NCLEX Review Test 1

The nurse is assessing a client who had a closed liver biopsy. The nurse should understand that the client is at increased risk for a. altered peripheral tissue perfusion b. sensory-perceptual alteration c. altered urinary elimination d. ineffective airway clearance

The correct answer is A. A client who had a liver biopsy is at risk for hemorrhage. Altered peripheral tissue perfusion is the nursing diagnosis associated with hemorrhage.

The nurse is reinforcing teaching with a client recently diagnosed with gout. The nurse should encourage the client to minimize the intake of a. alcoholic beverages b. citrus juices c. dairy products d. processed foods

The correct answer is A. A client with gout should minimize the intake of alcoholic beverages that may exacerbate the pain.

The nurse is preparing a 3-year-old child for a bone marrow aspiration from the iliac crest. Which of the following statements would be appropriate for the nurse to make to help ensure the child's cooperation during the procedure? a. "You will feel like someone is pressing the lower part of your tummy." b. "A small needle will be used to get important cells from your bone." c. "Take several deep breaths when I tell you to so you won't feel any pain." d. "After the dressing is put on your skin you will be able to go home."

The correct answer is A. A toddler needs simple explanations about what will be seen, heard, and felt. Advising the child that it will feel like someone is pressing on the lower part of the tummy will help the child understand the location of the procedure and the sensation to expect. The toddler is less likely to understand what a dressing means.

The unit clerk informs the nurse about the following client requests. The nurse should first check the client with a. primary hypertension who requests an analgesic for a headache b. peripheral vascular disease who requests lotion for burning in the feet c. diabetes mellitus who requests powder for a red area of skin in the axilla d. chronic obstructive pulmonary disease (COPD) who requests water for the humidifier

The correct answer is A. Maslow's hierarchy of human needs provides a framework to determine priorities. The client with hypertension who requests medication for a headache may be developing a potentially life-threatening change in cerebral perfusion, such as a cerebrovascular accident and should be checked first. The client with COPD should have increased humidity to help minimize drying of secretions but this request, if delayed, is not life-threatening.

The nurse has assessed a client with acute renal failure. The nurse should immediately report that the client has a. voided urine that looks like water b. frothy pink sputum c. not had a bowel movement in 3 days d. 1+ sacral edema

The correct answer is B. A client with acute renal failure is at risk for heart failure and pulmonary edema. The presence of frothy pink sputum requires immediate action by the nurse.

The nurse is assessing an adult client with hypothyroidism who is taking prescribed levothyroxine (Synthroid). Which of the following would indicate that the client's treatment has been effective? a. sleeping 6 hours a day b. daily bowel movements c. neck fullness d. pulse, 100

The correct answer is B. A client with hypothyroidism may experience weight gain, anorexia, cold intolerance, constipation, lethargy or slowed movements. Having a daily bowel movement would indicate that the client's treatment has been effective. Sleeping 6 hours a day requires additional information to help determine if this is a change in the typical sleep pattern since excess thyroid hormone replacement can cause insomnia.

The nurse is reviewing the record of a client who has several new prescriptions. The client has a history of coronary artery disease (CAD) and renal insufficiency. Which of the following new medications would be contraindicated based on this history and should be clarified by the nurse? a. metoprolol (Toprol XL) b. hydrochlorothiazide (HydroDIURIL) c. atorvastatin (Lipitor) d. clopidogrel (Plavix)

The correct answer is B. A client with renal disease should not take HydroDIURIL since this medication further compromises renal function.

The nurse is caring for a client with severe rheumatoid arthritis. Which of the following actions would be appropriate for the nurse to take while the client is resting in bed? a. Place a rolled washcloth in the client's hands. b. Support the client's forearms on a small pillow. c. Position a folded towel under the client's knees. d. Use a rolled sheet along the client's thighs.

The correct answer is B. A client with rheumatoid arthritis is at risk for increased joint deformities due to incorrect positioning and lack of exercise. The nurse should support the client's forearms on a small pillow while the client is resting in bed to help minimize strain on the shoulder region and to promote blood flow. A rolled washcloth in the client's hands will increase stiffness of the hands.

The nurse is assessing a client who takes prescribed furosemide (Lasix). Which of the following statements by the client may indicate that the client may be experiencing an adverse effect and would require follow-up? a. "My weight is unchanged." b. "I feel so tired." c. "My urine looks like water from the faucet." d. "I have greenish-colored bowel movements."

The correct answer is B. Clients who take Lasix are at risk for anemia and hypokalemia. The report of being tired may indicate an adverse effect of Lasix and would require follow up. A stable weight indicates the medication is effective.

