NCLEX exam 6 practice

The nurse is completing the intake and output record for a client. The client has had the following intake and output during the shift:Intake: 4 oz (120 mL) of cranberry juice, 1/2 bowl of oatmeal, 2 slices of toast, 8 oz (240 mL) of black decaffeinated coffee, tuna fish sandwich, 1/2 cup (120 mL) of fruit-flavored gelatin, 1 cup (240 mL) of cream of mushroom soup, 6 oz (180 mL) of 1% milk, and 16 oz (480 mL) of water.Output: 1,300 mL of urine.How many milliliters should the nurse document as the client's intake? Record your answer using a whole number.

1380mL There are 30 mL in each fluid ounce and 240 mL in each cup. The fluid intake for this client includes 4 oz (120 mL) of cranberry juice, 8 oz (240 mL) of coffee, 1/2 cup (120 mL) of fruit-flavored gelatin, 1 cup (240 mL) of cream of mushroom soup, 6 oz (180 mL) of milk, and 16 oz (480 mL) of water, for a total of 1,380 mL.

The health care provider ordered normal saline solution 1000 ml to be administered in 6 hours with a drop factor of 20 drops/ml. In whole numbers, what is the rate of infusion? Record your answer using a whole number.

56gtt/min Total Infusion Volume X drop factor/Total time of infusion in minutes = 1000 x 20/60 x 6 = 20000/360 = 55.55 = 56 drops per minute

The nurse is caring for an adolescent with type 1 diabetes who controls blood glucose levels well with twice-daily doses of insulin. The adolescent asks the nurse about participating in swimming after school without adversely affecting the blood glucose. What is the best response by the nurse? "Make sure you have a snack before swimming." "On days you swim, administer more insulin in the morning." "Increase the amount of insulin you take at dinnertime." "You should eat a smaller lunch."

A) "Make sure you have a snack before swimming."

During the first 24 hours after a client is diagnosed with Addisonian crisis, which task should the nurse perform frequently? A) Assess vital signs. B) Weigh the client. C) Administer oral hydrocortisone. D) Test urine for ketones.

A) Assess vital signs. Because the client in Addisonian crisis is unstable, the nurse should assess his vital signs and fluid and electrolyte balance every 30 minutes until he's stable. Daily weights are sufficient when assessing the client's condition. The client shouldn't have ketones in his urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn't administered during the first 24 hours in severe adrenal insufficiency.

After undergoing a right lower lobectomy for treatment of lung cancer, a 75-year-old client returns to his room with a chest tube in place. Several hours later a nurse finds the client out of bed barely able to speak, with the chest tube removed. Which action should the nurse take immediately? A) Cover the insertion site with an occlusive dressing, call for assistance, and remain with the client. B) Cover the insertion site with a sterile gauze dressing, assist the client back to bed, and monitor his vital signs. C) Assist the client back to bed, assess his respiratory status, and remain with him. D) Assist the client back to bed, assess his vital signs, and notify a physician.

A) Cover the insertion site with an occlusive dressing, call for assistance, and remain with the client.

After placing a client in full leather restraints, how often should the nurse check the client's circulation? A) Every 15 minutes B) Once per hour C) Every 2 hours D) Once per shift

A) Every 15 minutes Circulatory as well as skin and nerve damage can occur quickly. Therefore, circulation should be assessed at least every 15 minutes. Checking every hour, 2 hours, or 8 hours is not often enough and could result in permanent damage to the client's extremities.

The physician prescribes several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? A) Heparin sodium B) Methyldopa C) Phenytoin D) Dexamethasone

A) Heparin sodium Administration of heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a client with hemorrhagic stroke, dexamethasone may be used to decrease cerebral edema and pressure; methyldopa, to reduce blood pressure; and phenytoin, to prevent seizures.

A nurse caring for a client during the fourth stage of labor observes that the client has changed pads four times in the past hour and is reporting dizziness. What initial actions should the nurse take? Select all that apply. A) Notify the RN. B) Check the fundal height. C) Initiate IV therapy. D) Start blood transfusion. E) Check vital signs.

A) Notify the RN. B) Check the fundal height. E) Check vital signs. Obtaining vital signs and checking the fundus are required actions to establish the problem. The nursing process requires assessment of the problem first before any other action. Initiating IV therapy is outside the scope of practice for an LPN, as is starting a blood transfusion.

A client with toxoplasmosis and cytomegalovirus is confused and has been dislodging his I.V. access. Which action would be most appropriate for the nurse to take? A) Notifying the registered nurse and seeing if a nursing assistant is available to stay with the client B) Delaying I.V. fluid administration until the client's confusion ceases C) Placing bilateral wrist restraints on the client D) Asking the physician to give the client a tranquilizer

A) Notifying the registered nurse and seeing if a nursing assistant is available to stay with the client

The nurse is caring for a female client who is planning to start isotretinoin in 3 months. What should the nurse be sure to include in the instructions for the administration of this medication? A) Now is the time to begin contraceptive precautions. B) Isotretinoin is safe during pregnancy. C) Now is a good time to get pregnant, if she is planning to have a baby. D) Isotretinoin can cause women to become infertile.

A) Now is the time to begin contraceptive precautions.

