Hurst Questions (CC4)

The nurse is caring for a client immediately following a bilateral salpingo-oophorectomy. Which position would be best for this client? 1. Fowler's 2. Modified Sims 3. Side-lying 4. Supine

3. Side-lying

The nurse provides instructions on the proper use of crutches to a client. Which comment by the client indicates a need for additional instructions? 1. "I move the crutches 6 to 12 inches ahead prior to moving foot forward." 2. "To descend stairs I will move crutches and my unaffected leg first, followed by the affected leg." 3. "When rising from a chair, I will place crutches on my affected side, lean forward, and push off from the chair with one hand." 4. "To climb stairs I will advance my unaffected leg past crutches, then place weight on unaffected leg, and advance affected leg and the crutches to the step."

2. "To descend stairs I will move crutches and my unaffected leg first, followed by the affected leg."

A client with a new single chamber pacemaker is receiving instructions prior to discharge. What statement by the client indicates to the nurse the need to review the instructions again? 1. "I can use a cell phone on the side opposite my pacemaker." 2. "I must check and then record my heart rate every day." 3. "It is safe for me to go through the new airport security." 4. "I need monthly pacemaker checks to assess pacer function."

3. "It is safe for me to go through the new airport security."

A client with a history of intolerance to fatty foods is admitted to the hospital with a sudden onset of severe right upper quadrant pain radiating to the right shoulder. What should be included in the nurse's initial focused assessment of this client? 1. "Do you have pain in the middle of your stomach that is relieved by vomiting?" 2. "Have you noticed any red splotches on your skin?" 3. "Please describe your bowel habits and stool." 4. "Tell me how often you eat high fat meals."

3. "Please describe your bowel habits and stool."

The nurse is assessing a client admitted yesterday with a diagnosis of closed head injury and fractured pelvis following a motorcycle accident. Today the nurse observes a small petechial rash on the client's chest. What specific indications of a serious complication should the nurse report immediately to the healthcare provider? 1. An increased blood pressure with tachycardia. 2. A widening pulse pressure with increasing pulse. 3. A petechial rash with an increase in temperature. 4. A rapid respiratory rate with dropping oxygen levels.

3. A petechial rash with an increase in temperature.

The nurse is to administer a fluid bolus to a 25 pound (11.36 kg) child. The primary healthcare provider prescribes a bolus of 20 mL/kg. What should the nurse administer? 1. 500 mL isotonic solution 2. 500 mL hypotonic solution 3. 227 mL isotonic solution 4. 227 mL hypotonic solution

c. 227 mL isotonic solution

The charge nurse at a long-term care facility is discussing restraint policies with new staff members. The nurse explains that the use of restraints are only appropriate for what reasons? Select all that apply 1. Reduce wandering throughout the night shift. 2. Prevent confused client from exiting the building. 3. Keep combative clients from injuring staff or clients. 4. Eliminate any falls when the client is sitting in a chair. 5. Decrease potential for pulling out I.V.'s or dressings.

3. Keep combative clients from injuring staff or clients. 5. Decrease potential for pulling out I.V.'s or dressings.

The nurse is preparing to bathe a client who is confined to the bed. Which action by the nurse is important to preserve client's self-esteem as the task is completed? 1. Closes the door for privacy. 2. Introduces self and explains the procedure. 3. Bathes the client without the help of others. 4. Covers the client with a bath blanket.

4. Covers the client with a bath blanket

Which signs/symptoms should the nurse assess for the presence of in a client diagnosed with valvular heart disease? Select all that apply 1. Orthopnea. 2. Paroxysmal nocturnal dyspnea. 3. Petechiae on the trunk. 4. Increasing CVP with decreasing BP. 5. Pericardial friction rub. 6. Widening pulse pressure.

1. Orthopnea. 2. Paroxysmal nocturnal dyspnea.

Which assigned postpartum client should the nurse identify as being at highest risk for hemorrhage? 1. C-section delivery 2. Vaginal delivery of twins 3. Vaginal delivery of premature baby 4. Precipitous delivery of gravida 5

1. C-section delivery

which client would appropriate for the RN to assign to the LPN? 1. Client requiring enemas and antibiotics 2. Newly admitted client with diagnosis of diabetic ketoacidosis 3. Client returning from surgery post right upper lobectomy 4. Client with frequent reports of nausea and vomiting following chemotherapy 5. Client requiring frequent sterile dressing changes

1. Client requiring enemas and antibiotics 4. Client with frequent reports of nausea and vomiting following chemotherapy 5. Client requiring frequent sterile dressing changes

The nurse educates a client that the prescribed medication indomethacin is used to manage which symptoms? Select all that apply 1. Pain 2. Inflammation 3. Fever 4. Cough 5. Urticaria

1. Pain 2. Inflammation 3. Fever

The nurse is caring for a client diagnosed with dementia. Which task can the nurse assign to the unlicensed assistive personnel (UAP)? Select all that apply 1. Assist the client with toileting. 2. Inform family that the client needs a Computed Tomography (CT) scan. 3. Accompany the client while walking in the hall. 4. Reorient the client frequently. 5. Apply restraint belt for client safety.

1. Assist the client with toileting. 3. Accompany the client while walking in the hall. 4. Reorient the client frequently.

A client who is ventilator dependent is scheduled to be discharged home. What is the most critical assessment for the nurse case manager to make? 1. Financial stability for home health care. 2. Long-term home care needs. 3. Safe home environment. 4. Home medical equipment needed.

3. Safe home environment

A client has been started on intravenous gentamicin for osteomyelitis. The nurse informs the client frequent blood work will be done to monitor the amount of medication in the body. The nurse knows what labs are a priority to check every three days for the client? 1. BUN and creatinine. 2. Liver function studies. 3. Hemoglobin and hematocrit. 4. Peak and trough levels.

4. Peak and trough levels

A pregnant client has been receiving daily heparin injections for a history of deep vein thrombosis (DVTs) during pregnancy. Which laboratory test result should be immediately reported to the primary healthcare provider? 1. PT of 13 seconds 2. PTT of 22 seconds 3. INR of 1.0 4. Hemoglobin of 11 g/dL (6.8266 mmol/L)

2. PTT of 22 seconds

A client with a rare disorder has been admitted to a teaching hospital. The primary healthcare provider includes this client in medical students' morning rounds without notifying the client. When the angry client reports this to the charge nurse, what response by the nurse would be most appropriate? 1. "Consent is implied because this is a teaching hospital." 2. "These students will provide excellent care for you." 3. "I will call your primary healthcare provider to report how upset you are." 4. "You can refuse to be part of the students' study."

4. "You can refuse to be part of the students' study."

What term should the nurse use to document that a woman is pregnant for the first time? 1. Primigravida 2. Multigravida 3. Primipara 4. Multipara

1. Primigravida

The nurse is caring for a client on the psychiatric unit. The client is prescribed fluphenazine 10 mg. The drug is available as an elixir: 2.5 mg / 5 mL. How many mL will the nurse give to the client? ______mL. Round answer to the nearest whole number.

20

The nurse is talking to the parents of a 4 year old who is suspected to have iron deficiency anemia. What statement by the parents would suggest the cause of this anemia to the nurse? 1. "Breakfast consists of iron fortified cereal most days." 2. "A typical lunch would be a chicken sandwich with orange slices." 3. "Our child drinks 30 ounces (887 mL) of milk a day." 4. "It is difficult to get our child to eat broccoli."

3. "Our child drinks 30 ounces (887 mL) of milk a day."

Which assessment finding by the nurse is likely to indicate an increased level of stress in a client? 1. Weight at normal level. 2. Daily experience of headaches and other body aches. 3. Use of the problem solving method to handle daily annoyances. 4. Reports of increased creativity in the job situation.

2. Daily experience of headaches and other body aches.

Which nursing action takes priority once a term infant has delivered vaginally? 1. Apply identification bands 2. Apply eye ointment 3. Dry the baby 4. Obtain footprints

3. Dry the baby

A farm worker comes into the clinic reporting headache, dizziness, and muscle twitching after working in the fields. What condition does the nurse suspect? 1. Pesticide exposure 2. Heat stroke 3. Anthrax poisoning 4. Gastroenteritis

1. Pesticide exposure

Which signs/symptoms should the nurse monitor for in a client admitted with a diagnosis of pheochromocytoma? Select all that apply 1. Headache 2. Hypotension 3. Hyperglycemia 4. Bradycardia 5. Polycythemia 6. Leukopenia

1. Headache 3. Hyperglycemia

Which statement made by a 67 year old client who recently retired indicates to the nurse that client has developed ego integrity? 1. "I want to make my mark on the world." 2. "I am satisfied with my life so far." 3. "I wish I could go back and fix the mistakes I have made." 4. "Life is too short. I have more living to do."

2. "I am satisfied with my life so far."

The son of a client diagnosed with Alzheimer's Disease who is listed as a person who has access to the client's health information asks the nurse why his father has been prescribed donepezil. What response should the nurse make? 1. "Depression is often treated with this medication." 2. "This medication is used to treat confusion." 3. "Behavioral problems are diminished when the client receives this medication." 4. "This medication will address sleep disturbances."

2. "This medication is used to treat confusion."

What characteristics would indicate to the obstetrical nurse that a client is experiencing false labor? Select all that apply 1. Cervical dilation noted. 2. Contractions decrease with sleep. 3. Bloody show noted. 4. Contraction intensity increases with walking. 5. Contractions felt in abdomen above umbilicus.

2. Contractions decrease with sleep. 5. Contractions felt in abdomen above umbilicus.

Which menu selection by the client diagnosed with cholelithiasis indicates to the nurse that teaching of proper diet was understood? 1. Fried chicken, rice and gravy, broccoli and cheese, custard pie 2. Grilled pork chops in peach sauce, baked sweet potato, sherbet 3. Oven roasted bbq ribs, baked beans, tomato slices, ice cream 4. Pasta topped with boiled shrimp and butter sauce, salad, bread pudding

2. Grilled pork chops in peach sauce, baked sweet potato, sherbet

What room assignment would be best for the nurse to make for a primigravida with gestational diabetes who was admitted for glycemic control? 1. A private room near the nurses' station. 2. A room with a client admitted with a placenta previa. 3. A room with a client in preterm labor. 4. A room with a client admitted with pregestational diabetes.

4. A room with a client admitted with pregestational diabetes.

What discharge instructions should the nurse provide to the parents of a child diagnosed with sickle cell anemia? Select all that apply 1. Provide high-calorie, low protein diet. 2. Inheritance is by autosomal dominate genes. 3. Restrict all activities for 3 months. 4. Deferasirox helps prevent liver damage from iron deposits. 5. Avoid high altitudes.

4. Deferasirox helps prevent liver damage from iron deposits. 5. Avoid high altitudes.

What medications should the nurse anticipate the primary healthcare provider prescribing for the client with portal hypertension and bleeding esophageal varices associated with advanced cirrhosis? Select all that apply 1. Oxygen 2. Clopidogrel 3. Propranolol 4. Vitamin K 5. Lactulose

1. Oxygen 3. Propranolol 4. Vitamin K 5. Lactulose

A client newly diagnosed with Celiac disease is being instructed on a gluten-free diet. What statement by the client would indicate to the nurse that further teaching is needed? 1. "I will still have occasional abdominal discomfort." 2. "I may need to take iron or vitamin supplements." 3. "I can have eggs but no wheat toast for breakfast." 4. "I should avoid fresh apples and strawberries."

4. "I should avoid fresh apples and strawberries."

The nurse is caring for a primipara client at 27 weeks gestation. Which client learning need should the nurse identify as priority at this stage of pregnancy? 1. Appropriate nutrition 2. Signs of preterm labor 3. Fetal teratogens 4. Newborn care

2. Signs of preterm labor

A client presenting at the clinic has a history of systemic lupus erythematosus (SLE). Which finding would indicate to the nurse that the client is having a flare-up of the disease? Select all that apply 1. Abdominal discomfort 2. Alopecia 3. Butterfly rash on face 4. Fever 5. Weight gain

1. Abdominal discomfort 3. Butterfly rash on face 4. Fever

The nurse is caring for a client that is receiving blood that was started 2 hours ago. The nurse observes that the client has flushed cheeks. What should the nurse do first? 1. Inform the primary healthcare provider. 2. Stop the blood infusion. 3. Obtain a blood sample from the client. 4. Take vital signs.

2. Stop the blood infusion.

What develpomental milestone does the nurse expect to see in a 4 year old child? Select all that apply 1. Can say first and last name. 2. Draws a person with 2 to 4 body parts. 3. Copies a triangle. 4. Can tell what is real and what is make believe. 5. Sings a song from memory. 6. Talks about likes and interests.

1. Can say first and last name. 2. Draws a person with 2 to 4 body parts. 5. Sings a song from memory. 6. Talks about likes and interests.

What signs/symptoms would the nurse expect to assess in a client diagnosed with exocrine pancreatic cancer? Select all that apply 1. Dark tea colored urine 2. Clay colored stools 3. Jaundice 4. Coffee ground emesis 5. Lower abdominal pain

1. Dark tea colored urine 2. Clay colored stools 3. Jaundice

The nurse is reviewing the immunization record of a 3 month old. Which immunization does the nurse expect the child to have received by this age? 1. First Hepatitis B vaccination. 2. Second diphtheria vaccination. 3. Third Hib vaccination. 4. Influenza vaccination.

1. First Hepatitis B vaccination.

What physical changes should the nurse discuss with a client who is entering menopause 1. Loss of bone density 2. Loss of muscle mass 3. Improved skin elasticity 4. A reduction in waist size 5. Increase in fat tissue

1. Loss of bone density 2. Loss in muscle mass 5. Increase in fat tissue

The nurse is teaching a group of high school students about car accident prevention. Who would the nurse include as the highest risk for a motor vehicle crash (MVC)? 1. Males who have just turned 19 years of age. 2. Drivers who have recently acquired a driver's license. 3. A group of students that carpool to the senior prom. 4. Female students who drive to weekly football games.

2. Drivers who have recently acquired a driver's license.

The nurse is cleaning and dressing a foot ulcer of a diabetic client. Which actions are appropriate? Select all that apply 1. Uses a clean basin and washcloth to clean the ulcer. 2. Wears sterile gloves to clean the ulcer. 3. Cleans ulcer with normal saline. 4. Warms saline bottle in microwave for 1 minute. 5. Cleans ulcer in a full circle, beginning in the center and working toward the outside.

2. Wears sterile gloves to clean the ulcer. 3. Cleans ulcer with normal saline. 5. Cleans ulcer in a full circle, beginning in the center and working toward the outside.

Which task would be appropriate for the nurse to assign to an unlicensed assistive personnel (UAP)? Select all that apply 1. Clean client's halo fixation insertion sites with hydrogen peroxide. 2. Insert acetaminophen suppository in client's rectum. 3. Reapply pneumatic compression device to client's legs. 4. Check client's gag reflex prior to feeding. 5. Set up suction equipment in client room. 6. Reposition client every 2 hours.

3. Reapply pneumatic compression device to client's legs. 5. Set up suction equipment in client room. 6. Reposition client every 2 hours.

The nurse is reinforcing the dietary discharge instruction for a client prescribed warfarin. Which food choices should be avoided on the warfarin dietary instruction plan? Select all that apply 1. Corn 2. Carrot 3. Spinach 4. Broccoli 5. Watermelon

3. Spinach 4. Broccoli

The nurse working in a pediatrician's office is teaching a couple with small children about proper medication administration for children. What statement by the couple would indicate that further teaching is needed? 1. We should carefully measure elixir medication with the provided dropper. 2. Our children should not watch us take medicine. 3. We tell our children the medicine is candy so they will take it without a fuss. 4. Even though medicine comes in a childproof container, we will put medication out of reach.

3. We tell our children the medicine is candy so they will take it without a fuss.

Which assessment finding identified in a client diagnosed with Guillain-Barre Syndrome would indicate that the nurse needs to notify the primary healthcare provider? 1. Vital lung capacity of 900 mL. 2. Breathlessness while talking. 3. Heart rate of 98 beats per minute. 4. Respiratory rate of 24 breaths per minute.

