NCLEX Book Chapter 6-15
A client has pain at the peripheral IV site. The nurse determines the IV is not infusing, assess the site, and finds the area swollen, pale, and cool to touch. What is the best nursing action? A: D/C the IV and apply warm, moist packs to the involved area B: slow the IV infusion and see whether the swollen area decreases C: Notify the healthcare provider regarding the status of the IV D: D/C the IV and start another IV in the same vein, distal to the current site
A
A client is being referred to the hospice nurse for care. The nurse explains to the client and the family that the primary goal of hospice differs from the goal of traditional care in what way? Hospice care A: provides support to the family and to the client with a terminal illness B: is delivered only at home, so that no extraordinary means are initiated to prolong life C: provides a medicare-supported pain regimen so pain medications are affordable D: more readily recognizes advance directives related to the right to die
A
A client is diagnosed with an immunodeficiency disease. The nurse would understand what characteristic of this condition? A: occurs when a client's body is unable to defend itself from an invading microorganism B: creates a severe, sudden problem that is characterized by increased vascular permeability C: is precipitated by the destruction of the normal lymphocytes in the attempt to reduce the serum level of the antigen D: is a condition in which the normal immune response is interrupted and the body cells do not recognize healthy tissue
A
A client is receiving busulfan. The nurse would notify the physician regarding which assessment finding? A: persistent, nonproductive, dry cough B: hemoglobin 13, hematocrit 38% C: nausea and vomiting D: low serum uric acid
A
A client with AIDS has several cutaneous lesions identified as Kaposi sarcoma. How will the nurse care for these areas? A: Gently cleanse the areas, keeping them dry and free from abrasions B: Place sterile, saline-soaked gauze over the areas C: Apply a topical corticosteroid cream D: Decrease infection by applying an antibiotic ointment
A
A nurse is caring for a client who received a penicillin injection about 15 minutes earlier. The client complains if itching around the mouth, and this rapidly progresses to severe dyspnea and respiratory distress. What are the priority nursing action? A: anticipate need for possibility of endotracheal intubation, begin oxygen, call for assistance, and obtain emergency cart B: place the client in supine position and assess for patent airway and presence of breath sounds C: start oxygen at 6 L/min via nasal cannula; review chart for history of penicillin allergy D: place the client in semi-fowlers position, perform a chin lift to open the airway, and assess for air movement
A
An infant has an active acquired immunity. Which statement best explains this type of immunity? A: The infant has received immunizations B: immunity was transferred from mother to the infant C: the infant is recovering from a childhood disease that conferred immunity D: The infant has received gamma globulin after exposure to hepatitis
A
At the shift hand-off report, a nurse is told that one of her clients is becoming tolerant to his pain medication. what nursing observation would be in agreement with this conclusion? A: the current medication order, which has previously been effective, is no longer providing adequate pain relief B: the client becomes irritable and confused before the next scheduled dose of medication C: pain medication is being administered every 3 to 4 hours around the clock for adequate pain relief D: the client is sleeping and arouses with physical and verbal stimulation but is very lethargic
A
The nurse is assessing an IV site after the client has verbalized an increase in tenderness. The site is inflammed, streaks of inflammation are progressing up inside the client's arm, and the fluid is continuing to infuse at the prescribed rate. What is the best nursing action? A: remove the catheter and place warm packs on the area B: lower the IV bag below the site to determine whether there is blood return in the line C: Determine what medications the client is receiveing that may have caused the irritation D: Decrease the rate of the infusion to decrease the discomfort
A
The nurse is assisting a client to ambulate. Upon standing at the bedside, the client becomes weak, says "I feel dizzy" and sits back down on the bed. What should the nurses next action be? A: lay the client down in bed B: obtain a blood pressure C: ask the client to try again D: find additional help for ambulation
A
The nurse is assisting a client with his antiretroviral therapy. What can the nurse do to help the client take his medication as prescribed? A: assess the client's activities of daily living and his lifestyle routine to determine when he can most easily remember to take his medications B: provide the client with brochures that explain the side effects of the medications and why it is so important for him to adhere to his medication schedule C: plan for him to visit with other clients who use the same antiretroviral therapy and have them explain to the client how they handle their medications D: Emphasize to the client how important it is to take the medications on the schedule prescribed so that the virus will not get stronger
A
The nurse is caring for a client who is categorized as HIV positive, acute infection. What would the nurse anticipate finding on the nursing assessment? A: fever, swollen lymph glands, nausea B: confusion, wasting syndrome, localized infections C: dyspnea, dementia, persistent fever D: night sweats, low-grade fever, generalized lymphadenopathy
A
The nurse is caring for a client with excess fluid volume. Which action will best evaluate a change in the client's condition? A: Obtaining the client's daily weight before breakfast each day B: measuring fluid intake and output and comparing with values from the previous day C: assessing the blood pressure and comparing it with previous readings D: auscultating the lungs for the presence of advenitious breath sounds
A
The nurse is involved in a legal case against the hospital. Which judgement error by the nurse would be considered most damaging? A: Making illegal changes in the chart B: Arguing with the plantiff over the case C: Withholding information from the hospital attorney D: Being argumentative while on the witness stand
A
The nurse is reviewing the chart of a client who recently had a cervical biopsy. The test results indicate Tis, N0, M0. How will the nurse interpret this information? A: the cancer is in situ, which means it is localized and not invasive at this time B: the origin of the cancer is probably in the uterus, and further testing will be necessary C: the lymph nodes are involved, and the presence of distant metastasis cannot be determined D: there is no cancer present, the tissue was normal
A
The nurse is reviewing the health care provider's prescriptions for a new client returning from the post anesthesia care unit. The client is NPO with a naso gastric tube and stable vital signs. Which prescription should the nurse question? A: 20 mEq potassium IV push B: 1000 m D5 1/2 NaCl to infuse at 125 ml/hr C: Assist client to dangle at bedside in morning D: Mefoxin 1 gm IV in 50 ml D5W over 30 minutes
A
