who are hospitalized for similar surgery

a. Provide dolls and equipment to re-enact feelings associated with painful procedures

A low-risk primigravida at 28-weeks gestation arrives for her regular antenatal clinic visit. Which assessment finding should the nurse consider within normal limits for this client? a. Pulse increase of 10 beats/minute b. Fundal height of 22 centimeters c. Glucosuria d. Proteinuria

a. Pulse increase of 10 beats/minute

A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why the health care provider has prescribed all these medications. Which information should the nurse include when responding to this client? Select all that apply. a. Pupillary dilation is necessary to access the eye chamber for lens removal b. A medication is used to induce sleep during the procedure c. One of the medications is used to anesthetize the corneal surface d. The iris must be paralyzed during surgery to prevent it from reacting to light e. These medications assistant instructing the client's vision during the surgery

a. Pupillary dilation is necessary to access the eye chamber for lens removal d. The iris must be paralyzed during surgery to prevent it from reacting to light

The home health nurse is scheduling visits for clients with diabetes who need blood glucose measurements, one postoperative client who needs wound care, and two clients who need admission assessments and care plans established. Staffing includes one nurse (RN) and two licensed practical nurses (PN). Which is the best home visit assignment? a. RN completes the two admission assessments. 1 PN completes the blood glucose measurements, and 1 PN completes the post-operative visit b. RN completes the postoperative visit in two blood glucose measurements. Each PN completes one admission assessment c. RN completes 1 admission and the postoperative visit. 1 PN completes the blood glucose measurements, 1 PN completes an admission assessment d. RN completes the postoperative visit. Each PN completes one admission assessment and one blood glucose measurement

a. RN completes the two admission assessments. 1 PN completes the blood glucose measurements, and 1 PN completes the post-operative visit

When assessing the surgical dressing of a client who had an abdominal surgery the previous day, the nurse observes that a small amount of drainage present on the dressing and the wounds Hemovac suction device is empty with the plug open. How should the nurse respond? a. Recompress the wound suction device and secure the plug b. Notify the health care provider that the drain is not working c. Replace the dressing and remove the drainage device d. Repositioned the drainage device to keep the plug open

a. Recompress the wound suction device and secure the plug

A successful businessman presents to the community Health Center complaining of sleeplessness and anxiety over his financial status. What action should the nurse take to assist the client in diminishing his anxiety? a. Reinforce the reality of his financial situation b. Direct him to drink a glass of red wine at bedtime c. Teach him to limit sugar and caffeine intake d. Encourage him to initiate daily rituals

a. Reinforce the reality of his financial situation

When providing client care, the nurse identifies a problem and develops a related clinical question. Next the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence based. When gathering evidence, which consideration is most important? a. Relevance to the situation b. Related personal values c. Frequency that the problem occurs d. Past experience with similar problems

a. Relevance to the situation

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative. Which nursing care intervention should the nurse include in the client's plan of care? Select all apply. a. Remove urinary catheter as soon as possible and encourage voiding b. Assess pain level and medicate PRN as prescribed c. Maintain sequential compression devices while in bed d. Teach client to use incentives spirometer every two hours while awake e. Administer low molecular weight heparin as prescribed

a. Remove urinary catheter as soon as possible and encourage voiding d. Teach client to use incentives spirometer every two hours while awake

The nurse is managing care of a client with Cushing syndrome which intervention should the nurse delegate to the unlicensed assistive personnel? Select all that apply. a. Report any client complain of pain or discomfort b. Evaluate the client for sleep disturbances c. Assess the client for weakness and fatigue d. Weigh the client and report any weight gain e. Note and report the clients food and liquid intake during meals and snacks

a. Report any client complain of pain or discomfort d. Weigh the client and report any weight gain e. Note and report the clients food and liquid intake during meals and snacks

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? Select all that apply. a. Report serum albumin and globulin levels b. Provide diet low in phosphorus c. Increase oral fluid intake to 1500 ml daily d. Note signs of swelling and edema e. Monitor abdominal girth

a. Report serum albumin and globulin levels d. Note signs of swelling and edema e. Monitor abdominal girth

A seriously ill male client is transferred to the health care facility in a different state. Included in his records are advanced directive and a physician orders for life sustaining treatment. However, the state to which he is transferred does not endorse POLST. The client lapses into a coma shortly after admission to the new facility. What action should the nurse take? a. Request that the new health care provider cosine the POLST document b. Implement the clients wishes as described in his advanced directive c. Ask the clients family to make life sustaining treatment decisions d. Attached an advance directive copy to a medical record prescription page

a. Request that the new health care provider cosine the POLST document

Two days prior to discharge from the rehabilitation facility, the nurse is teaching a client who is recovering from Guillain-Barre syndrome about home care. Which actions should the nurse include when providing when providing discharge teaching to the client and spouse? a. Review safe transfer strategies b. Develop a nutritional plan c. Help identify community support d. Initiate a rigorous exercise routine e. Provide cooking instructions

a. Review safe transfer strategies b. Develop a nutritional plan c. Help identify community support

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time? a. Risk for infection b. Impaired physical mobility c. Self-care deficit d. Risk for impaired skin integrity

a. Risk for infection

A female client with dementia who needs assistance with meals and activities of daily living often screams at the staff and threatens to hit those who come near her period which nursing problems should be included in the treatment plan? a. Risk for other directed violence b. Impaired verbal communication c. Risk for acute confusion d. Caregiver role strain

a. Risk for other directed violence

The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal a. S3 ventricular gallop b. Apical click c. Systolic murmur d. Split S2

a. S3 ventricular gallop

A toddler presenting with a history of intermittent rashes hives abdominal pain and vomiting that occurs after ingesting of milk products arrives to the clinic accompanied by the parents. Which type of testing should the nurse provide education to the toddlers family about? a. Serum immunoglobulin E b. Intradermal test c. Atopy patch test d. Placebo controlled food challenge

a. Serum immunoglobulin E

An adult client who was admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the health care provider? a. Serum lithium level of 1.6 meq/L or mmol/l (SI) b. Six hours of sleep in the past three days c. Weight loss of 10 pounds in the past month d. Blood alcohol level of 0.09%

a. Serum lithium level of 1.6 meq/L or mmol/l (SI)

A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? a. Side-lying on the left with the head elevated 10 degrees b. Side-lying on the left with the head elevated 35 degrees c. Side-lying on the right with the head elevated 10 degrees d. Side-lying on the right with the head elevated 35 degrees

a. Side-lying on the left with the head elevated 10 degrees

A client is discussing feelings related to a recent loss with a nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior? a. Silence allows the client to reflect on what was said b. The nurse is respecting the client's loss c. The nurse is stating disapproval of the statement d. Silence is reflecting the client sadness

a. Silence allows the client to reflect on what was said

After learning that she has terminal pancreatic cancer, a female client becomes very angry and says to the nurse, "God has abandoned me. What did I do to deserve this?" Based on this response, the nurse decides to include which nursing problem in the clients plan of care? a. Spiritual distress b. Ineffective coping c. Acute pain d. Complicated grieving

a. Spiritual distress

The nurse should withhold which medication if the clients serum potassium level is too high? a. Spironolactone b. Hydrochlorothiazide c. Metolazone d. Furosemide

a. Spironolactone

The nurse is caring for client with flail chest secondary to 3 right rib fractures after sustaining a fall from a ladder. The client is anxious, but stable with an oxygen saturation of (spo2) 93%. Which action should the nurse take? a. Splint affected side b. Insert nasal airway c. Coach through taking deep breaths d. Apply a non-rebreather mask

a. Splint affected side

While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first? a. State it is unacceptable to undress during interview b. Change to less anxiety promoting questions c. Leave the client's room so she can act out her anxiety d. Ignore the client's inappropriate behavior

a. State it is unacceptable to undress during interview

An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? a. Stay with client and observe for airway obstruction b. Collect pillows and pad the side rails of the bed c. Place an oral airway in the mouth and suction d. Announce a cardiac arrest, and assist with intubation

a. Stay with client and observe for airway obstruction

A new nurse is preparing to irrigate an intravenous catheter and is attaching a 24 gauge needle. Which action should the nurse implement? a. Suggest the nurse use a 20 gauge needle b. Instruct them nurse to remove the needle c. Direct the nurse to change the IV tubing d. Prompt the nurse to apply povidone to the site

a. Suggest the nurse use a 20 gauge needle

The nurse arranging home care for an older client who has a new colostomy following a large bowel resection three days ago. The client plans to live with a family member. Which actions should the nurse implement? Select all that apply. a. Teach care of ostomy to care provider b. Assess the client for self-care ability c. Provide pain medication instructions d. Request a home safety inspection e. Call home care agency to set up oxygen

a. Teach care of ostomy to care provider b. Assess the client for self-care ability c. Provide pain medication instructions

A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this clients plan of care? a. Teach techniques for scanning the environment b. Practice visual exercises that focus on a still object c. Encourage the use of corrective lenses during the day d. Alternate an eye patch from eye to eye every two hours

a. Teach techniques for scanning the environment

A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. Which intervention should the nurse include in this clients plan of care? a. Teach techniques for scanning the environment b. Encourage the use of corrective lenses during the day c. Alternate an eye patch from eye to eye every two hours d. Practice visual exercises that focus on a still object

a. Teach techniques for scanning the environment

The nurse notes that a postoperative adult client's respiratory rate is 10 breaths/minute. Which factor is the most likely explanation for this finding? a. The client's PCA pump with morphine sulfate was discontinued 15 minutes ago b. The client's hemoglobin is 10.1 gm/dl and hematocrit is 30.4% c. The client has a 20-pack year history of smoking cigarettes d. The client has a history of allergic bronchitis with recurrent bacterial pneumonia

a. The client's PCA pump with morphine sulfate was discontinued 15 minutes ago

The nurse is caring for a 24 month old toddler who has sensory sensitivity, difficulty engaging in social behaviors, and has not yet spoken two word phrases. Which assessment should the nurse administer a. The modified checklist for autism and toddlers (M-CHAT) b. Psychology systems questionnaire (PHQ-2) c. Behavioral style questionnaire (BSQ) d. The ages and stages questionnaire (ASQ)

a. The modified checklist for autism and toddlers (M-CHAT)

A school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow up. The teacher should be instructed to report which situations to the school nurse? Select all that apply. a. Thirst and frequent requests for bathroom breaks b. Shaking that changes the child's handwriting legibility c. Bruises on both knees after the weekend d. Refuses to complete written homework assignments e. Sunburn with blisters on the face, arms, and hands

a. Thirst and frequent requests for bathroom breaks b. Shaking that changes the child's handwriting legibility e. Sunburn with blisters on the face, arms, and hands

The mother of a 2-day-old infant girl expresses concern about a "flea bite" type of rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer? a. This is a common newborn rash that will resolve after several days b. The rash is due to distended oil glands that will resolve in a few weeks c. The healthcare provider is being notified about the rash d. This rash is characteristic of a medication reaction

a. This is a common newborn rash that will resolve after several days

A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? a. Until the healthcare provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception b. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate. c. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days. d. The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.

a. Until the healthcare provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception

Prior to obtaining a trapeze bar for a client with limited mobility, which assessment is most important for the nurse to obtain? a. Upper body muscle strength b. Balance and posture c. Risk for disuse syndrome d. Pressure sore risk

a. Upper body muscle strength

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction should the nurse include in the clients discharge teaching plan? Select all that apply. a. Use recliner for long periods of sitting b. Continue wearing compression stockings c. Avoid prolonged standing or sitting d. Crossed legs at knee but not at ankle e. Maintain the bed flat while sleeping

a. Use recliner for long periods of sitting b. Continue wearing compression stockings c. Avoid prolonged standing or sitting

The nurse is developing an educational program for older clients who are being discharged with new hypertensive medications. The nurse should ensure that the educational materials include which characteristics? Select all that apply. a. Uses common words with few syllables b. Printed using a 12-point type font c. Uses pictures to help illustrate complex ideas d. Contains a list with definitions of unfamiliar terms e. Written at a twelfth-grade reading level

a. Uses common words with few syllables c. Uses pictures to help illustrate complex ideas d. Contains a list with definitions of unfamiliar terms

A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy tests and ultrasounds were negative, so an exploratory laparotomy was completed during the night. When coffee ground material is observed in the drainage from the nasal gastric tube, which intervention should the nurse implement? a. Verify correct placement of the nasogastric tube b. Perform gastroccult test on the nasogastric drainage c. Listen for evidence of diminished bowel sounds d. Irrigate the nasogastric tube with water until clear

a. Verify correct placement of the nasogastric tube

A combination multidrug cocktail is being considered for an 8 symptomatic HIV infected client with CD4 cell count of 500. Which nursing assessment of this client is most crucial in determining whether therapy should be initiated? a. Willing to comply with complex drug schedule b. Maintains an adequate social support system c. Qualifies for a prescription assistance program d. States various side effects of retroviral agents

a. Willing to comply with complex drug schedule

A male client with COPD smokes 2 packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly? a. "I always shake the inhaler several times before I start." b. "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away." c. "I have a hard time inhaling and holding my breath after I squeeze the inhaler, but I do my best." d. "I never use the inhaler unless I am feeling really short of breath."

b. "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away."

A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? a. "I have a sharp pain in my chest when I take a breath." b. "I have been coughing up foul-tasting, brown, thick sputum." c. "I have been sweating all day." d. "I feel hot off and on."

b. "I have been coughing up foul-tasting, brown, thick sputum."

A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? a. "The tube will drain fluid from your chest." b. "The tube will remove excess air from your chest." c. "The tube controls the amount of air that enters your chest." d. "The tube will seal the hole in your lung."

b. "The tube will remove excess air from your chest."

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to include in the assessment of this client? a. "How do you cope with the voices?" b. "What are the voices saying?" c. "Which medication works best?" d. "When do you hear voices?"

b. "What are the voices saying?"

A nurse working on an endocrine unit should see which client first? a. An older client with Addison's disease whose current blood sugar level is 62 milligrams per deciliter b. A client taking corticosteroids who has become disoriented in the last two hours c. An adolescent male with type one diabetes who is arguing about his insulin dose d. An adult with a blood sugar of 384 milligrams per deciliter in a urine output of 350 milliliters in the last hour

b. A client taking corticosteroids who has become disoriented in the last two hours

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations for the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply. a. A bedside commode is positioned near the bed b. A full pitcher of water is on the bedside table c. A low sodium diet tray was brought to the room d. The client is lying in the supine position in bed e. A saline lock is present in the right forearm

b. A full pitcher of water is on the bedside table d. The client is lying in the supine position in bed

The nurse is caring for an adolescent client with an intestinal obstruction who presents with severe, colicky pain, nausea, vomiting, and abdominal distention. Which pathophysiologic mechanism supports the client's clinical presentation? a. An incompetent lower esophageal sphincter b. A weakened diaphragm with high abdominal pressure c. Intestinal scar tissue buildup from a chronic condition d. History of having Helicobacter pylori infection

b. A weakened diaphragm with high abdominal pressure

The nurse who is working on a surgical unit received change of shift report for a group of clients for the upcoming shift. A client with which condition requires immediate attention by the nurse? a. Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson Pratt drain b. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills c. Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container d. Gunshot wound 3 hours ago with dark drainage of 2 cm noted on the dressing

b. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills

What is the primary goal when planning nursing care for a client with degenerative joint disease? a. Improve stress management skills b. Achieve satisfactory pain control c. Obtain adequate rest and sleep d. Reduce risk for infection

b. Achieve satisfactory pain control

While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to a. Call the health care provider immediately b. Administer acetaminophen as ordered as this is normal at this time c. Send blood, urine and sputum for culture d. Increase the client's fluid intake

b. Administer acetaminophen as ordered as this is normal at this time

A client's morning assessment includes bounding peripheral pulses, weight gain of two pounds (0.91 kg), pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client's plan of care? a. Restrict daily fluid intake to 1500 ml b. Administer prescribed diuretic c. Maintain accurate intake and output d. Weigh client every morning

b. Administer prescribed diuretic

A client's morning assessment includes bounding peripheral pulses, weight gain of two pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this clients plan of care? a. Maintain accurate intake and output b. Administer prescribed diuretic c. Weigh client every morning d. Restrict daily fluid intake to 1500 milliliters

b. Administer prescribed diuretic

The nurse is planning care for a client who has a fourth-degree midline laceration that occurred during vaginal delivery of an 8 pound 10 ounce infant. Which intervention has the highest priority for this client? a. Administer prescribed PRN sleep medications b. Administer prescribed stool softener c. Encourage use of prescribed analgesic perennial sprays d. Encourage breastfeeding to promote uterine involution

b. Administer prescribed stool softener

A male client with heart failure becomes short of breath, anxious, and has audible wheezing with pink frothy sputum. The nurse sits the client and provides oxygen per nasal cannula. The nurse receives a prescription to administer a one-time dose of morphine sulfate intravenously. Which action should the nurse take? a. Withhold the morphine until the client's dyspnea resolves b. Administer the dose of morphine sulfate as prescribed c. Consult with the charge nurse regarding the morphine prescription d. Review the need for the prescription with the health care provider

