NCLEX Prep Final

Anorexia, nausea, and vomiting are commonly seen with chemotherapy. What nutritional interventions can the nurse recommend to address these symptoms? a. small frequent meals b. high calorie, high protein diet c. increase fluid except at meal time d. all of the above

d. all of the above

when a patient is experiencing delirium tremens they experience a. anxiety b. hallucinations c. seizures d. all of the above

d. all of the above

which of the following statements about a living will are true? a. legally binding in most states b. names a person to make a decision if a patient is incapacitated c. may indicate life-saving measures d. all of the above

d. all of the above

causes of intellectual delay are a. fetal anoxia b. intracranial hemorrhage c. infection d. all the above

d. all the above

the nurse assesses the peripheral iv site of a patient receiving a doxorubicin infusion and suspects extravasation. after stopping the infusion and disconnecting the IV tubing, which of the following should the nurse do next a. apply a hot compress to the IV site b. apply a cool compress to the IV site c. elevate the affected extremity d. attempt to aspirate the residual drug

d. attempt to aspirate the residual drug

the nurse is developing a care plan for a patient with HepC. the nurse knows that the primary route of transmission of this hepatitis virus is which of the following a. contaminated food b. sputum c. feces d. blood

d. blood

the nurse is reviewing the chart of an older adult male pt after surgery for removal of the parathyroid glands. the pt reports difficulty swallowing and a feeling of pins and needles. the nurse expects which of the following laboratory values to be abnormal? a. lipase b. sodium c. potassium d. calcium

d. calcium

all of the statements regarding the denver II is correct except a. evaluated children in 4 skill areas b. is age-adjusted for prematurity c. has questionable value in testing children of minority/ethnic groups d. evaluates children from birth to 12 years old

d. evaluates children from birth to 12 years old *** birth to 6 years old

tonometry measures: a. test visual acuity b. range of vision (perimetry) c. uneven curve of cornea d. intraocular pressure

d. intraocular pressure

on the evening shift the nurse is caring for a patient who will be undergoing a mastectomy in the morning. a call from the front desk alerts the nurse that the patient's family has arrived. it would be the most appropriate for the nurse to take which of the following actions? a. tell the family they cannot come as it is after visiting hours b. tell the patient you want to make sure she has time to relax c. tell the nursing assistant to sit with the patient who needs company d. invite the family in to offer support after confirming with the patient

d. invite the family in to offer support after confirming with the patient

upon examining her patient the nurse detects a red lesion described as a bull's eye a. shingles b. herpes c. roseola d. lyme

d. lyme

international normalized ratio (INR) means: a. speed at which RBCs settle in well mixed blood b. measures platelet counts c. measures maturity of white blood cells d. monitors effectiveness of anticoagulation therapy

d. monitors effectiveness of anticoagulation therapy

when providing postoperative teaching for a patient with a fractured hip, the nurse instructs the patient to a. maintain adduction b. cross their legs c. flex hip 100 degrees d. not to sleep on operated side

d. not to sleep on operated side

The nurse is administering oral calcium gluconate to her patient. While doing discharge teaching the nurse advises the patient to take _____________ to increase absorption of the calcium gluconate? a. peanut butter b. spinach c. water d. orange juice

d. orange juice

an infection of the bone usually caused by staphylococcus is called a. osteomalacia b. bursitis c. osteoporosis d. osteomyletitis

d. osteomyletitis

play is an important aspect of growth and development. what kind of play is characteristic of toddlers a. associative play b. cooperative play c. solitary play d. parallel play

d. parallel play

the first-line treatment for seasonal affective disorder (SAD) is a. anti-anxiety medications b. group therapy c. medication d. phototherapy

d. phototherapy

for a child who is 9 months old list 2 measures you must enforce to provide protection from injury

pad sharp furniture edges don't use electrical wires near water

list 3 assessment findings an infant may present with who has been diagnosed with pyloric stenosis

projectile vomiting irritability failure to gain weight

indicate the secondary purpose of isotonic fluids

provide route for medications, nutrition, and blood components

3 conditions that require enteral feeding

- GI problems - adverse effects of oncology - head/neck disorders or surgery

name the steps of problem solving

1. define problem 2. gather data 3. analyze data 4. develop solution 5. select and implement a solution 6. evaluate results

3 purposes of traction

1. reduce fracture 2. promote healing 3. prevent/correct deformity

The physician has ordered a 2-L daily fluid restriction for a patient diagnosed with heart failure. The nurse is totaling the patient's fluid intake for the 8-hour shift. The patient drank 5 oz. of juice at breakfast, 2 oz. of water with medications, 8 oz. of soup at lunch and 6 oz. of milk at lunch. Intravenous fluids, flushes, and intravenous antibiotics for the shift were 400 mL. Urinary output was 300 mL, 100 mL. and 250 mL. What should the nurse document, in milliliters, as total fluid intake for the shift?

1030

the physician orders 0.5 mg of digoxin for a pt with a fib. the pharmacy has 250 mcg tablets available. how many tablets will the nurse give?

2

the nurse is caring for a patient on an inpatient psychiatric ward. the patient has known suicidal ideation. the 24 hour observer reports the patient has "taken off down the hall" and the nurse cannot find him. arrange the actions in order of the MOST appropriate a. notify security that the patient has eloped, provide a description of the patient b. notify the nurse manager c. notify other staff on the unit d. ask the observer which direction the patient headed

D. ask the observer which direction the patient headed C. notify other staff on the unit A. notify security that the patient has eloped, provide a description of the patient B. notify the nurse manager

define colors of mass casualty red yellow green black DOA

R- immediate Y- delayed G- minor B- decreased DOA- Dead on arrival

SBAR stands for

Situation Background Assessment Recommendation

__ is the 3rd leading cause of death in children from 1w-1y

SIDS

A nurse is working with a client who has systemic lupus erythematosus and recently lost her health insurance. Which of the following actions should the nurse take in the implementation phase of the case management process? a. Coordinating services to meet the client's needs b. Comparing outcomes with original goals c. Determining the client's financial constraints d. Clarifying roles of interprofessional team members

a. Coordinating services to meet the client's needs

the nurse is instructing a male patient on the proper use of crutches for an ankle injury. he will be required to be non-weight bearing for 4-6 weeks. which of the following crutch gaits should the nurse teach his patient for safe ambulation a. 3 point gait b. 4 point gait c. 2 point gait d. none

a. 3 point gait

a patient is admitted for GI bleeding. he has a platelet 15,000 and platelets have been ordered from the blood bank. which of the following does the nurse know are required for platelet transfusions (SATA) a. ABO compatibility b. crossmatching c. RH compatibility d. a specialized platelet filter

a. ABO compatibility c. RH compatibility d. a specialized platelet filter

A nurse is reviewing the health record of a client who asks about using propranolol to treat hypertension. The nurse should recognize which of the following conditions is a contraindication for taking propranolol a. Asthma b. Glaucoma c. Hypertension d. Tachycardia

a. Asthma

A client asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses by the nurse is appropriate? a. Call me when you're ready and I will return with it b. Since you were taking this medication at home, I will leave it for you c. I will come back in 30 minutes to make sure you took it and to record the time of administration d. If refuse to take the medication now, I cannot give it to you until the next scheduled time

a. Call me when you're ready and I will return with it

A nurse is caring for a client who has gonorrhea. Which of the following medications should the nurse anticipate the provider will prescribe? a. Ceftriaxone b. Fluconazole c. Metronidazole d. Zidovudine