The nurse is assessing a 72-year-old male client before the client's annual physical examination. The nurse should understand that which of the following changes is a normal part of the aging process? a. increased rapid eye movement (REM) sleep b. decreased bladder capacity c. increased difficulty remembering events d. decreased muscle tone

The correct answer is B. The normal aging process causes a decrease in the bladder capacity. Memory loss is not considered a normal part of the aging process.

The home health nurse is assessing a 2-week-old infant who was born at 35 weeks gestation. The parent states, "It seems like I just got home. I have not been able to do anything that I need to do. If I am not taking care of the baby then I am trying to clean the house. I feel overwhelmed." Which of the following responses would be appropriate for the nurse to make initially? a. "Do you have anyone to help?" b. "Let's talk." c. "The hardest days are in the past." d. "Are you sleeping?"

The correct answer is B. The transition to parenthood requires an opportunity to talk about common concerns and joys. Based on the question, the nurse should initially encourage the parent to continue talking by indicating that the nurse is available to talk. Asking questions that can be answered "yes" or "no" block communication if stated initially.

The nurse is reinforcing teaching with a client who has a prescription to begin metoprolol (Toprol XL). The nurse should advise the client that Toprol XL may cause a. urinary retention b. bronchospasms c. photophobia d. paresthesias

The correct answer is B. Toprol XL can cause bronchospasms, urinary frequency and joint pain, and orthostatic hypotension.

The nurse is reinforcing teaching with a client who has a prescription to begin metoprolol (Toprol XL). The nurse should advise the client that Toprol XL may cause a. urinary retention b. bronchospasms c. photophobia d. paresthesias

The correct answer is B. Toprol XL can cause bronchospasms, urinary frequency and joint pain, and orthostatic hypotension.

The nurse is conducting a staff education conference regarding end-of-life care of clients who practice a variety of religions. The nurse should state that which of the following practices is commonly associated with the Mormon religion? a. Cremation is required within 24 hours of death. b. The Burial Society washes the client's body after death. c. Last rites may be given when the client develops Cheyne-Stokes respirations. d. A white garment is placed on the client when the skin begins to look mottled.

The correct answer is C. A client from the Church of Jesus Christ of Latter-Day Saints (Mormonism) often receives last rites or communion as part of the death ritual. Cheyne-Stokes respirations are associated with impending death.

The nurse is talking with a client who has small oat cell lung cancer. The client states, "I have decided to stop my radiation therapy and will use an herbal treatment to help cure my cancer." Which of the following responses would be most appropriate for the nurse to make first? a. "What comments have your family members made about this?" b. "Do you understand your prognosis without radiation?" c. "How did you decide on this treatment?" d. "Has your primary health care provider been advised of this decision?"

The correct answer is C. A client has a right to make decisions regarding care based on accurate information about treatment alternatives. When a client decides to use alternative therapies rather than conventional therapies, it would be most appropriate for the nurse initially to explore how the client made the decision regarding the alternative treatment. The nurse should not initially ask if the primary health care provider has been advised about the decision since this may block communication.

The nurse is reviewing the record of a client who was just admitted with a traumatic brain injury. Which of the following prescriptions should the nurse clarify? a. Keep the head of the bed elevated 30 degrees. b. Deep breathing exercises without coughing every hour while awake. c. Start IV with D5W 1,000 ml every 8 hours. d. Bisacodyl (Dulcolax) 5 mg, po, q.d.

The correct answer is C. A client with a traumatic brain injury is at risk for increased intracranial pressure. The nurse should verify the prescription for D5W since this is contraindicated if a client is at risk for increased intracranial pressure. A stool softener may be given to help prevent straining with bowel movements which can increase the intracranial pressure.

The nurse is reviewing the record of a client who has prescriptions to begin the following medications. Which of the following medications should the nurse verify since the client reports a previous allergic reaction to sulfonamides? a. carbidopa/levodopa (Sinemet) b. carvedilol (Coreg) c. glimepiride (Amaryl) d. metronidazole (Flagyl)

The correct answer is C. A client with an allergic reaction to sulfonamides may have a cross-sensitivity reaction to Amaryl.

The nurse is assessing a client with bacterial pneumonia. The client has been receiving 0.9% normal saline and an anti-infective via IV piggyback as prescribed for 24 hours. The nurse must intervene if the client's a. oxygen saturation level via pulse oximetry is 92% b. cough is productive of green sputum c. peripheral IV site is cool to touch d. skin is pale

The correct answer is C. A client with bacterial pneumonia who is receiving fluids and medications via IV should be monitored for complications. A cool IV site would require intervention since this indicates an infiltration. The client's sputum color is expected based on the client's diagnosis and length of treatment.