The nurse is working on the pediatric unit and receives a phone order from the doctor for a 10-year-old client who weighs 40 kg. The order is for ceftazidime 1.5 gm every 8 hours IV. The therapeutic range is 90-150 mg/kg/24 hr. What would be the best nursing action? A: Administer the medication because it is within the therapeutic dose range B: Call the doctor to clarify the order because it is outside the therapeutic range C: call the hospital pharmacist and ask him or her to calculate the dosage Notify the nursing supervisor and request assistance
A
The physician orders an IV piggyback of cefotetan 1 gm in 100 ml D5W to run over 30 minutes. The drop factor for the tubing is 10 gtt /ml. At what rate in drops per minute would you run the IV? A: 33 B: 25 C: 12 D: 50
A
Which of the following biologic agents are disseminated by airborne release? A: botulism and anthrax B: anthrax and plague C: plague and smallpox D: botulism and smallpox
A
Which of the following conditions satisfies a green triage tag to an emergency triage scenario? A: A broken thumb from falling debris B: Burns over 98% of body from a chemical fire C: A 3 inch laceration on the forearm from window glass in a building explosion D: tension pneumothorax
A
Which of the following is a Centers for Disease control and prevention (CDC) category A biologic agent? A: smallpox B: sarin C: west nile D: tritium
A
Which of the following is an example of a level 2 disaster? A: train derailment that spills hazardous chemical into a small city B: a tsunami that strikes a major metropolitan area C: a three-alarm house fire D: a novel virus pandemic
A
Which of the following most clearly represents a situation of assault? A: in the emergency department, a client is intoxicated and verbally abusive; the nurse tell hime she will put him in restraints if he does not quit talking B: a client is in labor and has not received any medication for pain; she tell the nurse she does not want anything for pain; the nurse administers the pain medication ordered C: the client advises the nurse that he is leaving; the nurse tell the cleint that he cannot leave and threatens to restrain him if neccesary. D: a pastor calls regarding a client's condition; the nurse provides the pastor with detailed information regarding the client's condition
A
A client in the emergency department has been hydrated with normal saline over the last hour for hypovolemia. Assessment changes now include a rapid, bounding pulse and shortness of breath. What additional information would the nurse want to gather? Select all that apply A: Blood pressure B: LOC C: urinary output D: hemoglobin level E: oxygen saturation
A, B, C, E
The nurse is documenting information regarding an IV insertion. What info is important to include? Select all that apply A: time and date of insertion B: type of catheter and size C: name of vein used D: status of fluid infusing E: protective measures used F: Who ordered the IV and at what time
A, B, D
The nurse is performing a dressing change on a client who has a staphylococcus infection in an abdominal incision. Which infection-control precautions will the nurse implement? Select all that apply A: wear clean gloves to remove the old dressing B: put on a gown when entering the room C: wear a face shield D: dispose of the gown and mask in container outside the cleint's door E: leave all extra dressing supplies in the room F: carefully cleanse the stethoscope and scissors before taking them out of the room
A, B, E,
The nurse is planning to educate colleagues on best practices in decreasing central line infections. What practices should be included in staff education? Select all that apply A: follow agency policy for dressing and tubing changes B: use clean technique when changing caps and dressings C: report sites that are reddened D: change dressing that have moisture E: gauze dressings need changing less frequently
A, C, D
The nurse recognizes which of the following conditions as an oncologic emergency? Select all that apply A: cardiac tamponade B: leukopenia C: SIADH D: hypercalcemia E: hypophosphatemia F: tumor lysis syndrome
A, C, D, F
A client is scheduled for a total hip replacement, and he has a history of using several herbal and vitamin products. What would the nurse advise the client to discontinue at least 2 weeks before surgery? Select all that apply A: garlic B: vitamin C C: ginger root D: St. johns wart E: ma huang F: Black cohosh
A, C, E,
The nurse is preapring discharge teaching for a woman newly diagnosed with SLE. What will be important for the nurse to include in the teaching plan? Select all that apply A: wear sunscreen and protective clothing when in direct sunlight B: avoid nonsteroidal antiinflammatory drugs to prevent bleeding episodes C: Plan acitivites that encourage range of motion in extremities D: advise the client that pregnancy is contraindicated E: observe fingertips for changes in circulation F: help the client prioritize self-care activity
A, C, E, F
Which of the following statements are correct about latex allergy. Select all that apply A: typical reactions include skin redness, urticaria, and rhinitis B: latex allergy involves type 1 allergic reactions C: the more frequent the exposure to the latex, the more likely a person will develop an allergy D: hand lotions should be applied before putting on gloves to reduce exposure E: wash hands with mild soap after removing gloves F: persons should wear a medic alert bracelet and carry an epinephrine pen
A, C, E, F
The nurse is caring for a client who had a stroke (brain attack) 3 months ago and is taking warfarin 5 mg by mouth (PO). the client tells the nurse she has started taking some herbal and vitamin supplements. She gives the nurse a list of the supplements she is taking. What supplements would cause concern for the client who is on warfarin? Select all that apply A: garlic B: cyanocobalamin (vitamin B12) C: St. Johns wart D: vitamin E E: Saw palmetto F: ginkgo biloba
A, D, F
A client has developed stomatitis while receiving chemotherapy. What would be an appropriate intervention to suggest for the pain associated with the stomatitis? A: use lemon-flavored glycerin swabs B: apply antacid coating solutions and vicious lidocaine C: brush oral plaques off with a soft toothbrush D: have client swish mouth with a weak hydrogen peroxide solution
B
A client is going to begin external radiation therapy for his lung cancer. Which comment by the client would indicate to the nurse the need for additional teaching? A: i will shower with a mild soap and check my skin for areas of redness B: i am looking forward to swimming laps again for my exercise C: i am going to eat small meals and increase the protein and fiber in my diet D: i will use only unscented emollient creams to the dry skin areas on my chest
B
A client returns to the clinic to receive evaluation of his routine purified protein derivative (PPD) test for tuberculosis screening. The test result is positive. What is the best nursing interpretation of this information? A: this is a serious type II reaction and could indicate that he has active tuberculosis; he will need further evaluation immeditely B: The positive results indicate the client has been exposed to tuberculosis bacilli and has had a delayed type IV response C: the client's immune system has been compromised. which allows the immune system to build up antibiodies against the pathogen D: an autoimmune response has occurred, and the client will need further evaluation to determine appropriate treatment
B
