NCLEX Questions
What desired effect can the nurse expect after administering an antihistamine to a pediatric client with a disorder of the skin? Select all that apply. - sedation - decreased itching - less skin irritation - hyperactivity - increased appetite
- Decreased itching - Less skin irritation
The mother of an infant with iron deficiency anemia asks the nurse what she could have done to prevent the anemia. The nurse should teach the mother that it is helpful to introduce solid foods into the infant's diet at which age? - 3 months - 6 months - 8 months - 10 months
6 Months
The school nurse is conducting health assessments for a group of children. Which of the following situations encountered by the nurse raises suspicion of child neglect? - A child states, "I don't like my mother." - A child reports of constant hunger. - A child doesn't want to play with others. - A child tries to get attention from the nurse.
A child reports of constant hunger
A client taking newly prescribed metoprolol asks the nurse what medication to take for a headache. What is the nurse's best response? - aspirin - ibuprofen - acetaminophen - indomethacin
Acetaminophen
The client with glaucoma is scheduled for a hip replacement. Which prescription would require clarification before the nurse carries it out? - Administer morphine sulfate. - Administer atropine sulfate. - Teach deep-breathing exercises. - Teach leg lifts and muscle-setting exercises.
Administer atropine sulfate
A nurse on the pediatric floor is caring for a toddler refusing to take liquid acetaminophen for fever. What would be the best option? - Allow the parent to hold the child and give the medication. - Explain to the child why it is important. - Call the healthcare provider to change the order. - Give it up and try again in a couple hours.
Allow the parent to hold the child and give the medication
A client with diabetes has been diagnosed with hypertension, and the health care provider has prescribed atenolol, a beta-blocker. When teaching the client about the drug, what should the nurse tell the client about how it may interact with the client's diabetes? Atenol may cause: - a decrease in the hypoglycemic effects of insulin. - an increase in the hypoglycemic effects of insulin. - an increase in the incidence of ketoacidosis. - a decrease in the incidence of ketoacidosis.
An increase in the hypoglycemic effects of insulin
A nurse is preparing a teaching plan for a male client newly prescribed atenolol. Which information is important for the nurse to teach this client? - causes and treatments for erectile dysfunction - control of excessive flatus - management of incontinence - prevention of constipation
Causes and treatments for erectile dysfunction
A client has a nasogastric (NG) tube. How should the nurse administer oral medication to this client? - Heat the tablets until they liquefy; then pour the liquid down the NG tube. - Crush the tablets and prepare a liquid form; then insert the liquid into the NG tube. - Cut the tablets in half and wash them down the NG tube, using a water-filled syringe. - Crush the tablets and wash the powder down the NG tube, using a syringe filled with saline solution.
Crush the tablets and prepare a liquid form; then insert the liquid into the NG tube
Which medication would the nurse anticipate as the provider's treatment of choice for scarlet fever? - acyclovir - amphotericin B - prednisone - penicillin
Penicillin
Which principle should a nurse consider when administering pain medication to a client? - Use opioid combination drugs or nonopioid analgesics only for severe pain. - I.V. pain medications may take as long as 2 hours to relieve pain. - Sustained-release oral formulations should be given around the clock, if possible, for control of chronic pain. - Morphine and hydromorphone shouldn't be used to treat severe pain.
Sustained-release oral formulations should be given around the clock, if possible, for control of chronic pain
A 24-year-old primigravid client who gives birth to a viable term neonate is prescribed to receive oxytocin intravenously after delivery of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered? - The cord lengthens outside the vagina. - There is decreased vaginal bleeding. - The uterus cannot be palpated. - The uterus changes to discoid shape.
The cord lengthens outside the vagina
A nurse is teaching a female client about preventing osteoporosis. Which teaching point is correct? - Obtaining an X-ray of the bones every 3 years is recommended to detect bone loss. - To prevent fractures, the client should avoid strenuous exercise. - The recommended daily allowance of calcium may be found in a wide variety of foods. - Obtaining the recommended daily allowance of calcium requires taking a calcium supplement.
The recommended daily allowance of calcium may be found in a wide variety of foods
The nurse is aware that antihypertensives should be used cautiously in clients already taking - ibuprofen. - diphenhydramine. - thioridazine. - vitamins.
Thiordazine
Pancreatic enzyme replacements are prescribed for the client with chronic pancreatitis. When should the nurse instruct the client to take them to obtain the most therapeutic effect? - three times daily between meals - with each meal and snack - in the morning and at bedtime - every 4 hours, at specified times
With each meal and snack
When preparing a teaching plan for a client about imipramine, which substance should the nurse tell the client to avoid while taking the medication? - caffeinated coffee - sunscreen - alcohol - artificial tears
alcohol
A client is using patient-controlled analgesia (PCA) to manage postoperative pain. What should the nurse do when assisting the client with the PCA? - Reassure the client that pain will be relieved. - Document the client's response to pain medication. - Instruct the client to continue pressing the system's button whenever pain occurs. - Titrate pain medication until the client is free from pain.
document the client's response to pain medication
A client has been taking fluoxetine, 40 mg daily at 0900 for 1 week. The client states he feels nervous and has had diarrhea. What interpretation does the nurse make about the client's symptoms? important, probably suggesting a decrease in dosage or change to another medication not significant, because the client's symptoms are adverse effects of fluoxetine indicative of an exacerbation of the client's depression indicative that a dose increase is needed to treat the client's underlying anxiety
important, probably suggesting a decrease in dosage or change to another medication
A 7-year-old child is admitted to the hospital with acute rheumatic fever. During the acute phase of the illness, which diversional activity would the nurse most discourage? - reading a book with the father - playing with a doll with the nurse - watching the television with a sibling - playing checkers with a roommate
playing checkers with a roommate
A client prescribed propranolol calls the clinic to report a weight gain of 3 lbs (1.36 kg) within 2 days, shortness of breath, and swollen ankles. What is the nurse's best action - Have the client come to the clinic in order to assess the lungs. - Assess the client's dietary intake for the past 24 hours. - Review medication administration with the client. - Assess the client's knowledge of expected effects of the drug.
Have the client come to the clinic in order to assess the lungs
The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority? - reduction of risk potential - physiologic adaptation - psychosocial integrity - health promotion and maintenance
Health promotion and maintenance
While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The health care provider (HCP) is notified because the nurse suspects which complication? - phimosis - hydrocele - epispadias - hypospadias
Hypospadias
A client has been prescribed valproic acid for the treatment of bipolar disorder. The client tells the nurse, "I know that vitamin B can help with depressive episodes, so I am going to give that a try." What is the nurse's best response? - "Be sure to dialogue with your care provider before you start taking vitamin B supplements." - "Unfortunately, it is not safe to take supplements or herbal remedies while you are taking medications." - "Where did you first learn about the possible benefits of vitamin B?" - "Are you hoping that you will eventually be able to replace your medication with supplements?"
"Be sure to dialogue with your care provider before you start taking vitamin B supplements."
A young woman comes to the mental health clinic for routine medication follow-up. She has been married for 2 years and reports that she and her husband are ready to start a family. The client has a diagnosis of bipolar disorder and has been well managed with divalproex for at least 3 years. What is the mostessential counsel for the nurse to give? - "Schedule an appointment for a complete gynecological exam if you haven't had one in the past year." - "Pay careful attention to eating healthy from this point on to maximize the health of both mother and baby." - "Check with your health care provider as divalproex carries an increased risk for birth defects." - "Learning to reduce stress now is important to reduce your chances of developing postpartum depression."
"Check with your health care provider as divalproex carries an increased risk for birth defects."
During a home visit to a primiparous client 1 week postpartum who is bottle-feeding her neonate, the client tells the nurse that her mother has suggested that she feed the neonate cereal so he will sleep through the night. What would be the nurse's best response? - "It's permissible to give the baby cereal if it is thinned with formula." - "The time for starting cereal varies, so check with your pediatrician." - "Formula is the food best digested by the baby until about 4 to 6 months of age." - "If cereal is given too early in life, the undigested food can lead to a need for surgery."