A 30-year-old client whose mother died of breast cancer at age 44 and whose sister has ovarian cancer is concerned about developing cancer. A nurse who is a member of the oncology multidisciplinary team should suggest that the client ask the physician about which of the following actions? A) Obtaining genetic counseling B) Having a Papanicolaou (Pap) test C) Having a mammogram D) Contacting the American Cancer Society

A) Obtaining genetic counseling The nurse should suggest that the client ask the physician about genetic counseling, which is indicated for those at high risk of cancer because of a family or personal history of the disease. Genetic counseling involves obtaining a detailed medical and three-generational family history; calculating a personalized risk assessment and providing options for prevention, surveillance, and genetic testing; coordinating and interpreting genetic tests; and developing a management plan based on the test results. Mammography will assist with early detection of most breast cancers, but it won't establish a risk assessment and provide options for prevention, surveillance, and genetic testing. PAP testing every 6 months assists in early detection of most cervical cancers, but it won't establish a risk assessment. Contacting the American Cancer Society will provide the client with information about cancer but it won't help assess the client's risk of developing cancer.

When caring for a client who has had constipation for 4 days, what should be the nurse's primary client care concern? Promoting defecation Relieving pain Providing nutrition Monitoring output

A) Promoting defecation

The nurse is caring for a child with symptomatic aortic stenosis. Which instruction should be provided to the child and parents. A) Restrict exercise. B) Allow the child to exercise freely. C) Avoid prostaglandin E1. D) Avoid digoxin and diuretics.

A) Restrict exercise. In a child with symptomatic aortic stenosis, exercise should be restricted due to low cardiac output and left ventricular failure. Prostaglandin E1 is recommended to maintain the patency of the ductus arteriosus in neonates. This allows for improved systemic blood flow. Digoxin and diuretics may be required for critically ill children experiencing heart failure as a result of severe aortic stenosis. Strenuous activity has been reported to result in sudden death from the development of myocardial ischemia.

Just after delivery, the nurse measures a neonate's axillary temperature at 94.1° F (34.5° C). What should the nurse do? A) Rewarm the neonate gradually. B) Notify the physician when the neonate's temperature is normal. C) Observe the neonate at least hourly. D) Rewarm the neonate rapidly.

A) Rewarm the neonate gradually.

Flumazenil has been ordered for a client who has overdosed on oxazepam. Before administering the medication, the nurse should be prepared for which common adverse effect? A) Seizures B) Anxiety C) Shivering D) Chest pain

A) Seizures Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose. The effect is magnified if the client has a combined tricyclic antidepressant and benzodiazepine overdose. Less common adverse effects include shivering, anxiety, and chest pain.

A client is receiving chemotherapy and radiation for stage III breast cancer and has an ANC (absolute neutrophil count) of 800/mm3 (0.8 × 109/L) a hemoglobin of 10g/dL (100 g/L), and a platelet count of 108,000/mm3 (108 × 109/L) Based on these results, the nurse should be most concerned with which finding? A) Temperature of 100.8 °F (38.2 °C), fatigue, and shortness of breath B) Tenderness at the site of radiation, headache, and constipation C) Rhinitis and throat pain when swallowing D) Fatigue, nausea, and skin redness at the site of radiation

A) Temperature of 100.8 °F (38.2 °C), fatigue, and shortness of breath

A nurse gives a client the wrong medication. After assessment of the client, the nurse completes an incident report. What is the next anticipated step? A) The incident report would be used to promote quality care and risk management. B) The incident would be reported to the state board of nursing for disciplinary action. C) The medication error would result in the nurse being suspended and possibly terminated from employment at the facility. D) The incident would be documented in the nurse's personnel file.

A) The incident report would be used to promote quality care and risk management. Unusual occurrences and deviations from care are documented on incident reports. Incident reports are internal to the facility and are used to evaluate the care, determine potential risks, and identify possible system problems that could have contributed to the error. This type of error wouldn't result in suspension of the nurse or a report to the state board of nursing. Some facilities do trend and track the number of errors that take place on particular units (or by individual nurses) for educational purposes and as a way to improve the nursing process.

The parents of a child with attention deficit hyperactivity disorder (ADHD) say they are concerned because the child is losing weight. Which suggestion can the nurse give to the parents regarding the weight loss? have high-calorie finger foods available for the child to eat administer an appetite stimulant decrease the amount of medications being taken force the child to sit for three meals a day with the family

A) have high-calorie finger foods available for the child to eat

A student nurse is performing wound care while the instructor observes. Which observation by the instruction requires immediate intervention of the student nurse's action? A) pouring solution directly onto a sterile field barrier B) opening the outermost flap of a sterile package away from the body C) considering a 1-inch edge around the sterile field as contaminated D) holding sterile objects above the level of the waist

A) pouring solution directly onto a sterile field barrier

The nurse admits a client with Crohn's disease who is experiencing an exacerbation. Which intervention should the nurse make a priority of care? A) promoting bowel rest B) maintaining current weight C) encouraging ambulation D) providing mouth care

A) promoting bowel rest

A nurse is providing care for a pregnant 16-year-old client who says that she is concerned she may gain too much weight and wants to start dieting. What is the best response by the nurse? A) "You shouldn't begin dieting during pregnancy because you're eating for two." B) "Dieting could deprive your baby of nutrients leading to developmental and growth problems." C) "The prenatal vitamins should ensure that the baby gets all the necessary nutrients." D) "Let's talk about how you are feeling a bit more."

B) "Dieting could deprive your baby of nutrients leading to developmental and growth problems." The nurse should reinforce with the pregnant client who wants to start dieting that depriving the developing fetus of nutrients can cause serious problems. The client is "eating for two"; however, this means the woman should only eat enough for the nutritional needs of a growing fetus, not eat for two adults. Exploring feelings would help the client understand her concerns, but first, she needs to be aware of the risks at this time. Vitamins are supplements and do not contain everything a mother and baby need; they work in conjunction with a balanced diet.