b. Administer the dose of morphine sulfate as prescribed

A client who experienced a cerebrovascular accident (CVA) is a aphasic and has left sided paralysis. Which nurse should be responsible for coordinating the progression of this client care? a. Nurse case manager b. Adult nurse practitioner c. Neurology unit supervisor d. Risk management nurse

b. Adult nurse practitioner

A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. What action should the nurse take? a. Encourage the UAP to provide comfort care measures only b. Advise the UAP to resume positioning the client on schedule c. Assign a practical nurse to assist the UAP and turning the client d. Assume total care of the client and monitor neurologic function

b. Advise the UAP to resume positioning the client on schedule

The nurse enters the room of a client with Parkinson's disease who is taking carbidopa-levodopa. The client is a rising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take? a. Demonstrate how to help the client move more efficiently b. Affirm that the client should arise slowly from the chair c. Offer a PRN analgesic to reduce painful movement d. Tell the UAP to assist the client in moving more quickly

b. Affirm that the client should arise slowly from the chair

Which conditions are most likely to respond to treatment with antihistamines? Select all that apply. a. Bronchitis b. Allergic rhinitis c. Otitis media d. Contact dermatitis e. Myocarditis

b. Allergic rhinitis d. Contact dermatitis

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare providers attention? a. Enapril b. Allopurinol c. Fureosemide d. Aspirin low dose

b. Allopurinol

The nurse is caring for four clients on a medical unit. Which client is at an increased risk for candidiasis? a. An adolescent in the third trimester of pregnancy who has persistent hyperemesis b. An adult with acquired immunodeficiency syndrome who is taking antibiotics c. The client who is admitted for preoperative surgical consult for morbid obesity d. An older client with chronic kidney disease who has uremic frost

b. An adult with acquired immunodeficiency syndrome who is taking antibiotics

An older adult client us having photocoagulation for macular degeneration. Which intervention should the nurse implement during the post-procedure care in the outpatient surgical unit? a. Arrange food on the plate in clockwise order b. Apply bilateral eye patches while sleeping c. Verbally identify self when entering the room d. Use white board to communicate ideas

b. Apply bilateral eye patches while sleeping

In planning care for a client with early-stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury due to impaired judgement. Which intervention is most important for the nurse to include in this clients plan of care? a. Offer the client frequent reassurance that he/she will be safe b. Arrange the client's environment so the client can move about freely c. Engage the client in regularly scheduled activities during the day d. Assign a UAP to provide the client with total personal care

b. Arrange the client's environment so the client can move about freely

After administering a proton pump inhibitor, which action which should the nurse take to evaluate the effectiveness of the medication? a. Auscultates for bowel sounds in all quadrants b. Ask the client about gastrointestinal pain c. Monitor the client's serum electrolyte levels d. Measure the clients fluid intake and output

b. Ask the client about gastrointestinal pain

A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near drowning incident. While providing care to the child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. Which action should the nurse take? a. Develop a water safety teaching plan for the family b. Ask the older brother how he felt during the incident c. Tell the older brother that he seems depressed d. Commend the older brother for his heroic actions

b. Ask the older brother how he felt during the incident

A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be a. Cover the areas with dry sterile dressings b. Assess for dyspnea or stridor c. Initiate intravenous therapy d. Administer pain medication

b. Assess for dyspnea or stridor

The nurse receives report on a client who is 4 hours post total abdominal hysterectomy the previous nurse reports that it was necessary to change the clients perennial pad hourly, and that it is saturated again. The previous nurse also notes that the client's urinary output has decreased. Which action should the nurse implement first? a. Evaluate the skin turgor b. Assess for weakness or dizziness c. Change the perennial pad d. Measure the urinary output

b. Assess for weakness or dizziness

An older client comes to the clinic with a family member. When the nurse attempts to take the clients health history, the client does not respond to the questions in a clear manner. What action should the nurse implement first? a. Provide a printed healthcare assessment form b. Assess the surroundings for noise and distractions c. Ask the family member to answer the questions d. Defer the health history until the client is less anxious

b. Assess the surroundings for noise and distractions

A recently hired nurse who is in orientation is assigned to the medical unit. The charge nurse observes the new nurse prepare to administer a unit of packed red blood cells as seen in the picture. Which action should the charge nurse take? a. Verify that a 22-gauge intravenous catheter is used for the transfusion b. Assist the nurse in changing the intravenous tubing attached to the blood c. Tell the nurse to take the clients vital signs and then start the transfusion d. Assume responsibility for the care of the client during the blood transfusion

b. Assist the nurse in changing the intravenous tubing attached to the blood

When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we sought treatment sooner!" Which intervention is best for the nurse to implement? a. Refer the parents to the chaplain to provide grief counseling b. Assure the parents that a terminal diagnosis was inevitable c. Tell the parents that blame each other will not change the situation d. Explain to the parents that anger is a common response to grief

b. Assure the parents that a terminal diagnosis was inevitable but I think d???

A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent? a. Assessment of a bruit on the left forearm b. Auscultation of a thrill on the left forearm c. The left radial pulse is 2+ bounding d. Distended, tortuous veins in the left hand

b. Auscultation of a thrill on the left forearm

Oxygen at 5 L/minute per nasal cannula is being administered to a 10 year old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider? a. Taking a sedative at bedtime slows respiratory rate, which decreases oxygen needs b. Avoid administration of oxygen at high levels for extended periods c. Oxygen is less toxic when it is humidified with a hydration source d. Increase oxygen rate during sleep to compensate for slower respiratory rate

b. Avoid administration of oxygen at high levels for extended periods

The nurse is assigning care of a client with prostatitis to a practical nurse (PN). What instruction should the nurse provide the PN regarding care of this client? a. Restrict oral fluid intake b. Avoid urinary catheterization c. Strain all urine d. Maintain contact isolation

b. Avoid urinary catheterization

The nurse is evaluating the diet teaching of a client with hypertension. Which dinner selection indicates that the client understands the dietary recommendations for hypertension? a. Grilled steak, baked potato with sour cream, green beans, coffee, and raisin cream pie b. Baked pork chop, applesauce, corn on the cob, 1% milk, and Key Lime Pie c. Tomato soup, grilled cheese sandwich, Pickles, skim milk, and lemon meringue pie d. Beef stir fry, fried rice, egg drop soup, diet soda, and pumpkin pie

b. Baked pork chop, applesauce, corn on the cob, 1% milk, and Key Lime Pie

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safety? Select all that apply. a. Leans forward to pull a pan from a high shelf b. Bends from the waist to pick trash off the floor c. Locks knees while preparing food on the counter d. Brings a heavy can close to body before lifting e. Widens stance while working near the sink

b. Bends from the waist to pick trash off the floor d. Brings a heavy can close to body before lifting

Which self-care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus? a. Self injection techniques b. Blood glucose monitoring c. Diabetic diet meal planning d. A realistic exercise plan

b. Blood glucose monitoring

A client with hemorrhoids asked for information about high fiber diet. Which breakfast menu items should the nurse suggest? Select all that apply. a. Scrambled eggs b. Bowl of oatmeal c. Raisin bran muffins d. Cup of raspberries e. Bacon slices

b. Bowl of oatmeal c. Raisin bran muffins d. Cup of raspberries

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation? a. Continued development of the brain lesion determines the child's outcome b. Brain damage with CP is not progressive but it does have variable course c. CP is one of the most common permanent physical disability in children d. Severe motor dysfunction determines the extent of successful habilitation

b. Brain damage with CP is not progressive but it does have variable course

The nurse is providing discharge teaching to the parents of a 13-month-old child who underwent repair for an arterial septal defect. The healthcare provider prescribes aspirin and an antibiotic for the first 6 months postoperatively to prevent infective endocarditis (IE). What information is most important for the nurse to discuss with the parents about the child's recovery and prevention of IE? a. Refer the mother to the healthcare provider to discuss infective endocarditis b. Brush the child's teeth every day and ensure the child receives regular dental follow-up c. Give the child acetaminophen for pain or fever and visit the surgeon for follow-up d. Monitor the child for regular bowel movements and urine output that exceeds intake

b. Brush the child's teeth every day and ensure the child receives regular dental follow-up

The nurse is caring for a client with heart failure. Which method is used in computing the cardiac index to measure how the client's heart is functioning? a. Mean arterial pressure minus right atrial pressure b. Cardiac output divided by body surface area c. Stroke volume divided by end diastolic volume d. Stroke volume multiplied by heart rate

b. Cardiac output divided by body surface area

A client is recovering in the outpatient surgical unit after an endoscopic carpal tunnel release. The nurse assesses the client's vital signs, pain level, and dressing. Before discharging the client, which intervention should the nurse implement? a. Administer and non-steroidal anti-inflammatory drug for pain b. Check neurovascular status of the distal digits c. Change the dressing if drainage increases d. Position the arm in a sling for discharge

b. Check neurovascular status of the distal digits

An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia. Which intervention is most important for the nurse to implement? a. Prepare for emergent oral intubation b. Clarify end of life desires c. Offer sips of favorite beverages d. Initiate comfort measures

b. Clarify end of life desires

The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective? a. Average client scores improved on specific risk factor knowledge tests b. Clients who develop disease complications promptly received rehabilitation c. Only 30% of clients did not attend self-management education sessions d. More than 50% of at risk clients were diagnosed early in their disease process

b. Clients who develop disease complications promptly received rehabilitation

The mother of a child recently diagnosed with asthma ask the nurse how to help protect her child from having asthma attacks. To avoid triggers for asthma attacks, which instruction should the nurse provide the mother? Select all that apply. a. Decrease the raw sugars in the diet b. Close car windows and use air conditioner c. Avoid sudden changes in temperature d. Stay indoors when grass is being cut e. Keep away from pets with long hair

b. Close car windows and use air conditioner c. Avoid sudden changes in temperature d. Stay indoors when grass is being cut e. Keep away from pets with long hair

A male client who is experiencing musculoskeletal pain is discharged with instructions to take ibuprofen, on non-steroidal anti-inflammatory drug by mouth BID. After receiving discharge teaching, the client states he plans to take the medication twice daily, with breakfast and dinner. How should the nurse respond? a. Review the need to limit intake of leafy, green vegetables such as spinach b. Confirm that the client has an effective plan for when to take the medication c. Explain the need to take the medication before meals to increase absorption d. Remind the client to increase fluid intake while taking the medication

b. Confirm that the client has an effective plan for when to take the medication

A client at 28 weeks' gestation is admitted to the obstetrical unit following her involvement in a motor vehicle collision. After stabilizing the client, the nurse obtains a fetal monitor reading. What action should the nurse take if fetal tachycardia is assessed on the monitor? a. Recount the heart rate manually to confirm a monitor malfunction b. Contact the health care provider after initiating oxygen per face mask c. Explain that there is no indication the fetal heart rate is due to trauma d. Evaluate the presence of preterm labor by performing a vaginal examination

b. Contact the health care provider after initiating oxygen per face mask

The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. Which instruction should the nurse provide the unlicensed assistive personnel who is working with the nurse? a. Notify the nurse when the transfusion has finished, so further client assessment can be done b. Continue to measure the clients vital signs every 30 minutes until the transfusion is complete c. Monitor the client carefully for the next three hours and report the onset of a reaction immediately d. Since her reaction did not occur, the priority is to maintain client comfort during the transfusion

b. Continue to measure the clients vital signs every 30 minutes until the transfusion is complete

The nurse is evaluating the chest drainage system of a client with a chest tube inserted to treat a left hemothorax. Which finding requires intervention by the nurse? a. Rise and fall of water level with respiration b. Continuous bubbling in the water seal chamber c. Total fluid level in the water seal chamber unchanged d. An average collection of 50 milliliters per hour drainage

b. Continuous bubbling in the water seal chamber

While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? a. Serum albumin b. Culture for sensitive organisms c. Serum blood glucose (BG) level d. Creatinine level

b. Culture for sensitive organisms

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. Which effects is the nurse likely to note as a result of this increase in glaucoma surgeries? a. Decrease morbidity in the elderly population b. Decrease prevalence of glaucoma in the population c. Increase mortality in the elderly population d. Increased incidence of glaucoma in the population

b. Decrease prevalence of glaucoma in the population

A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately? a. Administer IV atropine b. Defibrillate with one shock c. Give a dose of amiodarone IV d. Prepare for external pacing

b. Defibrillate with one shock

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. Which action should the nurse implement? a. Advise the UAP to document the last blood pressure obtained in the client's graphic sheet b. Demonstrate how to palpate the popliteal pulse with a client supine and the knee flexed c. Document why the blood pressure cannot be accurately measured at the present time d. Estimate the blood pressure by assessing the pulse volume of the clients' radial pulses

b. Demonstrate how to palpate the popliteal pulse with a client supine and the knee flexed

A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. the child smells of chemicals on the hands, face, and on the front of the child's clothes. after ensuring the airway is patent, what action should the nurse implement first? a. Assess the child for altered sensorium b. Determine type of chemical exposure c. Obtain equipment for gastric lavage d. Call poison control emergency number

b. Determine type of chemical exposure

A new nurse preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement? a. Suggest the nurse use a 20-gauge needle. b. Direct the nurse to change the IV tubing. c. Instruct the nurse to remove the needle.d. Prompt the nurse to apply povidone to the site.

b. Direct the nurse to change the IV tubing.

Which assessment is most important for the nurse to include in the daily plan of care for a client with a burnt extremity? a. Extremity sensation b. Distal pulse intensity c. Presence of exudate d. Range of motion

b. Distal pulse intensity

The nurse is preparing to administer 1.6 ml of medication intramuscularly to a four-month-old infant. Which action should the nurse include? a. Is a quick dart like motion to inject into the dorsogluteal site b. Divide the medication into two injections with volumes under 1 ml c. Administer into the deltoid muscle while the parent holds the infant securely d. Select a 22 gauge 1 ½ inch (3.8 cm) needle for the intramuscular injection

b. Divide the medication into two injections with volumes under 1 ml

An S3 heart sound is auscultated in a client in their third trimester pregnancy. What intervention should the nurse take a. Prepare the client for an echocardiogram b. Document in the client's record c. Notify the health care provider d. Limited clients fluids

b. Document in the client's record

A client arrives for an annual physical exam and complains of having calf pain. The client's health history reveals peripheral atrial disease. Which question should the nurse ask the client about expected finding related to chronic arterial symptoms? a. Were your legs ever suddenly swollen, red, warm, and painful? b. Does the calf pain occur when walking short distances? c. Did you receive treatment for weeping ulcers on lower legs? d. Have you experienced ankle edema and varicose veins?

b. Does the calf pain occur when walking short distances?

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms? a. Positive Epstein-Barr, and malaise. b. Ear pain and fever. c. Elevated WBC and sedimentation rate. d. Increased BUN and serum creatinine.

b. Ear pain and fever.

A client is being discharged with a prescription of for warfarin. What instruction should the nurse provide this client regarding diet? a. Avoid eating all foods that contain any vitamin K because it is an antagonist of warfarin b. Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent c. Increase the intake of dark green leafy vegetables while taking warfarin d. Eat two servings of raw dark green leafy vegetables daily and continue for 30 days after warfarin therapy is completed

b. Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent

The nurse is teaching the client about home care after surgery for an ileal conduit placement. When reviewing the information, which statement should the nurse recognize as needing additional education? a. Report the presence of mucus in the urine b. Empty the pouch when it is half full c. Look at the stoma when replacing the appliance d. Anticipate shrinking of this stoma

b. Empty the pouch when it is half full

An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The nurse notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement? a. Ask family members to remain with the client in the evening from 1700 to 2100 p.m. b. Ensure that the client is assigned to a room close to the nurses' station. c. Postpone administration of nighttime medications until after 2300 p.m. d. Administer a prescribed PRN benzodiazepine at the onset of a confused state.

b. Ensure that the client is assigned to a room close to the nurses' station.