a. Ceftriaxone

When a patient experiences suspiciousness and interprets actions of others as a personal threat they may be experiencing which type of personality disorder a. borderline b. paranoid c. antisocial d. histrionic

b. paranoid

The nurse receives report on a patient with a right total knee arthroplasty who developed methicillin-resistant Staphylococcus aureus (MRSA) in the surgical incision. The incision was cultured and showed sensitivity to vancomycin. The patient's blood urea nitrogen (BUN) is 14 mg/dL and serum creatinine (Cr) is 0.9 mg/dL. Intake and output are balanced. A peak and trough have been ordered. The third dose of vancomycin is to be given on the nurse's shift. The nurse should do which of the following? a. Draw a trough 30" prior to dose and draw a peak 60" after infusion b. Draw a peak 30" prior to dose and draw trough 60" after infusion c. Hold the dose of vancomycin and notify the physician of the BUN and Cr levels. d. Give the dose of vancomycin as ordered and draw the peak and trough with other evening labs

a. Draw a trough 30" prior to dose and draw a peak 60" after infusion

A client is prescribed clozapine. The nurse should monitor for which of the following complications? a. Dyslipidemia b. Osteoporosis c. Hypertension d. Thrombocytopenia

a. Dyslipidemia

A client who is at 7 weeks of gestation is experiencing nausea and vomiting in the morning. Which of the following information should the nurse include in the teaching? a. Eat crackers or plain toast before getting out of bed. b. Awaken during the night to eat a snack. c. Skip breakfast and eat lunch after nausea has subsided. d. Eat a large evening meal

a. Eat crackers or plain toast before getting out of bed.

A client who has a recent closed head injury reports a severe headache and is restless. Which of the following is an appropriate nursing intervention? a. Elevate the head of the bed 30 degrees b. Place a cool cloth on the forehead c. Administer morphing 2 mg IV d. Prepare for a lumbar puncture

a. Elevate the head of the bed 30 degrees

A nurse is providing information to a client who has early Parkinson's disease and a new prescription for pramipexole. The nurse should instruct the client to monitor for which of the following adverse effects of this medication? a. Hallucinations b. Increased salivation c. Diarrhea d. Discoloration of urine

a. Hallucinations

An RN on a medical surgical unit is making assignments at the beginning of the shift. Which of the following tasks should the nurse delegate to the PN? a. Obtain vital signs for a client who is 2 hr post procedure following a cardiac catheterization. b. Administer a unit of packed red blood cells (RBCs) to a client who has cancer. c. Instruct a client who is scheduled for discharge in the performance of wound care. d. Develop a plan of care for a newly admitted client who has pneumonia.

a. Obtain vital signs for a client who is 2 hr post procedure following a cardiac catheterization.

the nurse is caring for a male patient. he is exhibiting signs of anxiety and hostility. the nurse is aware that the veteran patient has recently returned combat. the nurse should assess for which of the following conditions a. PTSD b. bipolar disorder c. schiophrenia d. borderline personality disorder

a. PTSD

A nurse is performing a nutritional assessment on a client. Which of the following clinical findings are suggestive of malnutrition? (SELECT ALL THAT APPLY) a. Poor wound healing b. Dry hair c. Blood pressure 130/80 mm Hg d. Weak hand grips e. Impaired coordination

a. Poor wound healing b. Dry hair d. Weak hand grips e. Impaired coordination

The nurse is on an Alzheimer's unit. A client is agitated and pulling at things. Which of the following should the nurse do? a. Provide the client with therapeutic sensory devices. b. Cohort the client with another client who is agitated because they will calm each other. c. Place the client in a room with several other clients. d. Leave the client alone for a period of time to reduce stimulation.

a. Provide the client with therapeutic sensory devices.

A nurse provides education to a client who has a gastric ulcer. Which of the follow medications decreases the secretion of gastric acid? a. Ranitidine b. Sucralfate c. Bismuth subsalicylate d. Magnesium hydroxide

a. Ranitidine

A nurse is caring for a client with diabetes mellitus and had a morning blood glucose level of 285 mg/dL. An assistive personnel (AP) reports that a clients finger-stick blood glucose reading 30 minutes before lunch is 58 mg/dL. Which of the following actions should the nurse take? a. Recheck the client's blood glucose b. Complete a facility incident report c. Inform the AP to give the client 120mL of orange juice d. Administer prescribed insulin

a. Recheck the client's blood glucose

A nurse is caring for a 10 year old child who has nephrotic syndrome. Which of the following findings should the nurse report to the provider? a. Serum protein 5.0 g/dl b. Hgb 14.5 g/dl c. Hct 40% d. Platelet 200,000 mm3

a. Serum protein 5.0 g/dl

During a home health assessment, the nurse witnessed a school-age child fall from a secondary window. Which of the following is the priority action? a. Tell the child not to move b. Provide support to the parents c. Apply pressure to bleeding d. Place the child on a rigid board

a. Tell the child not to move

A nurse is caring for a client who is pregnant and reviewing signs of complications the client should promptly report to the provider. Which of the following complications should the nurse include in the teaching? a. Vaginal bleeding b. Swelling of the ankles c. Heartburn after eating d. Lightheadedness when lying on back

a. Vaginal bleeding

after receiving report at the start of the evening shift, which of the following patients should the nurse attend to first? a. a man undergoing treatment for non-hodgkin lymphoma with a potassium level of 7.5 b. a woman with sickle cell anemia with a pain of 6/10 c. a woman with ovarian cancer awaiting to be discharged d. a woman with chronic obstructive disease and pulse oximetry of 96% room air.

a. a man undergoing treatment for non-hodgkin lymphoma with a potassium level of 7.5

an RN is in charge of a team on a medical surgical unit that includes an LPN. The RN understands that which of the following is an activity that falls within the scope of a practice of an LPN a. administer oral medications to patient b. collaborate with social services to develop a discharge plan c. formulate a nursing diagnosis d. develop a policy

a. administer oral medications to patient

which of the following describes an incident report a. agency record of unusual occurrence or accident and physical response b. regularly scheduled, structured exchange of information c. decision framework for solving ethical problems d. duty to help other by doing what is best for them

a. agency record of unusual occurrence or accident and physical response

Of the following, which is the earliest assessment sign of increased intracranial pressure? a. altered level of consciousness b. Glascow Coma scale of 3 c. patient unresponsive d. zero reflexes

a. altered level of consciousness

issues that adolescents struggle with in regard to psychosocial development are (SATA) a. conformity with peer pressure b. rapid body changes c. separation anxiety d. mature sexual identity

a. conformity with peer pressure b. rapid body changes d. mature sexual identity

allopurinol is a drug used to treat gout. how does this drug work? a. decrease uric acid levels b. decrease infection c. decrease calcium levels d. decrease sodium levels

a. decrease uric acid levels

a nurse is taking a patient's history that has been diagnosed with anorexia nervosa. which of the following might a patient with anorexia use? (SATA) a. diuretics b. enemas c. cathartics d. none of the above

a. diuretics b. enemas c. cathartics

the nurse is performing a assessment on a pt who developed cirrhosis. which of the following signs and symptoms should the nurse expect to see? select all that apply a. dull abdominal ache b. cyanosis c. poor tissue turgor d. bruises e. fruity breath

a. dull abdominal ache c. poor tissue turgor d. bruises

the alternative therapy that increases the effects of anticoagulants is a. garlic b. soy c. flaxseed d. green tea