Several clients have asked the nurse for a between-meal snack. The nurse should offer the client with a. lactose intolerance a milk shake b. diabetes mellitus a frozen fruit bar c. hyperthyroidism a liquid nutritional supplement d. moderate dysphagia a cup of diced fruit

The correct answer is C. A client with hyperthyroidism is expending extra energy with high levels of activity. A liquid nutritional supplement would be appropriate to provide nutrients to help prevent weight loss.

The home health nurse is assessing a client who is at 32 weeks gestation and who is being treated for preterm labor. Which of the following is an expected finding? a. low back pain b. yellow-colored vaginal discharge c. yellow discharge from the nipples d. suprapubic pressure

The correct answer is C. A normal finding for a client who is at 32 weeks gestation is yellow nipple discharge, since colostrum may be excreted from the breasts during the last trimester of pregnancy. The other findings may indicate uncontrolled preterm labor, a urinary tract infection and/or a vaginal infection.

The nurse is teaching a client who was recently diagnosed with hyperlipidemia and diabetes mellitus. The client has new prescriptions for atorvastatin (Lipitor) and rosiglitazone (Avandia). Which of the following statements would be correct for the nurse to make? a. "You will need to stop taking Avandia if you need to start taking insulin." b. "A common side effect of Lipitor is a metallic taste in your mouth." c. "Avandia may need to be changed to a different medication if your legs swell." d. "Lipitor may cause your blood glucose level to increase."

The correct answer is C. Avandia may cause peripheral edema that may necessitate changing to a different medication. Lipitor has not been associated with altered taste. The correct answer is C. Avandia may cause peripheral edema that may necessitate changing to a different medication. Lipitor has not been associated with altered taste. The correct answer is C. Avandia may cause peripheral edema that may necessitate changing to a different medication. Lipitor has not been associated with altered taste.

The nurse is completing the preoperative check list on a client who is scheduled for a cystectomy and urinary diversion. The nurse observes that the operative consent is signed by the client and was witnessed, the client's laboratory test results are within the normal range and the client's electrocardiography (EKG) is normal. The nurse should immediately report which of the following statements by the client? a. "My biggest fear is not waking up after surgery." b. "I hope I don't need a blood transfusion since I was not able to bank my own blood." c. "I am glad that I will only have a tube in my bladder for a couple of days." d. "My last bowel movement was two days ago."

The correct answer is C. During the preoperative time interval the nurse must make sure that the client's record is complete and that the client has completed any preoperative preparation that is required. The nurse should immediately report the client's statement regarding the tube in the bladder since this indicates the client does not understand that a cystectomy and urinary diversion means the client's bladder is being removed. If the nurse fails to report this, the facility is at risk for a charge of battery. The statement regarding the potential need for a transfusion indicates that the client understands the preoperative teaching and does not require notification of any members of the surgical team.

The nurse enters the room of a client who has metastatic cancer and who has a prescription not to resuscitate. The nurse observes that the client has sighing respirations and the client's extremities are cool. There has been no urine in the client's indwelling urinary catheter in over 12 hours. The nurse should a. dim the lights in the client's room before returning to the nurse's station b. elevate the client's legs above the level of the head c. remain at the client's bedside until the family member returns from the cafeteria d. administer an analgesic prescribed p.r.n. for pain

The correct answer is C. Palliative care for a client with terminal cancer includes offering comfort and dignity to the client during the dying process. The information in the question is an indication that the client's body systems are shutting down and that death is imminent. The nurse should remain at the client's bedside until the family member returns. The information in the question does not indicate the client is in pain, such as agitation, therefore the nurse should not administer an analgesic unless requested by a designated family member.

The charge nurse has reviewed several irregular occurrence reports during the past month associated with unwitnessed falls. To help resolve these occurrences, the nurse should first a. evaluate the layout of each client care area. b. interview the staff members who completed the irregular occurrence reports. c. identify what prescribed medications were given to the clients. d. determine if any equipment repairs have occurred in the areas of falls.

The correct answer is C. The charge nurse should be familiar with the problem-solving process when irregular occurrences are identified. The first step in the problem solving process is assessing client characteristics, such as types of medications that the clients received. Risk for falls include medications, lighting, muscle weakness and delay of staff in answering call lights. Interviewing staff members who discovered the incidents has lower priority than identifying client characteristics.

The home health nurse is checking a client with chronic obstructive pulmonary disease (COPD). The client is using oxygen around-the-clock. Which of the following information would indicate to the nurse that the client's condition is worsening? a. The client reports being able to breath better while leaning forward. b. The client uses purse-lipped breathing during conversations. c. The client reports chest pain with deep breathing. d. The client speaks with short sentences.

The correct answer is C. The client with COPD is at risk for pneumonia and pneumothorax. Painful breathing is an indication that the client's condition has worsened and requires follow up. The answers are consistent with this stage of illness that requires continuous oxygen. Pursed-lip breathing is characteristic for a client with COPD.