The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)? a. Measure the client's body weight each morning. b. Establish blood pressure parameters for client monitoring c. Evaluate a staff member providing wound care. d. Evaluate client teaching through return demonstration.

b. Establish blood pressure parameters for client monitoring

The nurse asked the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement? a. Use soothing statements to facilitate cooperation b. Examine the genitalia as the last part of the total exam c. Allow the child to keep underpants on to examine the genitalia d. Work slowly and methodically so not to stress the child

b. Examine the genitalia as the last part of the total exam

The nurse is planning care for a 16 year old, who has juvenile idiopathic arthritis (JIA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? a. Perform passive range of motion exercises twice daily b. Exercise in a swimming pool c. Splint affected joints during activity d. Begin a training program lifting weights and running

b. Exercise in a swimming pool

The nurse is preparing to send the client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure? a. Reports left chest wall pain prior to admission b. Experiences facial swelling after eating crab c. Verbalizes a fear of being in a confined space d. Drink a glass of water in the past two hours

b. Experiences facial swelling after eating crab

An adult client is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, the client requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the client asks for something stronger. Which intervention should the nurse implement? a. Review the client's history for use of illicit drugs b. Explain the reason for using only non-narcotics c. Assess clients' pupils for their reactions to light d. Request that the CT scan be done immediately

b. Explain the reason for using only non-narcotics

An older adult female asks the clinic nurse about getting a herpes vaccination because she gets cold sores on her mouth when she's sick or stressed. How should the nurse respond? a. Describe the use of the vaccination to treat herpes simplex type 2 b. Explain the use of the vaccination to reduce risk for herpes zoster c. Confirm that consent form is signed before administering the vaccination d. Arrange for skin testing to evaluate if the client is a candidate for the vaccine

b. Explain the use of the vaccination to reduce risk for herpes zoster

An older client is referred to a rehabilitation facility following a cerebrovascular accident. The client is aphasic with left sided paralysis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care? a. Initiate passive range of motion exercises b. Facilitate a consultation for speech therapy c. Use pictures and gestures to communicate d. Arrange for daily home care assistance

b. Facilitate a consultation for speech therapy

The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? a. Nausea and vomiting b. Fever of 103 degrees Fahrenheit (39.5 degrees Celsius) c. Diffuse macular rash d. Muscle tenderness

b. Fever of 103 degrees Fahrenheit (39.5 degrees Celsius)

A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation? a. Potassium 3.5 meq/L b. Fingertips feel numb c. Sodium 135 meq/L d. Cervical spine stiffness

b. Fingertips feel numb

When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack food should the nurse encourage the client to eat? Select all that apply. a. Fresh vegetables with mayonnaise dip b. Fresh Turkey slices and berries c. Chicken bouillon soup and toast d. Soda crackers and peanut butter e. Raw unsalted almonds and apples

b. Fresh Turkey slices and berries e. Raw unsalted almonds and apples

A client is admitted to the labor and delivery unit in early labor and the nurses assesses the status of her contractions. The frequency of contractions is most accurately valued by counting the minutes and seconds in which manner? a. From the peak of one contraction to the peak of the next contraction b. From the beginning of one contraction to the beginning of the next contraction c. From the beginning of one contraction to the end of that contraction d. From the end of one contraction to the beginning of the next contraction

b. From the beginning of one contraction to the beginning of the next contraction

A client with diabetic peripheral neuropathy has been taking pregabalin for four days. Which finding indicates to the nurse that the medication is effective? a. Reduced level of pain b. Full volume of pedal pulses c. Granulating tissue in foot ulcer d. Improved visual acuity

b. Full volume of pedal pulses

A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first? a. Check the protein level in urine b. Have the client turn to the left side c. Take the temperature d. Monitor the urine output

b. Have the client turn to the left side

The nurse is assessing a male with a history of Addison's disease. The client has flu-like symptoms and nausea with vomiting over the past week. The client's spouse reports that he acted confused and was extremely weak when he awoke this morning. The client is febrile and has tachycardia. The health care provider diagnoses acute adrenal insufficiency. Which medication will most likely be prescribed? a. Hypertonic saline solution at 100 ml/hr until all edema disappears b. Hydrocortisone 100 mg IV every six hours until systolic BP reaches 110 mmHg c. Potassium chloride 20 mEq IV to infuse over 2 hours until confusion resolves d. Regular insulin drip to keep blood glucose around 100 mg/dl (5.55 mmol/L)

b. Hydrocortisone 100 mg IV every six hours until systolic BP reaches 110 mmHg

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites and a client with cirrhosis? a. Hypoalbuminemia that results in a decreased colloidal oncotic pressure b. Hyperaldosteronism causing an increased sodium reabsorption in renal tubes c. Decreased renin angiotensin response related to an increase in renal blood flow d. Decrease portacaval pressure with greater collateral circulation

b. Hyperaldosteronism causing an increased sodium reabsorption in renal tubes ?

A female client who has borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by complaining about the aloofness of the night shift nurse and expresses joy to see that, "My favorite nurses on duty now." Which response is best for the nurse to provide to this clients dichotomous tendency? a. Tomorrow I will talk to that nurse about how you were treated last night b. I am happy that you are getting better and will be able to go home c. I am glad you like me. Which nurse was acting aloof to you? d. What did the night nurse do that makes you think she is aloof?

b. I am happy that you are getting better and will be able to go home

A client in menopause reports being lactose intolerant. She exercises three times a week, drinks wine one to three times a month, and drinks a cup of coffee daily. Which instruction should the nurse provide to the client to reduce her risk of developing osteoporosis? a. Increase weekly exercise b. Increase calcium intake c. Decrease wine consumption d. Decrease coffee consumption

b. Increase calcium intake

An adult woman who was recently diagnosed with type 2 diabetes mellitus (DM) is seen in the clinic for laboratory tests. The client's height is 5 feet 2 inches and weight is 165 pounds. Her recent laboratory findings are described above. In planning nutrition teaching for this client, what diet modification should the nurse recommend? Select all that apply. a. Reduce daily fat intake to 10% of total calories b. Increase dietary fiber such as whole grains c. Decrease processed carbohydrate in diet d. Eliminate alcohol intake except for special occasions e. Restrict protein to 10% of total calories in diet

b. Increase dietary fiber such as whole grains c. Decrease processed carbohydrate in diet d. Eliminate alcohol intake except for special occasions

A client asked the nurse for information about how to reduce risk factors for benign prostatic hyperplasia. Which information should the nurse provide? a. Consume a high protein diet b. Increase physical activity c. Take vitamin supplements d. Obtain a prostate specific antigen blood level test

b. Increase physical activity

A male client is admitted with a bowel obstruction and intractable vomiting for the last several hours despite the use of antiemetics. Which intervention should the nurse implement first? a. Maintain head of bed at 45 degrees b. Infuse 0.9% sodium chloride 500 ml bolus c. Insert nasogastric tube to intermittent suction d. Document strict and intake and output

b. Infuse 0.9% sodium chloride 500 ml bolus

A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. Which intervention should the nurse implement first? a. Insert a nasogastric tube for feeding b. Initiated a prescribed IV for parenteral fluid c. Give the infant 5% dextrose in water orally d. Feed the infant 3 ounces of isomil

b. Initiated a prescribed IV for parenteral fluid

A male client with a fracture of the left femur has skeletal traction in place while waiting for surgery. The client is restless and tells the nurse that he needs to urgently urinate. What intervention should the nurse implement? a. Log roll and place adult disposable briefs b. Insert an indwelling urinary catheter c. Maintain traction while client uses the urinal d. Release traction so client can use bedpan

b. Insert an indwelling urinary catheter

A UAP is assigned to ambulate the client with influenza who has droplet precautions implemented. The UAP requests change in assignment, stating the reason of having not been fitted yet for a N95 respirator mask. Which action should the nurse take? a. Send the UAP to be fitted for a particulate mask immediately so she can provide care to this client b. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client c. Before changing assignments, determine which staff members have fitted particulate filter masks d. Advise the UAP to wear a standard face mask to take vital signs , and then get fitted for a filter mask before providing personal care

b. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client

An older clients daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. The daughter states that her mother's behavior changed suddenly a few days ago and is now getting worse. Which action should the nurse take? Select all that apply. a. Encourage increase intake of high protein foods b. Instruct the daughter to check her mother's temperature c. Review the client's current food and medication allergies d. Ask if the mother is experiencing any pain with urination e. Determine if the mother has recently experienced a fall

b. Instruct the daughter to check her mother's temperature d. Ask if the mother is experiencing any pain with urination e. Determine if the mother has recently experienced a fall

The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life threatening and should be reported to the health care provider immediately? a. Difficulty with balance b. Intensifying headache c. Right ear hearing loss d. Facial numbness

b. Intensifying headache

A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce with the client? a. It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum) b. It is critical to report promptly to your health care provider any findings of peptic ulcers c. Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors d. With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine

b. It is critical to report promptly to your health care provider any findings of peptic ulcers

The nurse assesses a 72 year-old client who was admitted for right-sided congestive heart failure. Which of the following would the nurse anticipate finding? a. Decreased urinary output b. Jugular vein distention c. Pleural effusion d. Bibasilar crackles

b. Jugular vein distention

A client with cirrhosis of the liver having numerous, liquid, incontinent stools, and continues to be confused. After reviewing the clients laboratory studies, the nurse identifies an elevated serum ammonia level. Based on this finding, which prescription is most important for the client to receive? a. IV Human albumin b. Lactulose c. Furosemide d. Loperamide

b. Lactulose

A client with cirrhosis of the liver is having numerous, liquid, incontinent stools, and continues to be confused. In reviewing the client's laboratory studies, the nurse identifies an elevated serum ammonia level. Based on this finding, which prescription is most important for the client to receive? a. Furosemide b. Lactulose c. Loperamide d. IV human albumin

b. Lactulose

A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury? a. Administer hypertonic IV fluids as prescribed b. Limit oral water intake c. Assess neurological status every eight hours d. Initiate seizure precautions

b. Limit oral water intake

Which intervention should the nurse include in the plan of care for a child with tetanus? a. Encourage coughing and deep breathing b. Minimize the amount of stimuli in the room c. Reposition from side to side every hour d. Open window shades and provide natural light

b. Minimize the amount of stimuli in the room

While assessing a client who had a laparotomy the previous day, the nurse notices that 300 mL of dark red fluid has drained from the nasogastric tube in the last hour. Which action should the nurse take first? a. Determine the client's vital signs b. Monitor urinary output hourly c. Notify the surgeon immediately d. Assess the client's level of pain

b. Monitor urinary output hourly

The nurse is reviewing the diagnostic test prescribed for a client with a positive skin test. Which subjective findings reported by the client supports the diagnosis of tuberculosis? a. Barking coughing and vomiting b. Mucopurulent cough and night sweats c. Dry cough and chest tightness d. Chronic cough and fatty stools

b. Mucopurulent cough and night sweats

The nurse is auscultating a client's heart sounds. Which description should the nurse use to document the sound? a. Pericardial friction rub b. Murmur c. S1 S2 S3 d. S1 S2

b. Murmur

The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client? a. Identifies 2 treatments for constipation due to immobility b. Names 3 home safety hazards to be resolved immediately c. States 4 risk factors for the development of osteoporosis d. Lists five calcium rich foods to be added to her daily diet

b. Names 3 home safety hazards to be resolved immediately

A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high-pitched wheezing on inspiration and expiration. The medical diagnosis severe exacerbation of asthma. Which assessment finding, obtained 10 minutes after the admission assessment, should the nurse report immediately to the emergency department health care provider? a. An apical pulse of 120 beats per minute b. No wheezing upon auscultation of the chest c. Client reports being anxious d. Extreme agitation with staff and family

b. No wheezing upon auscultation of the chest

An older adult male who is in his early 70's is admitted to the emergency department because of a COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provide the nurse a copy of the client's living will. Which actionshould the nurse take? a. Facilitate a family meeting with the palliative care team. b. Notify the healthcare provider of the client's wishes. c. Place a certified copy of the living will in the client's record. d. Alert the nursing staff of the client's don't resuscitate status.

b. Notify the healthcare provider of the client's wishes.

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? a. Monitor the amount of drainage from the client's incision b. Observe both lower extremities for redness and swelling c. Evaluate the client's ability to use an incentive spirometer d. Palpate all peripheral pulse points for volume and strength

b. Observe both lower extremities for redness and swelling

A client who is admitted for primary hypothyroidism has early signs of myxedema coma. After assessing the client, in which sequence should the nurse complete these actions? Rank order. a. Assess blood pressure b. Observe breathing patterns c. Palpate for edema d. Measure body temperature

b. Observe breathing patterns a. Assess blood pressure d. Measure body temperature c. Palpate for edema

A client with cellulitis of the right great toe has been taking an antibiotic for seven days. Which assessment should the nurse complete to determine the effectiveness of this medication? a. Note any thickening, scarring, or ridge lines present on the toe b. Observe for signs of inflammation on and surrounding the toe c. Determine the length of the capillary refill time of the toe d. Compare the fetal pulse volumes of the right and left feet

b. Observe for signs of inflammation on and surrounding the toe

The nurse is caring for a child newly diagnosed with attention deficit hyperactive disorder (ADHD). The child's mother asked about information of the treatment options. Which information is most helpful for the nurse to provide? a. Emphasize the addictive nature of popular medications b. Offer effective time management strategies c. Explore the combination of medication and behavioral therapies d. Discuss dietary changes such as increasing protein intake

b. Offer effective time management strategies

In observing a client's face, which assessment finding requires the most immediate intervention by the nurse? a. Cornea are jaundiced b. Oral mucosa is cyanotic c. Face is flushed and diaphoretic d. Eyelids are matted and crusted

b. Oral mucosa is cyanotic

A client with a history of upper respiratory symptoms is admitted with chest tightness, a productive cough, and difficulty breathing. The client's arterial blood gases (ABGs) indicate respiratory acidosis. An increase in which laboratory test results supports this finding? a. Arterial ph b. PaCO2 c. HCO3 d. PaO2

b. PaCO2

Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? a. Hemoglobin level of 12 g/dI b. Pale mucosa of the eyelids and lips c. Hypoactivity d. A heart rate between 140 to 160

b. Pale mucosa of the eyelids and lips

The nurse is caring for a group of clients with the help of a practical nurse. Which nursing action should the nurse assign to the PN? Select all that apply. a. Start the second blood transfusion for the client 12 hours following a below knee amputation b. Perform daily surgical dressing change for a client who had an abdominal hysterectomy c. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus d. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty e. Initiate patient-controlled analgesia pumps for two clients immediately postoperatively

b. Perform daily surgical dressing change for a client who had an abdominal hysterectomy c. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus d. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty

The nurse is demonstrating correct transfer of procedures to the UAP working on the rehabilitation unit. The UAP asked the nurse how to safely move a physically disabled client from the wheelchair to a bed. Which action should the nurse recommend? a. Apply a gait belt around the client's waste once in the standing position b. Place the clients locked wheelchair on the client strong side next to the bed c. Pull the client into position by reaching from the opposite side of the bed d. Hold the client at arm's length while transferring to better distribute the body weight

b. Place the clients locked wheelchair on the client strong side next to the bed

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching? a. Find outlets for more social interaction b. Practice using muscle relaxation techniques c. Center attention on positive upbeat music d. Think about reasons the episodes occur

b. Practice using muscle relaxation techniques

A client has a new prescription for the maximum recommended dosage of piperacillin/tazobactam for nosocomial pneumonia. The nurse should report which laboratory finding to the health care provider before administering the prescribed dose? a. Elevated white blood cell count b. Presence of gram-positive bacteria in the sputum c. Decrease creatinine clearance d. Elevated cholesterol and lipoproteins

b. Presence of gram-positive bacteria in the sputum

The nurse is providing teaching to a client who has been recently diagnosed with gestational diabetes mellitus. Which complication poses the greatest risk to the fetus if euglycemia is not maintained? a. Cleft palate b. Preterm birth c. Low birth weight d. Macrosomic newborn

b. Preterm birth

A male client approaches the nurse with an angry expression on his face and raises his voice saying "my roommate is the most selfish, self-centered, angry person I've ever met. If he loses my temper one more time with me I am going to punch him out!" The nurse recognizes that the client is using which defense mechanism? a. Splitting b. Projection c. Rationalization d. Denial

b. Projection

An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan? a. Decreased abdominal girth b. Prothrombin time within normal limits c. Improved level of consciousness d. Clear, dark amber colored urine

b. Prothrombin time within normal limits ?

The nurse is feeding a client who is admitted this morning with syncope and generalized weakness. The client has a history of aspiration and begins coughing while attempting to drink through a straw. Which action should the nurse implement? a. Elevate head of bed for 30 minutes after meals b. Provide nectar thickened liquids c. Allow small amounts of liquids with meals d. Perform oral care before meals

b. Provide nectar thickened liquids

A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? a. Flaccid paralysis b. Pupils fixed and dilated c. Diminished spinal reflexes d. Reduced sensory responses

b. Pupils fixed and dilated

The nurse is caring for a client with a suspected diagnosis of osteomyelitis. Which diagnostic test should the nurse prepare the client to expect the health care provider to prescribe? a. Radiographs b. Radionuclide bone scan c. C reactive protein tests d. Erythrocytes sedimentation rate

b. Radionuclide bone scan

When assessing an IV site that was used for fluid replacement in medication administration, the client complains of tenderness when the arm is touched above the site. Which additional assessment finding warrants immediate intervention by the nurse? a. Client uses the arm cautiously b. Red streak tracking the vein c. A sluggish blood return d. Spot of dried blood at the insertion site

b. Red streak tracking the vein

An older client is admitted to the hospital because of recurring transient ischemic attacks. Neurological serial assessments for the past 24 hours were within normal limits. One day after admission, the client suddenly becomes confused and combative indicating impaired mental status (IMS). What intervention should the nurse implement first? a. Document neurologic changes. b. Reduce environmental stimuli. c. Administer prescribed neuroleptic. d. Review medications for interactions.

b. Reduce environmental stimuli.