a. garlic

the nurse has been asked to administer a drug by IV push. she is uncertain whether or not this task falls within her scope of practice. the nurse knows that which of the following are the best sources to refer to for information related to her scope of practice in this situation? (SATA) a. hospital and unit policies and procedure b. nurse practice act c. ordering physician d. hospital pharmacist

a. hospital and unit policies and procedure b. nurse practice act

the nurse is taking care if an adult male with bilateral leg fractures. he has a long leg cast on this right leg as well as traction applied to the left femur. which of the following is the main purpose served by he cast for this patient. a. immobilizes the tibia and fibula and corrects deformities b. keeps the patient, who is interaction, more comfortable c. immobilizes the pelvic bones for better healing d. encircles the trunk and stabilizes the spine

a. immobilizes the tibia and fibula and corrects deformities

all of the following statements are true regarding central venous access device except: a. must be changed every 24 hours b. can be flushed with normal saline alone c. blood pressure should not be taken on same arm the line is placed d. a normal saline flush can be followed by heparinized saline

a. must be changed every 24 hours

the nurse administers the first dose of chemotherapy to a patient on an oncology unit. the nurse knows that which of the following activities is appropriate to delegate to the LPN a. obtain the client's BP b. provide teaching about side effects of chemotherapy c. administer second dose of chemotherapy d. flush the patient's central line with heparin

a. obtain the client's BP

the nurse is taking a history from a patient. the patient has been taking lorazepam for 6 months. which of the following is the most likely side effect when using ativan for this time period a. physical dependence b. excessive appetite c. suicidal ideation d. seizure activity

a. physical dependence

a 60 year old woman with anorexia nervosa is having an indwelling central venous access device placed in preparation for TPN administration. which of the following factors does the nurse know accounts for the patient's increased risk of thrombophlebitis with a peripheral intravenous line (SATA) a. poor peripheral venous access b. age c. hypertonicity of the TPN d. hypotonicity of TPN

a. poor peripheral venous access b. age c. hypertonicity of the TPN

the nurse is teaching about the challenges of smoking cessation. which of the following factors will the nurse identify as known challenges that patients face when attempting to quit smoking? (SATA) a. psychosocial problems b. stress and depression c. continued exposure to smoking associated stimuli d. high level of education e. low level of income

a. psychosocial problems b. stress and depression c. continued exposure to smoking associated stimuli e. low level of income

a parent asks the nurse for suggestions of toys that would be appropriate for her 3 month old daughter. the nurse knows to suggest a. rattles, gym matts b. large toys with moveable parts, large pull/push toys, teddy bears c. books with large pictures d. one of the above

a. rattles, gym matts

the nurse is learning how to use the hospital's new electronic medication administration record. the nurse knows this tool has the potential to do which of the following? (SATA) a. reduce medication administration errors b. improve access to information at the point of care c. eliminate the need for the nurse to document medication administration d. eliminate the need for the nurse to verify dose calculations

a. reduce medication administration errors b. improve access to information at the point of care

the nurse completes a peripherally inserted central catheter (pPICC) line dressing change for a home care patient. when removing the PPE, the nurse should do which of the following a. remove the gloves then the mask b. remove the mask then the gloves c. remove only the mask d. remove only the gloves

a. remove the gloves then the mask

the provider verbally orders a medication for a patient during an emergency code. which of the following should the nurse do? a. repeat the order back to the provider for confirmation and administer it b. retrieve the medication and administer it c. write the order down, retrieve the medication, and administer it d. read the order to another nurse, have the nurse retrieve the medication and stay with the patient

a. repeat the order back to the provider for confirmation and administer it

which of the following are signs and symptoms of grave's disease (SATA) a. tachycardia b. thick hair c. diarrhea d. weight loss

a. tachycardia c. diarrhea d. weight loss

an older adult male pt with a hx of myasthenia gravis is admitted to the m/s unit. which of the following tests should the nurse expect to see ordered? select all that apply a. tensilon test b. nerve conduction studies c. lumbar puncture d. EEG e. electromyography

a. tensilon test b. nerve conduction studies e. electromyography

anticholinergic adverse effects of medications are (SATA) a. urinary retention b. dry mouth c. hallucinations d. dysphagia

a. urinary retention b. dry mouth d. dysphagia

a first time parent is discussing developmental milestones with the nurse. the nurse tells the parent that she can reasonable expect her child to achieve which of the following by the time the child is 1 years old. (SATA) a. vocalizing sounds (coos) b. transferring toys from hand to hand c. walking d. beginning to respond selectively to words e. rolling from tummy to side

a. vocalizing sounds (coos) b. transferring toys from hand to hand d. beginning to respond selectively to words e. rolling from tummy to side

A nurse is advocating for local leaders to place a newly approved community health clinic in an area of the city that has fewer resources than other areas. The nurse is advocating for the leaders to uphold which of the following ethical principles? a.Distributive justice b.Fidelity c.Respect for autonomy d.Veracity

a.Distributive justice

when a patient is experiencing DTs they are withdrawing from ___

alcohol

A nurse is providing teaching about dental care and teething to a parent of a 9-month-old infant. Which of the following statements by a parent indicates an understanding of the teaching? a. "I can give my baby a warm teething ring to relieve discomfort" b. "I should clean my baby's teeth with a cool, wet wash cloth" c. "I can give Advil for up to 5 days while my baby is teething" d. "I should place diluted juice in the bottle my baby drinks while falling asleep"

b. "I should clean my baby's teeth with a cool, wet wash cloth"

the nurse in a maternity unit is caring for a patient who has just delivered twins. the patient voices concerns about her ability to manage when she gets home. which of the following statements best illustrates quality care delivery by the nurse? (SATA) a. "just focus on how lucky you are to be have two healthy twins" b. "we can arrange for follow-up visits with a home health nurse" c. "here is some information on support groups for parents of multiples" d. "you will find it easier to formula feed your babies at home"

b. "we can arrange for follow-up visits with a home health nurse" c. "here is some information on support groups for parents of multiples"

when administering diazepam by IV push the nurse should never exceed more than a. 0.25mg/min b. 2.0mg/min c. 0.5mg/min d. 1.0mg/min

b. 2.0mg/min

the normal blood pH is: a. 85-95 mmHg b. 7.35-7.45 c. 35-45 mmHg d. 22-26 mEq/L

b. 7.35-7.45

A client is admitted to the telemetry unit for sustained paroxysmal supraventricular tachycardia. Which of the following medications should the nurse prepare to administer? a. Atropine b. Adenosine c. Nitroprusside d. Norepinephrine

b. Adenosine

A nurse is teaching a client who has intermittent explosive disorder about a new prescription for fluoxetine. Which of the following information should the nurse provide? (select all that apply.) a. An adverse effect of this medication is CNS depression. b. Administer the medication in the morning. c. Monitor for weight loss while taking this medication. d. Therapeutic effects of this medication will take 1 to 3 weeks to fully develop. e. This medication blocks the blocking the synaptic reuptake of serotonin in the brain

b. Administer the medication in the morning. c. Monitor for weight loss while taking this medication. e. This medication blocks the blocking the synaptic reuptake of serotonin in the brain

A labor room nurse is caring for a client in labor with a known history of sickle cell anemia. Which priority action would the nurse implement to assist in preventing a sickle cell crisis from occurring during labor? a. Continually reassure and coach the client b. Administer the prescribed oxygen throughout labor c. Maintain strict asepsis throughout the labor process d. Increase the intravenous (IV) fluids if the client complains of feeling thirsty

b. Administer the prescribed oxygen throughout labor

A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first a. Request a prescription for an antihypertensive medication. b. Ask the client if she is having pain. c. Request a prescription for an antianxiety medication. d. Return in 30 min to recheck the client's blood pressure.

b. Ask the client if she is having pain.