A woman explains to the nurse she thinks she has been exposed to HIV. However, she had a test 1 week after the exposure, and the result was negative. What is most important for the nurse to explain to this client? A: Make sure she understands the importance of safe sex practices, espeically the use of condoms and contraceptive practices to prevent pregnancy B: Even though the client tested negative, she needs to have a series of follow-up blood tests because of the possibility of seroconversion C: it is important that she obtain counseling regarding the transmission of the virus and how she may protect herself and her partner D: the client should abstain from sexual activity for the next three months until the blood test confirms she is negative for HIV
B
The doctor has indicated that ampicillin and gentamicin are to be given piggyback in the same hour, every 6 hours. (12-6-12-6). How would the nurse administer these drugs? A: Combine the drugs into 100 ml NS and administer B: give each drug separately, flushing between drugs C: retrograde both drugs into the tubing D: give one drug every 4 hours and the other every 6 hours
B
The nurse is administering medications to a client who has no allergy band on his arm. The nurse tells the client she has his penicillin medication. The client states that the last time he had penicillin, it made his mouth tingle and his hands itch. What would the best nursing action? A: administer the medication because there is no indication that the client is allergic to penicillin B: hold the medication and contact the physician regarding the client's statement about his previous experience with penicillin C: hole the medication and review the client's chart to determine whether there is a penicillin allergy noted D: notify the nursing supervisor regarding the cleint's statement and request further evaluation of the client
B
The nurse is assessing a client after beginning external radiation. What is a nursing observation that confirms the presence of early side effects of the radiation? A: a gradual weight loss and GI disturbances B: skin erythema followed by dry desquamation C: vertigo when sitting up quickly D: excoriation and blisters on the affected skin
B
The nurse is caring for a client who is experiencing a severe anaphylactic reaction caused by an allergy to peanuts. After administering subcutaneous epinephrine and beginning oxygen administration, what would be the next most important nursing action? A: administer analgesics to relieve the pain B: start an IV for fluid administration C: insert a catheter to determine urinary output D: obtain a history of possible reactions to penicillin
B
The nurse receives report on assigned clients. One client is reported to be at the nadir for his cancer chemotherapy. How will this affect the nursing care plan? A: implement bleeding precautions B: reinforce measures and teaching regarding preventing infections C: anticipate nutritional problems caused by nausea and vomiting D: assess for problems with fluid balance
B
To evaluate the progress of the client's systemic lupus erythematosus , the nurse evaluates which data? A: increased serum complement fixation, which correlates with reduction of butterfly rash B: increasing the levels of C-reactive protein and erythrocyte sedimentation rate C: overall bone marrow proliferation, which correlates with symptoms of inflammation D: presence of antinuclear antibodies, which correlates with a diminishing immune process
B
What should the nurse take into consideration when giving medication to an older client? A: the serum albumin level of an older adult is lower, thus decreasing drug metabolism B: the older client metabolizes and excretes at a decreased rate C: medication affects the older client during the early hours of the morning D: medication has an increased effects on the respiratory system of the older adult client
B
Which of the following is a comprehensive incident management system intended for use in both emergent and nonemergent situations for hospitals and health care agencies A: NIMS: national incident management system B: HICS: hospital incident command system C: START: simple triage and rapid treatment D: DIME: delayed, immediate, minor, expectant
B
Which of the following is an example of a level 1 disaster? A: category 5 hurricane B: three-car automobile accident with injuries C: F-4 tornado destruction through three cities D: 8.0 scale earthquake in a coastal city
B
Which of the following potential bioterrorism agents has three routes of exposures to humans? A: smallpox B: anthrax C: botulism D: tularemia
B
While caring for an 8 year old child with a broken wrist, the nurse notices red, raised streaks on the child's back. The child's father enters the room and the child becomes quiet and distant, leaning away from the father as he approaches. What is the best nursing action? A: Chart that the child was probably beaten by the father B: Notify the supervisor to report possible child abuse C: Disregard suspicions and care for the immediate needs of the child D: no action is required; there is no actual proof of abuse to the child
B
A client asks the nurse why he has to take several chemotherapy agents at the same time. the nurses response would be based on which principle? A: the more medications that can be given together, the shorter the treatment period B: the cost is decreased becuase the medications are administered at the same time C: multiple medications given together will attack the cancer cells at different levels D: one medication will interact with another teo reduce incidence of side effects
C
A client has just received 250ml of packed cells and is now reeiving 1000ml of D5W at 150ml/hr. The client tells the nurse that he feels dizzy and has a headache. the nurse observes the distended jugular veins with the client in a semi-fowler's position. What should be the nurse;s initial response? A: notify the health care provider of the client's symptoms B: check vital signs C: reduce the D5W infusion to keep vein open rate D: lay the cleint flat
C
A client is receiving chemotherapy with several antineoplastic agents. Which nursing observation is considered a common side effect of chemotherapy? A: slow, slurred speech B: increased leukocytes on complete blood count C: Stomatitis and oral ulcers D: Sinus dysrhythmias with bradycardia
C
A client who is being seen at the urgent care clinic with complaints of abdominal pain tells the nurse he has been taking kava. Which nursing intervention would be a priority at this time? A: Obtain the ECG results B: assess breath sounds and respiratory effort C: review liver function studies D: review complete blood count results
C
The nurse enters data on a paper chart and then discovers the entry was written on the wrong chart. How is this error best corrected? A: white-out the wrong info and write over it B: Recopy the page with the error so that the chart will be neat C: Draw a straight line through the error, initial, and date D: Obliterate the error so that it will not be confusing
C
The nurse is caring for a client who is being treated with chemotherapy for his lung cancer. The client has had two treatments in the last two days, and the nurse notes hyperkalemia and hyperuricemia on the latest serum laboratory values. The nurse understands that these are symptoms of A: third-space syndrome B: syndrome of inappropriate antidiuretic hormone C: tumor lysis syndrome D: parathyroid deficiency
C