2. Breathlessness while talking.

The nurse is caring for a client diagnosed with heat exhaustion. Which finding by the nurse suggests a problem? 1. Temperature 101 degrees F (38.3 degrees C) 2. Hot, dry skin 3. Profuse sweating 4. Headache

2. Hot, dry skin

The nurse should assess for what signs of toxicity in a child who is admitted with salicylate overdose? Select all that apply 1. Hypoventilation 2. Vomiting 3. Tinnitus 4. Diaphoresis 5. Dehydration 6. Hypothermia

2. Vomiting 3. Tinnitus 4. Diaphoresis 5. Dehydration

The nurse in the emergency department is caring for a client admitted in diabetic ketoacidosis (DKA). Which central venous pressure (CVP) reading would the nurse anticipate? 1. 1 mm of Hg 2. 3 mm of Hg 3. 6 mm of Hg 4. 12 mm of Hg

1. 1 mm of Hg

A client has been prescribed sodium polystyrene sulfonate 30 grams rectally every 6h times 2. Which laboratory value would indicate that the prescribed sodium polystyrene sulfonate has been effective? 1. Potassium 4.8 mEq/L (4.8 mmol/L) 2. Sodium 148 mEq/L (148 mmol/L) 3. Calcium 8.9 mg/dL (2.2207 mmol/L) 4. Magnesium 1.2 mEq (0.6 mmol/L)

1. Potassium 4.8 mEq/L (4.8 mmol/L)

A client is admitted to the surgical unit with cholelithiasis and a history of psychosis and a known allergy to phenothiazines. Which prescription should the nurse discuss with the primary healthcare provider? Orders - Clear liquid diet - Gallbladder ultrasound - IV of LR with KCL 20 mEq at 125 ml/hr - Thioridazine 50 mg PO TID​ - Ciprofloxicin 200 mg IVPB q 12 hours - Haloperidol 5 mg PO BID - Ondansetron 4 mg IM PRN for N/V Allergies - Phenothiazines​ - Penicillin 1. Thioridazine 50 mg PO tid 2. Ciprofloxicin 200 mg IVPB every 12 hours 3. Haloperidol 5 mg PO bid 4. Ondansetron 4 mg IM prn nausea or vomiting

1. Thioridazine 50 mg PO tid

The nurse is caring for a client taking a selective serotonin reuptake inhibitor (SSRI). The client tells the nurse "I am sweating more than ever!" What is the nurses best response? 1. This is a common side effect of antidepressant medications. Perhaps a different antidepressant would cause less side effects. 2. Excessive sweating can have many causes. 3. I think that you should report this side effect to your primary healthcare provider. 4. This symptom should go away within a few days.

1. This is a common side effect of antidepressant medications.

Which health promotion instructions should the nurse provide to a client diagnosed with cirrhosis? Select all that apply 1. Use a shower chair when performing hygiene. 2. Limit alcohol intake. 3. Stop any activity that causes dizziness. 4. Calculate daily sodium intake. 5. Proper hand hygiene.

1. Use a shower chair when performing hygiene. 3. Stop any activity that causes dizziness. 4. Calculate daily sodium intake. 5. Proper hand hygiene.

An elderly client is being discharged home on warfarin following treatment for a deep vein thrombosis. While reviewing discharge instructions, the client asks the nurse if the newly ordered medication will interfere with herbal supplements taken at home. After reviewing all meds taken at home, the nurse knows the client will need to discontinue which supplements? Select all that apply 1. saw palmetto 2. St. John's wort 3. garlic tablets 4. echinacea 5. ginkgo biloba

1. saw palmetto 2. St. John's wort 3. garlic tablets 5. ginkgo biloba

A nurse is planning to teach a group who works at a local mall about proper use of automated external defibrillators (AED). Which points should the nurse emphasize? Select all that apply 1. The standard AED can be used on children over the age of 5. 2. All users of the AED must be trained in its operation. 3. CPR should be taught to users. 4. Primary healthcare provider oversight is needed to ensure proper maintenance. 5. The local EMS should be notified of the type and location of AEDs.

2. All users of the AED must be trained in its operation. 3. CPR should be taught to users. 4. Primary healthcare provider oversight is needed to ensure proper maintenance. 5. The local EMS should be notified of the type and location of AEDs.

An elderly client is admitted to the outpatient unit with anemia and is receiving a blood transfusion. What is the nurse's priority assessment? 1. Monitor for peripheral edema. 2. Assess breath sounds. 3. Keep bedrails up at all times. 4. Monitor hemoglobin every 6 hours.

2. Assess breath sounds

The nurse is assisting a client with right sided weakness to transfer from the hospital bed to a wheelchair. The client has an IV attached to an IV pole on the right side of the bed. How should the nurse complete this transfer? 1. Place the wheelchair on the left side of the bed 2. Place the wheelchair on the right side of the bed 3. Face the wheelchair toward the foot of the bed 4. Face the wheelchair toward the head of the bed 5. Have the client grab the wheelchair with the right arm 6. Have the client grab the wheelchair with the left arm

2. Place the wheelchair on the right side of the bed 4. Face the wheelchair toward the head of the bed 6. Have the client grab the wheelchair with the left arm

The nurse is caring for a client diagnosed with major depression post electroconvulsive therapy (ECT). What nursing interventions should be included in this immediate post-treatment period? Select all that apply 1. Monitor vital signs every hour for eight hours. 2. Position the client on their side. 3. Stay with the client until fully awake. 4. Provide flexibility in scheduling routine activities. 5. Encourage the client to ambulate in room and hall.

2. Position the client on their side. 3. Stay with the client until fully awake.

What would the nurse expect to see when performing a neurological assessment on a 1 day old neonate suspected of having asphyxia in utero? 1. Grasps nurse's finger when placed in neonate's hand. 2. Toes curl downward when soles of feet stroked. 3. Turn's toward nurse's finger when cheek is touched. 4. Extends arms when nurse claps hands.

2. Toes curl downward when soles of feet stroked.

Following nasal surgery, the nurse suspects a client has developed diabetes insipidus. The nurse knows what laboratory results provide evidence of diabetes insipidus? Select all that apply 1. White blood cells of 9,500 mm3 (9.5 x 10^9/L) 2. Urine specific gravity of 1.004 3. Serum sodium level of 149 mEq/L (149 mmol/L) 4. Hemoglobin of 20 g/dL (200 g/L) 5. Glucose of 100 mg/dL (5.6 mmol/L)

2. Urine specific gravity of 1.004 3. Serum sodium level of 149 mEq/L (149 mmol/L) 4. Hemoglobin of 20 g/dL (200 g/L)

A client reports difficulty sleeping since starting a new job. The nurse's assessment identifies that the client is also working after hours from home. Which teachings are appropriate to promote sleep in this client? Select all that apply 1. Vary bed times to determine time best to promote sleep. 2. Use the bedroom for only sleep. 3. Schedule meal times earlier in the evening. 4. Avoid caffeine in the evening. 5. Use a white noise machine to help lull to sleep.

2. Use the bedroom for only sleep. 3. Schedule meal times earlier in the evening. 4. Avoid caffeine in the evening. 5. Use a white noise machine to help lull to sleep.

What should the nurse tell a 68 year old client who states that they have started experiencing tremors? 1. "This is nothing to worry about and is common with aging." 2. "You should increase your intake of potassium." 3. "We need to let your primary health care provider know because it may indicate a problem." 4. "Have someone check your blood pressure the next time you experience tremors."

3. "We need to let your primary health care provider know because it may indicate a problem."

The nurse is admitting an adolescent reporting severe depression and amenorrhea. What additional assessment findings by the nurse would suggest the client may develop anorexia nervosa? Select all that apply 1. Tight fitting clothes 2. Oily, elastic skin 3. Brittle, dry nails 4. Gingival infections 5. Low blood pressure

3. Brittle, dry nails 5. Low blood pressure

One hour after administering pyridostigmine, the nurse notes increased salivation, lacrimation, and urination in the client. What initial action should the nurse take? 1. Administer a second dose of pyridostigmine. 2. Place client in side lying position. 3. Notify the primary healthcare provider. 4. Prepare for intubation and mechanical ventilation.

3. Notify the primary healthcare provider.

A full-term client is admitted in labor, 5 centimeters dilated and having contractions 3 minutes apart which last 60 seconds. The current blood pressure is 85/50. What is the nurse's priority action? 1. Turn IV fluids to wide open. 2. Apply oxygen at 2L by nasal cannula. 3. Position the client onto the left side. 4. Recheck blood pressure in opposite arm.

3. Position the client onto the left side.

A client is to be discharged following cataract removal with lens implantation. What statement by the client indicates to the nurse that teaching has been successful? 1. "I must keep both eyes covered till my check-up." 2. "I should only have pain for about two days." 3. "I will no longer have to wear reading glasses." 4. "My vision will be blurry for a couple weeks."

4. "My vision will be blurry for a couple weeks."

The charge nurse is orienting a new nurse to the pediatric unit. Which teaching related to assessment is appropriate? 1. One assessment should be done daily on each client by the charge nurse. 2. An assessment should be done daily on each client at the beginning of the shift. 3. Assessments of clients should be updated as the nurse provides care to clients. 4. Assessments of clients should be done at the beginning of the shift and updated as nursing care is provided.

4. Assessments of clients should be done at the beginning of the shift and updated as nursing care is provided.

Labetalol has been prescribed for a client in the emergency room. Prior to administering this medication, what assessment should the nurse perform? 1. Listen to the client's breath sounds. 2. Check the client's temperature. 3. Monitor for peripheral edema. 4. Auscultate the apical pulse rate.

4. Auscultate the apical pulse rate.

A community health nurse is assessing a migrant farmer who raises chickens. The nurse notes the client has developed a cough, fever, dyspnea, and hemoptysis. What infection should the nurse suspect? 1. Lyme disease 2. Toxoplasmosis 3. Tuberculosis 4. Histoplasmosis

4. Histoplasmosis

A nine year old child with attention deficit hyperactivity disorder (ADHD) is being admitted to the pediatric unit. Who should the charge nurse assign this client to room with? 1. Ten year old with Crohn's disease. 2. Eight year old with a history of seizures. 3. Six year old admitted with asthma. 4. Seven year old with a urinary tract infection.

4. Seven year old with a urinary tract infection.

Which prevention strategy should the nurse consider when developing a health promotion plan for new parents concerning sudden infant death syndrome (SIDS)? 1. Place the infant in the prone position when placing the infant in the bed. 2. The child should sleep in a separate room from the parents. 3. The child should not have a pacifier in place when sleeping. 4. The child should be placed in the supine position when sleeping.

4. The child should be placed in the supine position when sleeping.

What signs/symptoms would the nurse expect to assess in a client diagnosed with tabes dorsalis neurosyphilis due to untreated syphilis? Select all that apply 1. Abnormal gait 2. Blindness 3. Hyperreflexia 4. Stiff neck 5. Hearing loss

1. Abnormal gait 2. Blindness

A nurse is performing eye care for an unconscious client. Which interventions should the nurse include? Select all that apply 1. Administer moist compresses to cover eyes every 2 hours. 2. Clean eyes with saline and cotton balls, wiping from outer to inner canthus. 3. Use a new cotton ball for each cleansing wipe. 4. Instill artificial tears into the lower eye lids as prescribed. 5. Protect the eyes with a protective shield. 6. Monitor eyes for redness and exudate.

1. Administer moist compresses to cover eyes every 2 hours. 3. Use a new cotton ball for each cleansing wipe. 4. Instill artificial tears into the lower eye lids as prescribed. 5. Protect the eyes with a protective shield. 6. Monitor eyes for redness and exudate.

When assessing for the development of an infection following the application of a plaster cast to the leg, the nurse should teach the client to observe for the presence of which sign of infection? 1. Hot spots 2. Cold toes 3. Warm toes 4. Paresthesia

1. Hot spots

Which cranial nerves should the nurse assess in a client diagnosed with Guillain-Barre' Syndrome? Select all that apply 1. Vagus 2. Olfactory 3. Vestibulocochlear 4. Facial 5. Trigeminal 6. Oculomotor

1. Vagus 4. Facial 5. Trigeminal 6. Oculomotor

What discharge education should a nurse provide to a client post hip replacement with a metal joint? Select all that apply 1. Weight bearing limits. 2. Use of a high seated chair. 3. Sexual intercourse in dependent position for up to six months. 4. Avoid taking showers. 5. Use of long handled tongs to assist with dressing.

1. Weight bearing limits. 2. Use of a high seated chair. 3. Sexual intercourse in dependent position for up to six months. 5. Use of long handled tongs to assist with dressing.

A client arrives at the emergency room with active gastrointestinal bleeding. What is the most important nursing action? 1. Treat the cause of the bleeding. 2. Record the amount of blood loss. 3. Initiate an intravenous access line. 4. Prepare client for stat endoscopy.

3. Initiate an intravenous access line.

The nurse is caring for a client diagnosed with schizophrenia who is admitted to the hospital for possible bowel obstruction. The client has a nasogastric tube (NG) and reports pain 8/10. What is the priority nursing action? 1. Decrease the stimuli and observe frequently. 2. Administer the prn sedative. 3. Call the primary healthcare provider immediately. 4. Administer the prn pain medication.

4. Administer the prn pain medication.

The nurse is performing peritoneal dialysis on a client diagnosed with renal injury. In what order should the nurse perform this procedure? a. Turn client from side to side. b. Infuse dialysate through peritoneal catheter. c. Provide 30 minute dwell time. d. Drain fluid for 30 minutes. e. Warm dialysate.

e. Warm dialysate. b. Infuse dialysate through peritoneal catheter. c. Provide 30 minute dwell time. d. Drain fluid for 30 minutes. a. Turn client from side to side.

A client with diabetes mellitus has a newly prescribed insulin pump. Which statements made by the client indicate understanding of an insulin pump? Select all that apply 1. "I will attach the pump to my waistband or wear it in the pocket of my pants." 2. "I can eat whatever I want as long as I cover the calories with sufficient insulin." 3. "I may take my insulin pump off when I exercise." 4. "I need to check my blood glucose level several times a day." 5. "I have to change the catheter at the end of the pump every week."

1. "I will attach the pump to my waistband or wear it in the pocket of my pants." 3. "I may take my insulin pump off when I exercise." 4. "I need to check my blood glucose level several times a day."

A nurse is teaching a client who has frequent urinary tract infections how to prevent future infections. What statement by the client would indicate to the nurse that treatment has been successful? Select all that apply 1. "I will go to the bathroom as soon as the urge to void hits me." 2. "It is important for me to drink five to six 8 ounce glasses of water every day." 3. "I should eat foods such as plums and prunes to increase the acidity of my urine." 4. "Nylon underwear should be worn when I am free from infection." 5. "When I clean after voiding, I will discard toilet paper after each swipe."

1. "I will go to the bathroom as soon as the urge to void hits me." 3. "I should eat foods such as plums and prunes to increase the acidity of my urine." 5. "When I clean after voiding, I will discard toilet paper after each swipe."

Which statements by an older adult indicate that teaching about adequate nutrition and hydration have been effective? Select all that apply 1. "Taking a multivitamin every day will help me get enough calcium and vitamin C." 2. "Enrolling in Meals on Wheels will provide me with a nutritious meal every day." 3. "I am less likely to become constipated if I increase my fiber intake to 20 grams a day." 4. "Drinking 1 liter of water a day will keep me hydrated." 5. "I will strive to eat at least 5 servings of fruits and vegetables a day."

1. "Taking a multivitamin every day will help me get enough calcium and vitamin C." 2. "Enrolling in Meals on Wheels will provide me with a nutritious meal every day." 5. "I will strive to eat at least 5 servings of fruits and vegetables a day."

A client diagnosed with terminal cancer wants information about an Advanced Directive for end-of-life care. What information should the nurse include? Select all that apply 1. An Advance Directive includes a Living Will and a Medical Power of Attorney. 2. A person can be designated to make medical decision in the event the client cannot. 3. The spouse can rescind the Advance Directive if the client becomes unresponsive. 4. Anyone over age 18 can have an Advanced directive. 5. The client can indicate desire for Do Not Resuscitate (DNR).