A nurse is obtaining data from a client with a urinary tract infection (UTI). Which statement should the nurse expect the client to make? Select all that apply. A) "My urine smells sweet." B) "It burns when I urinate." C) "I urinate large amounts." D) "I need to urinate frequently." E) "I need to urinate urgently."

B) "It burns when I urinate." D) "I need to urinate frequently." E) "I need to urinate urgently."

A client with type 1 diabetes has a highly elevated glycosylated hemoglobin (Hb) test result. In discussing the result with the client, the nurse would be most accurate in stating: A) "Your insulin regimen needs to be altered significantly." B) "It tells us about your sugar control for the last 3 months." C) "The test needs to be repeated following a 12-hour fast." D) "It looks like you aren't following the prescribed diabetic diet."

B) "It tells us about your sugar control for the last 3 months."

A client at 38 weeks gestation is in labor receiving external fetal monitoring. After reviewing this monitoring with the client, which client statement would the nurse identify as indicating that the client understands the information? A) "I'll need to lie perfectly still while this monitor is in place." B) "The monitor might need to be repositioned if I change my position in bed." C) "You won't need to come in and check on me while I'm wearing this monitor." D) "This monitor increases my risk of a uterine infection."

B) "The monitor might need to be repositioned if I change my position in bed."

A client admitted to the facility continually acts out a preoccupation with hand washing. The nurse should use which term to document this behavior? A) Delusion B) Compulsion C) Hallucination D) Obsession

B) Compulsion The nurse should document this finding as a compulsion. An obsession is an intense preoccupation that interferes with daily life. A hallucination is a false sensory perception with no basis in reality. A delusion is a false idea or belief accepted as real by the client.

Which intervention might safely prevent constipation in a client who has end-stage ovarian cancer and requires high doses of opioids to control pain? Instructing the client to avoid consuming alcohol Explaining the importance of increasing the intake of fiber and fluids Telling the client to avoid taking over-the-counter medications Informing the client that taking laxatives routinely might help

B) Explaining the importance of increasing the intake of fiber and fluids

After a stroke, a client develops aphasia. The nurse expects to observe which data collection finding in this client? Difficulty swallowing Inability to speak clearly Absence of the gag reflex Arm and leg weakness

B) Inability to speak clearly

A client with a full-term, uncomplicated pregnancy comes into the labor and delivery unit in early labor states, "I think my water has broken." Which action by the nurse would be the priority? A) Collect a sample of the fluid for microbial analysis. B) Note the color, amount, and odor of the fluid. C) Prepare the client for birth. D) Immediately contact the health care provider.

B) Note the color, amount, and odor of the fluid. Noting the color, amount, and odor of the fluid will help guide the nurse in her next action. There is no need to call the client's health care provider immediately or prepare the client for birth, if the fluid is clear and birth is not imminent. Rupture of membranes is not unusual in the early stages of labor. Fluid collection for microbial analysis is not routine if there is no concern of infection (maternal fever).

The LVN/LPN is transporting a surgical client to the operating room when the client says, "I am not sure what they are going to do to me." What is the nurse's best action? Document the client's concern in the chart. Notify the surgeon about the client's concern. Send the client to the operating room, and the nurse will explain the procedure there. Do nothing, because the client already signed the consent form.

B) Notify the surgeon about the client's concern.

A client is prescribed digoxin 0.125 mg by mouth stat. The pharmacy dispenses digoxin 0.25 mg. The nurse promptly administers the medication and then realizes the incorrect dose has been administered. How should the nurse proceed? Inform the pharmacist and the nursing supervisor of the error, and document the incident. Obtain vital signs, and immediately notify the primary health care provider and charge nurse of the error. Immediately inform the pharmacist of his dispensing error, and document the incident. Obtain a copy of the primary health care provider's prescription, and inform the pharmacy of the dispensing error.

B) Obtain vital signs, and immediately notify the primary health care provider and charge nurse of the error.

A licensed practical nurse (LPN) hears the facility code that indicates an infant has been abducted from the nursery. Which action should the LPN take? A) Go immediately to the nursery and inquire about what happened. B) Report to an exit and be alert for anyone carrying packages. C) Inform the police department about the incident. D) Document the names of all visitors on the medical-surgical floor.

B) Report to an exit and be alert for anyone carrying packages.

A nurse would observe a client undergoing electroconvulsive therapy (ECT) for which common adverse effect? A) Cardiac arrhythmias B) Short-term memory loss C) Brain damage D) Seizure

B) Short-term memory loss Short-term memory loss is the most common adverse effect of ECT. In most cases, memory returns within 3 months. There is no effect on the heart. A seizure is not an adverse effect; rather, it is intentionally induced. Brain damage has not been substantiated from ECT.

The nurse is administering two drugs concomitantly to a client. Which interaction, recognized by the nurse, occurs when two drugs with the same qualitative effects produce a response when given together that is greater than the response either drug produces when given alone? A) Tolerance B) Synergism C) Antagonism D) Hyporeactivity

B) Synergism

A 6-month-old is brought to the emergency department with a suspected femur fracture. The parents state that the infant fell from the couch. The X-ray reveals a spiral fracture of the femur. What is the priority action for the nurse to take? A) Inform the parents that the nurse suspects child abuse and must notify social services. B) Treat the parents professionally and answer their questions appropriately. C) Immediately ask the parents to leave the room and refuse to give them any information about the infant. D) Call security immediately, and inform them of the abuse.

B) Treat the parents professionally and answer their questions appropriately. Although the nurse may suspect abuse, the nurse must treat the parents professionally and answer their questions appropriately. The nurse should not ask the parents to leave the infant's room or tell them that that abuse is suspected. Until social services investigates the case, parental rights remain intact. The nurse has no reason to call security at this time.