A client who has a spinal cord injury asks the nurse about complications of prolonged immobility. Which of the following should the nurse discuss? Select all that apply a. Presbyopia b. Atelectasis c. Contractures d. Pressure sores e. Thrombus formation

b. Atelectasis c. Contractures d. Pressure sores e. Thrombus formation

An 82-year-old woman is admitted with a diagnosis of rapid atrial fibrillation. The nurse has initiated telemetry monitoring per the physician's order. Two hours after initiation of monitoring, an alarm sounds at the central monitoring station: the patient is in what appears to be ventricular tachycardia. Which of the following actions should the nurse take FIRST? a. Notify the physician of a change in rhythm. b. Check the patient and check the lead placement c. Silence the alarm and change the alarm parameters d. Call a code blue

b. Check the patient and check the lead placement

A nurse is completing a needs assessment and beginning analysis of data. Which of the following actions should the nurse take first? a. Determine health patterns within collected data. b. Compile collected data into a database. c. Ensure data collection is complete. d. Identify health needs of the local community.

b. Compile collected data into a database.

A nurse is assessing an infant who has heart failure. Which of the following findings should the nurse expect? (Select all that apply) a. Bradycardia b. Cool extremities c. Peripheral edema d. Increased urinary output e. Nasal flaring

b. Cool extremities c. Peripheral edema e. Nasal flaring

A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse promptly report to the provide. Which of the following complications should the nurse include in the teaching? a. Decreased blood pressure b. Diaphoresis c. Pinpoint pupils d. Bradycardia

b. Diaphoresis

A nurse is assessing a client who is postoperative from a gastric bypass and who just finished eating a meal. Which of the following findings are manifestations of dumping syndrome? (select all that apply) a. Bradycardia b. Dizziness c. Dry skin d. Hypotension e. Diarrhea

b. Dizziness d. Hypotension e. Diarrhea

A client who has COPD is prescribed ipratropium bromide. The nurse should instruct the client to report which of the following immediately? a. Nausea b. Eye pain c. Dry mouth d. Constipation

b. Eye pain

The nurse assesses a patient with a diagnosis of parathyroid disease. The patient is having abdominal cramping, positive Chovstek's and Trousseau's signs, and tingling in the extremities. The nurse knows that these findings could be signs and symptoms of which of the following? a. Hypermagnesemia b. Hypocalcemia c. Hypomagnesemia d. Hypercalcemia

b. Hypocalcemia

A newly hired public health nurse is familiarizing himself with the levels of disaster management. Which of the following actions is a component of disaster prevention? a. Outlining specific roles of community agencies b. Identifying community vulnerabilities c. Prioritizing care of individuals d. Providing stress counseling

b. Identifying community vulnerabilities

Of the following, which are the causes for Carcinoma of the Larynx? SATA a. Acute Laryngitis b. Industrial chemicals c. Cigarette Smoking d. Straining of the Vocal cord

b. Industrial chemicals c. Cigarette Smoking d. Straining of the Vocal cord

A nurse is planning to administer subcutaneous enoxaparin 40mg using a prefilled syringe of enoxaparin 40mg/0.4mL to an adult client following a hip arthroplasty. Which of the following actions should the nurse plan to take? a. Expel the air bubble from the prefilled syringe before injection b. Insert the needle completely into the client's tissue c. Administer the injection in the client's thigh d. Aspirate carefully after inserting the needle into the client's skin

b. Insert the needle completely into the client's tissue

A nurse is reviewing urinalysis results for four clients. Which of the following urinalysis results indicates a urinary tract infection? a. Positive for hyaline casts b. Positive for leukocyte esterase c. Positive for ketones d. Positive for crystals

b. Positive for leukocyte esterase

A client is admitted for pulmonary embolism and is receiving heparin 1500 units/ hour IV. In case of serious bleeding reaction, the nurse has which of the following drugs readily available? a. Vitamin K b. Protamine sulfate c. Promethazine hydrochloride d. Protamine

b. Protamine sulfate

A home health nurse is discussing portals of entry with a group of newly hired assistive personnel. Which of the following locations should the nurse include as a portal of entry? (select all that apply.) a. Respiratory secretions b. Skin c. Genitourinary tract d. Saliva e. Mucous membranes

b. Skin c. Genitourinary tract e. Mucous membranes

A nurse is completing an integumentary assessment of a client who has anemia. Which of the following findings should the nurse expect? a. Absent turgor b. Spoon-shaped nails c. Shiny, hairless legs d. Yellow mucous membranes

b. Spoon-shaped nails

A nurse in a clinic receives a phone call from a client seeking information about a new prescription for erythropoietin. Which of the following information should the nurse review with the client? a. The client needs an erythrocyte sedimentation rate (ESR) test weekly. b. The client should have his hemoglobin checked twice a week. c. Oxygen saturation levels should be monitored. d. Folic acid production will increase.

b. The client should have his hemoglobin checked twice a week.

The client is 7 months pregnant with her first child. She is anxious because she feels some mild contractions at times. The nurse tells her which of the following? a. She should increase her bed rest to prevent these precautions. b. The contractions are normal unless they increase in severity. c. The contractions are a way of her body asking her for more exercise. d. She should avoid getting constipated and having gas as a result.

b. The contractions are normal unless they increase in severity.

A client is seen for an outpatient appointment and asks the nurse if he can obtain a copy of his medical record. The nurse knows the client has the right to read and copy his medical records, and that this is guaranteed by virtue of which of the following? a. The code of ethics for nurses b. The health insurance portability and accountability act (HIPAA) c. The patient self-determination act d. The Americans with disabilities act

b. The health insurance portability and accountability act (HIPAA)

A nurse is observing a newly licensed nurse and an assistive personal (AP) pull a client up in a bed using a drawsheet. Which of the following actions by the newly licensed nurse indicates an understanding of this technique? a. The nurse stands with feet together b. The nurse uses body weight to counter the client's weight c. The nurse's feet are facing inward, toward the center of the bed d. The nurse uses the muscles in his back to lift the client off the bed using drawsheet.

b. The nurse uses body weight to counter the client's weight

A 70-year-old male presented to the ED with SOB, crackles in bases and middle of the lung fields bilaterally, 2+ pitting edema bilaterally of the lower extremities, and a weight increase of 6 lb. in one week. His heart rate is 82 and his blood pressure 162/90. Per physician's order, the nurse administers 40 mg of furosemide intravenously. The nurse knows that which of the following indicates effectiveness of the medication? a. A heart rate of 58 b. Urine output increase of 200 mL over the next hour c. A blood pressure of 100/52 d. diminished lung sounds bilaterally with crackles in the bases

b. Urine output increase of 200 mL over the next hour

the patient has a medical history of alcohol abuse and had a drink yesterday, the nurse notes tremors, diaphoresis, and an elevated HR. the nurse should perform which of the following first a. assess the patient every hour to monitor symptoms b. administer lorazepam per the alcohol withdrawal policy c. call the family and administer meperidine per the ETOH withdrawal policy d. call the physician to report symptoms and administer hydromorphone