The nurse is caring for a client with an acute onset of shortness of breath and a respiratory rate of 28 breaths per minute. Arterial blood gases are pH 7.20; paCO2 47, HCO3- 24. What is the priority plan of care? A: slow the respiratory rate with relaxation and sedation B: improve the pH by administering sodium bicarbonate C: determine a cause of the shortness of breath with further assessment D: intubation to maintain respiratory effort
C
The nurse is caring for an older adult client with edema, tachycardia, hypertension, and jugular venous distention. Which nursing action should the nurse prioritize to evaluate the client's fluid status? A: measure the intake and output (I&O) B: check for thirst and skin tugor C: evaluate changes in daily weight D: evaluate vital signs every four hours
C
The nurse is evaluating a central venous line before administering the client's chemotherapy . What observation would cause the nurse the most concern? A: nurse is unable to withdraw blood into line B: dressing was changed 24 hours ago C: inflammation and exudate are present at the insertion site D: fluid infusing is D5W and 0.45% normal saline
C
The nurse is preparing to administer an intramuscular injection to an infant who is 8 months old. Which muscle would be the most appropriate injection site? A: deltoid B: dosogluteal C: vastus lateralis D: ventrogluteal
C
The nurse prepares a liquid medication and then finds that the client no longer needs the medication. What is the most appropriate nursing action? A: to keep the count correct, record that the dose was taken B: charge for the dose because it must be paid for C: record the medication as not taken and discard the poured dose D: pour the medication back into the container
C
The nurse understands what major difference between benign and malignant tumors? Malignant tumors A: are encapsulated and immovable B: grow at a faster rate than benign tumors do C: invade adjacent tissue and metastasize D: cause death, whereas benign tumors do not
C
What is a common side effect of radiation therapy that is not associated with the effect of radiation in the treatment field? A: reddened skin B: bone marrow suppression C: fatigue D: GI disturbance
C
What is the first step the nurse should take to ensure that the right medication is being given to the client? A: check the client's ID band B: read the information insert for directions as to correct administration C: check the order with the medication administration sheet D: check the expiration date on the medication
C
What is the most likely source of exposure in a biologic weapon attack? A: absorption B: adsorption C: inhalation D: dermal
C
What is the nurse's best approach to avoid claims of negligence? A: a strong and binding contract for services B: adherence to all hospital policies C: competent practice of nursing D: keeping a current license
C
What would not be considered a violation of HIPAA? A: providing client information to an individual who claims to be a family member B: allowing a student nurse, who is taking care of the client, to make copies of laboratory results C: Discussing the client's condition on the telephone with a family member who has provided the client's information code D: reviewing the client's chart with the CEO of the hospital who is the client's brother in law
C
Which of the following events is an example of a level three disaster? A: a small building collapse that traps 111 workers B: a bus accident carrying 13 passengers C: an 8.0 scale earthquake in a major city D: F-4 tornado destruction through three cities
C
Which of the following is not considered a component of the medical assests stored in a strategic national stockpile? A: antibiotics B: ventilators C: Chemical antidotes D: personal protective equipment
C
Which term describes the sorting of clients according to medical need when resources are unavailable for all persons to be treated? A: tasking B: delegating C: triage D: prioritize
C
Which would the nurse identify as an indication that the client understands the informed consent document? A: the client states that the physician has explained the procedure to him B: the nurse finds the informed consent form already signed C: the client can give a return verbal explanation of the informed consent document D: the client states that his wife read it and said it was okay
C
The nurse understands that the following are general adverse effects of anitneoplastic drugs. Select all that apply. A: urinary retention B: infertility C: stomatitis D: bone marrow depression E: extravasation F: nausea
C, D, F
A client has returned to the room from the postoperative recovery area. He is lethargic but responsive. He has O2 via nasal cannula at 4 L/min and an IV infusing at 125 ml/hr. On the initial nursing assessment, the nurse notes that the O2 saturation is 82%. what is the prioirty nursing action? A: perform a complete neuro check B: increase the O2 flow and recheck the pulse oximetry C: suction the client and recheck the vital signs D: stimulate the client to cough and deep breath
D
A client has systemic lupus erythematosus (SLE). What statement best describes the client's immune response? A: a delayed hypersensitivity that is cell mediated B: an immediate reaction to prior exposure C: an immune complex that forms with antibody production D: an immune response that no longer recognizes normal body tissue
D
A client is being seen in the emergency department after an accident. He has no obvious physical injuries, and his blood pressure is 158/90. He is crying loudly, wringing his hands, and pacing the floor. His respiratory rate is 32 breaths/min and he says he feels lightheaded. What is the best nursing response? A: have him lie down and begin O2 per nasal cannula at 4 L/min B: pt him on a stretcher and begin a head-to-toe assessment C: Perform a quick neurologic exam to determine his level of orientation D: have him sit down and help him breathe into a brown paper sack
D
A client is worried he may have been exposed to AIDS. What will be important for the nurse to explain to the client? A: Symptoms of AIDS will develop immediately in sexually active individuals B: clients may remain asymptomatic for an indefinite period of time C: symptoms of AIDS are usually seen before the cleint is found to be HIV-positive D: after exposure to the virus, symptoms may develop within 6 to 12 weeks or as late as 6 months
D
A client with a diagnosis of AIDS has developed P. jiroveci pneumonia. What will be important for the nurse to include in the nursing care plan? A: put a mask on the client whenever he has visitors in his room B: explain to the client why he cannot go outside his room C: wear a mask and gown when providing direct care to the client D: wear a gown and gloves when assisting the client with personal hgyiene
D
An older adult client has a prescription for continuous fluid replacement at 75 ml/hr. the nurse is preparing to start the IV. which option would be best? A: a 22-gauge butterfly needle, right arm antecubital area B: An 18-gauge, 3 inch IV cannula, inserted in the left hand C: an 18-gauge, 1 inch IV cannula in the antecubital area of left arm D: a 22 gauge 1-inch IV cannula, top of the left hand
D
The client is receiving an IV of 0.9% NaCl at 125ml/hr. The client had a colon resection this morning. He has a nasogastric tube to suction and an ileostomy, and he is becoming increasingly restless. The nurse reviews the serum lab values. Which value should the nurse consider a priority? A: blood urea nitrogen 28 mg/dL B: serum glucose 155 mg/dL C: hemoglobin 13.5 mmol/L D: Sodium 155 mEq/L
D