The nurse must administer a liquid medication to an infant. Which step should the nurse take first? A) Hold the infant securely in the crook of her arm and raise the infant's head to about a 45-degree angle. B) Verify the physician's order. C) Identify the infant by checking the armband. D) Place the dropper at the corner of the infant's mouth so the drug runs into the pocket between the cheek and gum.

B) Verify the physician's order. The nurse should first verify the physician's order. Next, the nurse should make sure she has the right drug, dose, route, and time. She should then make sure she has the right client by checking the infant's armband. Next, the nurse should hold the infant securely in the crook of her arm and raise the infant's head to about a 45-degree angle. Then, the nurse should place the dropper at the corner of the infant's mouth so the drug runs into the pocket between the infant's cheek and gum. Doing so keeps him from spitting out the drug and reduces the risk of aspiration.

A nurse is working at a local emergency department. A nearby building explosion has occurred, and many of the victims involved are being brought to the facility. Which client would the nurse expect to be triaged first? A) a 10-month-old infant who is crying uncontrollably B) a 62-year-old with tachypnea C) a 57-year-old with a clavicle fracture D) a 37-year-old with a scalp laceration

B) a 62-year-old with tachypnea The client with tachypnea requires immediate attention. Abnormally rapid breathing takes priority over a clavicle fracture or scalp laceration. An infant who is crying uncontrollably needs comforting, not immediate medical attention.

Which finding is common when gathering data from a child with a total anomalous pulmonary venous return defect? A) normal growth and development B) frequent respiratory infections C) above average weight gain on the growth chart D) hypertension

B) frequent respiratory infections Children with total anomalous pulmonary venous return defects are prone to repeated respiratory infections due to increased pulmonary blood flow. Hypertension usually occurs with coarctation of the aorta, an acyanotic defect with obstructive flow. Poor feeding and failure to thrive are also signs of a total anomalous pulmonary venous return defect, as is a thin, malnourished appearance in infants.

A nurse is caring for a client who was admitted with pernicious anemia. Which set of findings should the nurse expect when gathering data for this client? A) reduced pulse pressure and hypotension B) pallor, tachycardia, and a sore tongue C) angina, double vision, and anorexia D) sore tongue, dyspnea, and weight gain

B) pallor, tachycardia, and a sore tongue Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision are not characteristic findings in pernicious anemia.

A client is examined and found to have pinpoint, pink-to-purple, nonblanching macular lesions 1 to 3 mm in diameter. How should the nurse document the findings? A) hematoma B) petechiae C) ecchymosis D) purpura

B) petechiae Petechiae are small macular lesions 1 to 3 mm in diameter. Ecchymosis is a purple-to-brown bruise, macular or papular, that varies in size. A hematoma is a collection of blood from ruptured blood vessels that's more than 1 cm in diameter. Purpura are purple macular lesions larger than 1 cm.

The nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should: A) have the client take deep breaths and cough. B) place the client in high Fowler's position. C) administer oxygen. D) perform chest physiotherapy.

B) place the client in high Fowler's position. The high Fowler's position will initially promote oxygenation in the client and relieve shortness of breath. Additional measures include administering oxygen to increase content in the blood. Deep breathing and coughing will improve oxygenation postoperatively but may not immediately relieve shortness of breath. Chest physiotherapy results in expectoration of secretions, which isn't the primary problem in pulmonary edema.

A nurse is caring for a client diagnosed with late stage Alzheimer's disease (AD). What nursing intervention is priority? A) encouraging activities B) providing supervision C) performing hygiene D) applying wrist restraints

B) providing supervision Whenever client safety is at risk, careful observation and supervision are of ultimate importance in avoiding injury. Physical contact is implemented during basic care. Applying restraints may cause agitation and combativeness. A high level of sensory stimulation may be too stimulating and distracting.

A 16-year-old female was admitted to the hospital for treatment of anorexia nervosa. A nurse is teaching the client's mother about the disease process. The nurse recognizes that the teaching was effective when the mother states that anorexia nervosa is characterized by: A) uncontrolled food consumption over a short time. B) refusal to maintain normal body weight. C) anxiety-related habits. D) weight loss of more than 10 lb (4.5 kg) in 6 months.

B) refusal to maintain normal body weight.

The nurse is teaching the parents of a child with hemophilia about how to provide a safe home environment throughout the child's life. Which nursing instruction is most appropriate? A) "Talk to your child about home safety and have him problem-solve hypothetical situations about his health." B) "Pad the corners of coffee tables when your child is a toddler." C) "Establish a written emergency plan that includes what to do in specific situations and the names and phone numbers of emergency contacts." D) "Be a role model for your child by wearing a helmet when riding a bike so your child will too."

C) "Establish a written emergency plan that includes what to do in specific situations and the names and phone numbers of emergency contacts." Establishing a written emergency plan that includes what to do in specific situations and the names and phone numbers of emergency contacts helps provide a safe environment for a child with hemophilia. Padding the corners of coffee tables doesn't provide a safe environment for children of all ages. Showing the child examples of bicycle safety is applicable only with children old enough to emulate a parent's behavior. Problem solving doesn't create a safe environment.

Which statement by a client demonstrates to the nurse that the client understands the best time to perform a self-breast exam? A) "Breast self-examination should be done every three weeks." B) "I should examine my breasts at the same time each day." C) "I'll examine my breasts a week after my menstrual period starts." D) "Every time I shower, I can do a breast examination."