"Formula is the food best digested by the baby until about 4 to 6 months of age."
The nurse is discussing medications with a client with hypertension who has a prescription for furosemide daily. Which comment by the client indicates the client needs further education? - "I know I shouldn't drive after taking my furosemide." - "I should be careful not to stand up too quickly when taking furosemide." - "I should take the furosemide in the morning instead of before bed." - "I need to be sure to also take the potassium supplement that the health care provider prescribed along with my furosemide."
"I know I shouldn't drive after taking my furosemide."
The nurse instructs the client in mixing and administering regular and NPH insulin. Which statement indicates that the client needs additional instruction? - "I draw up the regular insulin first." - "I shake the bottle of NPH insulin before drawing it up." - "I store the insulin in a cool place." - "I insert the needle at a 90-degree angle."
"I shake the bottle of NPH insulin before drawing it up."
Which client statement indicates a need for additional teaching about self-care during pregnancy? - "I should use nonskid pads when I take a shower or bath." - "I should avoid using soap on my nipples to prevent drying." - "I should sit in a hot tub for 20 minutes to relax after working." - "I should avoid douching even if my vaginal secretions increase."
"I should sit in a hot tub for 20 minutes to relax after working"
After the nurse explains about the second stage of labor, which client statement would indicate to the nurse that the client understands the information discussed? - "I'm going to have a higher blood pressure." - "My membranes are likely to have a foul odor." - "My contractions are going to be less painful." - "I should try to push with each contraction."
"I should try to push with each contraction"
The nurse teaches a client taking desmopressin nasal spray about how to manage treatment. The nurse determines that the client needs additional instruction when the client makes which comment - "I should check for sores in my nose while taking this medication." - "I should use the same nostril each time I take the medicine." - "I should report nasal congestion." - "I should report any signs of respiratory infection."
"I should use the same nostril each time I take the medicine"
A client with iron-deficiency anemia is prescribed liquid iron supplements. The nurse evaluates the client's understanding of how to take this drug. Which statement indicates the client has adequate knowledge? - "I can use antidiarrheal drugs if I develop diarrhea." - "I will report any black stools to the health care provider." - "I will check my gums for any bleeding." - "I will dilute the medication and drink it with a straw."
"I will dilute the medication and drink it with a straw."
A nurse is teaching a breast-feeding client how to care for her engorged breasts. Which statement by the client indicates the need for further teaching? - "I'll use massage to help soften my breasts." - "I'll use warm packs or a warm shower to ease engorgement." - "If the baby feeds only on one side, I'll express milk from the other side." - "If my breasts are uncomfortable, I'll limit the time I spend breast-feeding."
"If my breasts are uncomfortable, I'll limit the time I spend breast-feeding."
Two toddlers are arguing over a toy in the playroom. What should the nurse should say to the children? - "If you can't play together, I'll have to put you back in your rooms." - "Give the toy to me. Now neither of you will have it." - "Let me see if I can get both of you a similar toy." - "Let one of you play with it for a while, and then give it to the other."
"Let me see if I can get both of you a similar toy."
Which statement by a student nurse demonstrates that further instruction about cytotoxic drugs is needed - "Cytotoxic parenteral infusion containers should be marked with special hazard labels." - "Infusion set administration connections should be tight." - "Nurses who are pregnant must wear gloves during administration of cytotoxic drugs." - "Linen contaminated with blood or body fluids of a client receiving cytotoxic drugs should be placed in a leak-proof container and marked with a chemotherapy hazard label."
"Nurses who are pregnant must wear gloves during administration of cytotoxic drugs."
A client with chronic pancreatitis is discharged with a prescription for pancrelipase. Which instruction must the nurse include when providing discharge instructions regarding this medication? - "Store this medication in the refrigerator." -" Take this medication before going to bed." - "Dissolve the medication in a full glass of water." - "Swallow this medication whole. Do not chew it."
"Swallow this medication whole. Do not chew it."
A client is taking verapamil hydrochloride as an antihypertensive. Which statement made by the nurse instructs the client about an adverse effect of verapamil? - "A low-residue diet will help prevent the occurrence of diarrhea." - "You should obtain a complete blood count routinely to monitor for potential bone marrow depression." - "Take your pulse and report any irregular heartbeats." - "Restrict your fluid intake to decrease the chance of developing fluid retention."
"Take your pulse and report any irregular heartbeats."
While changing her newborn's diaper, a mother states: "there is some bleeding from the vagina." Which is the nurse's appropriate response? - "This is in response to your hormones and will stop within a week." - "Your infant is dehydrated, which is why there is some bleeding in the diaper." - "The wet wipes must be irritating the skin. I will call the healthcare provider." - "Because the newborn's stool was runny, I doubt you can see any bleeding."
"This is in response to your hormones and will stop within a week"
The nurse has completed discharge teaching with new parents who will be bottle-feeding their normal term newborn. Which statement by the parents reflects the need for more teaching? - "Our baby will require feedings through the night for several weeks or months after birth." - "The baby should burp during and after each feeding with no projective vomiting." - "Our baby should have 1 to 3 soft, formed stools a day." - "We should weigh our baby daily to make sure he is gaining weight."
"We should weigh our baby daily to make sure he is gaining weight."
A client with primary diabetes insipidus is ready for discharge on desmopressin (DDAVP). Which instruction should the nurse provide? - "Administer desmopressin while the suspension is cold." - "Your condition isn't chronic, so you won't need to wear a medical identification bracelet." - "You may not be able to use desmopressin nasally if you have nasal discharge or blockage." - "You won't need to monitor your fluid intake and output after you start taking desmopressin."
"You won't need to monitor your fluid intake and output after you start taking desmopressin."
The nurse is assessing a pregnant client using Leopold's maneuvers. Which of the following nursing actions are appropriate for this assessment? Select all that apply. - Have the client refrain from voiding for 2 hours prior to the exam. - Position the client on her side. - Palpate the client's upper abdomen using both hands. - Note the shape and consistency of the palpated part. - Note the mobility of the palpated part.
- Palpate the client's upper abdomen using both hands. - Note the shape and consistency of the palpated part. - Note the mobility of the palpated part
What desired effect can the nurse expect after administering an antihistamine to a pediatric client with a disorder of the skin? Select all that apply. - sedation - decreased itching - less skin irritation - hyperactivity - increased appetite
- decreased itching - less skin irritation
An unconscious client in the emergency department is given IV naloxone due to an overdose of heroin. Which findings would indicate a therapeutic response to the naloxone? Select all that apply. - decreased pulse rate - warm moist skin - dilated pupils - increased respirations - consciousness
- increased respirations - consciousness
An 8-month-old infant is seen in the well-child clinic for a routine checkup. The nurse should expect the infant to be able to do which tasks? Select all that apply. - saying "mama" and "dada" with specific meaning - feeding self with a spoon - playing peek-a-boo - walking independently - stacking two blocks - transferring an object from hand to hand
- playing peek-a-boo - transferring an object from hand to hand
A client is taking 600 mg of valproic acid twice daily. The nurse should assess the client for which adverse effects? Select all that apply. - tremors - hair loss - gastrointestinal upset - anorexia - weight gain
- tremors - hair loss - gastrointestinal upset - weight gain
A client with asthma has been prescribed fluticasone, one puff every 12 hours per inhaler. Place in correct order the nurse's statements when teaching the client how to properly use the inhaler with a spacer. - "Breathe out all of your air. Hold the mouthpiece of your inhaler and spacer between your teeth with your lips closed around it." - "Hold your breath for at least 10 seconds, then breathe in and out slowly." - "Press down on the inhaler once and breathe in slowly." - "Rinse your mouth." - "Attach the spacer." - "Take off the cap and shake the inhaler."