The nurse is caring for a client who has an abdominal aortic aneurysm. The client requests medication for back pain rated 8 on a scale of 0 (no pain) to 10 (severe pain). Which of the following actions should the nurse take first ? a. Assist the client into the lateral recumbent position. b. Determine how long it has been since the client received an analgesic. c. Ask the client if the pain has a knife-like quality. d. Offer the client a small pillow to support the back.

The correct answer is C. The nurse must be able to identify a client's risk for complications associated with an abdominal aortic aneurysm. If the client reports back pain, the nurse must first identify the quality of the pain to help identify if a potentially life-threatening emergency is occurring, such as aortic dissection. If the client's pain is knife-like, this is an emergency that requires action to prevent hemorrhage.

The home health nurse is providing care to an active 2-year-old client who has a tracheostomy. Which of the following actions by the nurse would increase the risk for a charge of negligence? a. flexing the client's neck before making the square knot b. positioning the square knot on the side of the client's neck c. securing the tracheostomy faceplate in place using Velcro-type ties d. removing the soiled ties from the tracheostomy faceplate after the parent has the clean ties in place

The correct answer is C. The nurse must remain aware of standards of care for clients with a tracheostomy and take action to minimize the risk for injury to the client. Negligence is defined as failure to provide care that meets the standard and that places the client at risk for injury. Velcro ties should not be used to secure the tracheostomy tube for a 2-year-old client since the client can easily reach and manipulate the Velcro. The neck should be flexed prior to securing the square knot to help ensure adequate room for expansion of the neck during movement.

The nurse is assessing a client with preterm labor at 32 weeks gestation. The client is receiving terbutaline sulfate (Bricanyl) as prescribed. The client reports feeling palpitations and leaking urine when coughing or sneezing. Which of the following actions should receive priority by the nurse? a. measuring the client's fundal height b. checking the client's weight c. obtaining a electrocardiography (EKG) on the client d. using nitrazine paper to check the moisture in the client's underwear

The correct answer is D. A client who is being treated for preterm labor is monitored for indications of a change in status associated with medications and effectiveness of the treatment regime. The nurse should give priority to using nitrazine paper to check the moisture in the client's underwear since this may be an indication of leaking or rupture of amniotic membranes. A potentially life-threatening infection can develop if the client has prolonged rupture of membranes. Palpitations are a common side effect of Bricanyl. The nurse should check the client's vital signs.

The nurse is assessing a client who is at 28 weeks gestation. Which of the following tests is common at this stage of pregnancy? a. alpha-fetoprotein (AFP) level b. contraction stress test (CST) c. glycosylated hemoglobin (HbA1C) level d. one-hour glucose tolerance test (GTT)

The correct answer is D. A one-hour GTT is typically performed at this stage of pregnancy. AFP is performed during an amniocentesis if fetal anomalies are suspected.

The nurse is assisting while an adult client has a thoracentesis. Which of the following actions would be correct for the nurse to take? a. Ask the client to hold the breath as the needle is inserted. b. Position the client on the side with a pillow support under the waist. c. Check the client's blood pressure while the pleural fluid is extracted. d. Attach a pulse oximetry probe to the client's finger.

The correct answer is D. During a thoracentesis, the client's respiratory status is monitored. Attaching a pulse oximetry probe to the client's finger would be appropriate. The client is not required to hold the breath as the needle is inserted.

The nurse is reinforcing teaching with a client who is at 38 weeks gestation with her first child. The client asks what changes should be reported prior to the next regular obstetrical appointment. The nurse should advise the client to report a. head congestion b. urinary frequency c. yellow-colored nipple discharge d. right upper quadrant abdominal pain

The correct answer is D. During the last few weeks of pregnancy the client continues to monitor for any indication of pregnancy-induced hypertension. The development of right upper quadrant abdominal pain may indicate liver congestion associated with PIH and would require reporting prior to the next scheduled appointment.

The nurse is talking with the parent of a child who just died. The parent states, "Just get out of here. No one can bring my child back to life." Which of the following should the nurse do first? a. Tell the parent anger is a normal response. b. Ask if the parent would like to talk. c. Slowly exit the room. d. Remain silent.

The correct answer is D. The death of a loved one can cause a variety of emotions. Anger is a common emotion and the nurse should initially remain silent to see if the parent will continue talking. Exiting the room is not a therapeutic initial response.

The nurse is assessing a 78-year-old client with prostate cancer. The client lives with an adult child in a ground-level apartment. Which of the following statements by the client should increase the nurse's suspicion regarding elder abuse and would require follow-up? a. "I don't know how I got all of these bruises on my hands." b. "I am home alone all day during the week." c. "My last haircut was about a month ago." d. "My friends are not allowed to visit."