1. An Advance Directive includes a Living Will and a Medical Power of Attorney. 2. A person can be designated to make medical decision in the event the client cannot. 4. Anyone over age 18 can have an Advanced directive. 5. The client can indicate desire for Do Not Resuscitate (DNR).

A child has been diagnosed with varicella in the clinic. What should the nurse tell the parents about home treatment of the child? Select all that apply 1. Apply calamine lotion to affected areas several times a day. 2. Provide cool baths with baking soda. 3. Administer aspirin for fever. 4. Do not allow visitors who have never had varicella. 5. Keep fingernails trimmed short.

1. Apply calamine lotion to affected areas several times a day. 2. Provide cool baths with baking soda. 4. Do not allow visitors who have never had varicella. 5. Keep fingernails trimmed short.

Which food items, if chosen by a client diagnosed with diverticulosis, would indicate to the nurse that the client understands the prescribed diet? Select all that apply 1. Avocados 2. Acorn squash 3. Applesauce 4. Lima beans 5. Raspberries 6. Cottage cheese

1. Avocados 2. Acorn squash 4. Lima beans 5. Raspberries High fiber foods include raw fruits, legumes, vegetables, whole bread, and cereals.

What assessment data would a nurse expect to find in a client diagnosed with acute inflammatory bowel disease? Select all that apply 1. Bloody stools that contain mucus 2. Pallor 3. Anorectal excoriation 4. Urine output below 30 mL/hr 5. Increased serum prealbumin

1. Bloody stools that contain mucus 2. Pallor 3. Anorectal excoriation 4. Urine output below 30 mL/hr

What should the nurse include in the teaching plan for a client who has iron deficiency anemia? Select all that apply 1. Consume iron rich foods such as dried lentils, peas, and beans. 2. Notify primary healthcare provider of glossitis, anorexia, and paresthesia. 3. Iron is needed for white blood cell development. 4. Educate about ferrous sulfate supplement. 5. After drinking liquid iron, follow immediately by water.

1. Consume iron rich foods such as dried lentils, peas, and beans. 2. Notify primary healthcare provider of glossitis, anorexia, and paresthesia. 4. Educate about ferrous sulfate supplement.

An alert elderly client has been admitted to the hospital and placed on bedrest following a fall at home. During evening medication rounds, the nurse notes the client has become disoriented to time and place. The nurse is aware a new onset of confusion could be the result of what factors? Select all that apply 1. Admission to the hospital. 2. Amount of physical pain. 3. Current bed confinement. 4. Advanced age. 5. Response to analgesic.

1. Admission to the hospital. 2. Amount of physical pain. 3. Current bed confinement. 5. Response to analgesic.

The nurse is discussing frostbite prevention with a group of teenagers who participate in cold weather activities. What risk factors for developing frostbite will the nurse include? Select all that apply 1. Alcohol use 2. Dehydration 3. Diabetes 4. Exhaustion 5. Low level altitude

1. Alcohol use 2. Dehydration 3. Diabetes 4. Exhaustion

What assessment data would a nurse expect to find in a client diagnosed with a severe episode of acute inflammatory bowel disease? Select all that apply 1. Dark yellow urine 2. Fever 3. Frequent, hard stools 4. Lower abdominal cramping 5. Tachycardia

1. Dark yellow urine 2. Fever 4. Lower abdominal cramping 5. Tachycardia

The nurse is discussing obesity prevention with a group of parents who have 3 and 4 year old children. What should the nurse include? Select all that apply 1. Ensure at least 11 hour of sleep. 2. Do not put a TV in the child's bedroom. 3. Select a day care center that provides physical activity opportunities every 4 hours. 4. Limit 100% fruit juice to 6 ounces (180 mL) per day. 5. Walk after the evening meal while the child rides a bike or skates.

1. Ensure at least 11 hour of sleep. 2. Do not put a TV in the child's bedroom. 4. Limit 100% fruit juice to 6 ounces (180 mL) per day. 5. Walk after the evening meal while the child rides a bike or skates.

What is the first nursing action that should be taken in caring for a client with suspected tuberculosis? 1. Identify the client's symptoms promptly. 2. Instruct the client to cover the mouth and nose with tissues when sneezing. 3. Isolate the client in a negative pressure room. 4. Place a surgical mask on the client.

1. Identify the client's symptoms promptly.

What signs/symptoms would the nurse expect to assess in a client diagnosed with multiple sclerosis (MS)? Select all that apply 1. Fatigue 2. Ptosis 3. Blurry vision 4. Leg weakness 5. Limited facial expression 6. Electric shock sensation when bending neck forward

1. Fatigue 3. Blurry vision 4. Leg weakness 5. Limited facial expression 6. Electric shock sensation when bending neck forward

Which of the following should the nurse teach regarding nutrition for a client with celiac disease? Select all that apply 1. Gluten is a protein found in wheat and oats. 2. A gluten intolerant person can eat foods that are made with barley or rye. 3. Fruits can be eaten on a gluten free diet. 4. Gluten causes inflammation of the large intestines of people with celiac disease. 5. Accidentally eating a product containing gluten may result in abdominal pain and diarrhea.

1. Gluten is a protein found in wheat and oats. 3. Fruits can be eaten on a gluten free diet. 5. Accidentally eating a product containing gluten may result in abdominal pain and diarrhea.

A client's central venous pressure (CVP) reading has changed significantly from the last hourly reading. Which data would the nurse assess that reflect changes in the CVP reading? Select all that apply 1. Heart sounds 2. Skin turgor 3. Temperature 4. Nail bed color 5. EKG rhythm 6. Urinary output

1. Heart sounds 2. Skin turgor 6. Urinary output

What lab values should the nurse monitor when caring for a client diagnosed with acute leukemia? Select all that apply 1. Hemoglobin 2. Hematocrit 3. Lactate dehydrogenase (LDH) 4. Platelets 5. White blood cells 6. Metanephrine

1. Hemoglobin 2. Hematocrit 4. Platelets 5. White blood cells

A client is admitted to the unit from the ED department. What acid base imbalance do the lab values indicate to the nurse? ABG's: -pH 7.48 -PaCO2 38 -HCO3 30 1. Metabolic alkalosis 2. Compensated metabolic alkalosis 3. Respiratory alkalosis 4. Compensated respiratory alkalosis

1. Metabolic alkalosis

What nursing interventions should the nurse include when planning care for a client admitted with Guillain-Barre' Syndrome? Select all that apply 1. Monitor for contractures. 2. Place prone for 30 minutes, 4 times per day. 3. Provide therapeutic massage for pain relief. 4. Teach range of motion exercises. 5. Provide high protein meals 3 times a day. 6. Refer to physical therapist.

1. Monitor for contractures. 3. Provide therapeutic massage for pain relief. 4. Teach range of motion exercises. 6. Refer to physical therapist.

What is the priority nursing action for a client that was admitted with tingling of the toes and feet after having the flu for several days when the client begins to have numbness in the legs and hips? 1. Notify the primary healthcare provider 2. Monitor for paresthesia in the fingers and hands 3. Insert an indwelling urinary catheter 4. Assist the client with performing passive range of motion

1. Notify the primary healthcare provider

A client has been admitted to the unit with acute pyelonephritis. What interventions should the nurse include in this client's plan of care? Select all that apply 1. Observe for changes in mental status. 2. Assist client to restroom. 3. Monitor temperature every 4 hours. 4. Help the client get in a comfortable position to void. 5. Instruct client to void every 30 minutes while ill.

1. Observe for changes in mental status. 2. Assist client to restroom. 3. Monitor temperature every 4 hours. 4. Help the client get in a comfortable position to void.

A nurse is planning care for a laboring client who is about to be started on oxytocin. What interventions should the nurse include in this plan of care? Select all that apply 1. Piggy back oxytocin into main IV fluid. 2. Monitor for early decelerations. 3. Discontinue if contractions last longer than 90 seconds. 4. Maintain one on one care. 5. Check fetal heart tones hourly.

1. Piggy back oxytocin into main IV fluid. 3. Discontinue if contractions last longer than 90 seconds. 4. Maintain one on one care.

A client is admitted to the pediatric unit with a diagnosis to rule out tuberculosis (TB). What room assignment should the charge nurse make? 1. Private room. 2. Private room and place on protective isolation. 3. Room with a client diagnosed with a respiratory infection. 4. Room with a client who is 24 hours post appendectomy.

1. Private room

The client has been prepared for surgery. As the nurse is discussing the post-op expectations, the client says to the nurse, "I am not sure what other options are available to me." What should the nurse do? 1. Request the surgeon visit the client again before surgery. 2. Check client records to see if the client signed the consent form. 3. Explain that the surgery is scheduled for 30 minutes from now. 4. Tell the client that the surgeon explained those options yesterday.

1. Request the surgeon visit the client again before surgery.

The nurse is caring for a client diagnosed with alcohol dependence who is prescribed a benzodiazepine. Which potential side effect of benzodiazepine has a higher priority for the nurse to monitor? 1. Sedation 2. Drowsiness 3. Drug dependence 4. Impaired coordination

1. Sedation

The nurse is discussing appropriate toys for preschoolers with an group of parents. what toys should the nurse include? 1. Six piece jigsaw puzzle 2. Puppets 3. Paint brush and paint set 4. Dress up clothes 5. Jump rope 6. Sewing cards

1. Six piece jigsaw puzzle 2. Puppets 3. Paint brush and paint set 4. Dress up clothes 6. Sewing cards

A client hospitalized with a deep vein thrombosis (DVT) is on a heparin infusion. The client asks the nurse why it is necessary to have blood drawn every six hours. What is the best explanation for the nurse to provide to the client? 1. "The medicine might make your blood much too thin." 2. "It helps us monitor and adjust the dose to work better." 3. "It is required for anyone getting heparin intravenously." 4. "The test results tell us whether the treatment is working."

2. "It helps us monitor and adjust the dose to work better."

A licensed practical nurse (LPN) on the Labor and Delivery unit is assisting the nurse with multiple admissions. What tasks could the LPN complete until the nurse is available? Select all that apply 1. Take initial vital signs. 2. Measure cervical dilation. 3. Check fundal height and fetal heart rate (FHR). 4. Obtain urine for protein and glucose. 5. Collect vaginal swab to test for chlamydia.

1. Take initial vital signs. 4. Obtain urine for protein and glucose. 5. Collect vaginal swab to test for chlamydia.

A nurse with less than one year of experience reports to an experienced nurse, "The charge nurses are always checking up on me and evaluating my client care. I feel as if the charge nurses do not trust me to give good care to my clients." Which response by the experienced nurse demonstrates an understanding of appropriate staff supervision? 1. The charge nurses are accountable for supervising client care and client safety after delegating the client care assignments. 2. The charge nurses do that to everyone. It can be annoying sometimes, wwhen they ask about your client care. 3. Why don't you speak to the charge nurses about your perception of not being trusted to care for your clients? This is probably not their intention. 4. You are a new nurse, and the charge nurses know that you do not have the experience and knowledge base yet to handle some of your assignments.

1. The charge nurses are accountable for supervising client care and client safety after delegating the client care assignments.

The nurse is assessing a newborn to determine gestational age. What findings by the nurse would indicate the infant is premature? Select all that apply 1. Folded ear pinna springs back slowly. 2. Peripheral cyanosis on feet and hands. 3. Shoulders and chest have moderate lanugo. 4. Vernix covering axilla, back and buttocks. 5. Feet soles entirely covered with creases.

1. Folded ear pinna springs back slowly. 3. Shoulders and chest have moderate lanugo. 4. Vernix covering axilla, back and buttocks.

The parents of a toddler tell the nurse that their child will not drink milk. What alternatives should the nurse recommend? Select all that apply 1. Frozen yogurt 2. Pudding 3. Hot cocoa in milk 4. Cheddar cheese 5. Watermelon

1. Frozen yogurt 2. Pudding 3. Hot cocoa in milk 4. Cheddar cheese

A client with type 2 diabetes, who is noncompliant, has a HbA1c of 8%. The finger stick blood sugar is 218 mg/dL (12.1 mmol/L) at 0900. The current medications prescribed are metformin and exenatide. Based on this data, what teaching should the nurse reinforce? Select all that apply 1. Nutritional counseling to help improve diet compliance 2. HbA1c measures glycemia control over a period of 1 month 3. Blood glucose testing 4. HbA1c of 8% tells us that your average glucose level is 180 mg/dL (10 mmol/L) 5. Without glycemic control, eye complications can occur

1. Nutritional counseling to help improve diet compliance 3. Blood glucose testing 4. HbA1c of 8% tells us that your average glucose level is 180 mg/dL (10 mmol/L) 5. Without glycemic control, eye complications can occur

What task can the nurse assign to an unlicensed assistive personnel (UAP) while caring for a client diagnosed with a stroke? Select all that apply 1. Check the client's gag reflex. 2. Assist with feeding the client. 3. Monitor the client's headache pain level. 4. Encourage client to expression frustrations. 5. Maintain the head of the bed at 25 - 30 degrees.

2. Assist with feeding the client. 5. Maintain the head of the bed at 25 - 30 degrees.

A client diagnosed with Addison's disease has been prescribed prednisolone. Which statement by the client indicates that the client's medication instructions for prednisolone have been effective? 1. "I should avoid foods high in protein." 2. "I will take prednisolone in the morning." 3. "I need to schedule an eye examination every 2 years." 4. "Infections will be reduced while taking prednisolone."

2. "I will take prednisolone in the morning."

The family of a client receiving treatment for substance abuse asks why they should get involved in treatment plan. Which statement by the nurse would best explain the rationale for including the family in the treatment plan? 1. "The treatment plan consists of having the family confront the client about the harm substance abuse causes." 2. "Family involvement reduces distress in family relationships to lessen the risk for relapse by the client" 3. "Involving the family helps the family learn ways to protect the client from additional harm." 4. "The family assists in ways to help reduce temptations for substances by the client."

2. "Family involvement reduces distress in family relationships to lessen the risk for relapse by the client"

The nurse is providing medication teaching to a client starting psyllium. What comment by the client indicates the teaching has been successful? 1. "I should take this medication just before bedtime." 2. "I need to drink large amounts of water with this drug." 3. "I might need to take as many as six doses every day." 4. "I should not eat or drink for two hours after the pill."

2. "I need to drink large amounts of water with this drug."

A client diagnosed with systemic lupus erythematosus (SLE) has been started on hydroxychloroquine sulfate to decrease joint pain and swelling. What statement by the client indicates to the nurse the medication teaching has been effective? 1. "I will be prone to infections while on this medication." 2. "I need to see my eye doctor at least once every year." 3. "I might develop a red rash on my nose and cheeks." 4. "I can stop this medicine after my symptoms are gone."

2. "I need to see my eye doctor at least once every year."

When explaining to caregivers how to reduce the risk of falls in their elderly parent, the nurse should educate about which measure? Select all that apply 1. Allow the parent to wear shoes that are most comfortable. 2. Assure there is adequate lighting with minimal glare. 3. Use sharply contrasting colors at edges of stairs. 4. Install grab bars beside the shower, tub, and toilet. 5. Encourage the parent to have an inside pet for comfort. 6. Rearrange the furniture for the parent to prevent stagnation.

2. Assure there is adequate lighting with minimal glare. 3. Use sharply contrasting colors at edges of stairs. 4. Install grab bars beside the shower, tub, and toilet.

A client with hemophilia has been scheduled for extraction of wisdom teeth. The nurse anticipates that the client will receive what priority intervention before this procedure? 1. Prophylactic antibiotics 2. A unit of cryoprecipitate 3. Packed red blood cells 4. Fresh frozen plasma

2. A unit of cryoprecipitate

A child is being discharged home following a bone marrow transplant. When providing discharge instructions to the parents, what information is most important for the nurse to include? 1. Clean toothbrush weekly with alcohol. 2. Avoid eating raw fruits and vegetables. 3. Drink bottled water the day. 4. Apply heating pad to bruised areas of the skin.

2. Avoid eating raw fruits and vegetables.

Four clients arrive at the emergency department. Which client should the nurse triage as the highest priority for care? 1. Adult with severe upper gastric pain. 2. Child with stridor and excessive drooling. 3. Adult with an open fracture to the right radius. 4. Child with fever of 103ºF (39.44 °C) and blood streaked sputum.