An older client with a long history of coronary artery disease, hypertension, and heart failure arrives at the emergency department in respiratory distress. The health care provider prescribes furosemide IV. Which therapeutic response to fursemide should the nurse expect in the client with acute heart failure? a. Increased cardiac contractility b. Reduced preload c. Relaxed vascular tone d. Decreased afterload

b. Reduced preload

When providing client care, the nurse identifies a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence-based. When gathering evidence, which consideration is most important? a. Past experience with similar problems b. Relevance to the situation c. Related personal values d. Frequency that the problem occurs

b. Relevance to the situation

Following morning care, a client with a C5 spinal cord injury who is sitting in a wheelchair becomes flushed and complaints of a headache. Which intervention should the nurse implement first? a. Teach the client to recognize symptoms of dysreflexia b. Relieve any kinks or obstruction in the client's Foley tubing c. Administer or prescribe PRN dose of hydralazine d. Assess the client's blood pressures every 15 minutes

b. Relieve any kinks or obstruction in the client's Foley tubing

The nurse on a pediatric unit of a healthcare facility observes a colleague leaving and open client electronic health record unattended while taking a lunch break. Which action should the nurse take? a. Close the computer and complete the day's assignments b. Remind the colleague of information security principles c. Comment about the action on a staff discussion board d. Discuss the incident with the facilities risk manager

b. Remind the colleague of information security principles

The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome. Which information is most important to provide parents of newborns and infants? a. Do not pop bottles for an infant during naps and bedtime b. Remove pillows and soft toys from the crib at bedtime c. Position the intent in a supine position while sleeping d. Keep a bulb syringe accessible for use for an infant

b. Remove pillows and soft toys from the crib at bedtime

A client with atrial fibrillation receives a new prescription for dabigatran etexilate. Which instruction is important for the nurse to emphasize when teaching the client about this medication? a. Check your pulse rate every day b. Report unusual bruising or bleeding c. Monitor your blood pressure regularly d. Elevate your feet if swelling occurs

b. Report unusual bruising or bleeding

The nurse notes that an older adult client has a moist cough that increases in severity during and after meals. Based on this finding, which action should the nurse take? a. Collect a sputum specimen immediately b. Request a consultation to confirm dysphasia c. Offer the client additional clear liquids frequently d. Encourage the client to do deep breathing exercises daily

b. Request a consultation to confirm dysphasia

1. A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base imbalance? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis Metabolic alkalosis

b. Respiratory alkalosis

Three days after initiating a parenteral fluid for a newborn with a ventricular septal defect, the nurse assesses and increase in heart rate and blood pressure. Which intervention is most important for the nurse to implement? a. View the graph of daily weights b. Restrict intake of oral fluids c. Assess bilateral lung sounds d. Decrease IV flow rate

b. Restrict intake of oral fluids

A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement? a. Check the client's hemoglobin level b. Review the clients current list of medications c. Assess the client for the presence of hemorrhoids d. Administer prescribed PRN anti-emetic

b. Review the clients current list of medications

A client with type 2 diabetes mellitus is admitted for frequent hypoglycemic episodes in a glycosylated hemoglobin A1C of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart every six hours are prescribed. Which action should the nurse include in this clients plan of care? Select all that apply. a. Do not contaminate the insulin aspart so that it is readily available for IV use b. Review with the client proper foot care and prevention of injury c. Teach subcutaneous injection technique, site rotation, and insulin management d. Coordinate carbohydrate-controlled meals at consistent times and intervals e. Mixed bedtime dose of insulin glargine with insulin aspart sliding scale dose f. Finger stick glucose assessments every 6 hours with meals

b. Review with the client proper foot care and prevention of injury c. Teach subcutaneous injection technique, site rotation, and insulin management d. Coordinate carbohydrate-controlled meals at consistent times and intervals f. Finger stick glucose assessments every 6 hours with meals

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products, such as milk, to help coat and protect their ulcer. Which is the best follow up action by the nurse? a. Remind the client that it is also important to switch to decaffeinated coffee and tea b. Review with the client the need to avoid foods that are rich in milk and cream c. Reinforced this teaching by asking the client to list dairy foods that he might select d. Suggest that the client also plan to eat frequent small meals to reduce discomfort

b. Review with the client the need to avoid foods that are rich in milk and cream

An older adult male reporting with abdominal pain is admitted to the hospital from a long-term care facility. It has been seven days since his last bowel movement, his abdomen is distended, and he just vomited 150 milliliters of dark brown emphasis. In what order should the nurse implement these interventions? a. Complete focused assessment b. Send emesis sample to the lab c. Elevate the head of the bed d. Offer PRN pain medication

b. Send emesis sample to the lab c. Elevate the head of the bed a. Complete focused assessment d. Offer PRN pain medication

An older adult client with systemic inflammatory response syndrome (SIRS) has a temperature of 101.8, heart rate 110 of beats/minute, a respiratory rate of 24 breaths/minute. Which additional finding is most important to report to the healthcare provider? a. Capillary glucose reading of 110 mg/dl b. Serum creatinine of 2.0 mg/dl c. Blood pressure of 130/88 mmhg d. Hemoglobin 12 g/dl

b. Serum creatinine of 2.0 mg/dl

Which laboratory value should the nurse review prior to administering the initial dose of a statin medication? a. Serum electrolytes b. Serum liver enzymes c. Capillary blood glucose d. Complete blood count

b. Serum liver enzymes

A client is admitted with a diagnosis of urolithiasis. Which finding is most important for the nurse to report to the health care provider? a. Volume of each voiding is more than 300 milliliters b. Serum potassium level is elevated c. Relief of flank pain that is radiated into the groin d. Hematuria that is beginning to turn pink

b. Serum potassium level is elevated

A client is admitted with a diagnosis of urolithiasis. Which finding is most important for the nurse to report to the health care provider? a. Volume of each voiding is more than 300 ml b. Serum potassium level is elevated c. Relief of flank pain that is radiating to the groin d. Hematuria that is beginning to turn pink

b. Serum potassium level is elevated

The nurse is completing the admission assessment of a 3-year-old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure? a. Tachycardia and tachypnea b. Sluggish and unequal pupillary responses c. Increased head circumference d. Blood pressure fluctuations and syncope

b. Sluggish and unequal pupillary responses

A male client with right-sided weakness calls for assistance with ambulating to the bathroom. What action should the nurse implement? a. Bring a bedside commode to the client. b. Stand on the client's right side as he walks. c. Walk directly behind the client to prevent a fall. d. Give the client a cane to hold in his right hand.

b. Stand on the client's right side as he walks.

A client is recovering in the critical care unit following a cardiac catheterization. IV nitroglycerin and heparin are infusing. The client is sedated but responds to verbal instructions. After changing positions, the client complains of pain at the right groin insertion site. Which action should the nurse implement? a. Check femoral site for hematoma formation b. Stimulate the client to take deep breaths c. Evaluate the integrity of the IV insertion site d. Assess distal lower extremity capillary refill

b. Stimulate the client to take deep breaths

A male client with hypertension, who is receiving a new antihypertensive prescription at his last visit returns to the clinic 2 weeks later to evaluate his blood pressure. His BP is 158/106 mmHg and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad." In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? a. Heart block due to myocardial damage b. Stroke secondary to hemorrhage c. Acute kidney injury due to glomerular damage d. Blindness secondary to cataracts

b. Stroke secondary to hemorrhage

The nursing staff on the medical unit uses a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which tasks should the charge nurse assigned to the RN? a. Transport a client who's receiving IV fluids to the radiology department b. Supervise a newly hired graduate nurse doing an admission assessment c. Complete ongoing focus assessments of a client with wrist restraints d. Administer PRN oral analgesics to a client with a history of chronic pain

b. Supervise a newly hired graduate nurse doing an admission assessment

After spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which is admission assessment finding should the nurse reports of the health care provider? Select all that apply a. Red blood cell count (RBC) b. Swollen lymph nodes in the groin c. Core body temperature d. White blood cell count (CBC) e. Location of the initial IV site

b. Swollen lymph nodes in the groin c. Core body temperature d. White blood cell count (CBC)

When conducting diet teaching for a client who is on postoperative full liquid diet, which food should the nurse encourage the client to eat? Select all that apply. a. Cheese b. Tea c. Lentils d. Whole grain breads e. Potato soup

b. Tea c. Lentils e. Potato soup

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include heart rate of 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmHg. Which assessment finding warrants the most immediate intervention by the nurse? a. Bilateral diffuse wheezing b. Temperature of 100.5 c. Yellow expectorated sputum d. Shortness of breath on exertion

b. Temperature of 100.5 ?

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately? a. Change the dressing using a compression bandage b. Test fluid on the dressing for glucose c. Document the findings in the electronic medical record d. Mark the drainage area with a pen and continue to monitor

b. Test fluid on the dressing for glucose

Following breakfast, the nurse is preparing to administer 0900 medications to the clients on the medical floor. Which medication should be held until a later time? a. The mucosal barrier, sucralfate, for a client diagnosed with peptic ulcer disease b. The antifungal nystatin suspension, for a client who has just brushed his teeth c. The antiplatelet agent aspirin, for a client who is scheduled to be discharged within the hour d. The loop diuretic furosemide, for a client with a serum potassium level of 4.2 meq/L

b. The antifungal nystatin suspension, for a client who has just brushed his teeth

After receiving a report on an inpatient acute care unit, which client should the nurse assess first? a. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid b. The client with a bowel obstruction due to a volvus who is experiencing abdominal rigidity c. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds d. The client with an obstruction of the large intestine who was experiencing abdominal distention

b. The client with a bowel obstruction due to a volvus who is experiencing abdominal rigidity

Which of these observations made by the nurse during an excretory urogram indicate a complicaton? a. The client complains of a salty taste in the mouth when the dye is injected b. The client's entire body turns a bright red color c. The client states "I have a feeling of getting warm." d. The client gags and complains " I am getting sick."

b. The client's entire body turns a bright red color

A client becomes increasingly lethargic and has a respiratory rate of 8 breaths per minute with 30-second periods of apnea, the healthcare provider is notified, and STAT arterial blood gases are drawn. What ABG results should the nurse anticipate? a. Compensated respiratory acidosis b. Uncompensated respiratory acidosis c. Uncompensated metabolic acidosis d. Compensated metabolic acidosis

b. Uncompensated respiratory acidosis

A client is admitted to the hospital with symptoms consistent with the right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse? a. Orientation to person in place only b. Unequal bilateral hand grip strengths c. Pupillary changes to ipsilateral dilation d. Left sided facial droop and dysphasia

b. Unequal bilateral hand grip strengths

The nurse is preparing a client who had a below the knee amputation for discharge to home. Which recommendation should the nurse provide this client? Select all that apply. a. Avoid range of motion exercises b. Use a residual limb shrinker c. Watch the stump with soap and water d. Inspect skin for redness e. Apply alcohol to the stump after bathing

b. Use a residual limb shrinker c. Watch the stump with soap and water d. Inspect skin for redness

The nurse is preparing a client who had a below the knee amputation for discharge to home. Which recommendation should the nurse provide to this client? Select all that apply. a. Avoid range of motion exercises b. User residual limb shrinker c. Apply alcohol to the stump after bathing d. Inspect skin for redness e. Wash the stump with soap and water

b. Use residual limb shrinker d. Inspect skin for redness e. Wash the stump with soap and water

The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity? a. Aerobic exercise b. Weight bearing exercise c. Muscle stretching and toning d. Core strengthening

b. Weight bearing exercise

The charge nurse is making assignments on a cardiac unit. Which client is best to assign to a new graduate who is orienting to the unit? A client... a. With pneumonia whose serum potassium level is 6.5 mg/dl b. With atrial fibrillation whose saline lock is infiltrated c. Who is receiving heparin infusion has developed hematuria d. With hypertension whose blood pressure is 230/118

b. With atrial fibrillation whose saline lock is infiltrated

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "kill, kill." What question should the nurse ask the client next? a. "When did these voices begin?" b. "Have you taken any hallucinogens?" c. "Are you planning to obey the voices?" d. "Do you believe the voices are real?"

c. "Are you planning to obey the voices?"

During discharge teaching, a male client recently diagnosed with malignant hypertension tells the nurse that he really enjoys downhill skiing and asks if he can continue with this sport. Which is the best response by the nurse? a. "It should be alright as long as you can find your skiing to the easier trails." b. "Go for it. Skiing should provide you with a terrific aerobic workout." c. "Cold weather may constrict your blood vessels raising your blood pressure'" d. "Skiing might produce too much exertion. How about sledding?"

c. "Cold weather may constrict your blood vessels raising your blood pressure'"

What might the nurse suggest to a client with fibrocystic breasts in the attempt to help relieve her symptoms? a. "Increase high calcium foods in your diet b. "Eat a low carbohydrate, high protein diet" c. "Eliminate caffeine from your diet" d. "Avoid vigorous physical exercise immediately after your menstrual period"

c. "Eliminate caffeine from your diet"

While providing a health history, a female client tells the clinic nurse that she frequently thinks about hurting herself. Which question is most important for the nurse to ask? a. "Do you often have feeling of sadness?" b. "Are you having problems concentrating?" c. "Have you though about taking your life?" d. "What problems are you facing right now?"

c. "Have you though about taking your life?"

The nurse documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment? a. "The fire is burning my skin away right now" b. "The voices are telling me to kill the next person I see" c. "The nurse at night is trying to poison me with pills" d. "The snakes on the wall are going to eat me"

c. "The nurse at night is trying to poison me with pills"

The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client demonstrates an understanding of the use of allopurinol to treat gout? a. "I need to take the prescribed amount of the drug to get rid of my gout" b. "I need to take this drug every day to keep from having any flare ups" c. "The pain and swelling can be controlled by taking this drug every day" d. "I should I take this drug when I have gout attacks to reduce symptoms"

c. "The pain and swelling can be controlled by taking this drug every day"

A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response? a. "What would you like to see me do to protect you?" b. "You are in a safe place. No one can get you here." c. "You seem quite frightened right now." d. "There is no one who will hurt you."

c. "You seem quite frightened right now."

The parents bring their one-year-old child with a ventricular septal defect to the clinic for a well child visit. Which assessment finding should the nurse report to the health care provider immediately? a. Respirations of 26 breaths/minute at rest b. Expected weight and growth care for an infant c. 2+ pitting edema in the extremities d. Heart rate of 105 beats/minute

c. 2+ pitting edema in the extremities

The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? a. Diminished bowel sounds b. Loss of appetite c. A cold, pale lower leg d. Tachypnea

c. A cold, pale lower leg

A client with bacterial meningitis is receiving phenytoin. Which assessment finding indicates to the nurse that the client is experiencing a therapeutic response to the phenytoin? a. Increased time of ambulation between periods of rest. b. Decrease in intracranial pressure and cerebral edema. c. Absence of seizure activity for the duration of treatment. d. Normal electroencephalogram after drug administration.

c. Absence of seizure activity for the duration of treatment.

A client is receiving a continuous infusion of normal saline at 125 ml/hr post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and a headache. The urine output is 800 ml over the past 24 hours with a central venous pressure of 15 mmHg. The nurse notes respiratory crackles and bounding central pulses. Vital signs: temperature 101.2 degrees Fahrenheit, heart rate 96 beats/minute, respirations 24 breaths/minute, and blood pressure of 160/90 mmhg. Which intervention should the nurse implement first? a. Review last administration of IV pain medication b. Decrease IV fluids to keep vein open (KVO) rate c. Administer PRN dose of acetaminophen d. Calculate total intake and output for the last 24 hours

c. Administer PRN dose of acetaminophen

The nurse caring for a client who has chronic obstructive pulmonary disease (COPD) and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a client with COPD? a. Monitoring telemetry and cardiac rhythm b. Assisting client to cough and deep breath c. Administering narcotics for pain relief d. Increasing the clients fluid intake

c. Administering narcotics for pain relief

The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The client receives a prescription for Clonidine 0.2 milligrams PO taken twice daily. Which action should the nurse take? a. Monitor for signs of bleeding or hemorrhage b. Compare daily electrolyte levels prior to each morning dose c. Advice to sit up slowly from a reclining position d. Administer the medication on an empty stomach

c. Advice to sit up slowly from a reclining position

An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? a. Determine the client's level of mobility and need for assistance. b. Instruct the UAP that all clients deserve equal care. c. Advise the client to maintain bedrest so that safety can be ensured. d. Assign another UAP to care for the client.

c. Advise the client to maintain bedrest so that safety can be ensured.

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention? a. A 16-year-old client diagnosed with major depression who refuses to participate in group. b. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack. c. An 18-year-old client with antisocial behavior who is being yelled at by other clients. d. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby..

c. An 18-year-old client with antisocial behavior who is being yelled at by other clients.

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? a. In adult one day postoperative laparoscopic cholecystectomy requesting pain medication b. An adult who's in Buck's traction, and scheduled for hip arthroplasty within the next 12 hours c. An older client who is receiving packed red blood cells on the third day postoperatively for colon resection d. An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery

c. An older client who is receiving packed red blood cells on the third day postoperatively for colon resection

Which class of drugs is the only source of cure for septic shock? a. Anticholesteremics b. Antihypertensives c. Antiinfectives d. Antihistamines

c. Antiinfectives

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the priority nursing problem for this client? a. Anticipatory grieving b. Pain (acute) c. Anxiety d. Knowledge deficit

c. Anxiety

When should intimate partner violence screening occur? a. Once the clinician confirms a history of abuse b. Only when a client presents with an unexplained injury c. As a routine part of each healthcare encounter d. As soon as the clinician suspects a problem

c. As a routine part of each healthcare encounter

A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client states that he is tired of fighting his illness and is only continuing treatments because his family wants him to live. Which action should the nurse take? a. Notify the family that treatments have been discontinued. b. Arrange a meeting with the family, physician, and client. c. Ask the chaplain to discuss death issues with the client. d. Request a consultation with the hospital social worker.

c. Ask the chaplain to discuss death issues with the client.