C) "I'll examine my breasts a week after my menstrual period starts." The breasts are least tender and have fewer nodules a week after menstruation starts. Breasts are typically most tender and nodular just before the onset of menstruation. Examining the breasts every day or during every shower is excessive and unnecessary.

A client becomes neutropenic 11 days after his last chemotherapy cycle. It's obvious that the client understands his condition when he states: "I love working in my garden; it gives me a lot of inner peace and tranquility." "I've found that eating fresh fruit and vegetables reduces the side effects of chemotherapy and also gives me more energy." "I'll monitor my temperature frequently and go to the nearest emergency department if my temperature rises above 38° C (100.4° F)." "I find that going out for a quiet dinner and a movie relieves the stress and anxiety of my cancer treatment."

C) "I'll monitor my temperature frequently and go to the nearest emergency department if my temperature rises above 38° C (100.4° F)."

The nurse is teaching a client how to use a diaphragm. Which instruction should the nurse provide? A) "Insert the diaphragm 4 hours before intercourse." B) "Remove the diaphragm immediately after intercourse." C) "Leave the diaphragm in place for at least 6 hours after intercourse." D) "You may use the diaphragm without spermicidal jelly or cream."

C) "Leave the diaphragm in place for at least 6 hours after intercourse." The diaphragm acts as a reservoir for spermicidal jelly or cream and must be left in place for at least 6 hours after intercourse to ensure spermicidal action. Inserting the diaphragm 4 hours before intercourse or removing it immediately afterward doesn't ensure spermicidal effectiveness. A diaphragm must be used with spermicidal jelly or cream.

The nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct? A) "Maintain a high-sodium, high-calorie diet." B) "Maintain a high-fat diet and drink at least 3 L of fluid a day." C) "Maintain a high-carbohydrate, low-fat diet." D) "Maintain a high-fat, high-carbohydrate diet."

C) "Maintain a high-carbohydrate, low-fat diet."

A client receiving ferrous sulfate therapy to treat an iron deficiency reports taking an antacid frequently to relieve heartburn. Which instruction should the nurse provide? A) "Avoid taking an antacid altogether." B) "Take ferrous sulfate and the antacid together." C) "Take ferrous sulfate and the antacid at least 2 hours apart." D) "Take ferrous sulfate and the antacid at least 1 hour apart."

C) "Take ferrous sulfate and the antacid at least 2 hours apart." The nurse should instruct the client to take ferrous sulfate and an antacid at least 2 hours apart because antacids bind with iron in the GI tract, decreasing the rate or extent of iron absorption.

The nurse is discussing posture with a client who's 18 weeks pregnant. The clients asks why should she avoid the supine position. How does the nurse respond? A) "This position may trigger heart palpitations." B) "This position promotes pregnancy-induced hypertension (PIH)." C) "This position impedes blood flow to the fetus." D) "This position may cause gastroesophageal reflux."

C) "This position impedes blood flow to the fetus."

A client with schizophrenia repeatedly uses profanity during an activity therapy session. Which response by the nurse would be appropriate? "Your behavior won't be tolerated. Go to your room immediately." "You're just doing this to get back at me for making you come to therapy." "Your cursing is interrupting the activity. Take time out in your room for 10 minutes." "I'm disappointed in you. You can't control yourself even for a few minutes."

C) "Your cursing is interrupting the activity. Take time out in your room for 10 minutes."

A client admitted to the psychiatric unit for treatment of repeated panic attacks comes to the nurses' station in obvious distress. After observing that the client is short of breath, dizzy, trembling, and nauseated, which action should the nurse first implement? A) Ask what the client is upset about B) Administer an antianxiety medication, as prescribed, and instruct the client to lie down in his room. C) Escort the client to a quiet area and suggest using a relaxation exercise that he or she has been taught. D) Reassure the client that the symptoms will disappear after he or she lies down and relaxes.

C) Escort the client to a quiet area and suggest using a relaxation exercise that he or she has been taught.

A nursing student is preparing to administer a parenteral medication. The nursing instructor asks the student which administration route places a drug directly into the circulation, requiring no absorption. Which method does the student relay to the instructor? Subcutaneous (subQ) Intradermal Intravenous (I.V.) Intramuscular (I.M.)

C) Intravenous (I.V.)

A client has diabetic ketoacidosis secondary to infection. As the condition progresses, which signs and symptoms might the nurse see? Cheyne-Stokes respirations and foul-smelling urine shallow respirations and severe abdominal pain Kussmaul respirations and a fruity odor on the breath decreased respirations and increased urine output

C) Kussmaul respirations and a fruity odor on the breath

The nurse is planning to discharge a 24-year-old gravida 1, para 1, non-English-speaking Hispanic client. Which nursing intervention takes priority? A) Ensuring that the client has family members available for assistance after discharge. B) Locating a family member to interpret the discharge instructions. C) Locating a staff member who can interpret the discharge instructions. D) Providing a family member and client with an information phone number in case questions or problems arise.

C) Locating a staff member who can interpret the discharge instructions. Most health care institutions have a language bank. Therefore, it is appropriate to locate a staff member who can translate. Using a family member may compromise client confidentiality, and accurate interpretation is not always guaranteed. The client and family members may not recognize when a problem arises to call an information number.

A client must undergo right thoracotomy for lung cancer. Which member of the health care team is responsible for obtaining informed consent from this client? A) Physician's assistant B) Primary nurse C) Physician D) Nurse working with the physician

C) Physician

A client who experienced alcohol withdrawal is no longer having hallucinations or tremors and states, "I would like to enter a rehabilitation facility to stop drinking." Which intervention is appropriate? A) Have the client discuss this with family members. B) Ask about insurance. C) Promote participation in a treatment program. D) Refer the client to Alcoholics Anonymous (AA).