2. Child with stridor and excessive drooling.

The charge nurse is planning the staff assignments for the clients on a neurological unit. Which client should be assigned to a nurse who was pulled from a medical unit to the neurological unit? 1. Client admitted 24 hours ago with a diagnosis of a stroke, who is now reporting a headache that intensifies when moving in the bed. 2. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam. 3. Client with an oral temperature of 103.2 F (39.5 C) 36 hours post intracranial surgery. 4. Client diagnosed with a hemorrhagic stroke 1 week ago, who currently has a blood pressure of 170/96.

2. Client admitted 48 hours ago with an ischemic stroke and a history of seizures, who has been prescribed clonazepam.

A client receiving chemotherapy for lung cancer reports increased fatigue. The family confirms client is sleeping most of the day and night. What priority action would the nurse take? 1. Discuss the risks of immobility with client and family. 2. Check current lab values of hematocrit and hemoglobin. 3. Suggest family seek counseling for the client's depression. 4. Request a referral from the healthcare provider for physical therapy.

2. Check current lab values of hematocrit and hemoglobin.

A psychiatric client tells the day shift nurse, "The night nurses have been stealing from all of us while we are sleeping." What is the nurse's best response? 1. "Can you prove what the nurses are stealing?" 2. "No nurse working here would steal." 3. "You must have misunderstood what you were seeing." 4. "Tell me more about what you saw."

4. "Tell me more about what you saw."

The charge nurse is observing a new LPN preparing to irrigate a client's indwelling urinary catheter. The nurse must intervene when the LPN initiates what action? 1. Gathers all sterile equipment for procedure. 2. Opens bottle of sterile distilled water to flush. 3. Allows return flow to be achieved by gravity. 4. Uses gentle pressure when flushing catheter.

2. Opens bottle of sterile distilled water to flush.

The nurse has been working on a health plan promoting increased physical activity for a sedentary client. Which client outcome would indicate that the interventions were successful? 1. Walks 10 minutes per day periodically. 2. Establishes a routine of 30 minutes of brisk walking three days per week. 3. Reports there is not enough time for exercise. 4. Reports walking daily for about two weeks out of the last three months.

2. Establishes a routine of 30 minutes of brisk walking three days per week.

A client has developed preeclampsia at 30 weeks' gestation. The nurse is instructing the client on an appropriate diet for preeclampsia. The nurse knows the teaching was successful when the client selects what menu? Select all that apply 1. Caesar salad with feta cheese 2. Grilled cheese with tomatoes 3. Chipped ham on a croissant roll 4. Hot dog with a glass of soda pop 5. Chicken sandwich on wheat toast

2. Grilled cheese with tomatoes 5. Chicken sandwich on wheat toast

A client has delivered a set of premature twins. The neonatal intensive care unit (NICU) notifies the charge nurse on the postpartum floor the death of one infant is expected within the hour. What is the priority action by the charge nurse? 1. Sit quietly with client and allow expression of feelings. 2. Instruct UAP to take mother to the NICU immediately. 3. Request hospital clergy to visit the mother right away. 4. Notify father of the baby about the current situation.

2. Instruct UAP to take mother to the NICU immediately.

A nurse wants to find out a better way to perform oral care on unresponsive clients. What is the best first action for the nurse to take in order to achieve this goal? 1. Try different methods of oral care on unresponsive clients to see what works best. 2. Discuss the issue with the leader of the "best practices" committee. 3. Read all the current literature related to oral care on unresponsive clients. 4. Ask the primary healthcare provider to suggest the best oral care procedure.

2. Discuss the issue with the leader of the "best practices" committee.

The nurse is planning discharge teaching for a client with thrombocytopenia. Which should the nurse include? Select all that apply 1. Floss between teeth daily. 2. Eat soft foods. 3. Take docusate sodium daily to prevent straining 4. Wear well fitted shoes while ambulating. 5. Apply a cool compress to site with any soft tissue trauma.

2. Eat soft foods. 3. Take docusate sodium daily to prevent straining 4. Wear well fitted shoes while ambulating. 5. Apply a cool compress to site with any soft tissue trauma.

A client is undergoing outpatient psychiatric treatment for somatization disorder. Prior to the beginning of group therapy, the client tells the nurse, "I keep having headaches that are killing me! This has never happened to me before." What is the nurse's best response to this client? 1. You need to sit down, because we need to start the group session now. 2. I will notify the group leader about your headaches, after the group session. 3. I guess we can discuss your pain now. Group therapy will have to start later. 4. Your headaches are not real, so ignore them. Go on into therapy so we can start.

2. I will notify the group leader about your headaches, after the group session.

A client is prescribed phenobarbital to control seizures. Which medication prescribed for the client would the nurse recognize interacts with phenobarbital? 1. Lovastatin 2. Loratadine 3. Lansoprazole 4. Lactulose

2. Loratadine

A client admitted to the psychiatric unit is diagnosed with depression. What is the nurse's best response? 1. I understand what you are feeling. I have been left by someone I loved before. 2. You feel upset and unhappy by the loss of your significant other? It is ok to cry. 3. Don't worry. You will feel better once we start giving you medication for depression. 4. Crying isn't going to help anything. Let's talk about your past medical history now.

2. You feel upset and unhappy by the loss of your significant other? It is ok to cry.

The nurse notices that the primary healthcare provider, who has been looking at a client's morning laboratory results, walked away from the computer work station without logging out of the system, leaving the page of client medical information visible on the computer screen. What is the most appropriate action by the nurse? 1. Log the primary healthcare provider off the facility's health information system. 2. Minimize the screen so that the client information is no longer visible, and then ask the primary healthcare provider if the computer can be logged out. 3. Do not interfere since the primary healthcare provider is responsible for this information. 4. Read the health information that the primary healthcare provider left visible on the computer screen to see if the document was completed.

2. Minimize the screen so that the client information is no longer visible, and then ask the primary healthcare provider if the computer can be logged out.

A female client arrives at the community health clinic seeking a form of contraceptive and tells the nurse that she really desires getting an intrauterine device (IUD). Following the assessment, the nurse realizes that the IUD would be contraindicated for this client. What factor would be an absolute contraindication for this client receiving an IUD? 1. History of irregular menstrual cycles 2. Ongoing pelvic infection 3. History of an ectopic pregnancy 4. Current fibrocystic breast disease

2. Ongoing pelvic infection

A client has experienced a cerebrovascular accident (CVA) which resulted in left homonymous hemianopia. Based on this fact, what measures will the nurse include in the client's initial plan of care? Select all that apply 1. Approach the client from his left side. 2. Place the client's meal on the right side of the over bed table. 3. Request a consult for an ophthalmologist. 4. Stand directly in front of the client when addressing. 5. Have client look at the left side of the body.

2. Place the client's meal on the right side of the over bed table. 5. Have client look at the left side of the body.

The nurse is caring for a client who has aphasia. What interventions should the nurse include in the plan of care to improve communication with this client? Select all that apply 1. Increase speaking volume and tone. 2. Present one thought at a time. 3. Use and encourage use of gestures. 4. Do not push communication if client is tired. 5. Give client time to generate a response. 6. Ask questions that can be answered with "Yes" or "No".

2. Present one thought at a time. 3. Use and encourage use of gestures. 4. Do not push communication if client is tired. 5. Give client time to generate a response. 6. Ask questions that can be answered with "Yes" or "No".

What signs or symptoms should the nurse assess for when monitoring a client who has a brain injury? Select all that apply 1. Increased pulse 2. Rhinorrhea 3. BP 150/60 4. Papilledema 5. Projectile vomiting

2. Rhinorrhea 3. BP 150/60 4. Papilledema 5. Projectile vomiting

After a thoracotomy, which interventions will the nurse initiate to reduce the risk of acute respiratory distress? Select all that apply 1. Allow 4 hours of rest between deep breathing and coughing exercises. 2. Splint the incision during deep breathing and coughing exercises. 3. Have the client drink a glass of water before coughing. 4. Perform percussion and vibration every 2 hours. 5. Promote incentive spirometer use several times per hour while awake.

2. Splint the incision during deep breathing and coughing exercises. 5. Promote incentive spirometer use several times per hour while awake.

The nurse manager is performing a chart audit for clients who were restrained. For which client would the side rails in the up position be considered a restraint? 1. The client who requests that the rails be placed in the up position. 2. The client who is confused and wanders about the unit. 3. The client who is ambulatory and places the side rails up without staff assistance. 4. The client who asks the family to place all the rails up before leaving.

2. The client who is confused and wanders about the unit.

Staff notifies the nurse that a client receiving tube feedings has increased liquid stool with new rectal excoriation. Following an assessment, the nurse is most concerned about what additional symptom? 1. Reports feeling increasingly tired. 2. Trousseau's sign noted when taking blood pressure. 3. Increased resistance to care activities. 4. Reports abdominal cramping.

2. Trousseau's sign noted when taking blood pressure.

A client with the diagnosis of mild anxiety asks the nurse why the primary healthcare provider switched medications from lorazepam to buspirone. What should the nurse tell the client? 1. "Lorazepam takes longer to start working than buspirone so the primary healthcare provider decided to switch medications." 2. "Buspirone can be stopped quickly if neccessary." 3. "Buspirone does not depress the central nervous system like lorazepam does, so you should not have as much sedation." 4. "You need to ask your primary healthcare provider why the medication was changed from lorazepam to buspirone."

3. "Buspirone does not depress the central nervous system like lorazepam does, so you should not have as much sedation."

Which tasks can the RN delegate to the unlicensed assistive personnel (UAP) when caring for a client who has had a stroke and is being rehabilitated? 1. Assess the clients ability to swallow 2. Develop a plan of care for hygiene needs 3. Assist the client using a walker 4. Calculating the intake and output 5. Encourage and assist the client with the use of a hairbrush on the affected side 6. Teach the family about the need to prevent pressure ulcers

3. Assist the client using a walker 4. Calculating the intake and output 5. Encourage and assist the client with the use of a hairbrush on the affected side

Which meal is most appropriate for a client during an acute manic episode? 1. Steak, salad, banana 2. Beef and vegetable stew, bread, vanilla pudding 3. Chicken leg, corn on the cob, apple 4. Fish fillets, cubed avocado, cake

3. Chicken leg, corn on the cob, apple

What instruction would the nurse give a client about a newly prescribed salmeterol inhaler? 1. "Use the inhaler immediately if wheezing and shortness of breath occur during exercise." 2. "Use the inhaler when you experience a stuffy nose due to seasonal allergies." 3. "Carry the inhaler with you at all times and take 2 puffs anytime you experience an exacerbation." 4. "This inhaler should be used routinely as prescribed even when free of symptoms."

4. "This inhaler should be used routinely as prescribed even when free of symptoms."

A client admitted to the psychiatric unit after a suicide attempt is placed on suicide precautions. Which nursing interventions would be appropriate? Select all that apply 1. Assign the client to a private room away from nurses station. 2. Make rounds to assess the client at regular intervals. 3. Secure a promise that the client will seek out staff when feeling suicidal. 4. Closely supervise the client during meals. 5. Formulate a no harm contract for the client to sign.

3. Secure a promise that the client will seek out staff when feeling suicidal. 4. Closely supervise the client during meals. 5. Formulate a no harm contract for the client to sign.

A nurse is caring for a client injured in a motor vehicle accident while driving intoxicated. After hearing that someone was critically injured because of the accident, the client mumbles, "but i only had just a few drinks". what is the most therapeutic statement the nurse could make to the client? 1. If you only had a few drinks how did you wreck? 2. What do you mean by just a few drinks? 3. Tell me what you remember about the accident. 4. You were driving when the accident happened.

3. Tell me what you remember about the accident.

A client diagnosed with a right embolic stroke is admitted to the rehabilitation unit. The client is presenting with dysphagia. Which nursing intervention would the nurse implement for a client with dysphagia? 1. Flex the neck backwards 2. Request a liquid diet for the client 3. Place food on the right side of the mouth 4. Turn the client's plate around halfway through the meal

3. Place food on the right side of the mouth

During a health fair, a client asks the nurse about the methods used to detect prostate cancer. What should the nurse tell the client about the detection process? 1. Abdominal x-rays to detect the presence of lesions and masses. 2. A serum calcium test to detect elevated levels, which may indicate bone metastasis. 3. Digital rectal exam (DRE) and prostate-specific antigen (PSA) test to evaluate the prostate. 4. A magnetic resonance image (MRI) study to detect tumors and other abnormal growths.

3. Digital rectal exam (DRE) and prostate-specific antigen (PSA) test to evaluate the prostate.

Two nurses are checking a unit of packed red blood cells (PRBCs) for client compatibility prior to infusion. What action should the primary nurse take after completing this process? 1. Initiate the PRBCs transfusion at 25 mL/hour for the first 15 minutes. 2. Ask blood bank personnel to type and cross match for PRBCs sent to unit. 3. Send unit of PRBCs back to the blood bank. 4. Notify the primary healthcare provider.

3. Send unit of PRBCs back to the blood bank. The blood compatibility label did not match the PRBC unit sent to the unit. This unit needs to be sent back to the blood bank and the correct unit needs to be obtained.

A client has been admitted with a diagnosis of portosystemic encephalopathy secondary to Laennec's cirrhosis. The primary healthcare provider writes prescriptions based on the lab values. The nurse would monitor the effectiveness of medications by observing for what specific neurologic changes in the client? Exhibit 1. Increased urination and improved memory. 2. Increased blood pressure and lower pulse. 3. Frequent diarrhea with orientation x three. 4. Clear speech and +2 pitting edema to BLE.

3. Frequent diarrhea with orientation x three.

The nurse is caring for a client diagnosed with Obsessive Compulsive Disorder (OCD). Which statement, made by the client, would be the best indicator of improvement? 1. "My friends don't know I have OCD." 2. "I only do my hand washing to reward myself when I am good." 3. "I know my thoughts and behaviors aren't very normal." 4. "I have more control over my thoughts and behaviors."

4. "I have more control over my thoughts and behaviors."

What should the nurse teach a client about testicular self examination? 1. This exam should be performed bi-annually. 2. The exam should be performed during a cold shower. 3. Gently roll each testicle with slight pressure between the fingers. 4. The epididymis should feel like a hard, knotty rope.

3. Gently roll each testicle with slight pressure between the fingers.

A client with a history of schizophrenia is currently being treated in a mental health facility. The client wants to vote in an upcoming election. The nurse understands what is true about the legality of this action? 1. Primary healthcare provider can decide if client may vote. 2. Psychiatric clients cannot vote if taking medication. 3. A lawyer must approve the finished ballot. 4. An absentee ballot from the polling place can be obtained.

4. An absentee ballot from the polling place can be obtained.

The charge nurse is reviewing correct body mechanics with a group of newly hired UAPs. The nurse reinforces that muscle injuries can best be prevented by avoiding what action? 1. Carry objects close to body but do not touch clothing. 2. Use the largest muscles for lifting, such as thigh muscles. 3. Move objects with quick fast tugs to avoid muscle fatigue. 4. Lean into objects such as a litter and push instead of pull.

3. Move objects with quick fast tugs to avoid muscle fatigue.

What is the most effective method of stroke prevention that the nurse should teach to the public? 1. Administering platelet inhibitors to prevent clot formation. 2. Undergoing transluminal angioplasty to open a stenosed artery and improve blood flow. 3. Maintaining normal weight, exercising, and controlling comorbid conditions. 4. Administering tissue plasminogen activator (tPA).

3. Maintaining normal weight, exercising, and controlling comorbid conditions.

A client who had a triple lumen catheter placed in the right subclavian vein 30 minutes ago reports chest discomfort and shortness of breath. The assessment reveals BP 92/58, HR 104, Resp 28, and unequal breath sounds over lung fields. What problem should the nurse suspect this client is exhibiting? 1. Myocardial infarction 2. Atelectasis 3. Pneumothorax 4. Pneumonia

3. Pneumothorax

A client diagnosed with major depression has been admitted to a psychiatric facility for medication management. During nighttime rounds, an LPN/VN notes the client is not in bed. Which behavior by the client should the LPN/VN report to the RN immediately? 1. Sitting in a chair crying. 2. Reports inability to sleep. 3. Rearranging furniture. 4. Pacing around the room.