The correct answer is D. The nurse must be observant for indications of elder abuse. A 78-year-old client is at risk for harm by others and the report of friends not being allowed to visit requires additional information to determine if the client is being isolated. Capillary fragility causes easy bruising on the hands of the elderly.

The home health nurse is checking an adult client who is receiving small-bore nasogastric (NG) tube feedings. The nurse should immediately report that the client has a. a dry cough b. hypoactive bowel sounds c. nasal crusting d. pale yellow urine

The correct answer is A. A client who is receiving a NG feeding is at risk for aspiration pneumonia which may be indicated by the presence of a dry cough. Hypoactive bowel sounds do not require immediate action.

The nurse is teaching a 50-year-old client about the scheduled screening colonoscopy. Which of the following statements would be correct for the nurse to make? a. "Before the test begins, an intravenous catheter will be placed into your arm." b. "You will be able to return home after the test is completed and you are able to urinate." c. "A full liquid diet is permitted the night before the test." d. "The test will be rescheduled if you have any rectal itching."

The correct answer is A. A client who is scheduled for a colonoscopy is advised that a intravenous catheter will be inserted before the test so that medications can be given as needed prior to and during the procedure. The client is discharged when fully awake and when the vital signs are stable.

The home health nurse has reinforced teaching with a pregnant client who is starting heparin sodium as prescribed. Which of the following statements by the client would indicate a correct understanding of the teaching? a. "I should keep a medical alert with me at all times." b. "I can no longer eat green leafy vegetables." c. "I should purchase an electric toothbrush." d. "I must limit my intake of carbonated beverages."

The correct answer is A. A client who starts heparin sodium should carry a medical alert with them at all times in case of injury or bleeding. Food precautions exist with warfarin sodium and an electric razor is recommended.

The nurse is distributing between-meal snacks to several clients. Which of the following snacks would be best for the nurse to offer each client? a. fresh vegetable sticks to a client with a white blood cell (WBC) count of 11,300/cu mm b. diced watermelon to a client with a hemoglobin (Hgb) level of 8.0 mEq/L c. graham crackers for a client with stomatitis d. plain gelatin to a client with end-stage renal disease (ESRD)

The correct answer is A. A client with an elevated WBC can eat fresh vegetables as a between-meal snack. Fresh fruit and vegetables would not be given if the client was immunosuppressed. A client with ESRD should receive high-quality proteins and calories to help maintain nitrogen balance.

The nurse is planning care for a client with bacterial pneumonia. The client is receiving oxygen therapy as prescribed via nasal cannula and a prescribed parenteral anti-infective medication. Which of the following nursing diagnoses should be included in the client's plan of care? a. Activity intolerance. b. Altered peripheral tissue perfusion. c. Sensory-perceptual alterations. d. Decreased cardiac output.

The correct answer is A. A client with bacterial pneumonia has nursing diagnoses that include ineffective airway clearance, ineffective breathing pattern, activity intolerance and pain.

The nurse is assessing a 7-day-old, full term infant who is breastfeeding. Which of the following observations should the nurse recognize as normal? a. The infant's weight is equal to the birth weight. b. The infant's conjunctivae are pale. c. The infant does not turn the head when the face is stroked. d. The infant has a bald spot over the occiput.

The correct answer is A. A full term infant who is breastfeeding typically regains weight and by one week is at the birth weight. A bald spot over the occiput may indicate child maltreatment associated with leaving the child supine in the crib for prolonged periods of time.

The home health nurse has assessed a client with a stage 3 pressure sore on the left foot that has been present for over 3 months without any improvement. The client has a normal serum protein level and has been non-weight bearing on the left foot since the pressure sore was diagnosed. The client is currently applying a topical medication and dry dressings to the site as prescribed. Which of the following individuals would be appropriate to consult initially regarding the client's care? a. enterostomal therapist b. plastic surgeon c. registered dietician d. orthopedic surgeon

The correct answer is A. An enterostomal therapist is trained to evaluate and develop treatment plans for complex wounds, such as the wound described in the question.

The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). The client has lost about 5 kg (11 lb) during the past two months and reports moderate muscle weakness. Which of the following actions would be most appropriate for the nurse to take? a. Encourage the client to add cheese to steamed vegetables. b. Encourage the client to perform ankle circling exercises while seated. c. Ask the client to drink a liquid nutritional supplement at the beginning of meals. d. Ask the client to consider enrolling in a water-aerobic exercise class in the community.

The correct answer is A. COPD is a high-energy disease and the client needs a higher caloric intake to help maintain weight and to prevent muscle weakness. Adding cheese to steamed vegetables adds calories. Steamed vegetables are also soft and easy to chew. Liquid nutritional supplements should be consumed at the end of meals or between meals. Drinking the supplement at the beginning of the meal may cause fatigue or early satiety resulting in decreased food intake by the client.