The national preparedness goal has now focused efforts in preparing for, responding to, and recovering from A: bioterrorism events B: chemical terrorism events C: natural disaster events D: all-hazard events
D
The nurse is admitting a 5-month-old infant. The health care provider has ordered an IV solution of normal saline. There is also an order for potassium chloride (KCl) to be added to the solution. the infant's temperature is 101 degrees rectally, and the pulse is 120 beats/min, the infant is irritable and has not voided. What is the priority nursing action? A: Wait for 1 hour from admission time and then begin the infusion of normal saline with the KCl B: Feed the infant before adding the KCl to the infusing solution C: consider the order a stat order and begin the infusion immediately D: start the normal saline infusion and hold the KCl until adequate urinary output has been documented
D
The nurse is admitting a client from the post anesthesia care unit. Postoperative prescriptions incude D5 1/2 NS with 40 mEq/L of KCl at 100 ml/hr. The current liter of lactated ringer's solution has 450 ml left in the bag. What should the nurse's next action be? A: finish the current liter at 100 ml/hr B: assess urine output C: change the solution to D5 1/2 NS with 40 mEq/L KCl at 100 ml/hr D: Assess the IV site
D
The nurse is admitting a client with type 1 diabetes. What values on the arterial blood gased would indicate the client is developing a complication because of his poorly controlled diabetes? A: PaCO2 48, pH 7.34, PaO2 98, HCO3 24 B: PaCO2 33, pH 4.48, PaO2 88, HVO# 26 C: PaCO2 40, pH 7.45, HCO3 32, O2 Saturation 90% D: PaCO@ 38, pH 7.31, HCO3 20, base excess -2
D
The nurse is reviewing with a certified nursing assitant (CNA) the care for a child who is diagnosed with acquired immunodeficiency syndrome (AIDS) and has developed P. jiroveci pneumonia. Which of the following precautions would the nurse review with the CNA? A: strict handwashing B: airborne precautions C: contact precautions D: standard precautions
D
The nurse is updating a teaching plan for a client who has cancer and has been taking doxorubicin for the past several months. What is important to review with the client? A: report symptoms of hematuria B: increase intake of oral fluids C: avoid folic acid intake D: report symptoms of dyspnea
D
The nurse is verifying whether to give a medication to a client. What would be the first nursing action? A: check the client's name and hospital band B: validate the expiration date of the drug C: determine the appropriate route of delivery D: review the orders on the medication administration record
D
The nurse stopped on the highway at a multiple-fatality accident to provide assistance. Immediately after the incident, the family members wee appreciative of the help the nurse provided. they offered to replace the nurse's soiled clothes. If the nurse accepts, which rights were in violation? A: ANA Code of Ethics B: HIPAA C: Patient Self-determination act D: good samaritan act
D
The nurse understands that there are no isolation precations for patients with A: TB B: plague C: smallpox D: botulism
D
The physician asks the nurse to give a client a medication to which the nurse knows the client has reported an allergy. When the nurse tries to point this out to the physician, the physician threatens to tell the nurses supervisor. What is the best response? A: tell the physician to give the medication himself B: walk away and ignore him C: agree to give the medication but do not initial the dose D: suggest a meeting involving the nurse, supervisor, and physician
D
What are the nursing interventions regarding care of a client with a vaginal radium implant? A: clamp and drain the urinary retention catheter B: provide a high-residue diet C: place the client in a semiprivate room D: raise the head of the bed no more than 20 degrees
D
What is an important aspect of client teaching regarding external radiation therapy? A: remain isolated after treatment B: fast before the treatment C: schedule treatments monthly D: leave skin markings between treatments
D
A client is receiving IV antibiotic therapy. The order is methicillin 750 mg IV. The nurse has a vial on hand that contains 1 gm. the instructions for reconstitution say add 1.5 ml sterile water. Reconstituted solution will contain 500 mg methicillin per milliliter. How much will the nurse give?
1.5 ml
The nurse is preparing medications for a client. The medication order is for cerfaclor 0.1 gm PO. The dose available in the unit is 125 mg/5 ml. How many ml will the nurse need to give?
4
The physician calls the unit and leaves an order for a client. The order is for cefaclor 0.1 gm PO. The dose available in the unit is 125 mg/5 ml. How many ml will the nurse give?
4
A client with cushings syndrome is admitted to the medical-surgical unit. During the admission assessment, the nurse notes that the client has a flat affect but is irritable when questioned, has a poor memory, reports a loss of appetite, wants to sleep all the time, and doesn't care if she gets well. what collaborative action should the nurse take in response to this information? A: discuss with the health care provider a concern for depression B: request a neurology consult for a CT scan C: discuss with the dietician a need for a nutritional consult D: request a social service consult for home evaluation
A
A nurse is urgently called to a homebound neighbor's house. the neighbor is found unconscious and has a history of insulin-dependent diabetes. After determining there is no functioning glucometer available, what should the nurse's next action be? A: administer 10 units of regular insulin subcutaneously B: arouse the client to drink 4 to 6 ounces of orange juice C: administer glucagon 1 mg subcutaneously D: find a phone to call EMS
C
An older adult client has an open wound over the coccyx that extends through the dermis and subcutaneous tissue, exposing the deep fascia. The wound edges are distinct, and the wound bed is pink-red color. There is no bruising or sloughing. The nurse would correctly document this ulcer at what stage? A: stage I B: stage II C: stage III D: stage IV
C
Combined therapy of radiation and chemotherapy can have a significant therapeutic impact on the survival of an individual with cancer. The nursing priority for these cleints includes measures to A: monitor for acute renal tubular necrosis B: control nausea and vomiting C: prevent infection D: maintain hydration and nutrition
C
The mother of a 15-month-old child who is immunocompromised asks about continuation of the childhood vaccines. Which immunizations are not recommended to be given to the child during immunosuppression? A: Diphtheria, tetanus, and pertusis ; hepatitis B B: haemophilus influenzae B C: varicella; MMR D: inactivated polio, DTAP
C
What is an allergic reaction that can quickly deteriorate into shock and death? A: anaphylaxis B: graft-versus-host disease C: type III, immune complex formation D: delayed sensitivity
A
What physical characteristics of a client would place the client at highest risk for development of malignant melanoma? A: light to pale skin, blond hair, blue eyes B: olive complexion, oily skin, dark eyes C: dark skin with freckles, dry flaky skin, hazel eyes D: course skin, ruddy complexion, brown eyes
A
A client is receiving IV antibiotic therapy. The order is for methicillin 750 mg IV. The nurse has a vial on hand that contains 1 g. The instructions for reconstitution say to add 1.5 ml sterile water. Reconstituted solution will contain 500 mg methicillin per milliliter. How much will the nurse give?