For the second time in four months, and overweight client is seen in the clinic because of vulvovaginitis resulting from a candida infection. Which intervention should the nurse implement first? a. Determine the client's typical menstrual cycle b. Obtain the client's blood glucose level c. Ask the client about recent sexual activity d. Review the client results for a complete blood count

c. Ask the client about recent sexual activity

A client tells the nurse about working out with a personal trainer and swimming three times a week in an effort to lose weight and sleep better. The client states that it still is taking hours to fall asleep at night. Which action should the nurse implement? a. Advise the client that lifestyle changes often take several weeks to be effective b. Encourage the client to exercise every day to eliminate bedtime wakefulness c. Ask the client for a description of the exercise schedule that is being followed d. Determine the amount of weight the client has lost since increasing activity

c. Ask the client for a description of the exercise schedule that is being followed

What action should the nurse take first when a client is inadvertently given an incorrect dose of a medication? a. Notify the health care provider b. Complete an incident report documenting the facts c. Assess the client for any adverse effects d. Document the events leading to the error in the nurses' notes

c. Assess the client for any adverse effects

An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran a marathon one year ago, his spouse states that the client no longer runs, but sits and watches television most of the day. Which intervention is most important for the nurse to include in this clients plan of care for today? a. Schedule client for a group that focuses on self esteem b. Help client to develop a list of daily affirmations c. Assist client in identifying goals for the day d. Encourage client to participate for one hour in a team sport

c. Assist client in identifying goals for the day

A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he has difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement? a. Advise him to take his own food with him on going to fast food restaurants with his friends b. Encourage him to find activities to do with his friends that do not involve eating c. Assist him in identifying popular fast foods that are within his meal plan for diabetes d. Recommend that he avoid fast food restaurants until he is familiar with his prescribed diet

c. Assist him in identifying popular fast foods that are within his meal plan for diabetes

The nurse is preparing discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan? a. Increase activity and exercise gradually, as tolerated b. Limit intake of fatty foods for one month after surgery c. Avoid crowds for first two months after surgery d. Notify healthcare provider if edema occurs

c. Avoid crowds for first two months after surgery

A young client involved in a motorcycle collision experienced a laceration of the gastrocnemius muscle. Which instruction should the nurse provide to the practical nurse who is caring for this client? a. Avoid washing the limb when assisting with bathing b. Elevate limb above the heart when lying in bed c. Avoid planter flexion of the affected limb d. Perform range of motion on the affected limb

c. Avoid planter flexion of the affected limb

1. In assessing a client with type one diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/minute with a normal depth to 32 breaths/minute and deep, and the client has become lethargic. Which assessment data should the nurse obtain next? a. Temperature b. Breath sounds c. Blood glucose d. White blood cell count

c. Blood glucose

In assessing a client with diabetes mellitus type 1, the nurse notes that the client's respirations have changed from 16 with normal depth to 32 and deep, and the client has become lethargic. What assessment data should the nurse obtain next? a. Arterial blood gases b. Core body temperature c. Blood glucose d. Oxygen saturation

c. Blood glucose

A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? a. Chemotherapy b. Immunosuppressive therapy c. Blood transfusions d. Bone marrow transplantation

c. Blood transfusions

The mother of a 12 month old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experienced a loss of appetite. Which instruction should the nurse provide? a. Perform CPT only in the morning, but increase frequency when appetite improves b. Perform CPT after meals to increase appetite and improve food intake c. CPT should be performed more frequently, but at least an hour before meals d. Stop using CPT during the daytime until the child has regained and appetite

c. CPT should be performed more frequently, but at least an hour before meals

Which assessment finding places a client at risk for problems associated with impaired skin integrity? a. Smooth nail texture b. Scattered macula on the face c. Capillary refill 5 seconds d. Absence of skin tenting

c. Capillary refill 5 seconds

The nurse is admitting a client from the postanesthesia unit to the postoperative surgical care unit. Which prescription should the nurse implement first? a. Straight catheterization if unable to avoid b. Advance from clear liquids as tolerated c. Cefazolin 1 gram IVPB q6 hours d. Complete blood count cell count (CBC) in AM

c. Cefazolin 1 gram IVPB q6 hours

When caring for a client with full thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? Select all that apply. a. Weeping serosanguinous fluid from wounds b. Sloughing tissue around wound edges c. Change in the quality of peripheral pulses d. Loss of sensation to the left lower extremity e. Complaint of increased pain and pressure

c. Change in the quality of peripheral pulses d. Loss of sensation to the left lower extremity e. Complaint of increased pain and pressure

A nurse who was working in the emergency department triage area is presented with four clients at the same time. The client presenting with which symptoms requires the most immediate intervention by the nurse? a. Low grade fever, headache, and malaise for the past 72 hours b. One inch bleeding laceration on the chin of a crying 5 year old c. Chest discomfort one hour after consuming a large, spicy meal d. Unable to bear weight on the left foot, with swelling and bruising

c. Chest discomfort one hour after consuming a large, spicy meal

A nurse who was working in the emergency department triage area is presented with four clients at the same time. The client presenting with which symptoms requires the most immediate intervention by the nurse? a. One-inch bleeding laceration on the chin of a crying5-year-old b. Low-grade fever, headache, and malaise for the past 72 hours c. Chest discomfort one hour after consuming a large, spicy meal d. Unstable to bear weight on the left foot, with swelling and bruising

c. Chest discomfort one hour after consuming a large, spicy meal

The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates the program is effective? a. Only 30% of clients did not attend self-management education sessions b. More than 50% of at-risk clients were diagnosed early in their disease process c. Clients who developed disease complications promptly received rehabilitation d. Average client scores improved on specific risk factor knowledge tests

c. Clients who developed disease complications promptly received rehabilitation

The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicate the program is effective? a. At-risk clients received an increased number of routine health screenings. b. Clients reported having new confidence in making healthy food choices. c. Clients who incurred disease complications promptly received rehabilitation. d. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.

c. Clients who incurred disease complications promptly received rehabilitation.

The nurse is providing care for a client with schizophrenia who receives haloperidol decanoate 75mg intramuscularly every 4 weeks. The client begins developing puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement? a. Monitor lying, sitting, and standing blood pressures b. Provide coaching in relaxation techniques c. Complete Abnormal Involuntary Movement Scale (AIMS) d. Discontinue all medications immediately

c. Complete Abnormal Involuntary Movement Scale (AIMS)

The mother of an adolescent female tells the clinic nurse that after every meal her daughter goes to the bathroom, locks the door and vomits. Which physical assessment should the nurse implement if bulimia is suspected? a. Skin of palms of the hand b. Current height and weight c. Condition of tooth enamel d. Length of last menses

c. Condition of tooth enamel

While the nurse is assessing an older clients fall risk, the client reports living at home alone and never falling. Which action should the nurse take? a. Inform the client that falls occur more often in the hospital than at home b. Record a minimal fall risk, documenting the client statement c. Continue to obtain client information needed to complete a fall risk survey d. Place the client on the high fall risk protocol because of advanced age

c. Continue to obtain client information needed to complete a fall risk survey

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction should the nurse include in the client's discharge teaching plan? Select all that apply. a. Cross legs at knee but not at ankle b. Maintain the bed flat while sleeping c. Continue wearing compression stockings d. Avoid prolonged standing or sitting e. Use recliner for long periods of sitting

c. Continue wearing compression stockings d. Avoid prolonged standing or sitting e. Use recliner for long periods of sitting

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? a. History of intravenous drug abuse b. Conversion of the client's PPD test from negative to positive c. Current diagnosis of hepatitis B d. Length of time of the exposure to tuberculosis

c. Current diagnosis of hepatitis B

Prior to surgery, written consent must be obtained. Which is the nurses legal responsibility with regard to obtaining consent? a. Explain the surgical procedure to the client and ask the client to sign the consent form b. Ask the client if a family member to stand the surgical consent form c. Determined that the surgical consent form has been signed and is included in the clients record d. Validate the clients understanding of the surgical procedure to be conducted

c. Determined that the surgical consent form has been signed and is included in the clients record

The nurse should expect a client diagnosed with regional enteritis (Crohn's disease) to exhibit which initial symptoms? a. Rigid board like abdomen and elevated white blood cell count b. Dull, left lower cramping pain and a low-grade fever c. Diarrhea, abdominal pain, and weight loss d. Change in bowel habits, blood and stool, and unexplained anemia

c. Diarrhea, abdominal pain, and weight loss

The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which finding should the nurse include as indicators to begin implementing the detoxification medication protocol? a. Excessive eating, constipation, headache b. Nausea, vomiting, diaphoresis, anxiety, tremors c. Dilated pupils, tachycardia, elevated blood pressure, elation d. Mood lability, poor hand coordination, fever, drowsiness

c. Dilated pupils, tachycardia, elevated blood pressure, elation

A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at the parent-teacher meeting. What action is most important for the nurse to include in the meeting? a. Provide information on ways to increase activity for the family. b. Have several teachers talk about health risks associated with obesity. c. Distribute a shopping list of suggested healthy snack items. d. Determine the parents' degree of concern about their children's weight.

c. Distribute a shopping list of suggested healthy snack items.

A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the last 48 hours. Based on these findings it is most important for the nurse to review the laboratory value for which medication? a. Lorazepam b. Fluoxetine c. Divalproex d. Olanzapine

c. Divalproex

The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention? a. Pallor b. Increased temperature c. Dyspnea d. Involuntary muscle spasms

c. Dyspnea

A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull gnawing pain that is relieved when he eats. Which is the best response by the nurse? a. Instruct the client that these mild symptoms can generally be controlled with changes in his diet b. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms c. Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer d. Assure the client that his symptoms may only reflect reflux since ulcer pain is not relieved with food

c. Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer

The husband of an older woman, diagnosed with pernicious anemia calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she may be getting Alzheimer's disease. What action should the nurse take? a. Encourage the husband to bring the client to the clinic for a complete blood count b. Determine if the client is taking iron and folic acid supplements c. Explain that memory loss and confusion are common with vitamin B12 deficiency d. Ask if the client is experiencing any change in bowel habits

c. Explain that memory loss and confusion are common with vitamin B12 deficiency

A client in the third trimester of pregnancy reports that she feels some lumpy places in her breasts and that her nipples sometimes leak yellowish fluid. She has an appointment with her health care provider in two weeks. Which action should the nurse take? a. Tell the client to begin nipple stimulation to prepare for breastfeeding b. Reschedule the clients prenatal appointment for the following day c. Explain that this is normal secretion and can be assessed at the next visit d. Recommend that the client start wearing a supportive bra

c. Explain that this is normal secretion and can be assessed at the next visit

When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage the client to eat? Select all that apply. a. Chicken bouillon soup and toast b. Fresh vegetables with mayonnaise dip c. Fresh Turkey slices and berries d. Raw unsalted almonds and apples e. Soda crackers and peanut butter

c. Fresh Turkey slices and berries d. Raw unsalted almonds and apples

An adolescent who was diagnosed with diabetes mellitus type one at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis? a. Eaten extra peanut butter sandwich before gym class b. Incorrectly administered too much insulin c. Had a cold and ear infection for the past two days d. Skipped eating lunch

c. Had a cold and ear infection

A toddler is brought to the emergency department after ingesting several tablets of acetaminophen from a bottle that the toddler found in the mother's purse. The healthcare provider prescribes N-acetylcysteine solution for oral administration. Which action should the nurse implement if the child vomits? a. Teach parents about poison prevention in young children b. Lavage activated charcoal before giving acetylcysteine dose c. If dose is vomited within one hour of administration, repeat that oral dose d. Obtain blood samples to monitor liver function

c. If dose is vomited within one hour of administration, repeat that oral dose

After several months of chronic fatigue, morning stiffness, and join pain, a young adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education should the nurse provide the client with regard to taking prednisone? a. Take prednisone doses before meals on an empty stomach. b. Wear sunglasses when exposed to bright sunlight. c. If sequential doses are missed, notify the healthcare provider. d. Schedule a monthly laboratory visit for a complete blood count.

c. If sequential doses are missed, notify the healthcare provider.

A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory period two days later she reports to the nurse that she is experiencing increased fatigue and visual problems. What teaching should the nurse provide? a. Plans to move into the dormitory need to be postponed for at least a semester b. These are common side effects of the vaccines and will resolve in a few days c. Immunizations can trigger a relapse of the disease, so get plenty of extra rest d. These early signs of infection may require medical treatment with antibiotics

c. Immunizations can trigger a relapse of the disease, so get plenty of extra rest

An older client is brought into the emergency department with the sudden onset of confusion that occurred after experiencing a fall at home. The client's daughter, who has power of attorney, has brought the clients prescriptions. Which information should the nurse provide first when reporting to the health care provider using SBAR communication? a. Currently prescribed medications b. Clients healthcare power of attorney c. Increase in confusion of the client d. Fall at home as reason for admission

c. Increase in confusion of the client

The nurse on the pediatric unit observes a distraught mother in the hallway scolding her 3-year-old son for wetting his pants. Which initial action should the nurse take? a. Provide disposable training pants while calming the mother b. Refer the mother to a community parent education program c. Inform the mother that toilet training is slower for boys d. Suggest that the mother consult a pediatric nephrologist

c. Inform the mother that toilet training is slower for boys

When meeting with a client with a diagnosis of transient ischemic attack, which intervention is most important for the nurse to include in this client's plan of care? a. Assess bilateral breath sounds b. Review client's daily medications c. Initiate neurological monitoring every two hours d. Palpate super pubic region for urinary retention

c. Initiate neurological monitoring every two hours

A client is experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. What is the best initial nursing action? a. Administer naloxone per PRN protocol b. Obtain a serum drug screen c. Initiate seizure precautions d. Instruct the family about withdrawal symptoms

c. Initiate seizure precautions

A client with chronic obstructive lung disease was receiving oxygen at 1.5 liters/minute by nasal cannula, is currently short of breath. What action should the nurse take first? a. Have the client breathe into a paper bag b. Increase oxygen to three liters/minute c. Instruct the client to purse lip breathe d. Ask the client to take short, rapid breaths

c. Instruct the client to purse lip breathe

A client who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about the procedure and preparing for the client for the procedure. Which intervention has the highest priority? a. Allow the client to gargle with warm salt water b. Administer sedative to alleviate anxiety c. Instruct the client to write down the questions d. Deny clients request for midnight snack

c. Instruct the client to write down the questions

A client with chronic renal insufficiency is preparing for discharge from the hospital. Which information is most important for the nurse to include in this client discharge teaching? a. Use of topical applications to manage pruritis b. Strategies to promote independent self-care c. Instructions regarding a restricted protein diet d. Need for maintaining good oral hygiene

c. Instructions regarding a restricted protein diet

A client with chronic renal insufficiency is preparing for discharge from the hospital. Which information is most important for the nurse to include in this client's discharge teaching? a. Use of topical applicants to manage pruritis b. Need for maintaining good oral hygiene c. Instructions regarding a restricted protein diet d. Strategies to promote independent self-care

c. Instructions regarding a restricted protein diet

The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect?a. It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes. b. In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain c. Kawasaki disease occurs more often in boys, children younger than the age of 5 and children of Hispanic descent d. Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to2 weeks

c. Kawasaki disease occurs more often in boys, children younger than the age of 5 and children of Hispanic descent

An older client arrives to the emergency department with reports of severe nausea and vomiting large amounts of liquid brown emesis at home. The client's vital signs are temperature of 95.4 degrees F, heart rate 112 beats/minute, respiration 14 breaths/minute, and blood pressure 74/37 mmhg. Which intervention is most important for the nurse to implement? a. Maintain strict intake and output b. Monitor blood glucose level c. Keep head of bed raised 45 degrees d. Assess warmth of extremities

c. Keep head of bed raised 45 degrees

The nurse is assessing a 4-year-old child with eczema. The child skin is dry and scaly, in the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? a. Be the child daily with bath oil b. Apply baby lotion to the skin twice daily c. Keep the nails trimmed short d. Allow the child to wear only 100% cotton clothing

c. Keep the nails trimmed short

The nurse observes a client prepare a meal in the kitchen at the rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance stability? Select all that apply. a. Brings heavy can close to body before lifting b. Leans forward to pull a pan from a high shelf c. Locks knees while preparing food on the counter d. Bends from the waist to pick up trash off the floor e. Widens stance while working near the sink

c. Locks knees while preparing food on the counter d. Bends from the waist to pick up trash off the floor