1. "Take off the cap and shake the inhaler." 2. "Attach the spacer." 3. "Breathe out all of your air. Hold the mouthpiece of your inhaler and spacer between your teeth with your lips closed around it." 4. "Press down on the inhaler once and breathe in slowly." 5. "Hold your breath for at least 10 seconds, then breathe in and out slowly." 6. "Rinse your mouth."
A client who has been taking warfarin has been admitted with severe acute rectal bleeding and these laboratory results: international normalized ratio (INR), 8; hemoglobin, 11 g/dL (110 g/L); and hematocrit, 33% (0.33). After starting an intravenous infusion, in which order should the nurse implement the prescriptions? All options must be used. - Schedule the client for signmoidoscopy - Give 1 unit fresh frozen plasma (FFP) - Administer vitamin K 2.5 mg by mouth - Administer IV dextrose 5% in 0.45% normal saline solution
1. Administer IV dextrose 5% in 0.45% normal saline solution. 2. Give 1 unit fresh frozen plasma (FFP). 3. Administer vitamin K 2.5 mg by mouth. 4. Schedule the client for signmoidoscopy.
The physician has placed a client who has suffered the loss of a child on a selective serotonin reuptake inhibitor (SSRI) for depression. The nurse is aware that the greatest risk for suicide would be
10 to 14 days after the initial medication regime is implemented
You are working as the triage nurse in the ED when the following four clients arrive. Which client requires the most rapid action to protect other clients in the ED from infection · 3-year-old who has paroxysmal coughing and who's sibling has pertussis · 5-year-old who has new pruritic rash and a possible chickenpox infection · 62-year-old who has a history of a MRSA abdominal wound infection · 74-year-old who needs TB testing after being exposed to TB during a recent international airplane flight
5-year-old who has new pruritic rash and a possible chickenpox infection
What is the main advantage of using a floor stock system? - A nurse can implement medication orders quickly. - A nurse receives input from the pharmacist. - The system minimizes transcription errors. - The system reinforces accurate calculations.
A nurse can implement medication orders quickly
The nurse is caring for a client in the medical unit. The nurse receives a health care provider's order for hydrocortisone 100 mg intravenously at a rate of 10 cc/hour for a client in acute adrenal crisis. The nurse understands that this treatment is common in clients with which disease process? - Addison's disease - Cushing's syndrome - hyperthyroidism - hypoparathyroidism
Addison's disease
A client with end-stage dementia is admitted to the orthopedic unit after undergoing internal fixation of the right hip. How should the nurse manage the client's postoperative pain? - Administer oral opioids as needed. - Provide patient-controlled analgesia. - Administer pain medication through a transdermal patch. - Administer analgesics around the clock.
Administer analgesics around the clock
A client with end-stage dementia is admitted to the orthopedic unit after undergoing internal fixation of the right hip. How should the nurse manage the client's postoperative pain? Administer oral opioids as needed. Provide patient-controlled analgesia. Administer pain medication through a transdermal patch. Administer analgesics around the clock.
Administer analgesics around the clock
A nurse teaches an adolescent client with asthma to independently administer breathing treatments. Which principle should the nurse keep in mind when planning the teaching session? - Adolescents tend to be uncooperative with instructions from adults. - Adolescents are worried about appearing different from their peers. - The client will learn better using a recorded video tutorial. - The client will need supervision for the first self-administrations.
Adolescents are worried about appearing different from their peers
The nurse should warn a client who is taking a benzodiazepine about using which medication in combination with his current medication? - antacids - acetaminophen - vitamins - aspirin
Antacids
A nurse is admitting an older female client to the gynecology surgical unit. When the nurse asks the client what medication she is taking at home, the client responds that she is taking a little red pill in the morning and a white capsule at night for her blood pressure. What should the nurse do next - Consult the pharmacist regarding identification of the medications. - Show pictures to the client from the Physician's Desk Reference to identify the medications. - Consult the previous medical record from 2 years ago, and notify the health care provider regarding medications that must be prescribed. - Ask a family member to bring the medications from home in the original vials for proper identification and administration times.
Ask a family member to bring the medications from home in the original vials for proper identification and administration times
After learning that a roommate is HIV-positive, a client asks a nurse about moving to another room on the psychiatric unit because the client no longer feels "safe." What should the nurse do first? - Move the client to another room. - Ask the client to describe the fears. - Move the client's roommate to a private room. - Explain that such a move wouldn't be therapeutic for the client or the roommate.
Ask the client to describe the fears
A depressed client, who is taking fluoxetine, tells the nurse that they have difficulty sleeping at night, is often sleepy during the day, and does not feel like doing anything. What is the nurse's best response? - Tell the client to stop taking the drug until they see their healthcare provider - Advise the client to continue taking the drug to see whether these effects wear off - Ask the prescriber whether the medication can be given early in the day - Advise the client to see another provider to obtain another opinion
Ask the prescriber whether the medication can be given early in the day
A client has had surgery for a deviated nasal septum. The client has returned from the postanesthesia care unit. What should the nurse do first? - Assess the client's pain. - Inspect the area for periorbital ecchymosis. - Assess respiratory status. - Measure intake and output.
Assess respiratory status
The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. When coaching the client about the diet, what should the nurse do first? - Determine the client's knowledge level about cholesterol. - Ask the client to name foods that are high in fat, cholesterol, and salt. - Explain the importance of complying with the diet. - Assess the client's and family's typical food preferences.
Assess the client's and family's typical food preferences
After having a total hip replacement, a client receives morphine sulfate by patient-controlled analgesia (PCA) pump. The client says, "This pump doesn't help my pain at all." What should the nurse do in response to this statement - Assess the client's understanding of the PCA pump. - Tell the physician that the ordered dose isn't sufficient for pain control. - Press the dose delivery button to give the client an immediate dose of the drug. - Push the "Flush" button on the PCA pump to make sure the I.V. line isn't infiltrated.
Assess the client's understanding of the PCA pump
The child is admitted to the hospital with congestive heart failure (CHF). Which nursing actions are performed prior to administration of digoxin? Select all that apply - Auscultate respirations for 1 full minute. - Call healthcare provider immediately. - Auscultate apical pulse for 1 full minute. - Promote good dental hygiene. - Hold if pulse is less than 90, then recheck in 1 hour.
Auscultate apical pulse for 1 full minute. Hold if pulse is less than 90, then recheck in 1 hour
The nurse caring for a 2-year-old client offers the child the choice to hold the syringe and squirt the medication in the mouth or have the nurse give the medication. According to Erikson, what does this help the child achieve? - trust - autonomy - industry - initiative
Autonomy
Which instruction is most important for the nurse to include in the teaching plan for a client who is taking phenelzine? - Eat a normal amount of salt in the diet. - Drink 10 to 12 glasses of water each day. - Allow 10 days to achieve therapeutic effects. - Avoid foods high in tyramine.
Avoid foods high in tyramine
A client has been prescribed valproic acid for the treatment of bipolar disorder. The client tells the nurse, "I know that vitamin B can help with depressive episodes, so I am going to give that a try." What is the nurse's best response - Be sure to dialogue with your care provider before you start taking vitamin B supplements - Unfortunately, it is not safe to take supplements or herbal remedies while you are taking medications - Where did you first learn about the possible benefits of vitamin B - Are you hoping that you will eventually be able to replace your medication with supplements
Be sure to dialogue with your care provider before you start taking vitamin B supplements
A nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings? - presence of menses - uterine enlargement - breast sensitivity - fetal heart tones
Breast sensitivity
A client at 40 + weeks' gestation visits the emergency department because she thinks she is in labor. Which is the best indication that the client is in true labor? - fetal descent into the pelvic inlet - cervical dilation and effacement - painful contractions every 3 to 5 minutes - leaking amniotic fluid clear in color
Cervical dilation and effacement
What toy should the nurse included as part of a recreational therapy plan of care for a 3-year-old child hospitalized with pneumonia and cystic fibrosis? - 100-piece jigsaw puzzle - child's favorite doll - fuzzy stuffed animal - scissors, paper, and paste
Child's favorite doll
Which adverse effect occurs when there is too rapid an infusion of TPN solution? - negative nitrogen balance - circulatory overload - hypoglycemia - hypokalemia
Circulatory overload
The primary care provider prescribes an intravenous infusion of oxytocin to induce labor in a 22-year-old primigravida client with insulin-dependent diabetes at 39 weeks' gestation. The fetus is in a cephalic position, and the client's cervix is dilated 1 cm. What should the nurse do before starting the oxytocin induction? - Administer a 500 mL bolus of intravenous fluid to prevent hypotension. - Continuously monitor fetal heart rate and contraction pattern for at least 20 minutes. - Insert an indwelling urinary catheter to determine intake and output accurately. - Call the anesthesiologist to begin administration of epidural anesthesia.