The nurse is contributing to a staff development conference regarding legal responsibilities of health care providers. Which of the following information, if documented in a client's record, should the nurse identify as increasing the risk for a charge of libel? a. Court date pending for charge of child molestation. b. Stab wound to the chest after incidence of domestic violence. c. Unprotected intercourse with multiple sexual partners. d. Use of crack cocaine in social settings.

The correct answer is A. Defamation of character is making false or malicious (intentionally harmful) statements that may harm another person's character or reputation. Oral statements are considered slander and written statements are considered libel. Documenting that a client has a pending charge for child molestation would increase the risk for a charge of libel. The history of unprotected sex with multiple sex partners is pertinent to the client's care.

The nurse is teaching a client with primary hypertension about methods to prevent hypokalemia since the client will start taking furosemide (Lasix) as prescribed. The nurse should advise the client that which of the following foods is highest in potassium per serving? a. dry milk b. dried beans c. apples d. strawberries

The correct answer is A. Dry milk is highest in potassium per serving of the foods listed.

The nurse is caring for an adult client with acute gastroenteritis. Which of the following observations by the nurse may indicate that the client is becoming dehydrated? a. pulse change from 68 to 80 b. blood pressure change from 110/78 mm Hg to 120/80 mm Hg c. musty urine odor d. hypoactive bowel sounds

The correct answer is A. Indications of dehydration include flushed skin, skin tenting, dry mucous membranes, hypotension or tachycardia. The increasing pulse rate may indicate the client is becoming dehydrated.

The nurse is assessing an adult client who was just diagnosed with primary hypertension. Which of the following questions would be essential for the nurse to ask the client? a. "When was your last eye examination?" b. "How often do you receive pedicures?" c. "What medication do you take when you have a headache?" d. "Have you ever had difficulty urinating?"

The correct answer is A. Primary hypertension causes changes in blood flow to target organs, such as the eyes and kidneys. It would be essential for the nurse to ask when the client had an eye examination. It would be most important for the nurse to identify the frequency and severity of headaches rather than the treatment of headaches since the client is at risk for a CVA.

The nurse is conducting a community education program regarding cancer. Which of the following statements would be correct for the nurse to make? a. "Prostate cancer is more common in African-American males." b. "Breast cancer risks increase for women if oral contraceptives have been used during adolescence." c. "Testicular cancer is common after the age of sixty years." d. "Colon cancer screening begins after the age of fifty years regardless of ethnic origin."

The correct answer is A. Prostate cancer is more common in African-American males and usually has a poor prognosis at the time of diagnosis. Colon cancer screening typically begins at the age of 50 years but is recommended starting around 40 years if the individual is African-American.

The nurse is teaching a health promotion class to a group of clients. The nurse should recognize that the risk for developing pneumonia is increased if a client has a. moderate Alzheimer's disease b. an ileostomy c. unstable angina pectoris d. renal stents

The correct answer is A. Risk factors for pneumonia include altered mental status, diabetes mellitus, chronic lung disease, and cancer. The client with moderate Alzheimer's disease has altered mental status.

The nurse is participating in a community-based health fair. The nurse should recognize that which of the following clients is at increased risk for suicide and should receive a depression screening questionnaire? a. an 80-year-old client with mild Alzheimer's disease (AD) b. a 48-year-old client with psoriasis c. a 16-year-old client who has changed schools d. an 8-year-old client with diabetes mellitus, type 1

The correct answer is A. Risk factors for suicide include being elderly, chronic illness, social isolation and individuals who misuse alcohol or other drugs. The 80-year-old client with mild AD is at increased risk for injury since the client is aware of the cognitive changes that are occurring. Also, this individual typically has multiple losses. This client should receive a depression screening questionnaire. A client who changed schools is at lower risk for depression based on the answer choices given.

The nurse is feeding a full term newborn who is on continuous cardiac monitoring. The infant starts to cough, the alarm on the monitor starts to ring and the newborn resumes sucking. The nurse should next a. silence the alarm b. check the monitor settings c. gently pat the newborn's back d. replace the electrodes on the newborn's chest

The correct answer is A. The cardiac alarm may sound whenever there is a change in infant activity, such as coughing. Coughing is a protective reflex and indicates an effort to clear the airway. Based on the question, the nurse should next silence the alarm and then check the electrodes.

The nurse has reinforced teaching with a client who is scheduled for a cardiac catheterization via the femoral artery. Which of the following statements by the client would indicate a correct understanding of the teaching? a. "I should avoid coughing or sneezing for several days after the procedure is completed." b. "I will be asked to hold my breath when the catheter is removed from my groin." c. "I can sit in a chair when I am in the recovery area after the procedure is completed." d. "I may have temporary residual numbness in my leg due to irritation of the nerves caused by the contrast dye."