A woman is brought to the labor and delivery unit after delivering a term infant and the placenta in the hospital parking lot 10 minutes ago. Which action should the nurse perform first? a. Inspect the perineum for lacerations b. Collect specimen for hemoglobin and hematocrit c. Massage the fundus and give oxytocic agent d. Place the infant to breast for bonding

c. Massage the fundus and give oxytocic agent

The nurse identifies an electrolyte balance, shortness of breath and a weight gain of 4.4 pounds in 24 hours in a client with progressive heart disease. Which intervention should the nurse include in the plan of care? a. Document abdominal girth b. Monitor daily sodium intake c. Measure ankle circumference d. Auscultate for irregular heart rate

c. Measure ankle circumference

The nurse is caring for a client after a thoracentesis that drained 50 ml of clear fluid from the left lung. Which assessment finding should the nurse report to the health care provider immediately? a. Serosanguinous drainage from the chest tube b. Dullness bilaterally on progression c. Mediastinal shift to the right d. Diminished breath sounds in the left lower lobe

c. Mediastinal shift to the right

While changing the clients postoperative dressing, the nurse observes are red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the health care provider, the nurse should evaluate which of the client's laboratory values? a. C reactive protein level b. Serum albumin c. Neutrophil count d. Creatinine level

c. Neutrophil count

After an older client receives treatment for a drug toxicity, the healthcare provider prescribes a 24-hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3 mg/dl. Which action should the nurse implement? a. Evaluate the client's serum BUN level b. Initiate the urine collection as prescribed c. Notify the healthcare provider of the results d. Assess the client for signs hypokalemia

c. Notify the healthcare provider of the results

A client with deep vein thrombosis (DVT) in the left leg is on heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care? a. Encourage mobilization to prevent pulmonary embolism b. Assess blood pressure and heart rate at least every four hours c. Observe for bleeding side effects related to heparin therapy d. Measure each calf's girth to evaluate edema in the affected leg

c. Observe for bleeding side effects related to heparin therapy

Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first? a. Encourage the mother to breastfeed b. Wrap tightly in a warm blanket c. Obtain a capillary glucose level d. Feed 30 ml of 10% dextrose in water

c. Obtain a capillary glucose level

The father of a 4-year-old has been battling metastatic lung cancer for the past two years. After discussing the remaining options with his health care provider, the client requests that all treatments stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care? a. Reassure the client that his child will be allowed to visit b. Provide the client written information about end-of-life care c. Obtain a detailed report from the nurse transferring the client d. Mark the chart with the clients request for no heroic measures

c. Obtain a detailed report from the nurse transferring the client

An older resident of an extended care facility has recurrent urinary tract infections. The nursing care plan includes the goal "increase daily intake of fluids." What nursing intervention is most useful in assisting the resident to meet this goal? a. Increase fluids provided with the client's meals b. Record the client's intake and output every shift c. Offer a glass of fluid every hour while awake d. Maintain a full pitcher of water at the bedside

c. Offer a glass of fluid every hour while awake

The nurse is providing care for a client with severe peripheral arterial disease (PAD). The client reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding? a. Elevate the legs to assess for color changes b. Provide a heating pad for PRN use c. Offer cold packs when the pain occurs d. Suggest dangling the legs when pain begins

c. Offer cold packs when the pain occurs

The nurse instructs and unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned? a. Empty the urinary drainage bag b. Assess the breath sounds c. Offer the client oral fluids d. Feed the client a snack

c. Offer the client oral fluids

A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse? a. Relieve the nurse performing CPR b. Go get the code cart c. Participate with the compressions or breathing d. Validate the client's advanced directive

c. Participate with the compressions or breathing

The nurse has received funding to design a health promotion project for African American women who are at risk for developing breast cancer. Which resource is most important in designing this program? a. A listing of African American women who live in the community b. Morbidity data for breast cancer in women of all races c. Participation of community leaders in planning the program d. Technical assistance to produce a video on breast self-examination

c. Participation of community leaders in planning the program

The client is admitted to the hospital after experiencing a stroke or a cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? a. Unilateral facial drooping b. Abnormal responses for cranial nerves I and II c. Persistent coughing while drinking d. Inappropriate or exaggerated mood swings

c. Persistent coughing while drinking

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? Select all that apply. a. Take out dentures and place in a labeled cup b. Apply a body shroud c. Place a small pillow under the head d. Remove resuscitation equipment from the room e. Gently close the eyes

c. Place a small pillow under the head d. Remove resuscitation equipment from the room e. Gently close the eyes

After placing a 36-week gestation newborn in and isolette and drying the infant with several blankets, what should the nurse implement next? a. Administer the vitamin K injection b. Remove the wet blankets and linens from the isolette c. Place erythromycin ophthalmic ointment in both eyes d. Open the isolate door to assess the infants' vital signs

c. Place erythromycin ophthalmic ointment in both eyes

A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room? a. Obtain the infants vital signs b. Observe the instant latching on to the breast c. Place the ID bands on the infant and mother d. Administer vitamin K injection

c. Place the ID bands on the infant and mother

A client is receiving enoxaparin 30 milligrams subcutaneously twice a day. In assessing for adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor? a. Glucose b. Calcium c. Platelet count d. White blood cell count

c. Platelet count

The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome (SIDS). Which information is most important to provide parents of newborns and infants? a. Remove pillows and soft toys from the crib at bedtime b. Keep a bulb syringe accessible for use for an infant c. Position the infant in a supine position while sleeping d. Do not prop bottles for an infant during naps and bedtime

c. Position the infant in a supine position while sleeping

Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing..... had a pulmonary embolus. What action should the nurse take first? a. Bring the emergency crash cart to the bedside. b. Prepare a continuous heparin infusion per protocol. c. Provide supplemental oxygen. d. Notify the healthcare provider.

c. Provide supplemental oxygen.

The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? a. Breath sounds can be heard bilaterally b. Mist is visible in the T-Piece c. Pulse oximetry of 88 d. Client is unable to speak

c. Pulse oximetry of 88

At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on the data contained in the record, what action should the nurse take before assisting the client with ambulation? a. Remove sequential compression devices b. Apply PRN oxygen per nasal cannula c. Reinforce the surgical wound dressing d. Administer a PRN dose of an antipyretic

c. Reinforce the surgical wound dressing

Which laboratory values are critical for the nurse to monitor for a client who is experiencing thyrotoxic crisis? a. Blood in urine cultures b. Glucose and calcium levels c. Renal and liver function tests d. Electrolytes and hemoglobin

c. Renal and liver function tests

The nurse provides teaching about a scheduled procedure to a male client who was admitted for diagnostic testing to determine the extent of metastasis of his cancer. An hour later the client asked the nurse for information about the scheduled procedure. What action should the nurse implement? a. Reassure the client that whatever the outcome, he will be able to cope with the results b. Encourage the client to take deep breaths in to avoid thinking negative thoughts c. Repeat the client teaching and leave written instructions for the client d. Remind the client of the instructions that were provided an hour ago

c. Repeat the client teaching and leave written instructions for the client

A nurse is managing the care of a client with Cushing syndrome. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. a. Evaluate the client for sleep disturbances b. Assess the client for weakness and fatigue c. Report any client complaint of pain or discomfort d. Note in report the client's food and liquid intake during meals and snacks e. Weigh the client and report any weight gain

c. Report any client complaint of pain or discomfort d. Note in report the client's food and liquid intake during meals and snacks e. Weigh the client and report any weight gain

The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement? a. Teach coughing and deep breathing b. Assess the client's oral cavity for ulcerations c. Request thick nectar liquids for the client d. Monitor the client when using a straw for liquids

c. Request thick nectar liquids for the client

The nurse is managing for a client in the intensive care unit who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for a client who is exhibiting which finding? a. An audible voice when the client is trying to communicate b. High pressure alarm sounds when the client is coughing c. Restrained and restless with a low volume alarm sounding d. Diminished breath sounds in the right posterior base

c. Restrained and restless with a low volume alarm sounding

The nurse is managing for clients in the intensive care unit who were mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding? a. High pressure alarm sounds when the client is coughing b. Diminished breath sounds in the right posterior base c. Restrained and restless with a low volume alarm sounding d. An audible voice when client is trying to communicate

c. Restrained and restless with a low volume alarm sounding

What is the priority nursing problem for a client with hypoparathyroidism? a. Anxiety b. Imbalanced nutrition c. Risk for injury d. Deficient knowledge

c. Risk for injury

A client is diagnosed with Meniere's disease. Which problem should the nurse identify as most important in the plan of care? a. Risk for ineffective self-health management related to deficient knowledge b. Ineffective coping related to personal vulnerability c. Risk for injury related to vertigo d. Anxiety related to disruption of lifestyle

c. Risk for injury related to vertigo

Which action should the nurse take first after obtaining a urine specimen for culture and sensitivity from an indwelling urinary catheter? a. Ensure that the drainage bag is attached to the bed frame b. Ensure continued sterility of the specimen container c. Securely fasten the clamp on the drainage bag d. Label the container with the clients identifiers

c. Securely fasten the clamp on the drainage bag ?

A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? a. Observe the stool for a clay-colored appearance b. Obtain a specimen for culture and sensitivity analysis c. Send a stool sample to the lab for guaiac test d. Assess for fatty yellow streaks in the client stool

c. Send a stool sample to the lab for guaiac test

A 7-year-old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the health care provider? a. Serum ph of 7.45 b. Shift intake of 640 ml IV fluids plus 30 ml PO ice chips c. Serum potassium of 3.0 mg/dl d. Gastric output of 100 ml in the last 8 hours

c. Serum potassium of 3.0 mg/dl

The nurse is assessing the mood of the depressed male client. When asked how he feels, the client looks down and states, "I don't know! I just can't think." Which activity should the nurse suggest that this client perform? a. Complete a written self-esteem assessment b. Review the client handbook about unit therapies c. Set daily goals in the community meeting d. Read, "The Depression Recovery Book"

c. Set daily goals in the community meeting

A 7 year old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant? a. Chicken pox b. Mumps c. Sore throat d. Influenza

c. Sore throat

The nurse should withhold which medication if the client's serum potassium level is 6.2 meq/L or mmol/L (SI)? a. Metolazone b. Furosemide c. Spironolactone d. Hydrochlorothiazide

c. Spironolactone

A group of nurses implemented a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes, and the nurses want to integrate the change throughout the facility. Which action should be taken? Select all that apply. a. Arrange in service training through the education department b. Obtain informed consent from clients who will receive care c. Submit a Sentinel event report to the research committee d. Invite data review by the quality improvement department e. Propose clinical practice guidelines to the nursing committee

c. Submit a Sentinel event report to the research committee d. Invite data review by the quality improvement department e. Propose clinical practice guidelines to the nursing committee

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider? Select all that apply. a. Location of initial IV sites b. Red blood cell count (RBC) c. Swollen lymph nodes in the groin d. White blood cell count (WBC) e. Core body temperature

c. Swollen lymph nodes in the groin d. White blood cell count (WBC) e. Core body temperature

A middle-aged man in the outpatient clinic receives a prescription for tetracycline due to folliculitis of the scalp. Which instruction should the clinic nurse provide? a. Keep the infected area covered until the infection is resolved b. Use a fine-tooth comb to remove any knits observed on the scalp c. Take your medication with a glass of water two hours after meals d. Wash your bed linens and hot water after starting the medication

c. Take your medication with a glass of water two hours after meals

A client with a prescription for do not resuscitate begins to manifest signs of impending to death. After notifying the family of the client status, what priority action should the nurse implement? a. The impending signs of death should be documented b. The client status should be conveyed to the chaplain c. The client's needs for pain medication should be determined d. The nurse manager should be updated on the client status

c. The client's needs for pain medication should be determined

The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? a. The client's skin on the lower legs will be intact at the next clinic visit b. The client will express acceptance of their newly diagnosed health status c. The clients blood pressure readings will be less than 160/90 mmHg d. The nurse will encourage the client to walk thirty minutes every day

c. The clients blood pressure readings will be less than 160/90 mmHg

A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? a. Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles usually are left in for 15 to 30 minutes. b. In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi — are thought to cause illness. c. The flow of life is believed to flow through major pathways or nerve clusters in your body. d. By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations it is believed that energy flow will rebalance to allow the body's natural healingmechanisms to take over.

c. The flow of life is believed to flow through major pathways or nerve clusters in your body.

The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred vision. Which outcome shows a plan of care for this client? a. The client will express acceptance of his changing health status. b. The client's family will state signs and symptoms about the disease. c. The nurse will demonstrate the procedure for accurate eye care. d. The client's daily blood pressure will be less than 140/80 mmHg this month.

c. The nurse will demonstrate the procedure for accurate eye care.

The nurse is educating a client in end stage renal failure who requires dialysis three times a week. Which information is important for the nurse to include about the clients daily diet? a. The intake of protein should be increased to stimulate the kidneys nephrons function b. The intake of protein should be increased due to its loss through the filter membrane c. The protein intake should be decreased to prevent nitrogenous waste buildup d. The intake of protein should be decreased due to the progressively failing function of the kidney

c. The protein intake should be decreased to prevent nitrogenous waste buildup ?

A client is admitted to a medical unit with a diagnosis of gastritis and chronic heavy alcohol use. What should the nurse administer to prevent the development of Wernicke's syndrome? a. Atenolol b. Lorazepam c. Thiamine d. Famotidine

c. Thiamine

A mother brings her four-month-old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter supposed to fix her child hernia. Which explanation should the nurse provide? a. The quarter should be secured with an elastic bandage wrap b. An abdominal binder can be worn daily to reduce protrusion c. This hernia is a normal variation that resolves without treatment d. Restrictive clothing will be adequate to help the hernia go away

c. This hernia is a normal variation that resolves without treatment

A client with hyperthyroidism is admitted to the postoperative unit after a subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse? a. T3 uptake at 50% b. Glucose 150 milligrams per deciliter c. Total calcium 5.0 milligrams per deciliter d. Thyroxine 12 micrograms per deciliter

c. Total calcium 5.0 milligrams per deciliter

The nurse is leading a care team on a medical surgical unit assigning client care to a practical nurse (PN) and unlicensed assistive personnel (UAP). Which task should the nurse delegate to the UAP? a. Evaluate a clients mobility progress toward the plan of care b. Assess for side effects of administered pain medications c. Turn and reposition a client with a total hip replacement d. Monitor an intravenous infusion rate on an established schedule

c. Turn and reposition a client with a total hip replacement

The nurse plans to administer a low dose prescription for dopamine to a client who is in septic shock. Which physiologic parameter should the nurse use to evaluate a therapeutic response to dopamine? a. Pupil response b. Heart sounds c. Urinary output d. Temperature

c. Urinary output

Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer? a. Frequently apply moisturizers to prevent dry skin b. Protect the site from getting wet during bathing c. Use a sponge to debride the affected area d. Gently pat the skin dry after rinsing with water

c. Use a sponge to debride the affected area

Which information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms? a. Discontinue all non-steroidal anti-inflammatory medications b. Avoid using heat or ice to injured muscles while taking this medication c. Use cold and allergy medications only as directed by a health care provider d. Take this medication on an empty stomach

c. Use cold and allergy medications only as directed by a health care provider

The nurse learns in report that a client was unstable during the previous shift. The nurse should plan to carefully monitor which parameter? a. Circadian rhythms b. Basal metabolic rate c. Vital signs d. Stress levels

c. Vital signs

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the health care provider? a. Nausea and headache b. Yellow tinged sputum c. Watery diarrhea d. Increased fatigue

c. Watery diarrhea

The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity? a. Core strengthening b. Aerobic exercise c. Weight bearing exercise d. Muscles stretching and toning

c. Weight bearing exercise

On admission to the emergency department, a female client who is diagnosed with bipolar disorder three years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain? a. Which family member has the client suicide note b. What drugs the client use for the suicide attempt c. When the client last took drugs for bipolar disorder d. Whether the client ever attempted suicide in the past

c. When the client last took drugs for bipolar disorder

A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? a. Light, pink urine b. occasional suprapubic cramping c. minimal drainage into the urinary collection bag d. complaints of the feeling of pulling on the urinary catheter

c. minimal drainage into the urinary collection bag

Following a lumbar puncture, the client voices several concerns. Which concern indicates that the nurse that the client is experiencing a complication of the procedure? a. "I Feel sick to my stomach and I'm going to throw up" b. "I'm having pain in my lower back when I move my legs" c. "My throat hurts badly when I swallow and when I talk" d. "I have a headache that gets worse when I sit up"

d. "I have a headache that gets worse when I sit up"

A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis? a. "I knew this would happen. I've been eating too much red meat lately." b. "I really enjoyed my fishing trip yesterday. I caught 2 fish." c. "I have really been working hard practicing with the debate team at school." d. "I went to the health care provider last week for a cold and I have gotten worse."

d. "I went to the health care provider last week for a cold and I have gotten worse."

Which might the nurse suggest to a client with fibrocystic breasts in attempt to help relieve her symptoms? a. "Eliminate caffeine from your diet" b. "Avoid vigorous physical exercise immediately after your menstrual period" c. "Eat a low-carbohydrate, high-protein diet" d. "Increase high-calcium foods in your diet"

d. "Increase high-calcium foods in your diet"

The nurse is conducting health assessments. Which assessment finding increases a 56-year-old woman's risk for developing osteoporosis? a. Body mass index of 31 b. Diabetes mellitus in family history c. Birth control pill usage until age 45 d. 20 pack year history of cigarette smoking

d. 20 pack year history of cigarette smoking

A 300 ml unit of packed red blood cells is prescribed for a client with heart failure who has 3+ pitting adima, shortness of breath with any activity, and crackles in both lung bases. What rate should the nurse administer the blood? a. 50 ml/hour b. 150 ml/hour c. 300 ml/hour d. 75 ml/hour

d. 75 ml/hour

During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first? a. The census report has not been completed. b. A client's wife has asked to speak with the charge nurse. c. One staff member has not reported to work. d. A bucket of water was spilled in the hallway.

d. A bucket of water was spilled in the hallway.