Continuously monitor fetal heart rate and contraction pattern for at least 20 minutes
A postpartum mother is concerned about a noted decrease in her breast milk production. Which response by the nurse best addresses this mother's concern? - Decrease supplemental feedings with formula. - Suggest the mother consume a diet high in vitamin C. - Have several alcoholic beverages for relaxation. - Feed the infant less frequently.
Decrease supplemental feedings with formula
An older adult is having abdominal surgery. The nurse should assess the client for which postoperative concern related to normal changes in the integumentary system of an older adult? - increased scarring - decreased melanin and melanocytes - decreased healing - increased immunocompetence
Decreased healing
A mother brings a 15-month-old child to the well-baby clinic. She states the child has been taking approximately 18 to 20 oz (540 to 600 mL) of whole milk per day from a bottle with meals and at bedtime. The nurse should suggest that she begin weaning the child from the bottle to avoid risking: - malnutrition. - anemia. - dental caries. - malocclusion.
Dental caries
The nurse is caring for a client with a serum sodium level of 128 mEq/L. Which order for intravenous fluids should the nurse should question? - dextrose 5% in half-normal saline solution D5.45 - normal saline solution 0.9 - dextrose 5% in water (D5W) - lactated Ringer's solution
Dextrose 5% in water (D5W)
A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has 300 mL of solution left. What should the nurse do? - Continue the infusion until the remaining 300 mL is infused. - Change the filter on the tubing and continue with the infusion. - Notify the health care provider (HCP) and obtain prescriptions to alter the flow rate of the solution. - Discontinue the current solution, change the tubing, and hang a new bag of TPN solution.
Discontinue the current solution, change the tubing, and hang a new bag of TPN solution
The nurse is teaching the parents of a child with sickle cell disease. What information should the nurse give the family on how to prevent sickle cell crisis? - Avoid exercising in cool temperatures. - Drink at least 2 quarts (2.3 liters) of fluids per day. - Stay away from other teenagers. - Avoid physical activity.
Drink at least 2 quarts (2.3 liters) of fluids per day
Which intervention should the nurse perform for a child who is receiving chemotherapy and allopurinol? - Encourage a high fluid intake. - Omit carbonated fluids. - Give foods that are high in potassium. - Limit foods that are high in natural sugar.
Encourage a high fluid intake
While preparing to examine a 6-week-old infant's scrotal sac and testes for possible undescended testes, which would be mostimportant for the nurse to do? - Check the diaper for recent urination. - Give the infant a pacifier. - Ensure that the room is kept warm. - Tap lightly on the left inguinal ring.
Ensure hat the room is kept warm
While preparing to examine a 6-week-old infant's scrotal sac and testes for possible undescended testes, which would be most important for the nurse to do? - Check the diaper for recent urination. - Give the infant a pacifier. - Ensure that the room is kept warm. - Tap lightly on the left inguinal ring.
Ensure that the room is kept warm
After the first breastfeeding, the client asks the nurse, "How often should I try to breastfeed?" What frequency should the nurse recommend? - at least every hour for the first 48 hours - every 2 to 3 hours for the first 48 hours - every 4 to 5 hours for the first 5 days after childbirth - whenever she desires, until weaning occurs
Every 2 to 3 hours for the first 48 hours
Assessment of a 6-week-old infant reveals weight and length in the 50th percentile for his age and a head circumference at the 95th percentile. What should the nurse do first? - Assess motor and sensory function of the legs. - Examine the fontanels and sutures. - Advise the mother of the need for follow-up in 1 month. - Obtain a written consent for transillumination.
Examine the fontanels and sutures
During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing her baby? - Apply an ice cube to the nipples. - Rub the nipples gently with lanolin cream. - Express a small amount of breast milk. - Offer the neonate a small amount of formula.
Express a small amount of breast milk
The obstetrical nurse is caring for a client who is three hours postpartum. The client tells the nurse that nearly a dozen family members will be soon arriving to visit her and her infant. The client assures the nurse that this is the norm in her culture. What is the nurse's best action? - Facilitate the visit, unless it is ruled out medically or logistically. - Make contact with a family member, and explain the client's need for rest. - Encourage the client to assert that the visit would be emotionally and physically tiring. - Communicate with a family member, and explain why having more than one visitor at a time is not permitted.
Facilitate the visit, unless it is ruled out medically or logistically
A client has her first prenatal visit at 15 weeks' gestation. The client weighs 144 lb (65.5kg) and states this is a 4-pound weight gain. Which assessment finding requires further investigation? - fundal height of 18 cm - blood pressure of 124/72 mmHg - urine negative for protein - weight of 144 lb (65 kg)
Fundal height of 18cm
A nurse is caring for a client who has just been immunized. When teaching the client's caregivers about potential adverse effects, the nurse should instruct the caregivers to immediately report - pain at the injection site. - generalized urticaria. - mild temperature elevation. - local swelling at the injection site.
Generalized urticaria
A client's fasting blood sugar (FBS) is 63 mg/dL (3.5 mmol/L) at 0700. The client is alert and oriented. What should the nurse do first - Give the prescribed dose of insulin - Give 15g of carbohydrate and recheck the blood glucose in 15 minutes - Give one ampule of 50% dextrose via rapid IV infusion - Give the client a large glass of orange juice with two packets of sugar
Give 15 g of carbohydrate and recheck the blood glucose in 15 minutes
A client's wife states, "I don't know what to do sometimes. It's so hard having a husband with a mental illness like bipolar disorder." After the nurse talks with the client's wife about her feelings and difficulties, which action is most appropriate? - Suggest that the wife see her health care provider (HCP). - Give the wife information about a support group. - Recommend that the wife talk with her close friend. - Have the wife share her feelings with her husband.
Give the wife information about a support group
The nurse is instructing a client with acute asthma who is taking short-term corticosteroid therapy. The nurse should tell the client that steroids will have which expected outcome? Steroids will: - promote bronchodilation. - act as an expectorant. - have an anti-inflammatory effect. - prevent development of respiratory infections.
Have an anti-inflammatory effect
A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activator (t-PA)? - Ask what medications the client is taking. - Complete a history and health assessment. - Identify the time of onset of the stroke. - Determine if the client is scheduled for any surgical procedures.
Identify the time of onset of the stroke
A client in early labor tells the nurse that she has a thick, yellow discharge from both of her breasts. What is the nurse's most appropriate intervention? - Tell her that her milk is starting to come in because she's in labor. - Complete a thorough breast examination and document the results in the chart. - Perform a culture on the discharge, and inform the client that she might have mastitis. - Inform the client that the discharge is colostrum, and a normal finding.
Inform the client that the discharge is colostrum, and a normal finding
A client is diagnosed with diabetes mellitus. The physician orders 15 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. The nurse checks the medication order, assembles equipment, washes their hands, rotates the NPH insulin vial, puts on disposable gloves, and cleans the stoppers. To draw the two insulin doses into the single U-100 insulin syringe, which sequence should the nurse use? - Inject 35 units air into NPH vial; inject 15 units air into regular insulin vial, withdraw 15 units regular insulin; withdraw 35 units NPH. - Inject 15 units air into regular insulin vial; inject 35 units air into NPH vial, withdraw 35 units NPH; withdraw 15 units regular insulin. - Inject 15 units air into regular insulin vial, withdraw 15 units regular insulin; inject 35 units air into NPH vial and withdraw 35 units NPH. - Inject 35 units air into NPH vial; inject 15 units air into regular insulin vial; withdraw 35 units NPH; withdraw 15 units regular insulin.