1.5 ml
A client is receiving NPH insulin 20 units subcutaneously at 0700 bolus daily. At 3 pm, the nurse finds the client apparently asleep. What priority nursing action should the nurse perform to assess for a hypoglycemic reaction? A: feel the client and bed for dampness B: observe the client for Kussmaul respirations C: smell the client's breath for acetone odor D: note if the client is incontinent of urine
A
A client is admitted to the inpatient psychiatric unit for medically monitored detoxification from alcohol. which of the following actions would be included in the client's plan of care? A: encourage increased fluid intake B: order a high-protein, high-fat diet C: provide a high-sodium, low-carbohydrate diet D: encourage ambulation and deep breathing
A
A parent and an 8-month-old child come into a public heath clinic for a well-child checkup. The parent tells the nurse the child has been crying more than usual. What information obtained during the nursing assessment would cause the nurse the most concern? A: crying when sucking on his bottle B: crying when placed in crib at night C: on-and-off crying throughout the day D: crying when left at the child care center
A
A patient with a pituitary tumor is treated with a transsphenoidal hypophysectomy. What would be a priority postoperative action? A: ensure that any clear nasal drainage is tested for glucose B: maintain the patient flat in bed to prevent cerebrospinal fluid leak C: assist the patient with tooth brushing to keep the surgical area clean D: encourage deep breathing and coughing to prevent respiratory complications
A
An unknown chemical was splashed into a client's eyes. What is most important for the nurse to tell the client to do immediately? A: rinse the eye with a large amount of water or saline solution B: put a pad soaked in sterile saline solution over the eye C: go to the closest emergency department D: have a coworker visually check the eye for a foreign body
A
The nurse is about to conduct an admission assessment on an 85-year-old female client who is admitted after falling down in her home. When determining the amount of time to set aside for the interview, the nurse will consider which of the following? A: allow ample time to gather psychosocial data from the client B: skip the psychosocial assessment; it is not important for the client with a physiologic problem C: interview the cleint's daughter and son about the client's psychosocial background D: ask the client whether she has any pressing or major issues she wants to talk about
A
The nurse is caring for a postoperative client who had a thyroidectomy. The client develops difficulty breathing from laryngospasms, muscular spasms, and twitching. Which medication should the nurse have available for emergency treatment in the client who has a thyroidectomy? A: calcium chloride B: potassium chloride C: magnesium sulfate D: propylthioracil
A
The nurse is teaching self-care to an older adult client. what would the nurse encourage the client do for his dry, itchy skin? A: apply a moisturizer on all dry areas daily B: shower twice a day with mild soap C: use a pumice stone and exfoliating sponge on areas to remove dry scaly patches D: wear protective pads on areas that show the most dryness
A
The nurse would question which medication order for a client with PACG (primary angle-closure glaucoma)? A: atropine 1 to 2 drops in each eye now B: hydrochlorothiazide 25 mg PO daily C: propanolol 20 mg PO two times a day D: carbamylcholine eye drops, 1 drop two times a day
A
When caring for a client admitted for medically monitored detoxification from alcohol, the nurse would assess for which of the following signs and symptoms of withdrawal? A: anorexia, irritability, nausea, and tremulousness B: bradycardia, hypotension, diaphoresis, and fever C: vivid hallucinations, coarse irregular tremor D: severe craving, euphira, profuse sweating, and paranoid ideation
A
Which of the following nursing interventions should be instituted for a client experiencing a manic episode? A: place the client in a quiet area, separate from others B: encourage the client to engage in some physical activity C: establish firm, set limits on behavior D: include the client in the group's activities
A
A client comes to the clinic with decreased hearing. Examination of the ear canal reveals a large amount of cerumen. what is the recommended method for removal of the cerumen? A: curettage with suction and irrigation B: warm sterile solution irrigation C: cool tap water irrigation D: cotton swab applicator
B
The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would be appropriate nursing interventions with this client? Select all that apply A: use active listening skills to seek information from the client B: encourage the client to describe the problem as she sees it C: ask the client to tell you exactly what she thinks is happening D: tell the client that she is delusional and you can help her E: explain to the client that most people are not investigated by the CIA or FBI F: reassure the client that you are not with the CIA
A, B, C,
A nurse is caring for a client with Addison's disease who has been in a car accident and presents to the emergency department with severe hypotension, fever, weakness, and confusion. Place the nurse's action in a priority order. A: vital sign assessment B: delivery of 0.9% saline and 5% dextrose solution C: placement of an IV D: delivery of high-dose hydrocortisone replacement E: health history information
A, C, B, D, E
A client with a diagnosis of type 2 diabetes has been prescribed a course of prednisone for severe arthritis pain. How should the nurse adjust the plan of care? select all that apply A: monitor blood glucose levels more frequently B: monitor for signs of bleeding C: monitor urine output every 4 hours D: monitor for increased signs of infection E: monitor for increased confusion
A, D
The nurse is caring for a client with thyroid disease who is experiencing a "racing heart", weight loss, exophthalmos, and heat intolerance. What additional actions should be the nurse take? select all that apply A: Evaluate if the client is receiving a beta-blocker B: assess for hypotension C: request increased calories with three balanced meals a day D: apply lubricating eye drops throughout the day E: place a circulating fan in the room
A, D, E
The nurse is caring for a client who began showing signs of diabetes insipidus 4 hours ago and was treated with IV fluids and one dose of nasal desmopressin (DDAVP). How will the nurse know the treatment is effective? Select all that apply A: urine output will decrease B: blood pressure will lower C: glucose level will normalize D: sodium level change from 128 mEq/L to 134 mEq/L E urine specific gravity of 1.029
A, E
The nurse is evaluating a client recently diagnosed with primary open-angle glaucoma (POAG). What will be an important nursing action? Select all that apply A: review all medications the client is currently taking to determine whether any of them cause an increase in intraocular pressure as a side effect B: determine whether the client has experienced any sudden loss of vision accompanied by pain C: discuss with the client the importance of controlling blood pressure to decrease the potential loss of peripheral vision D: instruct the client to take analgesics as soon as any discomfort occurs in the eye and to notify clinic if pain is not relieved E: have the client demonstrate the use of eye drops F: assess the client for chronic diseases such as diabetes
A, E, F