The nurse working in the psychiatric clinic has phone messages from several clients. Which cost should the nurse return first? a. A young man with schizophrenia who wants to stop taking his medications b. The mother of a child who was involved in a physical fight at school today c. A client diagnosed with depression who is experiencing sexual dysfunction d. A family member of a client with dementia who has been missing for five hours

d. A family member of a client with dementia who has been missing for five hours

Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? a. A young adult with a history of Down's syndrome b. A teenager who reads at a 4th grade level c. An elderly client with numerous arthritic nodules on the hands d. A preschooler with intermittent episodes of alertness

d. A preschooler with intermittent episodes of alertness

What is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)? a. Obtain adequate rest and sleep b. Reduce risk for infection c. Improve stress management skills d. Achieve satisfactory pain control

d. Achieve satisfactory pain control

Which environmental factors most significant when planning care for a client with ostemalacia? a. Quiet, calm surroundings b. Cool, moist air c. Stimulating sounds and activity d. Adequate sunlight

d. Adequate sunlight

A client is admitted with a severe asthma attack. For the last three hours the client has experienced increasing shortness of breath. Arterial blood gas results are: ph 7.22; paco2 55mmhg; HCO3 25 meq/L (25 mmol/L). Which intervention should the nurse implement? a. Space care to provide periods of rest b. Instruct client to purse lip breathe c. Position client for maximum comfort d. Administer PRN dose of albuterol

d. Administer PRN dose of albuterol

A client with peptic ulcer disease receives a prescription for an intermittent suction via a Salem Sump nasogastric tube (NGT). After inserting the NGT and obtaining coffee ground gastric contents, the nurse clamps the NGT because the client must leave the unit for diagnostic studies. Upon return to the unit, the client complaints of nausea. Which action should the nurse implement first? a. Connect the NGT to low intermittent suction b. Irrigate the NGT with sterile normal saline c. Provide oral suction using a Yankauer tip d. Administer a prescribed antiemetic agent

d. Administer a prescribed antiemetic agent

While making rounds the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bedside table. The client is currently receiving oxygen at 2 liters/minute via Nasal cannula. The client is wheezing and is using purse-lip breathing. Which intervention should the nurse implement? a. Increase oxygen to 6 liters/minute b. Call for an ambu resuscitation bag c. Assist the client to lie back in bed d. Administer nebulizer treatment

d. Administer nebulizer treatment

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention? a. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack b. A 16-year-old client diagnosed with major depression who refuses to participate in Group c. The 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby d. An 18-year-old client with antisocial behavior who is being yelled at by other clients

d. An 18-year-old client with antisocial behavior who is being yelled at by other clients

Which client is best to assign to the practical nurse (PN) who's assisting the registered nurse (RN) with the care of a group of clients? a. An older client who is scheduled for foot amputation due to diabetes complications b. An older client who is one day postoperative with a colostomy for colon cancer c. An adult with alcoholism, cirrhosis, and hepatic encephalopathy d. An adult who is one day postoperative for a laparoscopic cholecystectomy

d. An adult who is one day postoperative for a laparoscopic cholecystectomy

After reviewing the Braden scale findings of residents in a long term facility, the charge nurse should tell the unlicensed assistive personnel to prioritize skin care for which client? a. A poorly nourished client who requires liquid supplements b. An older adult who is unable to communicate in elimination needs c. A woman with osteoporosis who is unable to bear weight d. An older man who sheets are damp each time he is turned

d. An older man who sheets are damp each time he is turned

Which nursing responsibility is related to health promotion and teaching for the client with rheumatoid arthritis? a. Prevention through nutrition and exercise b. Avoidance of foods containing purine c. Immobilization of affected joints d. Application of heat and cold therapy

d. Application of heat and cold therapy

After years of struggling with weight management, a middle-aged man is evaluated for gastroplasty. He has experienced difficulty with managing his diabetes mellitus and hypertension, but has it's been approved for surgery. Which intervention is most important for the nurse to include in this client plan of care? a. Observed for signs of depression b. Monitor for urinary incontinence c. Provide a wide variety of meal choices d. Apply sequential compression stockings

d. Apply sequential compression stockings

A female client is scheduled for an intravenous pyelography today. The nurse instructs the client that the X-ray visualizes the kidneys, uterus, and bladder. Which information is most important for the nurse together before the client goes for the X-ray? a. Determine the last time the client had a bowel movement b. Inquire if she is taking her regularly scheduled medications c. Find out if the client can lie prone for the X-ray d. Ask if the client has an allergy to shellfish

d. Ask if the client has an allergy to shellfish

The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel (UAP) providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. What is the priority nursing action? a. Determine why the UAP did not notify the nurse of the change in the client's condition b. Advise the UAP stop providing care so the nurse can assess the client's condition c. Explain to the UAP that changes in the client's condition should be reported immediately d. Ask the UAP to position the client so the oral medications can be administered

d. Ask the UAP to position the client so the oral medications can be administered

A young adult male who's being seen at the employee health care clinic for an annual assessment tells the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficult indeed. Which response is best for the nurse to provide? a. Encourage the client to seek genetic counseling to determine his risk for mental illness b. Inform the client that his mother schizophrenia has affected his psychological development c. Tell the client that mental illness has a familial predisposition so he should go see a psychiatrist d. Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed

d. Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed

An adult client is admitted to the psychiatric unit with a diagnosis of major depression. After two weeks of antidepressant medication therapy, the nurse notices the client has more energy, is giving personal belongings away to visitors, and is in a better mood. Which intervention is best for the nurse to implement? a. Tell the client to keep one's belongings because they will be needed at discharge b. Support the client by validating the progress that has been made c. Reassure the client that the antidepressant drugs are apparently effective d. Ask the client if there are any recent thoughts of harming self

d. Ask the client if there are any recent thoughts of harming self

When preparing to administer an intravenous medication through a client's triple lumen central venous catheter, the nurse observes that there are no continuous intravenous fluids infusing. What action should the nurse take? a. Initiate an infusion of 0.9% normal saline solution b. Prepare a saline flush in a 3 ml syringe c. Position the clients head facing away from the site d. Aspirate for the presence of blood return

d. Aspirate for the presence of blood return

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? a. Determine if the client is experiencing any anxiety. b. Auscultate the client's bilateral lung sounds and oxygen saturation. c. Notify the healthcare provider about the client's distress. d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.

d. Assess the delivery mechanism of the oxygen tank, tubing, and cannula.

A client with chronic kidney disease has an arteriovenous (AV) fistula In the left forearm. Which observation by the nurse indicates that the fistula is patent? a. Distended, tortuous veins in the left hand b. Auscultation of a thrill on the left forearm c. The left radial pulses 2+ bounding d. Assessment of a bruit on the left forearm

d. Assessment of a bruit on the left forearm

The nurse observes an unlicensed assistive personnel (UAP) who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. What action should the nurse take? a. Remind the UAP to wash hands frequently while in the room b. Help the UAP reposition the gown sleeve over the glove edges c. Confirm that the gown is tide securely at the neck and waist d. Assist the UAP with application of a face mask or face shield

d. Assist UAP with application of a face mask or face shield

The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignment is best for the charge nurse to give to this nurse? a. Transfer a client to another unit b. Perform the admission of a new client c. Monitor the central telemetry d. Assist cardiac nurses with their assignments

d. Assist cardiac nurses with their assignments

A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement? a. Recommend he avoid fast food restaurants until he is familiar with his prescribed diet. b. Advise him to take his own food with him when going to fast food restaurants with his friends. c. Encourage him to find activities to do with his friends that do not involve eating. d. Assist him in identifying popular fast foods that are within his meal plan for diabetes.

d. Assist him in identifying popular fast foods that are within his meal plan for diabetes.

A client with postpartum depression, who is admitted to the behavioral health unit, refuses to leave her room or eat meals. In addition to maintaining physical safety, which short term goal should the nurse include in the plan of care? a. Sleeps at least six hours per night b. Consumes three meals and 1500 milliliter of fluid per day c. Engages in one client a client interaction daily d. Attends one group activity per day

d. Attends one group activity per day

The nurse identifies an electrolyte imbalance, and elevated pulse rate, and an elevated blood pressure in a client with chronic kidney disease. Which is the most important action for the nurse to take? a. Measure ankle circumference b. Monitor daily sodium intake c. Record usual eating patterns d. Auscultate for irregular heart rate

d. Auscultate for irregular heart rate

The nurse is preparing a client for discharge who was hospitalized with an acute flare of a systemic lupus erythematosus symptoms. Which instruction is most important for the nurse to include? a. Use a walker when weakness occurs b. Take prescribed cortisone accurately c. Decrease daily intake of sodium in the diet d. Avoid extreme environmental temperatures

d. Avoid extreme environmental temperatures

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which healthcare measure is most important for the nurse to recommend to these clients? a. Ensure supplemental oxygen and respiratory medications are available at all times b. Use nasal or cough tissues followed by hand washing at all times c. Get annual flu and pneumococcal vaccine polyvalent vaccines d. Avoid large crowded areas during the colder months of the year

d. Avoid large crowded areas during the colder months of the year

A client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client plans to take a multivitamin. What teaching should the nurse provide? a. As a nutritional supplement, orlistat already contains all the recommended daily vitamins and minerals b. Multivitamins are contraindicated during treatment with weight control medications such as Orlistat c. Following a well-balanced diet is a much healthier approach to a good nutrition than depending on a multivitamin d. Be sure to take the multivitamin and the medication at least two hours apart for the best absorption and effectiveness

d. Be sure to take the multivitamin and the medication at least two hours apart for the best absorption and effectiveness

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations, and his carotid pulse is not palpable. Which intervention should the nurse implement? a. Analyze the cardiac rhythm in another lead b. Obtain a 12-lead electrocardiogram c. Observe for swelling at the fracture site d. Begin chest compressions at 100/minute

d. Begin chest compressions at 100/minute

A client presents the believer in delivery unit with a report of leaking fluid that is greenish brown vaginal discharge. Which action should the nurse take first? a. Start an intravenous infusion b. Administer oxygen via face mask c. Performing vaginal exam d. Begin continuous fetal monitoring

d. Begin continuous fetal monitoring

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. Which action should the nurse take first? a. Call respiratory therapy b. Monitor oxygen saturation levels every five minutes c. Silence the alarm and call the technician d. Begin manual ventilation immediately

d. Begin manual ventilation immediately

The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis? a. Decrease in the appetite b. Weight of 227 pounds (103 kg) c. Dry mucosal membranes d. Body mass index (BMI) of 17

d. Body mass index (BMI) of 17

A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries and saying from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents? a. A retraining program will need to be initiated when the child returns home b. Diaper will be provided since hospitalization is stressful to preschoolers c. A potty chair should be brought home so he can maintain his toileting skills d. Children usually resume their toileting behaviors when they leave the hospital

d. Children usually resume their toileting behaviors when they leave the hospital

The nurse is conducing a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately? a. Gradual onset of continuous eye pain and blurred vision. b. Recent change in the ability to read and drive after dark. c. Gray-white circle around the iris of both eyes. d. Cloudy opacity of the crystalline lens.

d. Cloudy opacity of the crystalline lens.

The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski reflex. Which action should the nurse take in response to the finding? a. Ask the client to describe recent alcohol use b. Keep the clients feet elevated when in bed c. Assess the clients muscle strength and tone d. Complete a thorough neurological assessment

d. Complete a thorough neurological assessment

A client with postpartum depression, who is admitted to the behavioral health unit, refuses to leave her room or eat meals. In addition to patient's safety, which short-term goal should the nurse include in the plan of care? a. Attends one group activity per day. b. Sleeps at least 6 hours per night. c. Engages in one client-to-client interaction daily. d. Consumes 3 meals and 1500 mL of fluid per day.

d. Consumes 3 meals and 1500 mL of fluid per day.

The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the urine output flow is 100 ml less than the input flow. Which action should the nurse implement first? a. Irrigate the dialysis catheter b. Check the client's blood pressure and serum bicarbonate c. Change the client position d. Continue to monitor and take an output with next exchange

d. Continue to monitor and take an output with next exchange

After initiating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. What action should the nurse take next? a. Note the presence of an auscultatory gap b. Reinflate the cuff to a higher number c. Reposition the stethoscope over the brachial artery d. Continue with the blood pressure assessment

d. Continue with the blood pressure assessment

The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first? a. Prepare the client for spinal anesthesia b. Prepare the coach to accompany the client to delivery c. Empty the client's bladder using a straight catheter d. Convey to the client that birth is imminent

d. Convey to the client that birth is imminent

A woman at 12 weeks' gestation comes into the clinic for her first prenatal visit. After completing health history, the nurse should discuss which topic about pregnancy at this initial visit? a. Concerns about parenting b. Knowledge about labor and delivery c. Complications associated with childbirth d. Cultural practices related to childbearing

d. Cultural practices related to childbearing

As part of the treatment plan for a client diagnosed with acute pancreatitis, the nurse plans to withhold oral fluids based on which pathophysiological process? a. Removing gastric secretions and to relieve abdominal distention b. Reducing hydrochloric acid secretion c. Restoring and maintaining a positive fluid balance d. Decreasing the formation and secretion of pancreatic enzymes

d. Decreasing the formation and secretion of pancreatic enzymes ?

The practical nurse (PN) is preparing a client for a lumbar puncture. The nurse observes the PN turning the client on the side with the leg straight and the head of the bed in semi-Fowler's position. Which action should the nurse implement? a. Arrange for an unlicensed assistive personnel to assist the PN during the procedure b. Acknowledged that the PN has positioned the client safely and correctly c. Assume care of the client and assign the PN to care of a different client d. Demonstrates the PN how to position the client more effectively for the procedure

d. Demonstrates the PN how to position the client more effectively for the procedure

The nurse assesses a client who had bilateral total knee replacements for hours ago. The nurse notes that the dressing on the clients right knee is saturated with serosanguinous drainage. Which action should the nurse implement? a. Monitor the client's current white blood cell count b. Withhold the next scheduled dose of low molecular weight heparin c. Confirmed with the continuous passive motion device is intact d. Determine if the wound drainage device is functioning accurately

d. Determine if the wound drainage device is functioning accurately

Prior to surgery, written consent must be obtained. Which is the nurses legal responsibility with regard to obtaining written consent? a. Ask the client or a family member to sign the surgical consent form b. Explain the surgical procedure to the client and ask the client to sign a consent form c. Validate the clients understanding of the surgical procedure to be conducted d. Determine that the surgical consent form has been signed and is included in the clients record

d. Determine that the surgical consent form has been signed and is included in the clients record

The nurse knows that several complications can occur with the administration of blood. Which finding is an indication of an air emboli? a. Chills and tremors b. Nausea and vomiting c. Increased blood pressure d. Difficulty breathing

d. Difficulty breathing

The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the clients age or type of diabetes? a. Prior to exercising b. Before going to bed c. Immediately after meals d. During acute illness

d. During acute illness

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are being taken so often. Which response by the nurse is most accurate? a. Hypertension leading to sudden shock can develop at any time b. Blood pressure fluctuations means that the condition has become chronic c. Sodium intake with meals and snacks affects the blood pressure d. Elevated blood pressure must be anticipated and identified quickly

d. Elevated blood pressure must be anticipated and identified quickly

The nurse is preparing an adult with Addison's disease for self-management. Which information should the nurse include in the client's instructions? a. Importance of recording daily weights b. Adherence to a high fiber low fat diet c. Need to check temperature daily d. Events requiring steroid dosage adjustments

d. Events requiring steroid dosage adjustments

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for them to explore further prior to the start of the procedure? a. Drank a glass of water in the past 2 hours. b. Reports left chest wall pain prior to admission. c. Verbalize a fear of being in a confined space. d. Experience facial swelling after eating crab.

d. Experience facial swelling after eating crab.

A male client with cirrhosis and severe ascites, who is scheduled for a paracentesis tells the nurse that he is in pain and feel short of breath, so he wants to reschedule the procedure. How should the nurse respond? a. Advise the client that the procedure will help diagnose the cause of his symptoms b. Encourage the client to verbalize his fears about the outcome of the procedure c. Offer to notify the health care provider of his desire to reschedule the procedure d. Explain to the client that the paracentesis will provide relief from his discomfort

d. Explain to the client that the paracentesis will provide relief from his discomfort

A middle aged woman talks to the nurse in the health care provider's office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? a. I am one out of every 4 women that get fibroids, and of women my age - between the 30s or 40s, fibroids occurs more frequently. b. My fibroids are noncancerous tumors that grow slowly. c. My associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination or urine retention and constipation. d. Fibroids that cause no problems still need to be taken out.

d. Fibroids that cause no problems still need to be taken out.