Inject 35 units air into NPH vial; inject 15 units air into regular insulin vial, withdraw 15 units regular insulin; withdraw 35 units NPH
The nurse is assessing a 4-month-old client. For what finding will the nurse take immediate action? - abdominal wall rising with inspiration - respiratory rate between 30 and 35 breaths/minute - tympanic temperature is 99.4 oF (37.4 oC) - intercostal retractions on inspiration
Intercostal retractions on inspiration
What information should the nurse provide to the client who is receiving warfarin? - Partial thromboplastin time values determine the dosage of warfarin sodium. - Protamine sulfate is used to reverse the effects of warfarin sodium. - International Normalized Ratio (INR) is used to assess effectiveness. - Warfarin sodium will facilitate clotting of the blood.
International Normalized Ratio (INR) is used to assess effectiveness
A client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by nonopioid antitussive agents. The physician orders codeine, 10 mg P.O. every 4 hours. Which statement accurately describes codeine? - It's a centrally-acting antitussive and doesn't cause dependence. - It's a peripherally-acting antitussive and doesn't cause dependence. - It's a centrally-acting antitussive and can cause dependence. - It's a peripherally-acting antitussive and can cause dependence.
It's a centrally-acting antitussive and can cause dependence
A nurse is caring for a client who has been diagnosed with delirium. Which statement about delirium is true? - It's characterized by an acute onset and lasts about 1 month. - It's characterized by a slowly evolving onset and lasts about 1 week. - It's characterized by a slowly evolving onset and lasts about 1 month. - It's characterized by an acute onset and lasts hours to a number of days
It's characterized by an acute onset and lasts hours to a number of days.
The correct procedure for auscultating the client's abdomen for bowel sounds is to: - palpate the abdomen first to determine correct stethoscope placement. - encourage the client to cough to stimulate movement of fluid and air through the abdomen. - place the client on the left side to aid auscultation. - listen for 5 minutes in all four quadrants to confirm absence of bowel sounds.
Listen for 5 minutes in all four quadrants to confirm absence of bowel sounds
A primiparous client expresses concern, asking the nurse why her neonate's eyes are crossed. Which information would the nurse include when teaching the mother about neonatal strabismus? - The neonate's eyes are unable to focus on light at this time. - Neonates commonly lack eye muscle coordination. - Congenital cataracts may be present. - The neonate is able to fixate on distant objects immediately.
Neonates commonly lack eye muscle coordination
During a physical examination, a nurse asks a client to hold their breath briefly, and then uses a stethoscope to auscultate over the carotid arteries. Which finding is normal when auscultating over these arteries? - no sounds over either carotid artery - faint swishing sounds over both carotid arteries - throbbing pulsations bilaterally - louder sounds over the right carotid artery than over the left carotid artery
No sounds over either carotid artery
A client receiving chemotherapy for cancer has an elevated serum creatinine level. What should the nurse do next? - Cancel the next scheduled chemotherapy. - Administer the scheduled dose of chemotherapy. - Notify the health care provider (HCP). - Obtain a urine specimen.
Notify the health care provider (HCP).
Patient is 2-hours post-op after a tonsillectectomy, how are you going to ensure adequate hydration Offer warm soup, suction vigorously to remove old blood Offer ice chips, advance to cool, clear liquids, suction gently as needed Keep the child NPO and maintain IV fluids Offer soft warm foods and orange juice
Offer ice chips, advance to cool, clear liquids, suction gently as needed
The nurse is assessing a client with bipolar disorder during a follow-up appointment after initiating treatment with lithium carbonate. Which symptom would cause the nurse to suspect lithium toxicity? - black tongue - increased tearing - constipation - persistent GI upset
Persistent GI upset
The client's identification armband was cut and removed to start an IV line as a part of the preoperative preparation. The transport team has arrived to transport the client to the operating room. The nurse notices that the client's identification band is not on either wrist. What should the nurse do? - Send the removed armband with the medical record and the client to the operating room. - Place a new identification armband on the client's wrist before transport. - Tape the cut armband back onto the client's wrist. - Send the client without an armband because the client is alert and can respond to questions about his or her identity.
Place a new identification armband on the client's risk before transport
A hospitalized preschooler with meningitis who is to be discharged becomes angry when the discharge is delayed. Which play activities would be most appropriate at this time? - reading the child a story - painting with watercolors - pounding on a pegboard - stacking a tower of blocks
Pounding on a pegboard
A patient admitted with right abdominal discomfort. As a nurse what is the first measure you will take · Provide pain reduction techniques without administering medication · Provide pain medications · Lay them on their right side · Start a central line
Provide pain reduction techniques without administering medication
A client with a subarachnoid hemorrhage is prescribed a 1,000 mg loading dose of I.V. phenytoin. What information is most important when administering this dose? - Therapeutic drug levels should be maintained between 20 and 30 mg/ml. - Rapid phenytoin administration can cause cardiac arrhythmias. - Phenytoin should be mixed in dextrose in water before administration. - Phenytoin should be administered through an I.V. catheter in the client's hand.
Rapid phenytoin administration can cause cardiac arrhtyhmias
Which of the following indicates that the client with Addison's disease is receiving too much glucocorticoid replacement - Anorexia. - Dizziness. - Rapid weight gain. - Poor skin turgor.
Rapid weight gain
The nurse administers lactulose to a client with cirrhosis. What is the expected outcome from the administration of the lactulose - Stimulation of peristalsis of the bowel. - Reduced peripheral edema and ascites. - Reduced serum ammonia levels. - Prevention of hemorrhage.
Reduced serum ammonia levels
The nurse is administering epinephrine using an EpiPen autoinjector. Place the steps for administering the epinephrine using an EpiPen autoinjector in the correct order. All options must be used. 5Hold the EpiPen autoinjector against the thigh for 10 seconds. 3Remove the safety release cap. 4Jab the EpiPen autoinjector firmly into the outer thigh. 2Grasp the EpiPen autoinjector with the injecting end pointing downward. 1Remove the EpiPen autoinjector from its carrying tube. 6Massage the injection site area for 10 seconds
Remove the EpiPen autoinjector from its carrying tube. Grasp the EpiPen autoinjector with the injecting end pointing downward. Remove the safety release cap. Jab the EpiPen autoinjector firmly into the outer thigh. Hold the EpiPen autoinjector against the thigh for 10 seconds. Massage the injection site area for 10 seconds
When caring for a client who has had a cesarean birth, which action by a nurse requires intervention? - removing the initial dressing for incision inspection - monitoring pain status and providing necessary relief - supporting self-esteem concerns about the birth - assisting with parent-neonate bonding
Removing the initial dressing for incision inspection
A client who is receiving acetaminophen for osteoarthritis reports continuing pain. The healthcare provider prescribes celecoxib. What important information regarding this medication, should the nurse share with this client? - report black and tarry stools to the health care provider - use a stool softener or fiber laxative daily to prevent constipation - if you miss a dose, take a double dose the next day - don't take the medication with dairy products
Report black and tarry stools to the health care provider
An 11-year-old child is sent to the school nurse reporting difficulty reading the blackboard in the classroom. The nurse assesses that the child does not have difficulty reading a laptop screen or reading books. What is the best action by the nurse? - Request that the child be screened for myopia. - Inform the teacher that the child has strabismus. - Try to determine the cause of the child's photophobia. - Call the parents to discuss therapy for hyperopia.