C) Promote participation in a treatment program. The client should be encouraged to enter a facility if that's in his best interest. Arrangements can be made and discussed with the social services coordinator and health care provider as well as having social services discuss insurance concerns. The client can inform the family, and support should be encouraged. Referral to AA should be considered after rehabilitation takes place.

A client reports severe pain in the back and joints. Upon reviewing the client's history, the nurse notes a diagnosis of depression and frequent hospitalizations for somatic illnesses. What should the nurse encourage this client to do? A) Remember all of the previous "health problems" that weren't real. B) Ignore the pain and focus on happy things. C) Tell the physician about the pain so that its cause can be determined. D) Try to get more rest and use relaxation techniques.

C) Tell the physician about the pain so that its cause can be determined. Initially, the nurse should treat all symptoms as indicators of possible pathology because a history of psychophysiological illness doesn't rule out a purely physical illness as a cause of the client's current symptoms. The other options assume that the client has a psychophysiological illness, which could lead to ignoring a physical illness or condition.

The nurse educator is preparing an in-service about urinary incontinence in the elderly. Which information should the nurse share with her colleagues describing urinary incontinence in the elderly? A) Urinary incontinence in the elderly can not be treated. B) Urinary incontinence is a normal part of aging. C) Urinary incontinence is not a disease. D) Urinary incontinence is a disease.

C) Urinary incontinence is not a disease.

A nurse is caring for several clients on a medical floor. Which client does the nurse identify to have the greatest chance of developing cardiogenic shock? A) a client with coronary artery disease (CAD) B) a client with hypotension C) a client with acute myocardial infarction (MI) D) a client with decreased hemoglobin level

C) a client with acute myocardial infarction (MI) Of all clients with an acute MI, 15% suffer cardiogenic shock secondary to the myocardial damage and decreased function. CAD causes MI. Hypotension is the result of a reduced cardiac output produced by the shock state. A decreased hemoglobin level is a result of bleeding.

A newly hired licensed practical nurse (LPN) is establishing priorities for morning client evaluations with the assistance of a preceptor. Which client should the nurses evaluate first? A) a client who underwent surgery 3 days ago who requires a dressing change B) a sleeping client who received pain medication 1 hour ago C) a newly admitted client with acute abdominal pain D) a client receiving continuous tube feedings who needs the tube feeding residual checked

C) a newly admitted client with acute abdominal pain

The nurse prepares to administer morning medications to a client with hepatitis. The client's medications are listed below. Which medication should the nurse withhold? A) phytonadione 5 mg IM once daily B) lamivudine 150 mg orally twice daily C) acetaminophen 650 mg orally every day D) vitamin B12 one capsule twice daily

C) acetaminophen 650 mg orally every day Acetaminophen is contraindicated in clients with liver disorders. The medication should be withheld, and the health care provider should be contacted regarding this medication. Lamivudine is an antiviral used to treat Hepatitis B, B12 is a vitamin supplement used to treat anemia associated with hepatitis, and phytonadione, a form of vitamin K, is used to prevent bleeding when the liver is not functioning properly and does not produce adequate amounts to support clotting.

A nurse collecting data on a post-craniotomy client finds the urinary catheter bag with 1,500 mL the first hour and the same amount for the second hour. Which complication should the nurse suspect as a cause of this amount of output? A) adrenal crisis B) hyperglycemia C) diabetes insipidus D) Cushing's syndrome

C) diabetes insipidus Diabetes insipidus triggers an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. Cushing's syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. A hyperglycemic state is marked by polyuria, polydipsia, and polyphagia. Adrenal crisis is under secretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.

A nurse is removing an indwelling urinary catheter. Which nursing action reflects the best technique? A) cut the lumen of the balloon B) position the client on his left side C) document the time of removal D) wear sterile gloves

C) document the time of removal The client should void within 8 hours of the removal of an indwelling urinary catheter. Documenting the time of removal allows the nurse and health care provider to verify the duration of elapsed time since removal, thus contributing to continuity of care. Clean, disposable gloves are required because it isn't a sterile procedure. If the balloon is cut from the lumen and the catheter isn't secured, the catheter may retrograde into the bladder, requiring surgical removal. The client should be positioned comfortably on his back, and privacy should be provided.

The nurse is assisting with the development of a care plan for a postpartum client who had an uncomplicated vaginal birth of an 8-lb, 2-oz (3,693-g) neonate over an intact perineum 24 hours ago. While planning care for this client, the registered nurse collaborates with the licensed practical nurse to achieve which priority outcome in the next 8 hours? A) administering a rubella vaccination if the client isn't immune B) encouraging high-fiber foods to achieve a soft bowel movement C) encouraging the client to demonstrate an ability to breast-feed the neonate D) completing an initial sitz bath

C) encouraging the client to demonstrate an ability to breast-feed the neonate With an uncomplicated vaginal birth, the average client will be hospitalized for 48 hours or less. By 24 hours postpartum, it's important for the client to start demonstrating the ability to care for her neonate. The first bowel movement occurs on average 2 to 3 days postpartum. The rubella vaccine is given, when indicated, on the day of discharge. This client delivered over an intact perineum, so a sitz bath isn't a priority.

When children are more physically active, which change in the management of the child with diabetes should the nurse expect? A) increased risk of hyperglycemia B) decreased food intake C) increased food intake D) decreased risk of insulin shock

C) increased food intake If a child is more active at one time of the day than another, food or insulin should be altered to meet the child's activity pattern. Food intake should be increased when a child with diabetes is more physically active. There would be an increased risk of insulin shock if the child didn't take in more food, and the child would become hypoglycemic, not hyperglycemic.