b. administer lorazepam per the alcohol withdrawal policy

the nurse has been assigned to a 2day old infant male on the mother/baby unit of an acute care facility. the infant will undergo a circumcision procedure in the afternoon, before being discharged the following morning. which of the following non-pharmacologic interventions should the nurse teach the parents to keep this infant comfortable while the circumcision heals? a. fasten his diaper tightly to avoid having the wound move around b. apply petroleum jelly to gauge and place over the end of the penis when changing the diaper, leaving the diaper slightly loose when fastening c. offer feedings more often to soothe the child who is in pain d. wash the end of the penis vigorously to prevent infection

b. apply petroleum jelly to gauge and place over the end of the penis when changing the diaper, leaving the diaper slightly loose when fastening

the nurse is preparing to discharge a pt who is stable after sickle cell anemia crisis. which of the following instructions should the nurse provide to the pt to avoid future crisis? select all that apply a. limit your fluid intake b. avoid strenuous exercise c. apply cold compresses to painful areas d. take pain meds e. avoid tight clothing

b. avoid strenuous exercise d. take pain meds e. avoid tight clothing

the nurse is preparing to transfer a patient to the operating room. she knows that adhering to the hospital policy for patient handoff's best ensures which of the following? a. case management b. continuity of care c. confidentiality protection d. collaboration

b. continuity of care

the nurse has just administered insulin to a diabetic patient. in which of the following ways should the nurse dispose of the needle. a. break the needle and dispose of it in the nearest sharps container b. discard the needle in the sharps container c. recap the needle and discard in the nearest biohazard

b. discard the needle in the sharps container

an elderly man is admitted to the hospital from the ED during night shift. the nurse is assessing the pt's cerebellar function. which of the following questions should the nurse ask the pt? a. who is the current president of the US? b. do you have any problems with balance? c. do you have trouble swallowing fluids or foods? d. do you have any muscle pain?

b. do you have any problems with balance?

a patient is experiencing a manic episode. it would be most appropriate for the nurse to perform which of the following interventions a. give the patient materials to make a collage b. encourage the patient to use an exercise bike c. encourage the patient to attend a group on managing feelings d. as the patient to play a board game with other patients

b. encourage the patient to use an exercise bike

the nurse is assessing an elderly patient for risk for falls. which of the following should the nurse collect. a. the facility's restraint policy b. gait, balance, visual impairment c. psychosocial history d. the facility's environmental safety policy

b. gait, balance, visual impairment

the nurse is designing a diet plan for a 70 year old with poorly fitting dentures who has just recently diagnosed DM2. the nurse knows that which of the following is least likely to risk to the patient a. low blood sugar b. high blood sugar c. malnutrition d. dehydration

b. high blood sugar

erik erikson named developmental tasks each are group needs to master as they age. which task is specific to preschool children a. integrity vs despair b. initiative vs guilt c. industry vs inferiority d intimacy vs isolation

b. initiative vs guilt

the nurse working in an outpatient clinic has the opportunity to teach an insulin dependent patient. which of the following topics would be most appropriate for the nurse to include when teaching personal hygiene. a. personal hygiene is not included in diabetic teaching because it is an individual choice b. it is most important to keep skin clean and dry, especially the feet c. oral care is not a top priority d. hair care is the most important part of personal hygiene for a diabetic

b. it is most important to keep skin clean and dry, especially the feet

the nurse is taking care of an adult patient with a long-bone fracture. the nurse encourages the patient to move fingers and toes hourly, to change positions slightly every hour, and to eat high-iron foods as part of a balanced diet. which of the following foods or beverages should the nurse advise the patient to avoid while on bedrest? a. fruit juices b. large amounts of milk or milk products c. cranberry juice cocktail d. no need to avoid any foods while on bed rest

b. large amounts of milk or milk products

what position is a woman in when she is having a colposcopy procedure? a. side lying b. lithotomy c. prone d. supine

b. lithotomy

a 65 year old man with metastatic colon cancer has been prescribed hyrdromorphone PO/PRN to help manage pain/ the nurse knows that the rectal route of administration is contraindicated when which of the following is present a. nausea and vomiting b. neutropenia c. difficulty swallowing d. fever

b. neutropenia

a 3 month old child accompanies her parents to a seasonal flu clinic. assuming the child does not have a fever, can the nurse give the child a flu shot? a. yes, if regular immunizations are up to date b. no, because the child is not old enough c. yes, because the child won't get sick later d. no because it would interfere with regular immunizations

b. no, because the child is not old enough

Which of the following statements are true regarding a Holter Monitor? Select all that apply a. measures specific gravity of 32 hour urine output b. patient journals activities over a 24 hours period c. measures 24 hour continuous EKG tracings d. patient collects and measures a 23 hour urine output

b. patient journals activities over a 24 hours period c. measures 24 hour continuous EKG tracings

a patient is admitted for pulmonary embolism and receiving heparin 1500 units/hour IV. in case of serious bleeding reaction, the nurse has which of the following drugs readily available? a. vitamin k b. protamine sulfate c. promethazine hydrochloride d. protamine

b. protamine sulfate

the nurse is taking care of an elderly patient with left-sided heart failure. which of the following are the most appropriate nursing interventions to reduce the workload of the heart and to promote comfort and rest? a. assist he patient on short walks at least 2x per shift to increase circulation b. provide a comfortable armchair or raise the head of the bed to increase the reserve of the heart and to decrease the work of breathing c. allow the patient to lie flat to sleep d. help the patient walk to the bathroom rather than using a bedside commode

b. provide a comfortable armchair or raise the head of the bed to increase the reserve of the heart and to decrease the work of breathing

the nurse discovers a patient on the floor in the patient's hospital room. after examining the patient and assisting him safely back to bed, which of the following should the nurse do first? a. file an incident report b. put the bed alarm back on c. find the patient sitter to sit with the patient to prevent further falls d. notify the nurse manager

b. put the bed alarm back on

an older adult has been admitted with diagnosis for stroke and history of dementia. which of the following nursing diagnosis has the highest priority for this patient a. bathing/hygiene b. risk for injury c. impaired physical mobility d. disturbed thought process

b. risk for injury

the nurse wants to delegate the task of showering an elderly patient in a wheelchair to the NAP. before delegating a task to the NAP, the nurse should first ensure which of the following is accomplished a. the NAP is supervised at all times b. the NAP demonstrated competency for the task during orientation c. the NAP has performed the task before d. the NAP has received the assignment during report

b. the NAP demonstrated competency for the task during orientation

all of the following are true regarding infants, EXCEPT a. do not leave baby unattended in high place b. use a front-facing care safety seat c. place baby on back for sleeping d. be sure all paint is lead free

b. use a front-facing care safety seat

the most common type of skin cancer is what?

basal cell carcinoma

the nurse is preparing to set up an intravenous infusion of normal saline 1000ml over 6 hours period. the tubing drop factor is 10gtt/mL. which of the following rates of infusion should the nurse choose? a. 12 b. 33 c. 28 d. 36

c. 28

the nurse is caring for a woman who drinks heavily and would like to become pregnant. the patient asks the nurse for the safety of the child, how many months before i try to get pregnant should i stop drinking alcohol. the nurse tells the patient to quit drinking ___ months before possible a. 1 month b. 2 months c. 3 months d. don't worry until after you get pregnant

c. 3 months

a 20 yo patient has just given birth. the baby looks healthy, with the exception of giving a grimace instead of a cry. which of the following would the nurse expect the obstetrician to say? a. APGAR score of 2 b. APGAR score of 6 c. APGAR score of 9 d. APGAR score of 12

c. APGAR score of 9

A college student diagnosed with mononucleosis 2 weeks ago arrives at the clinic. Which of the following should be of greatest concern to the nurse? a. Headache and fatigue b. Swollen lymph nodes in neck c. Abdominal pain in the left upper quadrant d. Fever and sore throat

c. Abdominal pain in the left upper quadrant

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states she is anxious and unable to get enough air. Vital signs are heart rate 117/min, respirations 38/min, temperature 38.4C (102.2F), and blood pressure 100/54 mmHg. Which of the following actions is the priority? a. Notify the provider b. Administer heparin via IV infusion c. Administer oxygen therapy d. Obtain a spiral CT scan

c. Administer oxygen therapy

In the emergency room, the nurse assesses a 4 year old child suspected of having measles. Which of the following kinds of precautions should the nurse initiate? a. Contact precautions b. Droplet precautions c. Airborne precautions d. Reverse isolation

c. Airborne precautions

A PN ending her shift reports to the RN that a newly hired AP has not calculated the intake and output for several clients. Which of the following actions should the RN take? a. Complete an incident report. b. Delegate this task to the PN c. Ask the AP if she needs assistance. d. Notify the nurse manager

c. Ask the AP if she needs assistance.