Request that the child be screened for myopia
The health care provider (HCP) has prescribed pseudoephedrine. The nurse should instruct the client about which possible adverse effect of this drug? - constipation - bradycardia - diplopia - restlessness
Restlessness
The nurse assesses the development of an 18-month-old. The nurse anticipates that the child will be able to do which skill? - Build a tower of four cubes. - Say three words. - Use a spoon with little spilling. - Throw a ball overhand.
Say three words
After a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium at a nonintoxicating maintenance level for 2 days and at decreasing dosages thereafter. This regimen is effective if the client does not develop which complication - psychosis - seizures - hypotension - hypothermia
Seizures
When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which laboratory value? - serum sodium - serum potassium - serum creatinine - serum calcium
Serum creatinine
When discussing an infant's motor skill development with the mother, the nurse should explain that by age 7 months, an infant most likely will be able to perform which skill? - walking with one hand held - eating successfully with a spoon - standing while holding onto furniture - sitting alone using the hands for support
Sitting alone using the hands for support
One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. What should the nurse instruct the client to do to achieve this goal? - Avoid eating low-fat foods. - Elevate the legs above the heart. - Stop smoking. - Jog daily.
Stop smoking
A client receiving a blood transfusion calls the nurse to the room and reports feeling hot and itchy. The client's temperature is 101.4°F (38.6°C) after 100 mL of the blood is infused. What are the priority actions for the nurse - Call for help, then slow the blood transfusion rate to a KVO and wait for further instructions - Reassure the client that the blood bank has provided the correct blood and administer and antihistamine - Stop the blood transfusion and maintain the IV site with normal saline - Slow the transfusion, stay with the client, and call for help
Stop the blood transfusion and maintain the intravenous site with normal saline
Twenty minutes after a transfusion of packed red blood cells is initiated, a client reports shivering, headache, and lower back pain. The vital signs show a normal temperature and increased pulse and respiratory rate. What should be the first nursing actions
Stop the transfusion, continue with saline infusion, and notify the physician regarding a suspected hemolytic reaction
During labor, a low-risk multigravid client in active labor has begun pushing, and the fetal head is beginning to crown. What action should the nurse take to prevent perineal lacerations during the birth? - Stretch the perineal tissues with sterile gloved fingers. - Hold the fetal head back with a sterile gloved hand. - Tell her to stop pushing during the next two contractions. - Ask her to hold her breath while pushing during the entire contraction.
Stretch the perineal tissues with sterile gloved fingers
A nurse is planning a health teaching session for a group of parents with toddlers. When describing a toddler's typical eating pattern, the nurse should mention that many children of this age exhibit: - consistent table manners. - an increased appetite. - strong food preferences. - a preference for eating alone.
Strong food preferences
The nurse cares for a child receiving a blood transfusion. The child becomes flushed and is wheezing. What should the nurse do first? - Notify the health care provider (HCP). - Administer oxygen. - Switch the transfusion to normal saline solution. - Take the child's vital signs.
Switch the transfusion to normal saline solution
A nurse is caring for a 5-year-old child with end-stage acquired immunodeficiency syndrome (AIDS). The child confides that the child is ready to go to heaven and see Grandpa. The nurse knows that the child's parents aren't comfortable with the idea of discontinuing treatment. What should the nurse do? - Talk with the parents about the dying process and make the parents aware of what the child has confided. - Listen to the child but recognize that the child too young to make these decisions. - Tell the child that the nurse will talk with the parents and change the parents minds. - Tell the physician that the family would like to discontinue treatment.
Talk with the parents about the dying process and make the parents aware of what the child has confided
A nurse is developing a teaching plan for a client who has just been diagnosed with breast cancer. The nurse should include information about - acetaminophen. - dopamine. - tamoxifen. - progesterone.
Tamoxifen
The parents of three children ages 4, 7, and 11 years are interested in fostering spiritual development in their children. Then nurse informs the parents that the development of a child's spirituality is best accomplished by: - Teaching through parental behaviors. - Teaching the child about religion. - Teaching the child about God. - Teaching through religious-based schools.
Teaching through parental behaviors
On a crisis shelter hotline, the nurse talks to two 11-year-old boys who think a friend abuses inhalants. They say his breath sometimes smells like glue and he acts drunk. They say they are afraid to tell their parents about the friend. When formulating a reply, what is the most important factor for the nurse to consider? - The boys probably fear punishment. - Inhalant abuse is illegal. - The boys' observations could be wrong. - Inhalant abuse is a minor form of substance abuse.
The boys probably fear punishment
Which topic is most important to include in the teaching plan for a client newly diagnosed with Addison's disease who will be taking corticosteroids? - the importance of watching for signs of hyperglycemia - the need to adjust the steroid dose based on dietary intake and exercise - To notify the health care provider (HCP) when the blood pressure is suddenly high - how to decrease the dose of the corticosteroids when the client experiences stress
The importance of watching for signs of hyperglycemia
While caring for a mother and her 1-day-old neonate born vaginally at 30 weeks' gestation, the nurse explains about the neonate's need for gavage feeding at this time instead of the mother's plan for bottle feeding. What should the nurse include as the rationale for this feeding plan? - The neonate has difficulty coordinating sucking, swallowing, and breathing. - A high-calorie formula, presently needed at this time, is more easily delivered via gavage. - Gavage feedings can minimize the neonate's increased risk of developing hypoglycemia. - This type of feeding, easily given in the isolette, decreases the neonate's risk of cold stress.
The neonate has difficulty coordinating sucking, swallowing, and breathing
A client at 33 weeks' gestation is admitted in preterm labor. She is given betamethasone 12 mg IM q 24 hours × 2. What is the expected outcome of this drug therapy? - The contractions will end within 24 hours. - The client will give birth to a neonate without infection. - The client will give birth to a full-term neonate. - The neonate will be born with mature lungs.
The neonate will be born with mature lungs
Which goal is the most realistic for a client diagnosed with Parkinson's disease? - to cure the disease - to stop progression of the disease - to begin preparations for terminal care - to maintain optimal body function
To maintain optimal body function
A client is receiving furosemide as part of the treatment for heart failure. Which assessment finding indicates that the medication is attaining a therapeutic effect? - blood pressure 140/80 mm Hg - PaO2 80 mm Hg - crackles auscultated halfway up lungs, previously in bases - trace peripheral edema, previously +2
Trace peripheral edema, previously +2
A client presents to the emergency department with reports of acute GI distress, bloody diarrhea, weight loss, and fever. A family history of what would be significant to this client's diagnosis? - ulcerative colitis - Crohn's disease - peptic ulcers - appendicitis
Ulcerative colitis
The caregiver of a 2-month-old client calls stating that the client is "fussy and has a runny nose." The caregiver states that the client has been sleeping poorly at night and is not eating as well. Which of the following interventions will the nurse teach the caregiver? - Give the client an over-the-counter cough-and-cold medicine. - Have the caregiver make an appointment with the healthcare provider for antibiotics. - Encourage the caregiver to administer aspirin as needed for fever. - Use a bulb syringe to suction out the nasal passages.
Use a bulb syringe to suction out the nasal passages
A client is at risk for acute pyelonephritis. The nurse should instruct the client about which health promotion behaviors that will be most effective in preventing pyelonephritis? - Wash the perineum with warm water and soap, cleaning from front to back. - Treat fungal infections such as athlete's foot immediately. - Have a pneumonia immunization to prevent streptococcal infection. - Treat skin lesions with antibiotics, and cover any open lesions.
Wash the perineum with warm water and soap, cleaning from front to back.
A client with heart failure is given a prescription for torsemide. Two days after the drug therapy is started, which sign indicates the drug is having the intended outcome? The client: - has an improved appetite and is eating better. - weighs 7 lbs (3 kg) less than the client did 2 days ago. - is less thirsty than before the drug therapy. - has clearer urine since starting torsemide.