A client who is admitted with diabetic ketoacidosis is demonstrating Kussmaul breathing and has a severe headache along with nausea. Her arterial blood gases are: ph 7.50; paco2 30 mmhg; HCO3 24 meq/L. Which assessment finding warrants immediate intervention by the nurse? a. Muscle stiffness b. Abdominal pain c. Mental stupor d. Fruity breath

d. Fruity breath

As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? a. Mouth sores b. Fatigue c. Diarrhea d. Hair loss

d. Hair loss

In assessing a client at 34 weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, hematocrit of 28%, heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow up? a. Elevated thyroid hormone level b. Systolic murmur c. Heart rate of 92 beats per minute d. Hematocrit of 28%

d. Hematocrit of 28%

A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? a. Erythrocyte sedimentation rate b. Serum calcium c. Osmolality d. Hemoglobin

d. Hemoglobin

Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? a. I started my period and now my urine has turned bright red. b. I am a diabetic and today I have been going to the bathroom every hour. c. I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. d. I went to the bathroom and my urine looked very red and it didn't hurt when I went

d. I went to the bathroom and my urine looked very red and it didn't hurt when I went

An older male client, who is a retired chef, is hospitalized with a diabetic ulcer on his foot. His daughter tells the nurse that her father has become increasingly obsessed with the way his food is prepared in the hospital. The nurses response should be based upon what information? a. The client probably has an organic brain disease and will likely have alzheimers disease within a few years b. The family needs a social worker to talk to them about how to handle their father when he becomes annoying c. The daughter is under stress and should be encouraged to think about happier times d. If the client was compulsive about food when he was younger, the aging process can magnify this

d. If the client was compulsive about food when he was younger, the aging process can magnify this

What is the primary purpose for initiating nursing interventions that promote good nutrition, rest and exercise, and stress reduction for clients diagnosed with and HIV infection? a. Increase ability to carry out activities of daily living b. Promote a feeling of general well-being c. Prevent spread of infection to others d. Improve function of the immune system

d. Improve function of the immune system

A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding to the surgeon. Which action should the nurse implement first? a. Measure and document the client's urinary output. b. Request the client's reserved unit if packed red blood cells. c. Prepare the placement of a central venous catheter. d. Increase the infusion rate of Lactated Ringer's solution.

d. Increase the infusion rate of Lactated Ringer's solution.

A 46 year old male client who had a myocardial infarction (MI) 24 hours ago comes to the nurses station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care? a. Deficient knowledge of lifestyle changes b. Decisional conflict due to stress c. Anxiety related to treatment plan d. Ineffective coping related to denial

d. Ineffective coping related to denial

A woman with an anxiety disorder calls her obstetricians office and tells the nurse of increasing anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her anti-anxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? a. Describe the transmission of drugs to the infant through breast milk b. Encourage her to use stress relieving alternatives, such as deep breathing exercises c. Explain that anxiety is a normal response for a mother of a three-week old d. Inform her that some anti-anxiety medications are safe to take while breastfeeding

d. Inform her that some anti-anxiety medications are safe to take while breastfeeding

A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. The which action is most important for the nurse to implement? a. Obtain the client's 24 hour dietary recall b. Document mucosal membrane status c. Schedule a consult with a nutritionist d. Initiate prescribed intravenous fluids

d. Initiate prescribed intravenous fluids

The mother of a 7-month-old brings the infant to clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? a. Tell the mother to cleanse with soap and water at each diaper change b. Encourage the mother to apply lotion with each diaper change c. Ask the mother to decrease the infants intake of fruits for 24 hours d. Instruct the mother to change the child's diaper more often

d. Instruct the mother to change the child's diaper more often

The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life-threatening and should be reported to the healthcare provider immediately? a. Facial numbness b. Right ear hearing loss c. Difficulty with balance d. Intensifying headache

d. Intensifying headache

The nurse inserts and indwelling urinary catheter as seen in the video. What action should the nurse take next? a. Remove the catheter and insert into urethra opening b. Insert the catheter further and observe her discomfort c. Observe for urine flow and then inflate the balloon d. Leave the catheter in place and obtain a sterile catheter

d. Leave the catheter in place and obtain a sterile catheter

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room period which action should the nurse take? a. Encourage the client to implement relaxation techniques b. Explain that insulin is a lifesaving drug for the client c. Refer the client to a social worker for support therapy d. Leave their clients room and return later in the day

d. Leave their clients room and return later in the day

An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a tunnel." The client expresses great concern about going blind. Which instruction is most important for the nurse to provide this client? a. Wear prescription glasses b. Eat a diet high in carotene c. Avoid frequent eye pressure measurements d. Maintain prescribed eyedrop regimen

d. Maintain prescribed eyedrop regimen

The health care provider describes the sepsis protocol for client with multi organ failure caused by a ruptured appendix which intervention is most important for the nurse to include in the plan of care? a. Assess warmth of extremities b. Keep head of bed raised 45 degrees c. Monitor blood glucose level d. Maintain strict intake and output

d. Maintain strict intake and output

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. What action should the nurse take first? a. Determine if the newborn is in the nursery. b. Activate the lockdown procedure. c. Ask the mother if any visitors were expected to arrive. d. Match ID bands of all infants and mothers on the unit.

d. Match ID bands of all infants and mothers on the unit.

Which information is a priority for the RN to reinforce to an older client after intravenous pyelogram? a. Eat a light diet for the rest of the day b. Rest for the next 24 hours since the preparation and the test is tiring. c. During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days d. Measure the urine output for the next day and immediately notify the health care provider if it should decrease.

d. Measure the urine output for the next day and immediately notify the health care provider if it should decrease.

A client who is hypotensive is receiving dopamine, and adrenergic agonist IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication? a. Initiate seizure precautions b. Assess pupillary response to light hourly c. Monitor serum potassium frequently d. Measure urinary output every hour

d. Measure urinary output every hour

A client is receiving a hypertonic solution for bladder irrigation in as at risk for dilutional hyponatremia. The nurse should plan to observe for which common sign of hyponatremia? a. Irregular heartbeats b. Bradycardia c. Muscle spasms d. Mental status changes

d. Mental status changes

A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high-pitched wheezing on inspiration and expiration. The medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 minutes after the admission assessment, should the nurse report immediately to the emergency department health care provider? a. Client reports being anxious b. Extreme agitation with staff and family c. An apical pulse of 120 beats per minute d. No wheezing upon auscultation of the client

d. No wheezing upon auscultation of the client

An older adult male who is in his early 70s is admitted to the emergency department because of a COPD exacerbation. The client is struggling to breathe, and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provides the nurse a copy of the clients living will. Which action should the nurse take? a. Alert the nursing staff of the clients do not resuscitate status b. Facilitate a family meeting with the palliative care team c. Place a certified copy of the living will in the client record d. Notify the healthcare provider of the client wishes

d. Notify the healthcare provider of the client wishes

The father of a four-year-old has been battling metastatic lung cancer for the past two years. After discussing the remaining options with his health care provider, the client request that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care? a. Provide the client written information about end-of-life care b. Reassure the client that his child would be allowed to visit c. Mark the chart with the clients request for no heroic measures d. Obtain a detailed report from the nurse transferring the client

d. Obtain a detailed report from the nurse transferring the client

A client is admitted with possible urosepsis. Which intervention should the nurse perform as soon as possible? a. Teach the client about the side effects of the prescribed anti-infective drug b. Assess the last 24-hour oral and intravenous fluid intake and urine output c. Administer the initial dose of the anti-infective drug as prescribed d. Obtain a urine specimen for a prescribed culture and sensitivity test

d. Obtain a urine specimen for a prescribed culture and sensitivity test

The nurse instructs an unlicensed assistive personnel (UAP) to turn and immobilized older client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned? a. Empty the urinary drainage bag b. Feed the client a snack c. Assess the breath sounds d. Offer the client oral fluids

d. Offer the client oral fluids

Which assessment finding is most important when planning to provide a complete bed bath to a bed fast client? a. Right sided paralysis b. 2+ pitting edema of the feet c. Pallor d. Orthopnea

d. Orthopnea

Which clients' vital signs indicating increased intracranial pressure (ICP) should the nurse report to the health care provider? a. P 70, BP 120/60 mmhg; P 100, BP 90/60 mmhg; rapid respirations b. P 110, BP 130/ \70 mmhg; P 100, BP 110/70 mmhg; shallow respirations c. P 130, BP 190/90 mmhg; P 136, BP 200/100 mmhg; Kussmaul respirations d. P 55, BP 160/70 mmhg; P 50, BP 194/70 mmhg; irregular respirations

d. P 55, BP 160/70 mmhg; P 50, BP 194/70 mmhg; irregular respirations

A client with a history of upper respiratory symptoms is admitted with chest tightness, productive cough, and difficulty breathing period the client's arterial blood gases indicate respiratory acidosis. An increase in which laboratory test result supports this finding? a. HCO3 b. Arterial pH c. PaO2 d. PaCO2

d. PaCO2

The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be a. Irritable and "colicky" with no attempts to pull to standing b. Alert, laughing and playing with a rattle, sitting with support c. Skin color dusky with poor skin turgor over abdomen d. Pale, thin arms and legs, uninterested in surroundings

d. Pale, thin arms and legs, uninterested in surroundings

Client with end stage renal disease (ESRD) is refusing all treatment and requests that no life saving measures be implemented. The health care provider refuses to write do not resuscitate instructions. Which action should the nurse take? a. Initiate a review of the situation by the hospital's ethics committee b. Remind the client that new treatments are being developed daily c. Facilitate a palliative care meeting with the client and health care provider d. Provide the health care provider with a copy of the clients Bill of Rights

d. Provide the health care provider with a copy of the clients Bill of Rights

The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is a. Heart rate b. Pedal pulses c. Lung sounds d. Pupil responses

d. Pupil responses

An older adult client with chronic emphysema is admitted to the emergency room from home with acute onset of weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview? a. History of smoking over the past 6 months. b. Sleep patterns during the previous few week. c. Activity level prior to onset of symptoms. d. Recent compliance with prescribed medications.

d. Recent compliance with prescribed medications.

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing in the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. Which intervention should the nurse implement? a. Replace the IV site with a smaller gauge b. Apply soft bilateral wrist restraints c. Leave the lights on in the room at night d. Redress the abdominal incision

d. Redress the abdominal incision

A client with urge incontinence was treated with onabotuilinumtoxina injections and is now experiencing urinary retention. Which action should the nurse include in the clients plan of care? a. Provide a bedside commode for immediate use in the clients room b. Teach the clients techniques for performing intermittent catheterization c. Explain the need to limit intake of oral fluids to reduce client discomfort d. Remind the client to practice pelvic floor (Kegel) exercises regularly

d. Remind the client to practice pelvic floor (Kegel) exercises regularly

A male client who was in a motor vehicle collision yesterday is receiving a unit of packed red blood cells. When half of the unit is infused, the client reports lower back pain, and the nurse observes a fine rash over the chest and back. Which intervention should the nurse implement? a. Apply an anti-itch ointment over the rash area b. Instruct the client to avoid lying on his back c. Administer scheduled dose of glucocorticoid d. Replace the transfusion with normal saline

d. Replace the transfusion with normal saline

A client with a swollen right toe receives a prescription for colchicine to treat their present symptoms of gout and a prescription for allopurinol to control future attacks. What information is most important for the nurse to teach the client? a. Watch for thin hair b. Expect anorexia c. Anticipate fever d. Report diarrhea

d. Report diarrhea

The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement? a. Assess the client's oral cavity for ulcerations. b. Monitor the client when using a straw for liquids. c. Teach coughing and deep breathing exercises. d. Request thick nectar liquids for the client.

d. Request thick nectar liquids for the client.

A client with renal lithiasis is receiving morphine sulfate every four hours for pain and renal colic. Which assessment finding should prompt the nurse to administer a PRN dose of naloxone? a. Complaints of increasing flank pain b. Unresponsive to verbal or tactile stimuli c. Statements about visual hallucinations d. Respiratory rate of 12 breaths/minute

d. Respiratory rate of 12 breaths/minute

A multiparous client who delivered her infant 3 hours ago asks the nurse if she can take a warm sitz bath because it helped reduce perennial pain after her last delivery. What action should the nurse implement? a. Using analgesic spray to the perennial area to reduce pain b. Apply an ice pack to the perineum for the first 24 hours c. Teach the client how to practice kegel exercises d. Review the use of sitz bath equipment with the client

d. Review the use of sitz bath equipment with the client

The healthcare provider prescribes a low fiber diet for a client with ulcerative colitis. Which food selection indicates to the nurse that the client understands the prescribed diet? a. Roasted pork, fresh strawberries b. Pancakes, whole grain cereals c. Baked potato with skin, raw carrots d. Roasted Turkey, canned vegetables

d. Roasted Turkey, canned vegetables

The nurse is preparing to administer an IV dose of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse? a. White blood cell count of 12,000 mm^3 (12 x 10^9/L) b. Urine culture positive for MRSA c. Serum sodium of 145 meq/L (145 mmol/L) d. Serum creatinine of 4.5 mg/dl (398 mcmol/L)

d. Serum creatinine of 4.5 mg/dl (398 mcmol/L)

The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? a. Blood urea nitrogen 50 mg/dl b. Hemoglobin of 10.3 mg/dl c. Venous blood pH 7.30 d. Serum potassium 6 mEq/L

d. Serum potassium 6 mEq/L

A 7 year old is admitted to the hospital with persistent vomiting and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the health care provider? a. Shift intake of 640 milliliters IV fluids plus 30 milliliters PO ice chips b. Serum ph of 7.45 c. Gastric output of 100 milliliters in the last eight hours d. Serum potassium of 3.0 milligrams per deciliter

d. Serum potassium of 3.0 milligrams per deciliter

A client with diabetes insipidus (DI) has an average urinary output of 500 mL of dilute urine every hour for the last four hours. Which laboratory test is most important for the nurse to monitor? a. White blood cell count b. Capillary glucose c. Urine specific gravity d. Serum sodium

d. Serum sodium

When assessing a recently delivered, multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding? a. The second stage of Labor lasted 10 minutes b. She received butorphanol 2mg IVP during labor c. She is over 35 years of age d. She is gravida six, para of five

d. She is gravida six, para of five

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider? a. A change in the sleep-wake cycle b. Mild sedation c. Dizziness reported after the initial dose d. Somnambulism

d. Somnambulism

A client who is pregnant seems confused and presents with the onset of headache, polyurea, fatigue, and blurry vision. Which action should the nurse implement? a. Assess client for signs of Vertigo b. Palpate bladder for urinary retention c. Determine serum potassium (K) level d. Take serial blood pressure readings

d. Take serial blood pressure readings

A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow up by the nurse? a. CT scan that was performed six months earlier b. Metal hip prosthesis was placed twenty years ago c. Report of client sobriety for the past five years d. Takes metformin for type 2 diabetes mellitus

d. Takes metformin for type 2 diabetes mellitus

The wife of a newly diagnosed client with Parkinson's disease asks the nurse if alternative or complementary medical therapies might cure the disease. Which response should the nurse provide? a. Complete a list of alternative medications that are effective in curing parksinson's disease b. Explain there are no known conventional, alternative, or complementary therapies that cure Parkinson's disease c. Encourage the wife to ventilate her feelings about having a husband with Parkinson's disease d. Tell the wife that her husband's neurologist just would know more about alternative treatments to cure Parkinson's

d. Tell the wife that her husband's neurologist just would know more about alternative treatments to cure Parkinson's

A client is found the bathroom when left unattended by the unlicensed assistive personnel. Which information should the nurse include in the client's health record? a. The UAP left the client to assist another client b. The last time the client was assisted to the bathroom c. The unit was understaffed when the client fell d. The client fell sustaining a fractured to the left hip

d. The client fell sustaining a fractured to the left hip

After receiving report on an inpatient acute care unit, which client should the nurse assess first? a. The client with an obstruction of the large intestine who is experiencing abdominal distention b. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowl sounds c. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid d. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity

d. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity

The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? a. The client will express acceptance of their newly diagnosed health status. b. The nurse will encourage the client to walk thirty minutes everyday. c. The client's blood pressure readings will be less than 160/90 mmHg. d. The client's skin on the lower legs will be intact at the next clinical visit.

d. The client's skin on the lower legs will be intact at the next clinical visit.

The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? a. As the burn heels, the graft permanently attaches b. Graphs are later removed by a debriding procedure c. Grafting increases the risk for bacterial infections d. The xenograft is taken from non-human sources

d. The xenograft is taken from non-human sources

A client with multiple burn injuries is being treated in the burn trauma unit just hours after the injuries occurred. The healthcare provider instructs the nurse to avoid auto contamination when performing dressing changes. Which intervention is most important for the nurse to implement? a. Dress each wound separately b. Assign equipment to this one client c. Utilize reverse isolation protocol d. Use gown, mask, and gloves with dressing changes

d. Use gown, mask, and gloves with dressing changes

The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal? a. Case management and screening for clients with HIV b. Regional relocation Center for earthquake victims c. Lead screening for children in low-income housing d. Vitamin supplements for high-risk pregnant women

d. Vitamin supplements for high-risk pregnant women

When teaching a group of school age children how to reduce the risk for Lyme disease, which instruction should the camp nurse include? a. Wash hands frequently b. Avoid drinking lake water c. Do not share personal products d. Wear long sleeves and pants

d. Wear long sleeves and pants

A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is a. Difference in the intake and output b. Changes in the mucous membranes c. Skin turgor d. Weekly weight

d. Weekly weight

The healthcare provider prescribes an antibiotic cefdinir 300 mg PO Every 12 hours for a client with a postoperative wound infection. Which food should the nurse encourage this client to eat? a. Avocados and cheese b. Green leafy vegetables c. Fresh fruits d. Yogurt or buttermilk

d. Yogurt or buttermilk