A nurse is caring for a client with multiple myeloma. When assisting with the plan of care, which nursing intervention is most appropriate? A) monitoring respiratory status B) restricting fluid intake C) preventing bone injury D) balancing rest and activity

C) preventing bone injury When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the client well hydrated, not restrict the client's fluid intake.

The nurse is caring for a child experiencing a sickle cell crisis. What priority nursing intervention should the nurse perform? A) place ice packs on the child's painful joints B) administer antibiotics C) provide oral and IV fluids D) administer folic acid supplements

C) provide oral and IV fluids Priority care for a child in a sickle cell crisis includes providing hydration and oxygenation to prevent more sickling. Pain relief is also a concern; however, painful joints are treated with analgesics and warm packs because cold packs can increase sickling. Antibiotics are given to treat a sickle cell crisis if it is thought to be bacterial. Daily supplements of folic acid help counteract anemia.

The arterial blood gas analysis of a child with asthma shows a pH of 7.30, PaCO2 of 56 mm Hg, and HCO3- of 25 mEq/L. The nurse determines that the child has which condition? A) respiratory alkalosis B) metabolic alkalosis C) respiratory acidosis D) metabolic acidosis

C) respiratory acidosis Respiratory acidosis is an acid-base disturbance characterized by excess CO2 in the blood, indicated by a PaCO2 greater than 45 mm Hg. The pH level is usually below the normal range of 7.36 to 7.45. The HCO3- level is normal in the acute stage and elevated in the chronic stage.

A client with a phobia is being treated with behavior modification therapy. The client asks the nurse which treatment can be expected with this therapy. The nurse should tell the client to expect which treatment? A) free association B) electroconvulsive therapy (ECT) C) systematic desensitization D) dream analysis

C) systematic desensitization Systematic desensitization is a behavior therapy used in the treatment of phobias. Dream analysis and free association are techniques used in psychoanalytic therapy. ECT is used with depression.

A nurse is caring for a client who underwent stapedectomy. To prevent postoperative complications, what should the nurse instruct the client to do? A) "Resume bending when you are no longer experiencing any ear pain." B) "Blow your nose frequently." C) "Clean your operated ear with a cotton-tipped applicator twice per day." D) "Sneeze with your mouth open."

D) "Sneeze with your mouth open." If sneezing cannot be avoided, the client should sneeze with his mouth open to prevent air pressure changes in the middle ear, which can dislodge the prosthesis and graft. Blowing the nose and coughing should be avoided. Small objects, such as cotton-tipped applicators, should not be inserted into the ear. Straining during a bowel movement and bending should be avoided for at least 2 to 3 weeks, or as instructed by the primary care provider.

A young man is remanded by the courts for psychiatric treatment. His police record, which dates to his early teenage years, includes delinquency, running away, auto theft, and vandalism. He dropped out of school at age 16 and has been living on his own since then. The nurse recognizes his history suggesting maladaptive coping, and its association with which personality disorder? A) Narcissistic personality disorder B) Obsessive-compulsive personality disorder C) Borderline personality disorder D) Antisocial personality disorder

D) Antisocial personality disorder The client's history of delinquency, running away from home, vandalism, and dropping out of school are characteristic of antisocial personality disorder. This maladaptive coping pattern is manifested by a disregard for societal norms of behavior and an inability to relate meaningfully to others. Typically, there is a long-term pattern of manipulations, exploiting and violating the rights of others. In borderline personality disorder, the client exhibits mood instability, poor self-image, identity disturbance, and labile affect. Obsessive-compulsive personality disorder is characterized by a preoccupation with impulses and thoughts that the client realizes are senseless but can't control. Narcissistic personality disorder is marked by a pattern of self-involvement, grandiosity, and demand for constant attention.

Which scenario requires the licensed practical nurse (LPN) to notify the registered nurse (RN) immediately? A) Decrease in a client's blood pressure from 160/90 mm Hg to 140/84 mm Hg B) Family inquiry about the client's discharge time C) Complaint of pain that rates 7 on a 1-to-10 pain-rating scale D) Apical pulse rate of 90 beats/minute with a radial pulse rate of 70 beats/minute

D) Apical pulse rate of 90 beats/minute with a radial pulse rate of 70 beats/minute The LPN should immediately report an apical pulse rate of 90 beats/minute associated with a radial pulse rate of 70 beats/minute, which indicates a pulse deficit of 20 beats/minute. This finding signifies an irregular heartbeat that might lead to a decrease in cardiac output. Regarding the other answer options, the decrease in BP is a positive finding and doesn't need to be reported immediately; the LPN can assess pain and administer pain medications as prescribed; and the LPN can provide the family with an estimated discharge time without consulting the RN.

The nurse is aware that Standard Precautions represent the first tier of Centers for Disease Control guidelines for isolation precautions. Which is the nurse's primary responsibility when following Standard Precautions? A) Wear gloves for all contact with the client. B) Place a body substance isolation sign on the client's door. C) Wear gloves and a gown whenever caring for the client. D) Consider all body substances potentially infectious.

D) Consider all body substances potentially infectious. Standard precautions are based on the concept that all body substances are potentially infectious and direct contact with them must be avoided. The nurse should wear gloves when contact with body substances — not unsoiled articles or intact skin — is anticipated. Because all body substances from all clients are considered potentially infectious, signs on doors are unnecessary. Gloves and gowns are necessary only when contact with body fluids is likely.