3. Rearranging furniture

The nurse is talking with several high school students after a classmate from their school died in a motor vehicular accident. Which statement by the nurse is therapeutic? 1. "Sometimes bad things happen to people we care about." 2. "I was so upset that the student who died had been drinking." 3. "Why are you angry? Tell me how you feel about losing your friend." 4. "What would you like to talk about concerning the loss of your classmate?"

4. "What would you like to talk about concerning the loss of your classmate?"

A client being treated for major depressive disorder arrives at group therapy for the first time in a week wearing clean clothes after showering. What response by the nurse would be therapeutic? 1. "Why are you all dressed up for group?" 2. "Maybe you could add makeup tomorrow." 3. "You must feel better after finally showering." 4. "You look really nice in that flowered jacket."

4. "You look really nice in that flowered jacket."

A client who is being evaluated for a recent head injury requests hydrocodone with acetaminophen for a headache. What response by the nurse is most appropriate? 1. "A hydrocodone and salicylate combination would probably provide better relief." 2. "Due to the impact that your head received, the healtcare provider may want to order a narcotic to be given intravenously for a more rapid relief." 3. "Acetaminophen is not recommended for clients with head injuries, but I can ask for a substitution." 4. "Hydrocodone is an opioid which is usually avoided because it could cause drowsiness and possibly prevent recognition of a worsening condition."

4. "Hydrocodone is an opioid which is usually avoided because it could cause drowsiness and possibly prevent recognition of a worsening condition."

A client with a history of angina has returned to the unit following a cardiac catherization. What nursing action has the highest priority? 1. Obtain vital signs every thirty minutes. 2. Assess pedal pulses every ten minutes. 3. Place the call bell within client's reach. 4. Keep affected extremity immobilized for 6 hours.

4. Keep affected extremity immobilized for 6 hours.

A client taking phenelzine is admitted to the hospital. Which healthcare provider prescription should the nurse question? 1. Take blood pressure lying, sitting, and standing once per shift. 2. Order a complete blood count and liver profile studies. 3. Eliminate foods containing tyramine from diet. 4. Discontinue phenelzine. Begin fluoxetine 20 mg by mouth at bedtime.

4. Discontinue phenelzine. Begin fluoxetine 20 mg by mouth at bedtime.

The nurse is providing care to a client who has returned to the long-term facility following cataract surgery. Which finding would indicate a possible complication? 1. Slightly swollen eyelid 2. Slight discomfort of the eye 3. "Bloodshot" appearance of the eye 4. Extreme pain in the eye

4. Extreme pain in the eye

During morning report, the nurse learns that a client's call bell is not working and maintenance cannot do repairs until tomorrow. The nurse is aware that the safest temporary method for the client to signal staff is what? 1. Provide a hand-held bell for client to ring. 2. Ask family to stay with client to alert staff. 3. Tell client to call out loudly to the staff. 4. Have staff visit client's room every 15 minutes.

4. Have staff visit client's room every 15 minutes.

Two cognitively impaired siblings are clients in the same hospital room. During rounds, the nurse notes they have removed identification bracelets. Because of similar appearance, the nurse is unable to identify the correct client for blood work. What would be the most reliable method for the nurse to use to properly identify these clients? 1. Draw blood to type and crossmatch and compare with chart. 2. Call the primary healthcare provider to identify each client. 3. Ask nurses on the next shift to try to identify the clients. 4. Notify family to come in and identify clients in person.

4. Notify family to come in and identify clients in person.

Two days after a client has a chest tube inserted, the nurse notes constant bubbling in the water seal chamber. What action should the nurse take? 1. Do nothing since this is normal. 2. Decrease the amount of suction. 3. Replace CDU unit with another one. 4. Notify primary healthcare provider.

4. Notify primary healthcare provider.

The nurse enters the med room to prepare the AM medication pass. A new nurse is drawing up morning insulin using a tuberculin syringe instead of an insulin syringe. What is the nurse's priority action? 1. Report the new nurse to the charge nurse. 2. Offer to pass the medications for the new nurse. 3. Prepare an incident report describing the issue. 4. Offer to help the new nurse re-draw up the insulin.

4. Offer to help the new nurse re-draw up the insulin.

A client with a terminal illness, asks the nurse about palliative care. What would be the nurse's best response? 1. Palliative care is a holistic way of finding a cure for a serious illness. 2. Palliative care begins when the client has 3 months or less to live. 3. Palliative care will require you to change to a palliative care healthcare provider. 4. Palliative care prevents and treats symptoms and side effects of disease and treatments.

4. Palliative care prevents and treats symptoms and side effects of disease and treatments.

Which client with a heat-related illness should the emergency room nurse provide attention to first? 1. Elderly person with reports of dizziness and syncope following working in the yard in the sun for several hours. 2. Football player who was at summer practice and developed severe leg cramps, nausea, tachycardia, and diaphoresis. 3. Low income individual who reports that the power has been turned off and has not had air conditioning for several days and who is experiencing increased respiratory rate, fatigue, extreme diaphoresis, and hypotension. 4. Person who had been lying in a roadside ditch for an undetermined length of time and was found with altered mental status, poor muscle coordination, and hot, dry skin.

4. Person who had been lying in a roadside ditch for an undetermined length of time and was found with altered mental status, poor muscle coordination, and hot, dry skin.

A client diagnosed with thrombophlebitis is receiving an IV heparin infusion via a single port saline lock. The primary healthcare provider has just ordered an intravenous antibiotic. What action(s) by the nurse take priority at the time? Select all that apply 1. Call pharmacist to determine compatibility. 2. Contact HCP to verify the need for IV antibiotic. 3. Piggyback antibiotic into heparin tubing to infuse. 4. Start another IV site to infuse the antibiotics. 5. Tell client to report any untoward side effects.

4. Start another IV site to infuse the antibiotics. 5. Tell client to report any untoward side effects.

A client has just developed an abdominal wound evisceration post bowel resection. In what position should the nurse place the client? 1. Sims' position. 2. Dorsal recumbent. 3. Right side lying in the fetal position. 4. Supine, head of bed at 15 degrees with knees and hips bent.

4. Supine, head of bed at 15 degrees with knees and hips bent.

A client with cervical cancer received an internal cervical radiation implant. What should be the initial nursing action if the radiation implant becomes dislodged and is found lying in the bed? 1. Call the client's primary healthcare provider. 2. Pick up the implant immediately with gloved hands and place it in double biohazard bags. 3. Notify the radiology department. 4. Utilize long-handled forceps to pick up the implant and dispose of it in a lead container.

4. Utilize long-handled forceps to pick up the implant and dispose of it in a lead container.

A client has been admitted voluntarily to the psychiatric unit. During the admitting interview, the client confides to the nurse that they have a lethal plan for committing suicide. At the end of the interview the client asks the nurse, "How long will I have to stay here?" What should the nurse say to this client? 1. "Let's discuss this after the health team has assessed you." 2. "Since you signed papers to be admitted, you cannot leave until the primary healthcare provider discharges you." 3. "A lawyer will have to make that decision." 4. "You can leave when you are no longer suicidal."

1. "Let's discuss this after the health team has assessed you."

Twelve hours post coronary artery bypass surgery (CABG), the nurse notes the client's level of consciousness has decreased from alert to somnolent. BP 88/50, HR 130 and thready, resp 32, urinary output (UOP) has dropped from 100 mL one hour earlier to 20 mL this hour. What would be the nurse's first action? 1. Administer 100% oxygen per mask. 2. Lower the head of the bed. 3. Give furosemide STAT. 4. Re-check the BP in the other arm.

1. Administer 100% oxygen per mask.

A long-term care nurse is planning care for a newly admitted client diagnosed with Alzheimer's disease. What should the nurse include in the plan of care. 1. Assess the clients ability to perform self care. 2. Educate nursing staff in all activities of daily living. 3. Separate tasks into small manageable steps. 4. Relieve family of stress by advising them to visit 1 time per week. 5. Have nursing staff spent time talking and listening to client

1. Assess the clients ability to perform self care. 3. Separate tasks into small manageable steps. 5. Have nursing staff spent time talking and listening to client

What food should the nurse include when teaching an older adult about increasing vitamin B12 intake? Select all that apply 1. Calf liver 2. Feta cheese 3. Fresh spinach 4. Shrimp 5. Tuna 6. Tofu

1. Calf liver 2. Feta cheese 4. Shrimp 5. Tuna

The nurse is having an education class for pregnant women. A question is raised about exercise. What is the nurse's best response? 1. Discuss with healthcare provider your current exercise regimen and history. 2. You can continue any exercise that you have been doing before pregnancy. 3. If you haven't already started an exercise program, you should wait until after delivery. 4. Exercise is required during pregnancy for a minimum of 15 minutes each day.

1. Discuss with healthcare provider your current exercise regimen and history.

When inspecting the equipment in a client's room, what would the nurse recognize as electrical safety hazard(s)? Select all that apply 1. Flickering overhead light 2. Ground-fault circuit interrupter electrical sockets 3. Hospital labeled UL power strip 4. Bent electrical bed cord 5. Cracked electrical socket

1. Flickering overhead light 4. Bent electrical bed cord 5. Cracked electrical socket

To promote rapid diuresis in a client in acute pulmonary edema, which prescription should the nurse administer first? 1. Furosemide 40 mg IVP 2. Dopamine 15 mcg/kg/min 3. Hydrochlorothiazide 25 mg PO 4. Captopril 25 mg PO

1. Furosemide 40 mg IVP

A home health nurse is interpreting Mantoux skin test results of clients who received the test 48 hours ago. Which clients have a positive tuberculin skin test reaction? Select all that apply 1. HIV+ client with an induration of 6 millimeters. 2. Client who immigrated from Haiti 6 months ago who has an induration of 10 millimeters. 3. Client working at a nursing home with an induration of 8 millimeters. 4. 3 year old client with an induration of 12 millimeters. 5. Healthy client with no known TB exposure who has an induration of 5 millimeters.

1. HIV+ client with an induration of 6 millimeters. 2. Client who immigrated from Haiti 6 months ago who has an induration of 10 millimeters. 4. 3 year old client with an induration of 12 millimeters.

What lab values should the nurse monitor when caring for a client diagnosed with acute leukemia? Select all that apply 1. Hemoglobin 2. Hematocrit 3. Lactate dehydrogenase (LDH) 4. Platelets 5. White blood cells 6. Metanephrine

1. Hemoglobin 2. Hematocrit 4. Platelets 5. White blood cells

What nursing interventions should the nurse include when planning care for a client admitted with Guillain-Barre' Syndrome? Select all that apply 1. Monitor for contractures. 2. Place prone for 30 minutes, 4 times per day. 3. Provide therapeutic massage for pain relief. 4. Teach range of motion exercises. 5. Provide high protein meals 3 times a day. 6. Refer to physical therapist.

1. Monitor for contractures. 3. Provide therapeutic massage for pain relief. 4. Teach range of motion exercises. 6. Refer to physical therapist.

The housekeeper and a nurse, having lunch together in the staff lounge, begin discussing the housekeeper's neighbor who has been admitted to the floor. The housekeeper occasionally helps the neighbor with shopping and cleaning. The conversation is overheard by the unit secretary, though no names were mentioned. The conversation is reported to the nurse manager, who determines the situation reflects what HIPAA criteria? 1. Not permissible because the housekeeper is not medical personnel. 2. Is permissible since the housekeeper does help care for the neighbor. 3. Not permissible despite family stating housekeeper is "like family". 4. Is permissible given that no other family members are available now.

1. Not permissible because the housekeeper is not medical personnel.

A client arrives by ambulance after being thrown from a horse. The client is pale, clammy and tachycardic with bruising over left upper abdominal quadrant. The nurse is aware what prescription by the primary healthcare provider takes priority? 1. Obtain blood for type and cross match. 2. Administer hydromorphone IV for pain. 3. Increase Lactated Ringers to 150 mL/hour. 4. Send client to radiology for stat CAT scan.

1. Obtain blood for type and cross match.

A client requires external radiation therapy. The nurse knows external radiation may cause which problems? Select all that apply 1. Pancytopenia 2. Leukocytosis 3. Erythema 4. Fever 5. Fatigue

1. Pancytopenia 3. Erythema 5. Fatigue

A client arrives at the Emergency Department after receiving 3rd degree burns to the upper chest, neck, and face area. What would be the priority nursing intervention? 1. Prepare for endotracheal intubation. 2. Monitor hourly urinary output. 3. Treatment of the open burn wounds. 4. Assessment and management of pain.

1. Prepare for endotracheal intubation

What signs of cannula displacement should the nurse monitor for at an arterial line insertion site? Select all that apply 1. Swelling 2. Fluid leakage 3. Blanching 4. Poor arterial waveform 5. Pyrexia 6. Purulent drainage

1. Swelling 2. Fluid leakage 3. Blanching 4. Poor arterial waveform

What should be included in the discharge teaching plan for a client who has lymphedema post right mastectomy? Select all that apply 1. Use a thimble when sewing. 2. Wear a heavy duty oven mitt for removing hot objects from the oven. 3. Long sleeves should be worn to prevent insect bites. 4. Shave underarms with an electric razor. 5. Avoid wearing jewelry.

1. Use a thimble when sewing. 2. Wear a heavy duty oven mitt for removing hot objects from the oven. 3. Long sleeves should be worn to prevent insect bites. 4. Shave underarms with an electric razor.

The nurse is working in the term nursery. Which task should be performed first on a newborn? 1. Prepare the circumcision equipment for a two day old newborn. 2. Assess the five minute APGAR of a newborn. 3. Perform the gestational age assessment on a 30 minute old newborn. 4. Obtain a blood sample for metabolic testing on a 24 hour old newborn.

2. Assess the five minute APGAR of a newborn.

An unresponsive 13 year old is brought into the emergency department. Based on the nursing assessment and current lab data, which interventions would be appropriate for the nurse to initiate? Nurse Notes: Unresponsive 13 year old admitted to ED trauma room 1. Assessment reveals rapid and deep respirations at 38/min, BP 90/60, HR 126/min, Temp 101.5°F (38.6°C) with polyuria. Lab Values: Potassium = 5.2 mEq/dL (5.2 mmol/L) Glucose = 420 mg/dL (23 mmol/L) Urine ketones = positive ABGs pH = 7.25 PCO2 = 35 mm Hg HCO3 = 18 mEq/L PO2 = 96mm Hg Select all that apply 1. Administer kayexelate 2. Initiate IV of NS 100 ml with Regular insulin 100 units at 10 mL/hr 3. Start oxygen at 2 liters per nasal cannula 4. Start a second IV for fluid resuscitation. 5. Insert indwelling urinary catheter Select all that apply 1. Administer kayexelate 2. Initiate IV of NS 100 ml with Regular insulin 100 units at 10 mL/hr 3. Start oxygen at 2 liters per nasal cannula 4. Start a second IV for fluid resuscitation. 5. Insert indwelling urinary catheter

2. Initiate IV of NS 100 ml with Regular insulin 100 units at 10 mL/hr 4. Start a second IV for fluid resuscitation. 5. Insert indwelling urinary catheter

The nurse is caring for a client with chronic pyelonephritis. Which lab value noted by the nurse indicates a problem? 1. Estimated glomerular filtration rate - 90 mL/min/1.73 m2 2. Serum creatinine - 2.1 mg/dL (186 micro mol/dL) 3. Blood urea nitrogen - 19 mg/dl (6.78 mmol/L) 4. Urine culture isolates Escherichia coli

2. Serum creatinine - 2.1 mg/dL (186 micro mol/dL)

What information would the nurse include when participating in community health training about sexually transmitted infections? 1. Clients are screened for chlamydial infection and/or gonorrhea only if the client is experiencing cervical discharge, dyspareunia, and dysuria. 2. Women with chlamydial infection or gonorrhea are likely to be asymptomatic. 3. In many instances, chlamydia infection and/or gonorrhea will go away without intervention. 4. It is only necessary for females to be treated for chlamydial infections and/or gonorrhea due to the potential damage to a female's reproductive system.