The nurse is initiating cefazolin therapy following a physician's order. The nurse notes that the patient has an allergy to penicillin. The patient states he becomes a little short of breath and itches after receiving penicillin. The nurse should do which of the following? a. Ask another nurse, give the medication as ordered. b. Call the pharmacy to therapeutically change the medication and notify the physician of this change. c. Hold the medication and call the physician to double-check the order. d. Give the medication as ordered

c. Hold the medication and call the physician to double-check the order.

A client arrives to the emergency department and reports a headache, neck stiffness, and sensitivity to light. Which of the following is the priority nursing action? a. Notify recent contacts b. Administer acetaminophen c. Implement droplet precautions d. Decrease environmental stimuli

c. Implement droplet precautions

A nurse is participating in a quality improvement study of a procedure frequently performed on the unit. Which of the following information will provide data regarding the efficacy of the procedure? a. Frequency with which procedure is performed b. Client satisfaction with performance of procedure c. Incidence of complications related to procedure d. Accurate documentation of how procedure was performed

c. Incidence of complications related to procedure

A nurse enters the room of a client who is on contact precautions and finds the client lying on the floor. Which of the following actions should the nurse take first? a. Call the provider. b. Ask a staff member for assistance getting the client back in bed. c. Inspect the client for injuries. d. Instruct the client to ask for help if he needs to get out of bed

c. Inspect the client for injuries.

A nurse provides care for a client with a Jackson Pratt drain. Which of the following actions will ensure proper functioning? a. Coil the tubing b. Empty bulb every day c. Keep bulb compressed d. Place drain to wall suction

c. Keep bulb compressed

A nurse is caring for a client with a new prescription for captopril for hypertension. The nurse should monitor the client for which of the following adverse effects of this medication? a. Hypokalemia b. Hypernatremia c. Neutropenia d. Bradycardia

c. Neutropenia

A nurse is caring for a hospitalized client who is receiving IV heparin for a deep vein thrombosis. The client begins vomiting blood. After the heparin has been stopped, which of the following medications should the nurse prepare to administer. a. Vitamin K b. Atropine c. Protamine d. Calcium gluconate

c. Protamine

A nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions should the nurse take? a. Contact the hospital's spiritual services. b. Ask him what is making him cry. c. Provide quiet times for these moments. d. Turn on the television for a distraction.

c. Provide quiet times for these moments.

A 76-year-old man is brought into the Emergency Department by his spouse. The patient's spouse tells the nurse he is confused, disoriented, and weak, and has not been eating well. The nurse obtains blood work as ordered by the physician, including a complete blood count (CBC) and a comprehensive metabolic panel (CMP). For which the result should the nurse immediately notify the physician? a. Hemoglobin (Hgb) 12 g.dL b. Potassium (K+) 3.8 mEq/L c. Sodium (Na+) 122 mEq/L d. Magnesium (Mag+) 1.9 mg/dL

c. Sodium (Na+) 122 mEq/L

A nurse is assessing a client for Chvostek's sign. Which of the following techniques should the nurse use to perform this test? a. Apply a blood pressure cuff to the client's arm. b. Place the stethoscope bell over the client's carotid artery. c. Tap lightly on the client's cheek. d. Ask the client to lower her chin to her chest

c. Tap lightly on the client's cheek.

The nurse in an outpatient clinic has received an order from the physician to remove the patient's sutures. The nurse should do which of the following? a. Use gloves when removing sutures. b. Apply hydrogen peroxide gauze pads to cleanse the area first, then remove the sutures. c. Use sterile technique when removing sutures. d. Nothing, suture removal is outside of the nurse's scope of practice.

c. Use sterile technique when removing sutures.

in the emergency room, the nurse assess a 4yo child suspected of having measles. which of the following kinds of precautions should the nurse initiate? a. contact b. droplet c. airborne d. reverese

c. airborne

a patient is receiving a blood transfusion. the nurse observes that the patient is experiencing diarrhea, abdominal pain chills. which of the following actions should the nurse take first a. assist the patient to the bathroom b. administer merperidine c. stop the transfusion d. get a warm blanket

c. stop the transfusion

the home care nurse makes a visit to an elderly patient who has episodic confusion by remain safe at home while occasionally alone. the nurse finds the patient disheveled, confused, and agitated, and the home is messy. this degree of confusion is unusual for this patient. the nurse takes his vitals which are BP 115/70, HR 70, RR 16, T 98.7, which of the following should the nurse take first a. nothing the patient's vitals are normal b. encourage the patient to verbalize his feelings c. call the patient family to transport the patient to be evaluated by a physician because the patient is not safe to be alone d. plan to come back the next day to reevaluate the patient

c. call the patient family to transport the patient to be evaluated by a physician because the patient is not safe to be alone

a high pressure injury within a muscle of the right that compromises circulation is called a. fat emboli b. sepsis c. compartment syndrome d. hemorrhage

c. compartment syndrome

an injury of soft tissue that is treated with cold applications followed by moist heat is called an a. dislocation b. strain c. contusion d. sprain

c. contusion

a 14 year old boy has been prescribed amphetamine and dextroamphetamine for ADHD. the nurse explains that the patient should be alert for adverse drug effects a. bradycardia b. weight gain c. depression d. somnolence

c. depression

the lab values of an adult male pt reveal the presence of hepatitis B surface antigens and hepatitis B antibodies. which of the following lab results should the nurse also expect to see? select all that apply. a. elevates serum albumin b. low serum globulin c. elevated serum transaminase (ALT, AST) d. prolonged prothrombin time (PT) e. low urine bilirubin

c. elevated serum transaminase (ALT, AST) d. prolonged prothrombin time (PT)

the nurse is developing a care plan for a patient with HepA. the nurse knows that the primary route of transmission of this hepatitis virus is which of the following a. contaminated food b. sputum c. feces d. blood

c. feces

the nurse is assessing a pt admitted with a CVA. the physician has ordered a swallow study. the nurse knows which of the following lobes of the cerebral hemisphere is involved in the control of voluntary muscle movement, including those necessary for the production of speech and swallowing? a. parietal b. occipital c. frontal d. temporal e. occipital

c. frontal

the nurse is making a home visit to an elderly patient during the winter. the nurse notices upon arrival that the patient has the oven turned on with the oven door open, using it as a form of heat. which of the following actions by the nurse is most appropriate? a. take care of patient's medical needs and do not get involved in the patient's private matters b. shut the oven off and continue the home visit c. have meeting with the patient and family and warn them of the fire and safety risks of using the oven for heat d. report the even to local fire department