Weights 7 lbs (3 kg) less than the client did 2 days ago
The client who is 28 weeks gestation is at the obstetric (OB) clinic reviewing lab work. The human immunodeficiency virus (HIV) test is positive, and treatment is indicated. Which medication should the nurse expect to administer that will help to prevent transmission of the virus to the fetus? - zidovudine - fluvastatin - dimenhydrinate - disulfiram
Zidovudine
A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode - the type of anticonvulsant prescribed to manage the epileptic condition - recent stress level - recent weight gain and loss - compliance with the prescribed medication regimen
compliance with the prescribed medication regimen
A pregnant client comes to the facility for her first prenatal visit. When providing teaching, the nurse should be sure to cover which topic? - labor techniques - danger signs during pregnancy - signs and symptoms of pregnancy - tests to evaluate for high-risk pregnancy
danger signs during pregnancy
A client with cholecystitis is taking propantheline bromide. What should the nurse tell the client to expect as a result of taking this drug? - increased bile production - decreased biliary spasm - absence of infection - relief from nausea
decreased biliary spasm
The nurse is caring for a client in the intensive care unit. Which drug is most commonly used to treat cardiogenic shock - dopamine - enalapril - furosemide - metoprolol
dopamine
After the first breastfeeding, the client asks the nurse, "How often should I try to breastfeed?" What frequency should the nurse recommend? - at least every hour for the first 48 hours - every 2 to 3 hours for the first 48 hours - every 4 to 5 hours for the first 5 days after childbirth - whenever she desires, until weaning occurs
every 2 to 3 hours for the first 48 hours
When caring for a client receiving haloperidol, the nurse should assess for which problem - orthostasis - extrapyramidal symptoms - hypersalivation - oversedation
extrapyramidal symptoms
A client with rheumatoid arthritis has been on aspirin therapy for an extended time. Which assessment is the most important for the nurse to obtain - weight - gait - hearing - muscle mass
hearing
Which assessment findings indicates that epoetin alfa is having a therapeutic effect? - neutrophil count 8.0 × 109/L - hemoglobin 12 g/dL - platelet count 150 × 109/L - white blood cell count 7.0 × 109/L
hemoglobin 12 g/dL
The nurse is performing a focused assessment on a client's gastrointestinal system. Which assessment is an expected finding? - two to three bowel sounds per minute - high pitched, tinkling bowel sounds - high pitched gurgling noises in four abdominal quadrants - sounds heard only in bilateral lower quadrants
high pitched gurgling noises in four abdominal quadrants
The nurse is administering eye drops to a client with glaucoma. Which technique is correct for instilling the eye drops? The eye drops are placed - in the lower conjunctival sac. - near the opening of the lacrimal ducts. - on the cornea. - on the scleral surface.
in the lower conjunctival sac.
Which results would indicate that levothyroxine sodium is effectively resolving the symptoms of a client with hypothyroidism - increased energy, weight loss, and a higher temperature and pulse rate - decreased edema, stable temperature, and decreased respiratory rate - improved appetite, weight gain, and sleeping fewer hours - elevated blood pressure, reduced pulse rate, and lower oxygen saturation levels
increased energy, weight loss, and a higher temperature and pulse rate
A 10-month-old infant is brought to the well-baby clinic for a follow-up visit. The mother tells the nurse that she has been having trouble feeding her infant any solid foods. The infant only prefers breastfeeding and pushes food from the mouth. To help correct this problem, the nurse should: instruct the mother that tongue thrusting is the infant's way of rejecting food. - instruct the mother to place the food further back and to the side of the - - infant's mouth. - instruct the mother to offer small, bite-size food. - instruct the mother to limit the infant's breast milk.
instruct the mother to place the food further back and to the side of the infant's mouth
Which nursing intervention takes highest priority when caring for a client who's receiving a blood transfusion - monitoring the client for itching, swelling, or dyspnea - informing the client that the transfusion usually takes 1½ to 2 hours - documenting blood administration in the client care record - assessing the client's vital signs at the conclusion of the transfusion
monitoring the client for itching, swelling, or dyspnea
A full-term client is admitted for an induction of labor. The health care provider (HCP) has assigned a Bishop score of 10. Which drug would the nurse anticipate administering to this client? - oxytocin 30 units in 500 ml D5W - prostaglandin gel 0.5 mg - misoprostol 50 mcg - dinoprostone 10 mg
oxytocin 30 units in 500 ml D5W
A hospitalized preschooler with meningitis who is to be discharged becomes angry when the discharge is delayed. Which play activities would be most appropriate at this time? - reading the child a story - painting with watercolors - pounding on a pegboard - stacking a tower of block
pounding on a pegboard
A woman who is Rh negative has given birth to an Rh-positive infant. The nurse explains to the client that she will receive Rho(D) immune globulin. The nurse determines that the client understands the purpose of the treatment when she reports that Rho(D) immune globulin has which action? - protecting her next baby if it is Rh negative - preventing antibody formation in her blood - preventing antigen formation in her baby's blood - preventing jaundice in her baby
preventing antibody formation in her blood
Which laboratory test should the nurse monitor when the client is receiving warfarin sodium therapy - partial thromboplastin time (PTT) - serum potassium - arterial blood gas (ABG) values - prothrombin time (PT)
prothrombin time (PT)
A health care provider prescribes gentamicin for a client with peritonitis. The client has preexisting impaired vision and hearing. The nurse should: - give the drug as prescribed. - question whether the drug is appropriate for treatment of peritonitis. - question the prescription because gentamicin could cause further hearing impairment. - question the prescription because gentamicin could cause further visual impairment.
question the prescription because gentamicin could cause further hearing impairment.
A woman is taking oral contraceptives. The nurse teaches the client to report which complication - breakthrough bleeding - severe calf pain - mild headache - weight gain of 3 lb (1.4 kg)
severe calf pain
A nurse observes two 2-year-old children playing. The nurse documents what form of play as normal for this age group? - playing catch with a ball - playing together with trucks in the dirt - sitting side-by-side building sand castles - riding tricycles together
sitting side-by-side building sand castles
A client and her partner, both 25 years old, are having trouble conceiving. Infertility in this couple is defined as: - the inability to conceive after 6 months of unprotected attempts. - the inability to sustain a pregnancy. - the inability to conceive after 1 year of unprotected attempts. - a low sperm count and decreased motility.
the inability to conceive after 1 year of unprotected attempts
As an initial step in treating a client with angina, the health care provider (HCP) prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by: - antispasmodic effects on the pericardium. - causing an increased myocardial oxygen demand. - vasodilation of peripheral vasculature. - improved conductivity in the myocardium.
vasodilation of peripheral vasculature
The nurse is educating the parents of a 2-year-old child regarding immunizations. When the parents ask where the injections will be given the nurse answers that the most appropriate site for an intramuscular injection for a child this age is the - vastus lateralis muscle. - dorsogluteal muscle. - ventrogluteal muscle. - deltoid muscle.
vastus lateralis muscle
The nurse should teach the client that signs of digoxin toxicity include: - rash over the chest and back. - increased appetite. - visual disturbances such as seeing yellow spots. - elevated blood pressure.