2. Women with chlamydial infection or gonorrhea are likely to be asymptomatic.

The nurse is discussing information on adolescent obesity with parents of high-school students. What statement by the nurse is most comprehensive regarding obesity among teens? 1. Obesity among teens is often accompanied by psychologic issues like poor self-esteem. 2. Weight issues among teens are often due to excess eating out of boredom or stress. 3. Adolescent obesity is usually an inability to recognize signals of hunger or satiety. 4. Undiagnosed problems of the thyroid or pituitary contribute to teen obesity.

3. Adolescent obesity is usually an inability to recognize signals of hunger or satiety.

The nurse is planning an activity for the client who has a diagnosis of paranoid schizophrenia. Which activity would be most appropriate for the client? 1. A game of Scrabble with peers 2. A group game of basketball. 3. An individual art project. 4. A card game with the nurse.

3. An individual art project.

What signs and symptoms does the nurse expect a client diagnosed with bacterial pneumonia to exhibit? Select all that apply 1. Asymmetrical chest expansion 2. Night sweats 3. Dyspnea 4. Tachypnea 5. Pleuritic chest discomfort 6. Increased tactile fremitus

3. Dyspnea 4. Tachypnea 5. Pleuritic chest discomfort 6. Increased tactile fremitus

The nurse is providing care for an elderly client who has a percutaneous endoscopic gastrostomy (PEG) feeding tube and is receiving continuous feeding. Which interventions should the nurse include when providing care? Select all that apply 1. Add medications to enteral feeding formula. 2. Change dressing around insertion site weekly. 3. Flush feeding tube with 30 mL warm tap water every 4 hours. 4. Maintain head of bed at 30 degree elevation. 5. Monitor for hypoglycemia.

3. Flush feeding tube with 30 mL warm tap water every 4 hours. 4. Maintain head of bed at 30 degree elevation.

The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Which action should the nurse interrupt the UAP from performing? 1. Draining the colostomy bag on a client with diarrhea. 2. Performing passive range of motion (ROM) on the client with right sided paralysis. 3. Placing the traction weights on the bed to transfer the client to x-ray. 4. Discarding the first urine voided by the client starting a 24 hour urine test.

3. Placing the traction weights on the bed to transfer the client to x-ray.

The nurse manager of an Alzheimer's unit as completed inservice education to new nursing staff regarding guidelines for dealing with dementia. Which identified guidelines by the new nursing staff indicates to the nurse manager that education was successful? Select all that apply 1. Use a firm touch to guide the client to a different location when needed. 2. Be persistent when getting the client to do something. 3. Provide simple directions using gestures or pictures. 4. Do not argue with the client. 5. Play memory games to decrease dementia. 6. Require participation in daily activities.

3. Provide simple directions using gestures or pictures. 4. Do not argue with the client.

The home health nurse is caring for an elderly client who lives with an adult child. The client's child is divorced, works full-time, and is responsible for caring for two young children. Recently, the client has become incontinent of urine. Which stressor on the caregiver may increase the risk for abuse of this elderly client? 1. Care of young children 2. Being divorced 3. Recent increased care demands 4. Loneliness of the adult child

3. Recent increased care demands

A hospitalized client diagnosed with rheumatoid arthritis is receiving IV methylprednisolone every six hours. What is the best method for the nurse to provide client safety? 1. Place "fall precautions" sign above client's bed. 2. Change the intravenous site for steroids daily. 3. Restrict any visitors with visible illnesses. 4. Put client on full contact precautions.

3. Restrict any visitors with visible illnesses.

Which assignment would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? 1. Obtaining a sterile urine specimen from a Foley catheter. 2. Inserting an in-and-out catheter on a client postpartum. 3. Taking vital signs on a client 12 hours postpartum. 4. Removing a Foley catheter on a client postpartum.

3. Taking vital signs on a client 12 hours postpartum.

A renal transplant client has received discharge education. Which statement by the client indicates that further teaching is necessary? 1. "I will need to notify my primary healthcare provider if I develop a fever." 2. "I need to check my BP daily and report an increased B/P." 3. "I will tell my primary healthcare provider if I become easily fatigued." 4. "I will be on steroids for 3 months, then I will not have to take them."

4. "I will be on steroids for 3 months, then I will not have to take them."

In what order should the nurse assess assigned clients following shift report? Place in priority order. a. Client diagnosed with pneumonia who has a pulse oximetry reading of 89%. b. Client who had a feeding tube inserted, due to recurrent aspiration pneumonia, which is now clogged. c. Client diagnosed with active tuberculosis who has a sputum specimen that needs to go to the lab. d. Client diagnosed with pneumonia who has an arterial oxygenation level of 85%.

a. Client diagnosed with pneumonia who has a pulse oximetry reading of 89%. d. Client diagnosed with pneumonia who has an arterial oxygenation level of 85%. c. Client diagnosed with active tuberculosis who has a sputum specimen that needs to go to the lab. b. Client who had a feeding tube inserted, due to recurrent aspiration pneumonia, which is now clogged.

Place the steps in order that the nurse should take to administer a subcutaneous injection. a. Hold syringe and pinch the skin with nondominant hand b. Apply gloves and locate the injection site c. Remove the needle cap by pulling it straight off d. Inject the needle and administer the medication e. Dispose the syringe in sharps container f. Perform hand hygiene g. Cleanse site with antiseptic swab

f. Perform hand hygiene b. Apply gloves and locate the injection site g. Cleanse site with antiseptic swab c. Remove the needle cap by pulling it straight off a. Hold syringe and pinch the skin with nondominant hand d. Inject the needle and administer the medication e. Dispose the syringe in sharps container

An alcoholic client has agreed to take disulfiram 250 mg PO daily. The nurse recognizes that education has been successful when the client makes which statements? Select all that apply 1. "If I decide to stop taking disulfiram, I should not ingest any alcohol for at least 2 weeks or I will have a reaction." 2. "I must read labels carefully so that I know that alcohol is not an ingredient." 3. "I am allowed to eat chili made with beer since the alcohol evaporates from the chili with prolonged cooking." 4. "This medication is not a cure. I still need to attend therapy sessions." 5. "I should avoid eating a lot of chocolate while on this medication."

1. "If I decide to stop taking disulfiram, I should not ingest any alcohol for at least 2 weeks or I will have a reaction." 2. "I must read labels carefully so that I know that alcohol is not an ingredient." 4. "This medication is not a cure. I still need to attend therapy sessions." 5. "I should avoid eating a lot of chocolate while on this medication."

The client diagnosed with active tuberculosis has been prescribed isoniazid 300 mg by mouth every day. What should the nurse teach this client? Select all that apply 1. "Notify your healthcare provider if your urine turns dark." 2. "Your healthcare provider has prescribed B6 along with the isoniazid to prevent neuritis." 3. "You should avoid eating aged cheeses and smoked fish." 4. "Eat foods such as tuna twice a week." 5. "Rise slowly from lying to sitting, or sitting to standing."

1. "Notify your healthcare provider if your urine turns dark." 2. "Your healthcare provider has prescribed B6 along with the isoniazid to prevent neuritis." 3. "You should avoid eating aged cheeses and smoked fish." 5. "Rise slowly from lying to sitting, or sitting to standing."

A client has just developed an abdominal wound evisceration post bowel resection. In what position should the nurse place the client? 1. Sims' position. 2. Dorsal recumbent. 3. Right side lying in the fetal position. 4. Supine, head of bed at 15 degrees with knees and hips bent.

4. Supine, head of bed at 15 degrees with knees and hips bent.

A nurse is caring for a group of clients and is considering the risk of infection for each. Place the client conditions in rank order from the highest to least potential for infection. a. Total hip prosthetic device placement 3 days ago b. Indwelling foley catheter inserted the previous day c. Laparoscopic exploration of right knee 2 days ago d. Thermal burns covering 30% of body surface area (BSA) 2 days ago

d. Thermal burns covering 30% of body surface area (BSA) 2 days ago a. Total hip prosthetic device placement 3 days ago c. Laparoscopic exploration of right knee 2 days ago b. Indwelling foley catheter inserted the previous day

The nurse is caring for a client diagnosed with Addison's disease. Which finding would indicate to the nurse that a client has received excessive mineralocorticoid replacement? Select all that apply 1. Oily skin 2. Weight gain of 4 pounds in one week 3. Loss of muscle mass in extremities 4. Blood glucose of 58 mg/dL 5. Serum potassium of 3.2 mEq

2. Weight gain of 4 pounds in one week 5. Serum potassium of 3.2 mEq

A nurse walks into the medication area of a long-term care facility and sees a colleague taking a pill from a resident's supply of narcotics. The nurse says, "Please don't say anything. I need my job and I have a migraine." What actions should the nurse take? Select all that apply 1. Reassure the colleague that she won't tell this time. 2. Insist that the colleague get some help. 3. Report what was seen to the supervisor. 4. Send the colleague home. 5. Follow procedure to return medication to the resident's supply.

3. Report what was seen to the supervisor. 5. Follow procedure to return medication to the resident's supply.

A mother of a newborn is crying and tells the nurse, "I am worried about my baby. His Apgar score was 6 and the nurses had to help him breath for a while." What response should the nurse make to this mother? 1. "Don't worry about what score your baby received on the Apgar. The nurses know how to take care of him." 2. "Stop crying. Your baby is fine now and will continue to get stronger as the day progresses." 3. "Your baby's Apgar score was normal. The score was 6 at 1 minute which is typical." 4. "It is normal for you to feel this way. Let me explain what the Apgar score is used for."

4. "It is normal for you to feel this way. Let me explain what the Apgar score is used for."

A client has been admitted with a diagnosis of community-acquired pneumonia to the left lower lung lobe. What assessment findings by the nurse would validate this diagnosis? Select all that apply 1. Bronchial breath sounds over left lower lobe 2. Upper abdominal discomfort 3. Percussion reveals resonant sound over affected area 4. Tachypnea 5. Use of accessory muscles with breathing

1. Bronchial breath sounds over left lower lobe 2. Upper abdominal discomfort 4. Tachypnea 5. Use of accessory muscles with breathing

A male client diagnosed with primary hyperaldosteronism is receiving spironolactone. Which potential side effect should the nurse educate the client regarding? Select all that apply 1. Erectile dysfunction 2. Gastrointestinal upset 3. Gynecomastia 4. Hypernatremia 5. Hypokalemia

1. Erectile dysfunction 2. Gastrointestinal upset 3. Gynecomastia

A nurse is developing a proposal to implement a pet therapy program at a nursing home. What information should the nurse include in the proposal to support this program? Select all that apply 1. Evidence has shown that animals can directly influence a person's mental and physical well-being. 2. Bringing a pet into a nursing home for the elderly has been shown to enhance social interaction. 3. Petting an animal can be helpful in lowering a client's blood pressure. 4. Some researchers believe that animals actually may retard the aging process among those who live alone. 5. Nursing home clients are more submissive after petting an animal.

1. Evidence has shown that animals can directly influence a person's mental and physical well-being. 2. Bringing a pet into a nursing home for the elderly has been shown to enhance social interaction. 3. Petting an animal can be helpful in lowering a client's blood pressure. 4. Some researchers believe that animals actually may retard the aging process among those who live alone.

A client who was diagnosed with amyotropic lateral sclerosis (ALS) has been immobile for 2 weeks. Which of the nursing interventions would the nurse implement? Select all that apply 1. Explore diversional activities. 2. Perform range of motion exercises. 3. Maintain the feet in dorsiflexion position. 4. Assess pressure points for skin changes. 5. Encourage a fluid intake of 1500 mL/24 hours.

1. Explore diversional activities. 2. Perform range of motion exercises. 3. Maintain the feet in dorsiflexion position. 4. Assess pressure points for skin changes.

A client diagnosed with cirrhosis is being treated for ascites and increased ammonia levels. Prior to discharge, the nurse reviews dietary instructions. The nurse knows teaching was successful when the client selects what menu plan? 1. High calorie, low protein 2. High protein, low sodium 3. Low calcium, low potassium 4. Low carbohydrates, high fat

1. High calorie, low protein

An unlicensed assistive personnel (UAP) is assisting a client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention by the nurse? 1. Holds chest drainage unit (CDU) at the level of the chest. 2. Disconnects the chest tube from suction. 3. Allows the client to ambulate. 4. Helps client use a walker.

1. Holds chest drainage unit (CDU) at the level of the chest.

client receiving chemotherapy for lung cancer reports increased fatigue. The family confirms client is sleeping most of the day and night. What priority action would the nurse take? 1. Discuss the risks of immobility with client and family. 2. Check current lab values of hematocrit and hemoglobin. 3. Suggest family seek counseling for the client's depression. 4. Request a referral from the healthcare provider for physical therapy.

2. Check current lab values of hematocrit and hemoglobin.

The nurse is performing a routine history and physical on a client who attends the Senior Citizen's Center. What finding noted by the nurse would suggests that the client may have a history of chronic emphysema? Select all that apply 1. Barrel chest 2. Green sputum 3. Kyphosis 4. Tracheal deviation 5. Resonance to percussion of bilateral lung fields 6. Reports frequent morning headaches

1. Barrel chest 6. Reports frequent morning headaches

The nurse is teaching a client about the use of a cane. Which is the correct cane technique? 1. Place the cane on weaker side of the body to support the weaker leg. Using the cane for support, the client should step forward with strong leg, and then move the weaker leg and cane forward to the strong leg. 2. Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. 3. Place cane on weaker side of body. The cane is placed forward 6 to 10 inches while the client advances weaker leg to the cane. 4. Place cane on stronger side of body to help support weaker leg. Using cane for support, step forward with the strong leg and then move the weaker leg and the cane forward to the strong leg.

2. Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time.

The nurse is assigned a group of clients on the inpatient psychiatric unit. Which client presents the greatest risk for violence toward others? 1. 24 year old man with paranoid delusions 2. 62 year old woman with bipolar disorder 3. 72 year old man with major depression 4. 28 year old woman with borderline personality disorder

1. 24 year old man with paranoid delusions

A nurse is teaching a client who has frequent urinary tract infections how to prevent future infections. What statement by the client would indicate to the nurse that treatment has been successful? Select all that apply 1. "I will go to the bathroom as soon as the urge to void hits me." 2. "It is important for me to drink five to six 8 ounce glasses of water every day." 3. "I should eat foods such as plums and prunes to increase the acidity of my urine." 4. "Nylon underwear should be worn when I am free from infection." 5. "When I clean after voiding, I will discard toilet paper after each swipe."

1. "I will go to the bathroom as soon as the urge to void hits me." 3. "I should eat foods such as plums and prunes to increase the acidity of my urine." 5. "When I clean after voiding, I will discard toilet paper after each swipe."

A client who is suicidal confides to the night nurse, "I will try again when I get out of this place." What is the nurse's best response? 1. "What do you plan to do?" 2. "You will try what again?" 3. "Why would you want to do that? You have everything to live for." 4. "Are you trying to get back at your family for sending you here?"

1. "What do you plan to do?"

A client delivered a term infant four hours ago. The infant was stillborn. Which room would be most appropriate for the nurse to assign to this client? 1. A private room on the gynocological unit. 2. A private room on the postpartum unit. 3. Discharge her home as soon as her condition is stable. 4. Room her with another client with a pregnancy loss.

1. A private room on the gynocological unit.

The nurse is caring for a client in the emergency department with a suspected arm fracture. What assessment data would support this finding? Select all that apply 1. Pain and tenderness at the fracture site 2. Unnatural movement 3. Stiffness in the arm 4. Shortening of the extremity 5. Deformity of the extremity

1. Pain and tenderness at the fracture site 2. Unnatural movement 4. Shortening of the extremity 5. Deformity of the extremity

What assessment findings would the nurse expect when evaluating whether treatment has been effective for a client hospitalized with systolic heart failure? Select all that apply 1. 3+ pedal edema 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.9 kg) 4. Purse-lip breathing 5. Pale nail beds 6. Urine output at 50 mL/hr

2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.9 kg) 6. Urine output at 50 mL/hr

What interventions should the nurse initiate while caring for a client who has a cooling blanket in place? Select all that apply 1. Assess temperature every hour. 2. Perform comparison check with another thermometer periodically. 3. Assess client skin condition hourly. 4. Turn blanket off when temperature is at goal temperature. 5. Observe for signs of chilling.