c. have meeting with the patient and family and warn them of the fire and safety risks of using the oven for heat

the nurse is administering vancomycin 1G every 12 hours for a soft tissue infection. the nurse reminds the patient to report symptoms associated with one of the serious side effects of the drug, ototoxicity, which of the following statements by the patient indicates to the nurse that the patient is experiencing the adverse effects a. i have a bad taste in my mouth b. the iv is burning c. i hear ringing in my ear d. my skin is very itchy

c. i hear ringing in my ear

the nurse is reviewing her patient's lab results. she notes that the ESR is elevated above the normal result (>15-20mm/h). the nurse knows this indicates: a. head lice b. abnormal pap c. inflammation d. pediculosis

c. inflammation

a patient who has chronic pain asks the nurse about alternative therapy in conjunction with traditional treatment. which of the following forms of alternative therapy could the nurse provide for this patient a. kegal exercises b. none nurses do not participate in this kind of therapy c. music therapy or guided imagery d. acupuncture

c. music therapy or guided imagery

the nurse is caring for a young child who has recently had a vesicostomy. which of the following nursing interventions should the nurse undertake to assist the child with basic care and comfort. a. apply a urine bag and change it daily b. double diapering the area is the only intervention needed c. offer fluids, apply an absorbent diaper or incontinence pads, and dilate the opening once or twice a day as ordered by the physician d. double-diaper the area after applying a urine bag

c. offer fluids, apply an absorbent diaper or incontinence pads, and dilate the opening once or twice a day as ordered by the physician

a warm, tender, swollen reddened area around an IV insertion site a. blown IV b. normal IV c. phlebitis d. infiltration

c. phlebitis

all of the following are true regarding restraints except a. can be seen as false imprisonment if patient consent is not provided b. must use the least restrictive type of restraint first c. psychotropic drugs can be used as a restraint to control behavior d. restraints cannot be ordered as PRN

c. psychotropic drugs can be used as a restraint to control behavior

the nurse noticed an increase in prevalence of pressure ulcers among patients in the ICU. she documented her findings and worked with her manager to develop and implement a new policy using a pressure ulcer risk assessment scale. which of the following best describes the nurse's actions? a. case management b. advocacy c. quality improvement d. collaboration

c. quality improvement

the nurse is educating a mother to be about possible danger signs during the last 3 months of pregnancy. which of the following would NOT cause the nurse concern about danger signs a. blurred vision b. continuous headaches c. rectal bleeding d. marked swelling of the hands

c. rectal bleeding

the nurse is giving a lecture at the senior center about preventative health activities for people over the age of 60. the nurse tells the clients that the CDC now recommends which of the following vaccines for this age group a. meningitis b. pertussis c. shingles d. diphtheria

c. shingles

A community health nurse is implementing health programs with several populations in the local area. In which of the following situations is the nurse using primary prevention? a.Performing a home safety check at a client's home b.Teaching healthy nutrition to clients who have hypertension c.Providing influenza immunizations to employees at a local preschool d.Implementing a program to notify individuals exposed to a communicable disease

c.Providing influenza immunizations to employees

A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of teaching? a. "air should be instilled into the monitoring system prior to the procedure" b. "the client should be positioned on the left side during procedure" c. "the transducer should be level with the second intercostal space after the line is placed" d. "a chest x-ray is needed to verify placement after the procedure"

d. "a chest x-ray is needed to verify placement after the procedure"

a hallucinating patient is asking the nurse to "kill the bugs" crawling on the floor. which of the following is most appropriate for the nurse to make? a. "what do the bugs look like" b. "can you tell me more about them" c. "i see them too" d. "it seems like you see bugs, but i do not see them"

d. "it seems like you see bugs, but i do not see them"

the nurse is preparing to administer a unit of packed red blood cells to an anemic patient. after obtaining the blood from the blood bank, the nurse must begin administering it within which of the following time periods? a. 15 minutes b. 45 minutes c. 60 minutes d. 30 minutes

d. 30 minutes

a 34 year old woman who developed stevens-johnson's syndrome while undergoing treatment with carbamazepine is being transferred in stable condition from the ICU to the medical unit. there are 4 beds available. the nurse knows the best choice of roommates for this patient is which of the following? a. 40 year old man wit MRSA b. 28 year old woman diagnosed with diarrhea c. 72 year old man with fever of unknown origin d. 68 year old with atrial fibrillation

d. 68 year old with atrial fibrillation

A nurse reviews the plan of care for a client who has myasthenia gravis. Which of the following interventions requires a revision? a. Monitor for sudden increase in weakness b. Perform pulmonary percussion and postural drainage c. Refer to speech and occupational therapy for evaluation d. Assist with daily activities prior to medication administration

d. Assist with daily activities prior to medication administration

IV or intracoronary nitroglycerin or sublingual nifedipine is given to prevent: a. Migraine headache b. Blood clots c. Coronary vasodilation d. Coronary vasospasm

d. Coronary vasospasm

After obtaining a blood specimen from a client's peripherally inserted central catheter (PICC), which of the following actions should the nurse take next? a. Resume continuous IV infusion b. Perform sterile dressing change c. Instill heparin solution 10 units/mL d. Flush with 20 mL 0.9% sodium chloride

d. Flush with 20 mL 0.9% sodium chloride

In regard to bathing a newborn, which area of the body should you wash last? a. Chest b. Face c. Arms d. Groin

d. Groin

A nurse is planning to perform a vision test on a child. Which of the following findings should the nurse take? a. Place the child 10 feet away from a Snellen Chart b. Show a set of cards to the child one at a time c. Cover the child's eye while performing the test on the other eye d. Have the child focus on an object while performing the test

d. Have the child focus on an object while performing the test

A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. The nurse should identify the client has manifestations of which of the following conditions? a. Allergic reaction b. Ringworm c. Systemic lupus erythematosus d. Herpes zoster

d. Herpes zoster

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? a. Prodromal b. Incubation c. Convalescence d. Illness

d. Illness

How do you prevent umbilical cord infection in a newborn? a. Wash the cord with chlorhexidine b. Provide a warm tub bath for the infant after meals c. Remove the cord clamp to ensure proper irrigation of cord from pathogens d. Keeping the cord dry and keep the top of the diaper folded underneath it.

d. Keeping the cord dry and keep the top of the diaper folded underneath it.

A nurse is assessing an older adult female. Which of the following would be unexpected when considering the natural physical changes of aging? a. Increased chest wall rigidity and decreased cough reflex b. Decrease urinary sphincter tone c. Decreased size and muscle tone of breasts d. Lower back tenderness and decreased lumbar spine movement

d. Lower back tenderness and decreased lumbar spine movement

A 39-year-old patient has been diagnosed with end-stage renal disease and is on the transplant waiting list. The patient has been receiving dialysis through a subclavian central vein catheter while an arteriovenous fistula is maturing. Besides dialysis access, the surgical floor nurse can utilize this subclavian central vein catheter for which of the following? a. Blood draws only b. Infusion of medications, all intravenous fluids, and obtaining blood cultures c. Infusion of normal saline (0.9% NS) and obtaining blood draws d. Nothing

d. Nothing

A nurse is caring for a client who arrived in the PACU following a total hip arthroplasty. the client is not responding to verbal stimuli. Which of the following actions should the nurse perform first? a. Compare and contrast the peripheral pulses. b. Apply a warm blanket. c. Assess dressings. d. Place the client in a lateral position.

d. Place the client in a lateral position.