visual disturbances such as seeing yellow spots
Intraosseous infusion of a medication would be most appropriate for which client · An 18-month-old client with cystic fibrosis · A 2-year-old client with a ruptured spleen and hypovolemia · A 4-year-old client with celiac disease · A 5-year-old client with status asthmaticus
· A 2-year-old client with a ruptured spleen and hypovolemia
After receiving report from the night nurse, which of the following clients should the nurse see first? · A 31-year old woman refusing sucralfate before breakfast · A 40-year old man with left-sided weakness asking for assistance to the commode · A 52-year old female complaining of chills who is scheduled for a cholecystectomy · A 65-year old man with a nasogastric tube who had a bowel resection yesterday
· A 52-year old female complaining of chills who is scheduled for a cholecystectomy
What is the main advantage of using a floor stock system? · A nurse can implement medication orders quickly · A nurse receives input from the pharmacist · The system minimizes transcription errors · The system reinforces accurate calculations
· A nurse can implement medication orders quickly
The physician orders a CAT scan of the chest for an adult male patient. Which of the following findings should the nurse report to the physician? · Allergy to contrast dye · Implanted cardiac pacemaker · History of chronic obstruction pulmonary disease (COPD) · Recent administration of oral Ativan
· Allergy to contrast dye
A 21-year-old woman is in active labor and admitted to labor and delivery floor. The nurse observes a glistening white cord protruding from the vagina. Which of the following actions should the nurse take FIRST? · Return to the nurse's station and place an emergency call to the physician · Administer oxygen by mask at 10-12 L/min and assess the mother's vital signs · Place a clean towel over the cord and wet it with sterile normal saline · Apply manual pressure to the presenting part and have the mother assume a knee-chest position
· Apply manual pressure to the presenting part and have the mother assume a knee-chest position
When starting the client's intravenous infusion line, the nurse applies a tourniquet and selects the site for inserting the needle. When should the nurse remove the tourniquet? · When the skin has been cleansed · As soon as the needle is in the vein · As soon as the needle is positioned under the skin · When the needle has been secured with tape
· As soon as the needle is in the vein
A 21-year-old is newly diagnosed with type I insulin dependent diabetes mellitus and has been home sick for several days with flu like symptoms. She comes into the ED to seek treatment. If the client is experiencing ketoacidosis, the nurse would expect to see which of the following lab results · Serum glucose of 140 mg/dL · Serum creatinine of 3.2 mg/dL · Blood pH of 7.28 · Hematocrit 38%
· Blood pH of 7.28
An elderly non-English speaking woman is being admitted to the hospital with worrisome symptoms. She is accompanied by family members who speak English. The nurse admitting the client needs to ask some general questions. IT would be MOST appropriate for the nurse to take which of the following actions · Call the hospitals interpreter services to assist in asking the client questions in her native language · Ask family members the questions and document their responses · Ask family members to translate and ask the questions for the nurse · Document "unable to obtain response due to language barrier"
· Call the hospitals interpreter services to assist in asking the client questions in her native language
Following the initiation of a unit of PRBC's the patients vital signs have changed. HR-84 to 132 with bounding pulses. Patient complains of shortness of breath. Assessment reveals- wheezing and rales. Which action should the nurse implement first · Maintain bedrest with foot of the bed elevated · Change position to high fowler's · Increase IV fluid rate · Consult HCP for oxygen therapy
· Change position to high fowler's
Packed red blood cells have been prescribed for a female patient with a hemoglobin level of 6.6g/dL and a hematocrit level of 24%. The nurse takes the patient's temperature before hanging the blood transfusion and records 100.6 orally. Which action should the nurse take? · Delay hanging the blood and notify the health care provider · Administer two tablets of Tylenol and begin transfusion · Begin transfusion · Administer antihistamine
· Delay hanging the blood and notify the health care provider
A cast is applied to a 9-month-old for the treatment of talipes eqiniovarus. Which of the following instructions is MOST essential for the nurse to give to the child's mother regarding her care? · Offer appropriate toys for her age · Make frequent clinic visits for cast adjustment · Do frequent circulatory checks
· Do frequent circulatory checks
Which of the following is MOST effective means of preventing infection? · Washing hands after client contact · Washing hands after removing gloves · Hand hygiene between clients · Hand hygiene before entry to a client's room and before exiting
· Hand hygiene before entry to a client's room and before exiting
The nurse is instructing a client with acute asthma who is taking short-term corticosteroid therapy. The nurse should tell the client that steroids will have which expected outcome. Steroids will: · Promote bronchodilation · Act as an expectorant Have an anti-inflammatory
· Have an anti-inflammatory effect
The nurse has just answered a call light for a patient who is two days post-op for abdominal surgery. The patient states: "I coughed and heard this pop". The nurse assesses the surgical site and observes dehiscence of the wound. Which of the following should the nurse do first? · Stay with the patient and have a colleague notify the physician · Help the patient lie with his head slightly elevated with knees bent · Apply warm, sterile normal saline soaks · Help the patient sit up to reduce harmful effects of further coughing
· Help the patient lie with his head slightly elevated with knees bent
The nurse assesses a patient with a diagnosis of parathyroid disease. The client is having abdominal cramping, positive Chovstek's and Trousseau's sign and tingling in the extremities. The nurse understands these symptoms may be due to which of the following · Hypomagnesemia · Hypophosphatemia · Dehydration · Hypocalcemia
· Hypocalcemia
A 31-year-old multigravida client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous LR solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for which adverse reaction? · Hypotension · Diaphoresis · Headache · Tremors
· Hypotension
When teaching a client how to take a sublingual tablet, the nurse should instruct the client to place the tablet · On the top of the tongue · On the roof of the mouth · On the floor of the mouth · Inside the cheek
· On the floor of the mouth
A primiparious client, 48 hours after a vaginal birth, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take medication with which liquid? · Orange juice · Herbal tea · Milk · Grape juice
· Orange juice
You are preparing to leave the room after performing oral suctioning on a client who is on contact and airborne precautions. What is the order you will perform the following actions: Take off goggles Perform hand hygiene Take of gown Remove gloves Remove N95 respirator
· Remove gloves · Take off gown · Take of goggles · Remove N95 respirator · Perform hand hygiene
When leaving an isolation room what steps should be followed in removing PPE? Drag and drop · Remove gown · Remove mask or respirator without touching front of mask/respirator · Wash hands or sanitize with alcohol · Remove goggles/face shield without touching front of goggles/face shield
· Remove gloves and discard · Remove goggles/face shield without touching front of goggles/face shield · Remove gown · Remove mask or respirator without touching front of mask/respirator · Wash hands or sanitize with alcohol
A client is leaving the hospital with a new prescription for Lisinopril. Which of the following should be included in discharge teaching to minimize one of the major effects of Lisinopril · Eating fruits and vegetables high in iron · Rising slowly from a sitting position · Increasing fluid intake · Avoiding aspirin containing drugs
· Rising slowly from a sitting position
The nurse is taking care of a quadriplegic male who suffered a C2-C3 fracture in a MVA. He has a tracheostomy and is ventilator dependent. What to do to prevent? autonomic dysreflexia · Straight catheterize to prevent bladder distension and maintain a bowel regiment to prevent impaction · Turn the patient every 2 hours and look for skin breakdown · Allow 8-10 hours of rest without interruption each night · Offer fluids at least every 2 hours during the day to promote hydration
· Straight catheterize to prevent bladder distension and maintain a bowel regiment to prevent impaction
You note air bubbles in chamber C. This informs the nurse that · The chest tube is kinked · The appropriate amount of suction has not been applied · The lung is not fully expanded · Call the physician bc this is an emergent situation
· The lung is not fully expanded
A client is being treated for heart failure with diuretic therapy. Which of the following assessments BEST indicates to the nurse that the client's condition is improving? · The client's weight has remained stable since admission · The client's systolic blood pressure has decreased · There are fewer crackles heard when auscultating the client's lungs · The client's urinary output is 1,500 mL per day
· There are fewer crackles heard when auscultating the client's lungs
You are caring for a patient with chronic lymphocytic anemia. The patient has a chest tube to the right draining a large pleural effusion. The physician orders the CT to be clamped for 4 hours to determine patient readiness for tube removal. The CT is draining minimal serosanguinous and there are no air leaks noted. Ten minutes after the tube is clamped the patient develops shortness of breath with an O2 saturation of 89%. The nurse's best action includes · Applying oxygen at 2L nasal cannula · Unclamp the chest tube · Call an RRT · Increase the HOB at least 30 degrees
· Unclamp the chest tube
The nurse is caring for a client who has streptococcal pneumonia. Which of the following infection control precautions should the nurse implement first? · Request the dietary department to provide disposable utensils · Wear a surgical mask when obtaining the clients vital signs · Remove fresh flowers from the client's room · Place the client in a private room with monitored negative pressure room
· Wear a surgical mask when obtaining the clients vital signs