2. Perform comparison check with another thermometer periodically. 3. Assess client skin condition hourly. 5. Observe for signs of chilling.

A child presents to the school nurse with left knee pain after suffering a fall on the playground. Which action should the nurse initiate? 1. Instruct the child to extend the affected knee 2. Perform range of motion exercise on both knees 3. Compare the appearance of the left knee to the right knee 4. Have the child soak the affected knee in warm water

3. Compare the appearance of the left knee to the right knee

A 70 year old client was admitted to the unit during the night shift with chronic hypertension. At 0830, the unlicensed nursing assistant (UAP) reports that the clients blood pressure is 198/94 mm Hg. What would be the BEST action for the charge nurse to delegate to at this time 1. Ask the UAP to put the client back in bed immediately 2. Tell the UAP to take the BP on the opposite arm in 15 minutes 3. Have the LPN/LVN administer the 0900 furosemide and enalapril now 4. Ask the LPN/LVN to assess the client for pain

3. Have the LPN/LVN administer the 0900 furosemide and enalapril now

What information should be included when a nurse is teaching a group of college students about the transmission of hepatitis B and human immunodeficiency virus (HIV)? 1. HIV is transmitted via toilet seats whereas hepatitis B is not. 2. HIV is transmitted by sexual contact whereas hepatitis B is not. 3. Hepatitis B is more readily transmitted via needle sticks than HIV. 4. Neither virus is transmitted via body fluids.

3. Hepatitis B is more readily transmitted via needle sticks than HIV.

A client is scheduled for surgery today. As the nurse prepares the pre-op medication, the client says, "I have changed my mind. I don't want to go through with the surgery." What should the nurse do first? 1. Convince the client to proceed with the plans for surgery. 2. Notify the surgery department to cancel surgery. 3. Notify the primary healthcare provider of the client's decision. 4. Suggest that the client talk over the decision with family members.

3. Notify the primary healthcare provider of the client's decision.

The nurse is preparing to administer 0800 medications to a client. How many mg of Citalopram should the nurse administer? Citalopram 20mg; Take 1 tablet daily @ 0800 Citalopram 10mg; Take 1 tablet daily @ 0800

30

A homecare client with terminal cancer is taking morphine sulfate and reports the current dose is no longer relieving the pain. What would the nurse tell the client about the increased discomfort? 1. The pain medication will need to be taken consistently around the clock. 2. A different pain medication will need to be prescribed since addiction has occurred. 3. As the cancer spreads, the pain medication will no longer help. 4. A tolerance to the current dose has occurred, so the dose will need to be increased.

4. A tolerance to the current dose has occurred, so the dose will need to be increased.

The primary healthcare provider has prescribed ampicillin and ciprofloxacin piggyback in the same hour, every 6 hours. How will the nurse administer these medications? 1. Administer one of the medications every 4 hours and the other every 6 hours. 2. Administer the medications by combining them into 150 mL of normal saline (NS). 3. Administer the medications at the same time by connecting the secondary tubing to two separate ports on the primary tubing. 4. Administer the medications separately, flushing with normal saline (NS) between medications.

4. Administer the medications separately, flushing with normal saline (NS) between medications.

Which comment by the client indicates understanding of possible complications of long term hypertension? 1. "I would like to have my serum creatinine checked at this visit." 2. "My blurred vision is part of getting older." 3. "I have leg pain caused by excessive exercise." 4. "Adding salt to my food is permissible."

1. "I would like to have my serum creatinine checked at this visit."

What foods should the nurse teach a client who has been diagnosed with iron deficiency anemia to increase in the diet? Select all that apply 1. Chickpeas 2. Milk 3. Oysters 4. Raisins 5. Spinach 6. Tuna

1. Chickpeas 3. Oysters 4. Raisins 5. Spinach 6. Tuna

The case manager is arranging a planning meeting for the care of a client diagnosed with chronic obstructive pulmonary disease (COPD). Who should be included in the meeting? Select all that apply 1. Client 2. Nurse 3. Pulmonologist 4. Social worker 5. Pharmacist 6. Occupational therapist

1. Client 2. Nurse 3. Pulmonologist 4. Social worker 5. Pharmacist

The parents of a 4 year old child have recently had a new baby and the parents report that the 4 year old had been dry all night for 8 months and is now wetting the bed again. What should the nurse assess first? 1. Urinalysis 2. Normal urination habits. 3. Adjustment to the new baby. 4. Fluid intake after 6 pm.

1. Urinalysis

For a client with a major burn, which evaluation criterion identified by the nurse best indicates that fluid resuscitation has been effective during the first 24 hours of care? 1. Urine output of 860 mL / 24 hours. 2. Increase in weight from preburn weight. 3. Heart rate of 122 beats per minute 4. Central venous pressure of 18 mm

1. Urine output of 860 mL / 24 hours.

A client was admitted to CCU with a diagnosis of acute coronary syndrome. Continuous cardiac monitoring has been implemented. Which assessment finding by the nurse is most significant? 1. Ventricular fibrillation 2. Ventricular tachycardia 3. 2nd degree AV block 4. Atrial fibrillation

1. Ventricular fibrillation

Which client is legally able to sign a consent for surgery? Select all that apply 1. An 86 year old client who is disoriented. 2. A 62 year old client who speaks only Spanish. 3. A 41 year old client who just received midazolam. 4. A 17 year old client needing an emergency appendectomy whose parents cannot be contacted. 5. A 44 year old with schizophrenia who is hallucinating.

2. A 62 year old client who speaks only Spanish. 4. A 17 year old client needing an emergency appendectomy whose parents cannot be contacted.

Which assigned client should the nurse see first? 1. Diagnosed with urinary tract infection 2 days ago who is to be discharged. 2. Admitted last night with a diagnosis of severe pneumonia. 3. 45 year old who had a hernia repair 24 hours ago. 4. Scheduled for an endoscopy in two hours.

2. Admitted last night with a diagnosis of severe pneumonia.

A client with diabetes has a history of ignoring the primary healthcare provider's prescription for daily medication management of the illness. The client has been working toward a health promotion goal of increased adherence to prescribed medication regimen. Which outcome suggests that the client has met the health promotion goal? 1. Client has lost five pounds. 2. Client takes medication as prescribed. 3. Client has been hospitalized twice for complications of diabetes. 4. Client walks one mile per day.

2. Client takes medication as prescribed.

The nurse is caring for a trauma client who is receiving a unit of whole blood. The client begins to experience lower back pain. What actions should the nurse take? 1. Administer diphenhydramine 2. Collect a urine specimen 3. Stop the transfusion 4. Take the client's vital signs 5. Change the IV tubing

2. Collect a urine specimen 3. Stop the transfusion 4. Take the client's vital signs 5. Change the IV tubing

A client is admitted with a hip fracture after falling. Based on these lab values, what is the nurse's priority nursing intervention? Na+ 147 mEq/L (147 mmol/L) Specific gravity 1.030 Hct 55% 1. Provide foods high in iron 2. Increase fluid intake 3. Obtain a urine for culture 4. Measure intake and output

2. Increase fluid intake

What interventions should the nurse include when teaching a client how to prevent and treat fungal infections of the feet? Select all that apply 1. Apply cornstarch to the feet after bathing. 2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 3. Wear socks at all times until infection has cleared up. 4. Wash feet daily with soap and water. 5. Wear shower sandals when showering in public places. 6. Wear shoes that allow the feet to breathe.

2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 4. Wash feet daily with soap and water. 5. Wear shower sandals when showering in public places. 6. Wear shoes that allow the feet to breathe.

The nurse is teaching a client diagnosed with asthma about using a peak expiratory flow meter. The nurse asks the client what action should be taken if the reading is 65% of the client's personal best value. What statement by the client indicates to the nurse that education was successful? 1. "This is a good reading for me, so I can go about my usual activities." 2. "I will administer my long-term inhaler medication." 3. "My as needed inhaler medication needs to be administered." 4. "I need to immediately call 911."

3. "My as needed inhaler medication needs to be administered."

A client is admitted to the hospital at 36 weeks gestation with a diagnosis of placental abruption. Following an initial assessment, what action by the nurse is most important? 1. Apply the fetal monitor. 2. Complete an abdominal prep. 3. Insert large bore intravenous line. 4. Have client sign the consent form.

3. Insert large bore intravenous line.

A client has been admitted to the emergency department after repeated food binging and purging by vomiting and laxative abuse. The client reports leg pains and weakness. ECG reveals a depressed ST segment and flattened T wave. Based on this data, what does the nurse anticipate that this client will need to receive first? 1. Oral fluids 2. Kayexalate enemas 3. Intravenous potassium (KCL) 4. An antidiarrheal medication

3. Intravenous potassium (KCL)

A client has been admitted to the med-surg floor with lower abdominal pain and bloating, fever, chills, and vomiting. Following a Cat scan, a diagnosis of diverticulitis is made. What action by the nurse is most appropriate after the initial assessment? 1. Obtain a stool specimen for ova and parasites. 2. Prepare client for emergency exploratory surgery. 3. Notify dietary the client will need a clear liquid diet. 4. Give client a heating pad to ease abdominal pain.

3. Notify dietary the client will need a clear liquid diet.

An expectant HIV positive client asks why zidovudine (ZDV) must be continued throughout the pregnancy. What is the best explanation by the nurse? 1. "The medication permits safe breastfeeding after delivery." 2. "It protects you against other infections during pregnancy." 3. "This drug prevents transmission of HIV to your partner." 4. "ZDV decreases the chance the baby will contract HIV."

4. "ZDV decreases the chance the baby will contract HIV."

The nurse is preparing to teach a client about post percutaneous transluminal coronary angioplasty (PTCA) care. Which teaching points should the nurse include? Select all that apply 1. Restricting oral fluids until the gag reflex has returned. 2. Encouraging early ambulation and deep breathing exercises. 3. Discontinuing medicines following percutaneous intervention. 4. Reporting any chest discomfort following percutaneous intervention. 5. Avoid lifting more than 10 pounds until approved by healthcare provider.

4. Reporting any chest discomfort following percutaneous intervention. 5. Avoid lifting more than 10 pounds until approved by healthcare provider.

A nurse caring for a client diagnosed with osteomyelitis instructs an experienced unlicensed assistive personnel (UAP) to obtain vital signs on the client. Which value should the nurse tell the UAP to report immediately? 1. Heart rate 98/min 2. Respirations 22/min 3. Blood pressure 138/82 4. Temperature 101°F (38.3°C)

4. Temperature 101°F (38.3°C)

The nurse admits a child with a history of cystic fibrosis (CF) with vomiting for 3 days, headache, and unusual behavior. What does the nurse anticipate the lab values will show? 1. Hypernatremia 2. Hypercalcemia 3. Hypocalcemia 4. Hyponatremia

4. Hyponatremia

A client with a history of angina has returned to the unit following a cardiac catherization. What nursing action has the highest priority? 1. Obtain vital signs every thirty minutes. 2. Assess pedal pulses every ten minutes. 3. Place the call bell within client's reach. 4. Keep affected extremity immobilized for 6 hours.

4. Keep affected extremity immobilized for 6 hours.

The nurse is monitoring care provided to clients by a newly hired unlicensed assistive personnel (UAP). Which action by the UAP would require the nurse to intervene? 1. Uses a gait belt when ambulating a client with right sided weakness. 2. Repositions a client in bed using a lift sheet. 3. Disconnects nasogastric (NG) tube from suction to allow ambulation to toilet. 4. Massages a surgical client's calf after reports of leg cramping.

4. Massages a surgical client's calf after reports of leg cramping.

A palliative care client is suffering from persistent diarrhea. What foods should the nurse suggest? Select all that apply 1. Applesauce 2. Rice 3. Bananas 4. Tea 5. Yogurt

1. Applesauce 2. Rice 3. Bananas

Shortly after being admitted to the cardiac unit, a client reports shortness of breath. The nurse prepares to administer the prescribed morphine. How many mL should the nurse administer? Use numbers and decimals only to answer. Order: Morphine 2 mg q 2h PRN SOB (Available is Morphine 5mg/mL)

0.4

Which statement by the nurse would be the correct response to a client who is postmenopausal with a uterus when the client asks about temporary hormonal therapy for hot flashes? 1. "Hormonal therapy with a combination of low doses of estrogen and progestin may be prescribed." 2. "Unopposed estrogen hormonal therapy would be most appropriate." 3. "Hormonal therapy is an outdated treatment and can no longer be prescribed so you should try an alternative such as ginseng." 4. "Hormonal therapy is not an option for women with a uterus so you may need to consider a hysterectomy."

1. "Hormonal therapy with a combination of low doses of estrogen and progestin may be prescribed."

A client presents to the emergency department (ED) with tachycardia, elevated blood pressure, seizures, and a history of chronic alcoholism. Which electrolyte imbalance would be the nurse's priority concern? 1. Hypomagnesemia 2. Hyponatremia 3. Hyperkalemia 4. Hypercalcemia

1. Hypomagnesemia

A nurse is caring for a client who has been prescribed metoprolol. What education should the nurse provide to the client? Select all that apply 1. Information on skin turgor. 2. Check for edema in lower extremities. 3. Take medication 30 minutes prior to a meal. 4. Do not use over the counter (OTC) nasal decongestants. 5. Notify primary healthcare provider if the pulse is < 60 beats per minute.

2. Check for edema in lower extremities. 4. Do not use over the counter (OTC) nasal decongestants. 5. Notify primary healthcare provider if the pulse is < 60 beats per minute.

After obtaining vital signs, which prescribed medication should the nurse hold when caring for a client on the cardiac unit? Exhibit 1. Rosuvastatin 2. Enalapril 3. Digoxin 4. Clopidogrel

2. Enalapril

A client from Indonesia is being admitted to the Labor and Delivery unit. Her spouse brought her to the hospital. She is 39 weeks gestation, her contractions are 4 minutes apart, and she experienced spontaneous rupture of the membranes at home. She does not speak English, but a hospital-based interpreter is present. Which questions by the nurse would be appropriate to ask the client when performing the admission assessment? Select all that apply 1. Are there any odd cultural practices that we need to be aware of in caring for you during labor and delivery? 2. In your culture, are fathers generally present for the delivery? 3. Are there any foods that are not permitted or are requested based on your culture or religion? 4. Do you have any personal beliefs or customs prohibiting physical activity during pregnancy, birth and the postpartum period that you will be observing? 5. Will you be observing any special or culturally accepted way for expression of pain? 6. Are there any special considerations that need to be observed for newborn care?

2. In your culture, are fathers generally present for the delivery? 3. Are there any foods that are not permitted or are requested based on your culture or religion? 4. Do you have any personal beliefs or customs prohibiting physical activity during pregnancy, birth and the postpartum period that you will be observing? 5. Will you be observing any special or culturally accepted way for expression of pain? 6. Are there any special considerations that need to be observed for newborn care?

A newly hired unlicensed assistive personnel (UAP) has consistently completed all assignments in a safe and timely manner. What is the most appropriate action by the charge nurse? 1. Assign more daily tasks to the UAP. 2. Provide positive feedback to the UAP. 3. Allow the UAP to work without supervision. 4. Teach the UAP to change surgical dressings.

2. Provide positive feedback to the UAP.

A nurse is participating in a community health fair for middle aged individuals. Which points should the nurse stress for decreasing the risk of stroke? Select all that apply 1. Reduce dietary intake of unsaturated fat. 2. Swim or walk most days of the week. 3. Treat obstructive sleep apnea, if present. 4. Drink five or more 8 ounce glasses of water daily. 5. Decrease smoking to less than ½ pack a day.

2. Swim or walk most days of the week. 3. Treat obstructive sleep apnea, if present. 4. Drink five or more 8 ounce glasses of water daily.