A nurse is caring for a child in skeletal traction. Which of the following actions by the nurse is appropriate? a. Resting the weights on the floor during the night b. Promoting a low-fiber diet c. Encouraging active range of motion on affected joints d. Positioning a pressure reduction mattress under the child's back

d. Positioning a pressure reduction mattress under the child's back

13. A preoperative nurse is caring for a client who is having a colon resection. Which of the following actions should the nurse take? a. Encourage the client to void after preoperative medication administration b. Administer antibiotics 2 hour prior to surgical incision c. Remove hair using a manual razor d. Remove nail polish on fingers and toes

d. Remove nail polish on fingers and toes

The nurse knows which of the following body systems is responsible for the production of erythropoietin? a. endocrine system b. lymphatic system c. cardiovascular system d. Urinary system

d. Urinary system

of the following phobias, which one is the fear of open spaces? a. monophobia b. acrophobia c. claustrophobia d. agoraphobia

d. agoraphobia

the patient is an intoxicated male o the med/surg unit who attempts to get out of bed every few minutes. he is unsteady on his feet and the nurse is concerned that he will fall if he does get out of bed. the doctor writes an order for the nurse to place wrist restraints to maintain the patient's safety and prevent him from falling. the man refuses the restraints. the nurse should take which of the following actions a. check on the patient every hour to ensure safety b. refrain from placing restraints to honor the patient's wishes, because he has the right to refuse care c. call the physician for advice on how to proceed d. place the restraints in compliance with hospital policy

d. place the restraints in compliance with hospital policy

the nurse has been assigned to an adult male patient who is less than 24 hours post-op. in a report, the nurse learns that he rings his call light frequently, is anxious, and has had pain medication as ordered. which of the following non-drug nursing interventions should the nurse include when caring for this patient. a. assure the patient his anxiety is understandable, because the pain medication needs time to take effect b. assess the patient first, giving this patient time to relax before evaluating his level of pain c. call the patient's physician to increase this amount or frequency of pain medications ordered d. provide a quiet environment, offer repositioning, straighten the bed linen, offer fluids, and assess his pain level

d. provide a quiet environment, offer repositioning, straighten the bed linen, offer fluids, and assess his pain level

a patient is leaving the clinic with a new prescription for lisinopril. which of the following suggestions an the nurse make to minimize one of the major effects of lisinopril? a. eat fruits and vegetables high in iron b. increase fluid intake c. avoid aspirin-containing drugs d. rise slowly when lying to sitting position

d. rise slowly when lying to sitting position

the nurse is talking to a patient who is still grieving the loss of a parent to stomach cancer. the nurse knows that which of the following would increase a patient's risk of cancer a. keeping a strict high protein diet b. following a low-fat, low carb diet c. using considerable spices when smoking d. smoking cigarettes

d. smoking cigarettes

a nursing home pt is admitted to the hospital with a pressure ulcer involving full thickness loss extended to the bone. the nurse documents the pressure ulcer as being at which of the following stages? a. stage 1 b. stage 2 c. stage 3 d. stage 4

d. stage 4

the nurse makes a home visit to a child with a g-tube. upon arrival the nurse notices that the patient's sister is wearing dirty clothes that are too small. the nurse also notices that there is no food in the refrigerator or in the kitchen cabinets. which of the following is most appropriately describes what ht nurse should do? a. the nurse should not do anything as the sister is not her patient b. the nurse should not do anything as there are no signs of physical abuse c. the nurse should only be concerned with the care of her assigned patient d. the nurse needs to take action since the sister has no food and is dressed poorly

d. the nurse needs to take action since the sister has no food and is dressed poorly

the nurse is preparing a community educational presentation. the topic is the leading cause of death for people ages 1-44 the nurse knows that which of the following is the leading cause of death a. diabetes b. cancer c. heart disease d. unintentional injury

d. unintentional injury

an adult diagnosed with pancreatic cancer is having a consultation with the nurse about nutrition and hydration. which of the following suggestions might the nurse include when providing education to the patient a. drink clear water, progress diet rapidly as tolerated, and weigh daily b. puree foods, choose low-protein foods easier for digestion, and weigh daily c. take herbal therapies, avoid vitamins, and don't monitor weight d. use spices to stimulate taste buds, eat cool foods to decrease odor, and eat small but frequent high-protein and high-carbohydrate meals

d. use spices to stimulate taste buds, eat cool foods to decrease odor, and eat small but frequent high-protein and high-carbohydrate meals

the schilling test diagnoses: a. vitamin b6 deficiency b. diabetes c. crohn's disease d. vitamin B 12 deficiency

d. vitamin B 12 deficiency

list 2 long term effects on patients who has been victims of family violence

depression suicidal ideation

define tarsoff act:

duty to warn of threatened suicide or harm to others

Patients who have a suppressed immune system may be on "Neutropenia Precautions". The following are recommended for a patient with a neutrophil count < then or = to 1000 cells X 10/mm. Which one is not? a. No flowers or standing water in the room b. Deep breathe every 4 hours around the clock c. Meticulous IV site skin care hygiene d. Private room when possible e.. High fiber diet of unpeeled fruit and vegetable

e. High fiber diet of unpeeled fruit and vegetable

causes of separation of the retina include: a. tumors b. trauma c. diabetes d. aging e. all of the above

e. all of the above

mandated reporters are a. teachers b. guidance counselors c. pediatricians d. nurses e. all of the above

e. all of the above

minors can provided their own consent for treatment a. married b. pregnant c. seeking birth control services d. seeking voluntary admission to psychiatric facility e. all the above

e. all the above

true or false adverse medication effects are less intense effects of the medication

false

true or false a patient who has been drinking alcohol or has been premeditated can provide signed consent

false

3 signs/symptoms of superinfection

fever diarrhea black hairy tongue glossitis mucus membrane lesions vaginal itching/discharge

methylprednisone is under what classification of medications

glucocorticoid

list 2 anaphylactic reactions that indicate a patient may be having an allergic reaction to blood transfusion

hypotension dyspnea decrease O2 sat flushing

hepatitis is an infection of the __

liver

indicate the main purpose of isotonic fluids

maintain/restore fluid & electrolyte

do no harm means to act with empathy toward patient and staff, withot resentment or malice defines which of the following ethical principles of nursing

nonmalificence

6 rights of delegation

right person right task right time right supervision/direction right circumstance right communication

True or False in regard to blood group compatibility, the blood group O can donate blood to all blood groups but can only receive blood from group O

true

True/False Decrease in noisy respirations for a child with croup may indicate decompensation.

true

true or false a rapid increase in height and weight tends to be cynical for example in utero, infancy, and adolescence

true

true or false anesthesia, immobility, and surgery can affect any system of the body

true

true or false fetal alcohol syndrome is the leading cause of intellectual delay

true

true or false sleep is a basic physiological need of which the purpose and reason for sleep in unclear

true

true or false syrup of ipecac is no longer recommended for an at home treatment if a child ingests a poisonous substance

true

true or false tuberculosis is a reportable disease to the state health department

true

true or false women and children are the most common victims of domestic violence

true

define the following: urinary retention evisceration dehiscence

urinary retention: partial or complete inability to empty the bladder evisceration- protrusion of wound contents dehiscence- disruption of surgical incision or wound

The children and elderly are at high risk for burn injuries. List at least three things families can do to prevent such injuries.

use caution when cooking, keep matches/lighters away from children, do not leave children alone near fires