A nurse educator in the cardiac care unit is assigned to orient a newly hired nurse. Included in the orientation is the medication administration system. What is the best way to determine if the nurse understands the medication system? Quiz the nurse verbally, repeating the instructions. Give a written quiz on the medication system. Ask the nurse if she understands the procedure. Have the nurse demonstrate the procedure.

D) Have the nurse demonstrate the procedure.

Which medication is a nonantipsychotic that may be used to treat a client with schizoaffective disorder? A) Imipramine B) Chlordiazepoxide C) Phenelzine D) Lithium carbonate

D) Lithium carbonate Lithium carbonate, an antimania drug, is used to treat cyclical schizoaffective disorder. This psychotic disorder was once classified under schizophrenia and causes affective symptoms, including manic-like activity. Lithium helps control the affective component of this disorder. Phenelzine is a monoamine oxidase inhibitor prescribed for clients who don't respond to other antidepressant drugs such as imipramine. Chlordiazepoxide, an antianxiety agent, generally is contraindicated in psychotic clients. Imipramine, primarily considered an antidepressant agent, is also used to treat clients with agoraphobia and those undergoing cocaine detoxification.

The nurse is observing pupillary responses from a client. Which method should the nurse use to evaluate pupil accommodation? A) Check for peripheral vision. B) Have the client follow an object upward, downward, obliquely, and horizontally. C) Touch the cornea lightly with a wisp of cotton. D) Observe for pupil constriction and convergence while focusing on an object coming toward the client.

D) Observe for pupil constriction and convergence while focusing on an object coming toward the client. Accommodation refers to convergence and constriction of the pupil while focusing on a nearing object. Touching the cornea lightly with a wisp of cotton describes evaluation of the corneal reflex. Having the client follow an object upward, downward, obliquely, and horizontally refers to cardinal fields of gaze. Checking for peripheral vision refers to visual fields.

A nurse is preparing to teach a group of school-age children about injury prevention. Which intervention is most appropriate? A) Have the children try on safety equipment. B) Encourage children to be independent. C) Teach the children to say "no" to their peers. D) Play group games involving sports safety equipment.

D) Play group games involving sports safety equipment. School age safety issues are related to the child moving more from the home environment to the community, decrease in fear and the increased use of tools and household items. Important safety issues that impact school-age children include burn injuries, pedestrian injuries, sport injuries and drowning. From peers, children learn how to cooperate, compete, bargain, and follow rules. Peer approval is of major importance as children look to their friends for recognition and support. The influence of peers becomes stronger as the child grows older. School-age children are subject to peer pressure, and would rather not participate in injury prevention if they must wear safety apparel that provokes taunts from peers. The nurse should discuss stylishness, comfort, and social acceptance because these are major determinants of compliance.

A nurse is reinforcing education to parents who are planning to give growth hormone to their child at home. What is the best time to administer growth hormone in order to achieve optimal dosing? A) in the middle of the day B) after dinner C) first thing in the morning D) at bedtime

D) at bedtime Optimal dosing is usually achieved when growth hormone is administered at bedtime. Pituitary release of growth hormone occurs during the first 45 to 90 minutes after the onset of sleep, so normal physiologic release is mimicked with bedtime dosing.

A nurse cares for a client that reports sexual dysfunction. Which condition should the nurse consider as one of the most common causes of sexual dysfunction? A) osteoarthritis B) peripheral artery disease C) peptic ulcer disease D) diabetes mellitus

D) diabetes mellitus A variety of vascular, neurologic, respiratory, endocrine, and genitourinary conditions can cause sexual dysfunction in men. Diabetes is one of the most common due to the deleterious effect of diabetes on blood vessels. The other conditions do not necessarily cause sexual dysfunction.

A neonate born 8 weeks preterm has no spontaneous respirations but is successfully resuscitated. Within several hours, the neonate develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions and is diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. When implementing the neonate's plan of care, which intervention would be most appropriate to assist in preventing retinopathy of prematurity? A) Humidifying the oxygen. B) keeping the neonate's body temperature low C) covering the neonate's eyes while the neonate receives oxygen D) monitoring partial pressure of oxygen (PaO2) levels

D) monitoring partial pressure of oxygen (PaO2) levels Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within normal limits reduces the risk of retinopathy of prematurity in a premature neonate receiving oxygen. Covering the neonate's eyes is appropriate for a neonate receiving phototherapy. Humidifying the oxygen aids in keeping the mucous membranes of the respiratory tract moist. Neither helps to reduce the risk of retinopathy of prematurity. Because cooling increases the risk of acidosis, the neonate should be kept warm to reduce the metabolic demands and prevent exacerbating his or her already stressed respiratory status.

A client in the fifth month of pregnancy is having a routine clinic visit. When gathering data from the client, the nurse would be alert for which common second trimester condition? A) metabolic alkalosis B) mastitis C) respiratory acidosis D) physiologic anemia

D) physiologic anemia Hemoglobin level and hematocrit decrease during pregnancy as the increase in plasma volume exceeds the increase in red blood cell production. The result is physiologic anemia. Mastitis is an infection in the breast characterized by a swollen, tender breast and flulike symptoms. This condition is most commonly seen in breast-feeding clients. Alterations in acid-base balance during pregnancy result in a state of respiratory alkalosis, compensated by mild metabolic acidosis.

The nurse is teaching parents how to reduce the spread of impetigo. The nurse should encourage parents to: isolate the child with impetigo from other members of the family. teach children to cover mouths and noses when they sneeze. have their children immunized against impetigo. teach children the importance of proper hand washing.

D) teach children the importance of proper hand washing.