The correct answer is A. The femoral artery is the most common site of catheter insertion for a cardiac catheterization. A client is discouraged from coughing or sneezing after the procedure to help minimize bleeding at the catheter insertion site. The client does not need to hold the breath during the procedure.

The nurse is completing a neurological assessment on a client who sustained a closed head injury 2 hours ago. Which of the following actions by the nurse would be correct? a. using a tongue blade to check the client's glossopharyngeal nerve b. using the tip of a sterile needle to check the client's facial nerve c. checking the client's patellar deep tendon reflexes after extending the client's leg d. checking the client's biceps reflex after turning the client's palm downward

The correct answer is A. The glossopharyngeal and vagus nerves are checked using a tongue blade. The facial nerve is tested by asking the client to make various facial movements and to identify several different tastes. The client's knee should be flexed before checking the patellar deep tendon reflex. The client's palm should be upward before checking the biceps reflex.

The nurse is caring for a client who has end-stage chronic obstructive pulmonary disease (COPD). The client receives continuous oxygen via nasal cannula and bronchodilators via nebulizer q.i.d as prescribed. Which of the following actions by the nurse would increase the risk for a charge of negligence? a. using a container of acetone to remove adhesive from the client's skin b. allowing the client to use an electric razor to shave c. making sure that the client's undershirt is made from cotton d. mixing a hydrogen-peroxide solution for the client to use as a mouth rinse

The correct answer is A. The nurse must remain aware of standards of care for clients who are receiving oxygen therapy and take action to minimize the risk for injury to the client. Negligence is defined as failure to provide care that meets the standard and that places the client at risk for injury. Using acetone is a potential fire hazard when oxygen is being used so this action increases the risk for a charge of negligence if the client and/or others are adversely affected by this action.

The home health nurse is checking a client who had an open cholecystectomy and insertion of a biliary drainage tube (T-tube). Which of the following actions would be appropriate for the nurse to take? a. laying a plastic garbage bag across the client's legs before removing the T-tube dressing b. rotating the T-tube 90 degrees before cleaning around the tube c. applying gentle pressure on both sides of the T-tube to check for leaks d. obtaining a specimen for culture and sensitivity testing from the yellow drainage in the T-tube

The correct answer is A. The nurse should maintain infection control procedures when dressings are changed in a client's home. A water-proof bag, such as a trash bag, can be placed over the client's legs to place soiled dressings and to minimize contamination of the immediate area.

The nurse is assessing a client who had a partial thyroidectomy 24 hours ago. The nurse must a. check the client's pupillary reaction to light b. observe the response when the client's cheek is tapped c. measure the client's neck circumference d. auscultate the client's carotid pulses

The correct answer is B. A client who had a partial thyroidectomy is at risk for a calcium imbalance. The nurse should tap the client's cheek and observe for muscle twitching (Chvostek's sign) which may indicate hypocalcemia. The client's neck circumference is not measured.

The nurse is assessing a client who is receiving total parenteral nutrition (TPN). The nurse observes that the client's skin is warm and the client's pulse rate is increased. The client reports feeling weak and confused. The nurse should first check the client's a. pupillary response to light b. glucose level c. urine output d. oral temperature

The correct answer is B. A client who is receiving TPN is at risk for fluid and electrolyte imbalances. Hyperglycemia may be indicated by warm skin, tachycardia, muscle weakness and change in mental status. The nurse should first check the client's blood glucose level so that appropriate care can be initiated. The client's oral temperature can be checked after the blood glucose level is checked.

The nurse is preparing to administer a unit of packed red blood cells to a client as prescribed. The nurse should ask the client to immediately report the onset of a. a dry mouth b. back pain c. yawning d. urinary urgency

The correct answer is B. A client who is receiving blood products is at risk for an acute transfusion reaction, such as a hemolytic reaction, that may be life-threatening. The client should immediately report the onset of chills, headache, backache, dyspnea or chest pain.

The nurse is preparing to administer the measles, mumps, and rubella (MMR) vaccine to a client as prescribed. Which of the following should the nurse have immediately available? a. a latex-free tourniquet b. epinephrine (Adrenaline) 1:1000 c. a commercial cold pack d. methylprednisolone (Solu-Medrol)

The correct answer is B. A client who is receiving injectable medications and vaccines is at risk for an immediate hypersensitivity reaction. The nurse should have epinephrine 1:1000 immediately available to administer to help prevent airway collapse.