A client is found to be comatose with a blood glucose level of 50 mg/dL/ What action should the nurse implement first? A: Infuse 1000 ml of D5W over a 12-hour period B: administer 50% glucose intravenously C: check the client's urine for presence of sugar and acetone D: encourage the client to drink orange juice with added sugar
B
A client experiencing severe depression is admitted to the inpatients psychiatric unit. During the initial assessment, she says "I feel like killing myself, but i wouldnt do that because of my kids." The nurses priority nursing action would be to A: explore the reasons that the client might want to take her life B: determine the severity of her suicidal risk C: prevent the client from harming herself D: guide her to consider alternative ways of coping
B
A client had extensive burns with eschar on the anterior trunk. What is the nurse's primary concern regarding eschar formation? A: it prevents fluid remobilization in the first 48 hours after burn trauma B: infection is difficult to assess before the eschar sloughs C: it restricts the ability of the client to move about D: circulation to the extremities is diminished because of edema formation
B
A client who has glaucoma is concerned about her adult children "inheriting" the condition. What is the best nursing response? A: there is no need for concern, glaucoma is not a hereditary disorder B: your children should have an ophthalmologic examination with screening for glaucoma around age 40. After that exam should be done every 2 to 3 years C: there may be a genetic factor with glaucoma and your children over 30 years of age should be screened yearly D: are your grandchildren complaining of any eye problems? glaucoma generally skips a generation
B
A client with diabetes receives a combination of regular and NPH insulin at 0700 hours. At what point in the day should the client be educated about peak incidence of hypoglycemia> A: 12 pm to 1 pm (12-1300 hours) B: 9 am and 5 pm C: 10 am and 10 pm D: 8 am and 11 am
B
A client's eye has been anesthetized for an ophthalmology exam. What instructions will be important for the nurse to give to the client? A: Do not watch television for at least 24 hours B: do not rub the eye for 15 to 20 minutes C: irrigate the eye every hour to prevent dryness D: wear sunglasses when in direct sunlight for the next 6 hours
B
A teacher notifies the school nurse that many of the students in her third-grade class have been scratching their heads and complaining of intense itching of the scalp. The nurse notices tiny white material at the base of a student's hair shaft. What condition does this assessment reflect? A: tinea capitis B: pediculosis capitis' C: dandruff D: scabies
B
The nurse is assigned to care for a newly admitted client with acute pancreatitis. Admitting assessment includes mid epigastric pain of an 8 out of 10, low-grade fever, and elevated amylase and lipase levels with hypocalcemia and hyperglycemia. What should be the nurse's priority action? A: deliver proton pump inhibitor B: place nasogastric tube C: administer IV calcium gluconate D: administer oral analgesic
B
What is the priority assessment finding for a client who has sustained burns on the face and neck? A: spreading large, clear vesicles B: increased hoarseness C: difficulty with vision D: increased thirst
B
What is the type of skin cancer that is most difficult to treat? A: dysplastic nevi B: malignant melanoma C: basal cell epithelioma D: squamous cell epithelioma
B
Which client is at highest risk for retinal detachment? A: a 4-year-old with amblyopia B: a 17-year-old who plays physical contact sports C: a 33-year-old with severe ptosis and diplopia D: a 72-year-old with nystagmus and bell palsy
B
herpes zoster has been diagnosed in an older adult client. What will the nursing management include? A: apply antifungal cream to the areas daily B: maintain client on contact precautions C: instruct on the need for sexual abstinence D: closely inspect the perineal area for lesions
B
A client with a diagnosis of schizophrenia repeatedly states, "There are flies eating my brain and making me feel weird." The client is most likely experiencing which of the following? A: Ideas of reference B: grandiose delusions C: somatic delusions D: persecutory delusions
C
The nurse is caring for a client postoperative thyroidectomy. What action should the nurse prioritize? Select all that apply. A: have the client speak every 5 to 10 minutes if hoarseness is present B: support the head with pillows and avoid flexion of the neck C: check the breath sounds for stridor D: assess for tingling in the toes, fingers, and around the mouth or muscular twitching E: assess every 4 hours for the first 24 hours for signs of hemorrhage F: place with head of bed flat, in a side-lying position in case of vomiting
B, C, D
The nurse is creating a plan of care about exercise for a client newly diagnosed with diabetes. What should be included in the plan? Select all that apply A: exercise needs to be vigorous and daily B: properly fitting footwear is important C: exercise is best done after meals when glucose levels are rising D: it is important to monitor glucose levels before, during, and after exercise E: exercise-induced hypoglycemia may occur several hours after exercise
B, C, D, E
Which nursing intervention will assist in reducing pressure points that may lead to pressure ulcers? Select all that apply A: position the client directly on the trochanter when side-lying B: avoid the use of donut-type devices C: massage bony prominences D: elevate the head of the bed no more than 30 degrees when possible E: when the client is side-lying, use the 30-degree lateral inclined position F: avoid uninterrupted sitting in any chair or wheelchair
B, D, E, F
Which of the following are appropriate nursing actions when measuring visual acuity using a snellen chart? select all that apply A: position the client 30 feet away from the chart B: have the client first read the chart with both eyes open C: record visual acuity as the largest line that the client can read correctly D: test each eye individually with the opposite eye covered E: repeat the test with the client wearing corrective lenses F: use a picture chart if the client is unable to read
B, D, E, F
A 3-year-old child had a myringotomy about a week ago. The mother calls the nurse to report that one of the tubs fell out. she found the tube on the child's pillow. After the nurse makes an appointment for the child to be seen in the clinic, what would be important to tell the mother? A: observe for any purulent or bloody drainage from the ear B: rinse the tube in soapy water and keep it C: do not allow any water to get into the child's ears D: do not allow the child to play outside
C
A client admitted with a pheochromocytoma returns from the operating room after adrenalectomy. Which assessment is most concerning? A: glucose of 70 mg/dl B: potassium of 3.4 mEq/L C: blood pressure of 169/98 D: sodium of 146 mEq/L
C
A client comes to the outpatient clinic with impetigo on his left arm. What information would the nurse give this client? A: apply antibiotic ointment to the crusted lesions B: wash the lesions with soap and water and then apply a steroid ointment C: soak the scabs off the lesions an apply an antibiotic ointment D: wash the lesions with hydrogen peroxide and apply an anti-fungal cream
C
A client is walking down the hall, and he begins to experience vertigo. What is the most important nursing action when this occurs? A: have the client sit in a chair in a brightly lit room B: administer meclizine PO C: help the client sit or lie down D: assess whether the problem is vertigo or dizziness
C