A client has recently been diagnosed with rheumatoid arthritis. The nurse anticipates which class of pharmacologic agents will likely be a part of the client's treatment regimen? 1. Mitotic inhibitors 2. Systemic glucocorticoids 3. Antifungals 4. Anticoagulants

2. Systemic glucocorticoids

What should a nurse include when preparing to educate a female client on how to prevent recurrent cystitis? Select all that apply 1. Drink at least eight, 4 ounce glasses of water per day. 2. Urinate as soon as the urge occurs. 3. Avoid irritating perineum with harsh soap. 4. Empty your bladder post coitus. 5. Avoid use of a diaphragm.

2. Urinate as soon as the urge occurs. 3. Avoid irritating perineum with harsh soap. 4. Empty your bladder post coitus. 5. Avoid use of a diaphragm.

A palliative care client is suffering from persistent diarrhea. What foods should the nurse suggest? Select all that apply 1. Applesauce 2. Rice 3. Bananas 4. Tea 5. Yogurt

1. Applesauce 2. Rice 3. Bananas

The nurse suspects a client admitted with myasthenia gravis is going into a cholinergic crisis. Which signs and symptoms would validate the nurse's suspicions? Select all that apply 1. Diarrhea 2. Increased urination 3. Dilated pupils 4. Tachycardia 5. Nausea and vomiting

1. Diarrhea 2. Increased urination 5. Nausea and vomiting Remember the pneumonic "DUMBELLS"

A client arrives at the emergency room with severe right foot pain and is admitted with a diagnosis of hyperuricemia (gout). The nurse is reviewing diet habits and life style with the client to develop a teaching care plan. The nurse has identified what habits that may contribute to an exacerbation of gout? Select all that apply 1. A daily glass of white wine 2. Bacon and eggs on weekends 3. Smoking two cigars every day 4. One half liter of soda daily 5. Baked cod twice a week 6. A BMI of 31.5 kg/m2

1. A daily glass of white wine 4. One half liter of soda daily 5. Baked cod twice a week 6. A BMI of 31.5 kg/m2

The nurse is caring for a client who is preparing to undergo a total hysterectomy for stage 4 cervical cancer. The client is crying and states, "I want to have more children, and I am unsure if I should have the procedure." What is the nurse's best action? 1. Allow the client to discuss her fears, and encourage her to talk more with her primary healthcare provider. 2. Discuss the fun things that she will be able to do after her surgery, and encourage her to make a list of positive things. 3. Explain to the client that her ovaries can be frozen for egg harvesting at a later time, and she can find a surrogate. 4. Advise the client to put off having the surgery until she is certain, and notify the surgeon of the decision.

1. Allow the client to discuss her fears, and encourage her to talk more with her primary healthcare provider.

When shopping at the mall, a nurse witnesses an individual collapse in cardiac arrest. A bystander begins CPR while the nurse opens an automatic external defibrillator (AED) brought by security. What critical actions should the nurse perform before delivering a shock? Select all that apply 1. Apply defibrillator pads to bare skin. 2. Verify that synchronizer button is on. 3. Continue CPR until advised to deliver shock. 4. Stop CPR while machine analyzes the rhythm. 5. Shout "clear" prior to activating shock button. 6. Apply cream under de-fib pads to prevent burns.

1. Apply defibrillator pads to bare skin. 3. Continue CPR until advised to deliver shock. 4. Stop CPR while machine analyzes the rhythm. 5. Shout "clear" prior to activating shock button.

A nurse is planning to provide education to a client wishing to breastfeed. What instructions should the nurse include when teaching this client? Select all that apply 1. Apply warm compresses to breast just prior to breastfeeding. 2. Establish a routine for breastfeeding. 3. Massage breasts during feeding. 4. Wear well-fitting bra continuously for first 24 hours after birth. 5. Wash hands before breastfeeding.

1. Apply warm compresses to breast just prior to breastfeeding. 3. Massage breasts during feeding. 5. Wash hands before breastfeeding.

A client diagnosed with a brain injury continues to attempt to get out of the bed without assistance. Which nursing interventions would the nurse implement? Select all that apply 1. Ask a familiar person to stay with the client. 2. Apply position change sensor to the bed. 3. Move client closer to the nursing station. 4. Reinstruct the client to not get out of the bed. 5. Provide positive and negative reinforcement.

1. Ask a familiar person to stay with the client. 2. Apply position change sensor to the bed. 3. Move client closer to the nursing station.

After reviewing the client assignments, the LPN/VN tells the RN the assignment is very unfair and requests that some of the clients be redistributed to the other staff. What should the RN do first? 1. Ask the LPN/VN how the client assignment should be adjusted. 2. Assign one of the LPN/VN's clients to another nurse. 3. Encourage the LPN/VN to use teamwork skills in caring for the clients. 4. Develop a strategic plan to assist with client assignments.

1. Ask the LPN/VN how the client assignment should be adjusted.

The nurse is caring for a client post heart transplant who is being discharged on cyclosporine and azathioprine. Which precautions would be important for the nurse to teach the client? Select all that apply 1. Avoid crowds. 2. Do not obtain live vaccinations. 3. Drink at least 3 liters of fluids per day and watch the urine for sediment. 4. Use a soft-bristled brush to clean your teeth. 5. Advise to use contraceptive measures during treatment.

1. Avoid crowds. 2. Do not obtain live vaccinations. 4. Use a soft-bristled brush to clean your teeth. 5. Advise to use contraceptive measures during treatment.

Which teaching points should the nurse include when preparing the school-age child for heart surgery? Select all that apply 1. Discuss postoperative discomfort and interventions. 2. Show unfamiliar equipment. 3. Explain that an endotracheal tube will be needed. 4. Let the child hear the sounds of an ECG monitor. 5. Answer questions about surgery using words at the child's level of understanding.

1. Discuss postoperative discomfort and interventions. 2. Show unfamiliar equipment. 4. Let the child hear the sounds of an ECG monitor. 5. Answer questions about surgery using words at the child's level of understanding.

A client who is 36 weeks gestation has been admitted to the labor and delivery area for evaluation due to worsening signs of pregnancy induced hypertension (PIH). The BP upon arrival is 168/96. While being monitored, she reports a sudden onset of severe abdominal pain. Further nursing assessment reveals vaginal bleeding, abdominal rigidity, and a fetal heart rate of 90/min on the fetal monitor. What nursing actions would be appropriate for this client? Select all that apply 1. Continuously monitor the client's vital signs. 2. Keep the mother informed of the fetus' condition. 3. Careful monitoring of the fetal heart rate electronically. 4. Accurate measurement of I & O. 5. Prepare for emergency vaginal delivery. 6. Monitor for restlessness and decreased level of consciousness (LOC).

1. Continuously monitor the client's vital signs. 2. Keep the mother informed of the fetus' condition. 3. Careful monitoring of the fetal heart rate electronically. 4. Accurate measurement of I & O. 6. Monitor for restlessness and decreased level of consciousness (LOC).

A medication has been prescribed to be administered through a medication or drug-infusion lock (intermittent peripheral venous access device). The nurse would implement which nursing interventions prior to administering an intravenous (IV) medication through a medication infusion lock? Select all that apply 1. Identify the client 2. Flush the medication lock with normal saline 3. Aspirate the medication lock for blood return 4. Clamp the IV tubing while flushing with saline 5. Verify the administration dosage of the medication 6. Assess the intravenous site for inflammation or infiltration

1. Identify the client 2. Flush the medication lock with normal saline 3. Aspirate the medication lock for blood return 5. Verify the administration dosage of the medication 6. Assess the intravenous site for inflammation or infiltration

A client is being evaluated for possible Rheumatoid Arthritis (RA). Which lab data and assessment findings by the nurse would be indicative of RA? Select all that apply 1. Joint pain, swelling, and warmth. 2. Decreased movement in joints. 3. Presence of Rheumatoid factor on lab analysis. 4. Presence of Dupuytren's contractures. 5. Elevated erythrocyte sedimentation rate (ESR). 6. Presence of Cyclic Citrullinated Peptide Antibody.

1. Joint pain, swelling, and warmth. 2. Decreased movement in joints. 3. Presence of Rheumatoid factor on lab analysis. 5. Elevated erythrocyte sedimentation rate (ESR). 6. Presence of Cyclic Citrullinated Peptide Antibody.

A nurse is monitoring a newly hired unlicensed assistive personnel (UAP) perform a bed bath on a client needing total care. Which action by the UAP would require further teaching? Select all that apply 1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus. 3. Makes certain bath water temperature is between 110-115°F (43-46°C). 4. Uses long, firm strokes to wash from wrist to shoulder of each arm. 5. Performs a back massage after completing the bath.

1. Lowers side rails on both sides of bed. 2. Washes eyes with mild soap and water from the inner to outer canthus.

What symptoms of meningeal irritation would the nurse anticipate when performing an assessment on a newly admitted client with a diagnosis of bacterial meningitis? Select all that apply 1. Positive Kernig's sign 2. Positive Brudzinski's sign 3. Presence of Babinski's reflex 4. Photophobia 5. Severe headache 6. Nuchal rigidity

1. Positive Kernig's sign 2. Positive Brudzinski's sign 4. Photophobia 5. Severe headache 6. Nuchal rigidity

A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. What interventions should the nurse initiate? Select all that apply 1. Provide a quiet environment 2. Pad side rails 3. Place on droplet precautions 4. Maintain head in midline position 5. Place ice packs under axilla for fever greater than 101°F (38.3°C)

1. Provide a quiet environment 2. Pad side rails 3. Place on droplet precautions 4. Maintain head in midline position

The out patient surgical unit has admitted multiple clients currently awaiting early morning procedures. What client should the nurse assess first? 1. The client awaiting repair of hiatal hernia reporting chest pain. 2. The client with a torn right rotator cuff reporting shoulder pain. 3. The client with an inguinal hernia repair reporting skin irritation. 4. The client awaiting a hemorrhoidectomy reporting rectal bleeding.

1. The client awaiting repair of hiatal hernia reporting chest pain.

The nurse is preparing to give a client's prescribed azithromycin dose. How many tablets will the nurse give to the client? Answer with numbers only. Prescription: Azithromycin 1 gram by mouth times one dose now Drug Cart: Zithromax 500 mg, 30 tablets

2

A client who is 20 weeks pregnant and diagnosed with pelvic inflammatory disease is given a prescription for metronidazole. What should the nurse inform the client to avoid in order to prevent an interaction with metronidazole? 1. Furosemide 2. Alcohol 3. Doxycycline 4. St. John's Wort

2. Alcohol

The nurse receives report about a client who is termed "a drug seeker". The nurse giving report states that the client does not need the pain medication and is just asking for medication because the client is "hooked on it." After receiving report, what actions should the nurse take? Select all that apply 1. Consult with the primary healthcare provider. 2. Assess the client. 3. Increase gradually the time between pain medication. 4. Encourage the client to wait longer before requesting the medication. 5. Utilize a pain scale to determine level of pain.

2. Assess the client. 5. Utilize a pain scale to determine level of pain.

A hospital has incorporated new equipment on all units without nursing or staff input. Frustrated staff members approach the nurse manager, requesting a resolution of the situation. What response by the nurse manager would be most appropriate? 1. "You are over-reacting to this new equipment." 2. "Perhaps you just need some further training." 3. "Unexpected changes can be difficult to accept." 4. "If we work together, everything will get better."

3. "Unexpected changes can be difficult to accept."

The nurse is providing care to a client who had an endoscopic retrograde cholangiopancreatogram (ERCP) two hours ago. Which finding would indicate a possible complication? 1. Occasional cough 2. Sore throat reported 3. Abdominal pain rated 8/10 4. Drowsy

3. Abdominal pain rated 8/10

The nurse is caring for a client diagnosed with deep vein thrombosis, who has been treated with intravenous heparin for one week. The primary healthcare provider plans to change the medication from heparin IV to warfarin sodium by mouth. The nurse understands which approach would be appropriate? 1. Begin the warfarin sodium and stop the heparin simultaneously. 2. Stop the heparin 24 hours, then begin the warfarin sodium. 3. Begin the warfarin sodium before stopping the heparin. 4. Stop the heparin, wait for the coagulation studies to reach the control value, and begin the warfarin sodium.

3. Begin the warfarin sodium before stopping the heparin.

Which task would be appropriate for the charge nurse to assign to a LPN/VN? 1. Assessing a client who was just admitted to the unit. 2. Administering morphine IV push to a two day post-op client. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a PICC line that a client accidentally pulled out.

3. Bolus feeding a client who has a gastrostomy tube.

A client is sedated. His wife asks the nurse about her husband's test results. The client does not have a healthcare proxy or durable power of attorney executed at this time. How should the nurse respond in compliance with HIPAA (Health Insurance Portability and Accountability Act) regulations regarding the confidentiality of the sedated client's health information? 1. I can't give you those results. You should ask his primary healthcare provider the next time that he comes in to examine your husband. 2. Those test results are confidential, but since you are his wife I can give them to you. Let me look them up in the computer system. 3. The health information of all clients is confidential and is protected by law. Those test results cannot be released without the consent of the client in order to protect the client's right to choose who receives health information. 4. Your husband is only lightly sedated. I can wake him up and ask him if it is all right to release these test results to you.

3. The health information of all clients is confidential and is protected by law. Those test results cannot be released without the consent of the client in order to protect the client's right to choose who receives health information.

The charge nurse is making assignments for the evening shift. Which client would be an appropriate assignment for a new LPN/VN graduate? 1. A middle aged adult admitted with syncope. 2. An adolescent with skin grafts to right hand. 3. A young adult receiving IV chemotherapy. 4. An elderly adult diagnosed with diverticulitis.

4. An elderly adult diagnosed with diverticulitis.

The nurse is caring for a post op client who is drowsy but arousable. The client will take a few deep breaths when instructed but drifts to sleep when left alone. The O2 saturation while sleeping drops to 82% on 3 liters of nasal oxygen. The client received a dose of oxycodone/acetaminophen 2 tabs one hour ago. What is the nurse's best action at this time? 1. Keep the O2 sat machine at the bedside and set the alarm to beep loudly when O2 sat drops below 93%. 2. Give bath to arouse client and then report that oxycodone/acetaminophen 2 tabs is too much for next dose. 3. Let the client sleep until he has rested, then discuss abuse potential of narcotics. 4. Call the primary healthcare provider and report client assessment findings.

4. Call the primary healthcare provider and report client assessment findings.

An elderly homeless client is brought to the emergency room for evaluation following a fall. What assessment findings by the nurse should be reported immediately to the primary healthcare provider for further evaluation? 1. The client is unsteady when walking to the bathroom. 2. The client cannot state day, date or present location. 3. The client refuses to remove either shoes or socks. 4. The client has loss of sensation below the left knee.

4. The client has loss of sensation below the left knee.

A client returns to the unit after having extracorporal lithotripsy. Which assessment finding by the nurse would be the best indicator that the treatment has been effective? 1. Decreased urinary retention 2. Absence of hematuria 3. Increased urinary output 4. Tiny fragments noted in strainer after voiding

4. Tiny fragments noted in strainer after voiding

A client on routine dialysis asks the nurse about the process of a family member donating a kidney. In what order should the nurse explain the steps for kidney organ donation? a. The recipient and donor will be assessed and treated for any dental caries. b. The recipient will receive immunosuppressive agents. c. The donor and recipient will undergo tissue typing and antibody screening. d. The donor will undergo a psychosocial examination and counseling. e. The recipient will undergo hemodialysis.

c. The donor and recipient will undergo tissue typing and antibody screening. d. The donor will undergo a psychosocial examination and counseling. a. The recipient and donor will be assessed and treated for any dental caries. e. The recipient will undergo hemodialysis. b. The recipient will receive immunosuppressive agents.

In what order should the nurse assess assigned clients following shift report? What would be the priority order? a. Client on ventilator needing a nasogastric tube feeding. b. Client with emphysema who has a pulse oximetry reading of 89%. c. Newly admitted client diagnosed with esophageal cancer. d. Client reporting shortness of breath after receiving a bronchodilator respiratory treatment. e. Client two hour post lobectomy.

d. Client reporting shortness of breath after receiving a bronchodilator respiratory treatment. e. Client two hour post lobectomy. c. Newly admitted client diagnosed with esophageal cancer. a. Client on ventilator needing a nasogastric tube feeding. b. Client with emphysema who has a pulse oximetry reading of 89%.