The nurse is admitting a postoperative client after removal of an acoustic neuroma. What would be most important to include in the postoperative nursing care for this client? A: determining when the client will begin chemotherapy B: evaluating hearing status C: assessing for clear, colorless nasal discharge D: encouraging the client to discuss problem with hearing loss
C
The nurse is discharging a client with bilateral cataracts following cataract surgery on one eye. What statement by the client would indicate to the nurse the need for additional teaching? A: ill call if i have a significant amount of pain B: Ill remember to wash my hands before changing the eye dressing C: ill be okay by myself at home today D: i will have someone help me with my eye medications
C
The nurse is evaluating a teenager for hearing loss. In reviewing the client's history the nurse knows that which finding is not associated with a hearing loss? A: listening to loud music on an iPod B: repeated chronic ear infections C: taking penicillin and cephalosporin medications D: history of increased ear cerumen
C
The nurse prepares to irrigate the external auditory canal for a client with impacted cerumen. What would be included in the correct technique for irrigation? A: use cool tap water B: pour solution into ear canal C: assess for signs of pain and tenderness in the ear D: use a cotton-tipped applicator to clean near the tympanic membrane
C
The nurse understands that scaling around the toes, blistering, and pruritis is characteristic of what condition? A: eczema B: psoriasis C: tinea pedis D: pediculosis corporis
C
When preparing a client for electroconvulsive therapy, the nurse would include which of the following actions? A: provide orientation to time B: assess vital signs for 30 minutes to 1 hour C: remove dentures and maintain NPO status D: encourage problem solving in social settings
C
When teaching a family and a client about the use of a hearing aid, the nurse will base the teaching on what information regarding the hearing aid? A: it provides mechanical transmission for the damaged part of the ear B: it stimulates the neural network of the inner ear to amplify sound C: it amplifies sound and directs it into the ear canal D: it will assist the client to interpret the incoming sounds more effectively
C
Which of the following signs and symptoms would the nurse assess for in a client with possible lithium toxicity? A: hypotension, bradycardia, polyuria B: tachycardia, hypertension, convulsions C: diarrhea, ataxia, seizures, lethargy D: urinary frequency, vomiting, fever
C
A client is prescribed levothyroxine daily.. What should the nurse include in the discharge teaching? select all that apply A: taper the dose, never stop abruptly B: take it at bedtime to avoid the side effects C: call the health care provider if you experience palpitation or nervousness D: decrease the intake of juices and fruits with high potassium and calcium contents E: regular follow-up care will be required
C, E
A nurse case worker suspects older adult neglect. which assessment findings during a home visit would confirm this? Select all that apply A: confusion and disorientation B: recent hip fracture C: poor nutrition and hygiene D: dirty dishes in the sink E: outdated prescription bottles F: missing hearing aids
C, E, F
Hospitals and health care facilites were required by the joint commission to be compliant with this program by the end of calendar 2007. This program is called A: Emergency system for the advance registration of colunteer health professionals B: medical reserve corps C: CHEMPACK D: national incident management system
D
Most states have reporting laws that require health care workers to report certain situations and behavior to authorities. Which is not usually a reportable matter? A: Child abuse B: communicable disease C: Gunshot wounds D: attempted suicide
D
A client is experiencing a lack of logical thought progression, resulting in disorganized and chaotic thinking. the nurse understands this to be A: delusions of grandeur B: ideas of reference C: depersonalization D: associative losseness
D
A client is experiencing difficulty breathing, periorbital swelling, flushing, and itching. He had a diagnostic test in which an iodine-based dye was used about an hour earlier. What medication will the nurse anticipate administering immediately? A: a bronchodilator such as aminophylline B: a corticosteroid such as dexamethosone C: an antihistamine such as diphenhydramine D: an adrenergic agonist such as epinephrine
D
A child is scheduled for a myringotomy with placement of tympanostomy tubes. What is the long-term goal of this procedure that the nurse will discuss with the parents? A: to decrease pressure on the tympanic membrane B: to irrigate the eustachian tube C: to correct a malformation in the inner ear D: to prevent recurrent ear infections
D
A client asks the nurse about an alternative remedy for hot flashes. Which dietary supplement is the client asking about? A: ginseng B: Valerian C: fever few D: black cohosh
D
A client has sustained a third degree burn. What would the nurse expect to find during assessment of the burn? A: area reddened, blanches with pressure, no edema B: blackened skin and underlying structures C: thick, clear blisters, underlying skin edematous and erythematous D: dry white, charred appearance, damage to subcutaneous tissues
D
A client is being admitted for problems with Meniere disease. What is most important for the nurse to assess to promote the client's safety? A: diet history B: screening for hearing tests C: effect on client's activities of daily living D: frequency and severity of attacks
D
A client is scheduled for a routine glycosylated hemoglobin A1C. What needs to be included in the teaching about the test? A: drink only water after midnight and come to the clinic early in the morning B: eat a normal breakfast and be at the clinic 2 hours later C: expect to be at the clinic for several hours because of the multiple blood draws D: come to the clinic at the earliest convenience to have blood drawn
D
A nurse is planning care for a client with SIADH. What is a priority problem that the nurse should consider for the patient, based on an understanding of this conditiion? A: disturbed sleep pattern related to nocturia B: risk for fall related to hypovolemia C: electrolyte imbalance related to metabolic acidosis D: risk for seizures related to hyponatremia
D
A teenager is diagnosed with conjunctivitis. Which statement indicates that the teenager understood the nurse's teaching? A: I can let my friends use my sunglasses while we are together B: it's okay for me to softly rub my eye, as long as i use the back of my hand C: i can pick the crusty stuff out of my eyeballs with my fingers when i wake up in the morning D: i will use my own wash cloth and towel for my face while my eyes are sick
D
The nurse receives the new orders below for a client admitted in thyroid crisis. Which order should the nurse question? Admission orders-5/20/19 1) admit to hospital for thyroid crisis 2) cardiac monitor continuous 3) hyperthermia blanket PRN 4) IV fluids 0.9% 50 ml/hr x 1 Liter 5) propanolol 6) prophylthiouracil 7) stat T3, T4, and TSH serum level A: IV fluids B: serum blood tests C: propylthioruracil D: a hyperthermia blanket
D
When caring for a client with diabetes insipidous, which assessment changes require a priority nursing action? Select all that apply A: urine output change from 270 ml/hr to 100 ml/hr B: finger stick glucose of 182 mg/dL C: weight decrease of 1 kg overnight D: urine becoming paler in color E: serum osmolality of 300 mOsm/kg
D, E
Which of the following are agents listed by the CDC as agents most likely to be involved in bioterrorism. Select all that apply A: influenza B: West nile virus C: cryptosporidiosis D: anthrax E: plague F: Smallpox
D, E, F