The home health nurse is administering an intravenous anti-infective as prescribed to a client with osteomyelitis. Which of the following observations would indicate that the client's peripheral intravenous catheter site needs to be changed before the nurse completes the infusion as prescribed? a. ecchymosis distal to the site b. pallor proximal to the site c. a margin of redness outside of the site's transparent dressing d. skin blisters visible underneath the site's transparent dressing

The correct answer is B. A client who is receiving medications via a peripheral intravenous site needs to be monitored for indications of infiltration. This is manifested by localized swelling, coolness, pallor and discomfort at the IV site. If an infiltration is present, the infusion is stopped, the catheter is removed and the infusion is restarted at a new site. Blisters under the dressing may indicate reaction to the adhesive but is not an indication that the site needs to be changed.

The home health nurse is checking an adult client with chronic obstructive pulmonary disease (COPD). Which of the following observations would require intervention by the nurse? a. oxygen saturation 91% via pulse oximetry b. oxygen at 5 liters/minute via nasal cannula c. clubbing of the nail beds d. discolored nail beds

The correct answer is B. A client with COPD should have oxygen flowing no higher than 3 liters/minute via nasal cannula to help maintain the respiratory drive. Clubbing of the nail beds is a normal finding for a client with COPD.

The nurse is teaching a client who was recently diagnosed with a generalized seizure disorder. Which of the following should the nurse state has been associated with the onset of seizure activity? a. drinking cold beverages b. sunlight flickering through tree branches c. working in a noisy environment d. the smell of burning debris

The correct answer is B. A client with a generalized seizure disorder should be taught methods to help minimize seizure activity. Flickering lights have been identified as a stimulus for seizure activity.

The charge nurse in the long-term care facility is scheduling procedures for several clients as prescribed. Which of the following clients should the nurse make sure is scheduled for the first appointment in the morning? a. A client with an elevated blood urea nitrogen (BUN) level who needs to have a renal ultrasonography. b. A client with a low white blood cell count (WBC) who needs to have a chest radiography. c. A client with dark-colored bowel movements who needs to have a colonoscopy. d. A client with severe heartburn who needs to have an upper endoscopy.

The correct answer is B. A client with a low WBC is at risk for infection and should have procedures scheduled at the first available appointment time to help minimize the client's risk for infection in a busy or crowded waiting area. The client with an elevated BUN is at lower risk for a potentially life-threatening infection.

The home health nurse is talking with a client who has hepatic cirrhosis and esophageal varices. The client reports losing about 2.2 kg (5 lbs) during the past 4 weeks without any attempt at weight loss. Which of the following should the nurse recommend to help the client maintain weight? a. adding butter to popcorn b. eating fruit canned in syrup c. adding cheese to raw vegetables d. eating toasted wheat bread with jelly

The correct answer is B. A client with hepatic cirrhosis and esophageal varices is at risk for altered nutrition. The client should avoid foods that are hard, like popcorn and fresh fruit, since this may increase the risk for bleeding. Eating fruit canned in syrup would help to add calories and vitamins with minimal risk for bleeding.

The nurse is conducting a community-based health fair. The nurse should recognize that which of the following is an appropriate age-based screening? a. breast cancer screening for a 16-year-old female who has anorexia nervosa b. skin cancer screening for a 27-year-old female who is a bridge construction worker c. prostate cancer screening for a 30-year-old male who is Asian d. colorectal cancer screening for a 35-year-old male who is Caucasian

The correct answer is B. Cancer screening is an important role for the nurse in the community. Skin cancer screening is appropriate for a 27-year-old female construction worker since the client works outdoors. Prostate cancer screening begins between 45 and 50 years of age, colorectal cancer screening begins at 50 years of age and breast cancer screening begins at 18 years of age.

The home health nurse is reinforcing teaching with the parents of a child who has a new permanent tracheostomy. Which of the following statements should the nurse make? a. "The portable suction unit should be set at 15 mm Hg." b. "A routine tracheostomy tube change should be scheduled prior to a feeding or at least an hour after a feeding." c. "Wait at least four hours between suctioning intervals." d. "Each new tracheostomy tube is inserted by holding one edge of the tube at the lateral edge of the stoma then gently lifting the tube until it is centered over the stoma."

The correct answer is B. Changing a tracheostomy tube may cause episodes of coughing. Scheduling the change prior to a meal or at least an hour after a meal may help to minimize vomiting.

The nurse is teaching a client about prescribed insulin lispro (Humalog). Which of the following statements would be correct for the nurse to make? a. "If you are nauseated, do not take this insulin until you are able to eat a meal." b. "This type of insulin can cause hypoglycemia within an hour." c. "This insulin normally looks cloudy." d. "If you need to change to an insulin pump, a different type of insulin will be required."

The correct answer is B. Humalog insulin peaks within an hour therefore this is the time interval that the client is at increased risk for hypoglycemia. Humalog insulin should be clear and should not be used if it is cloudy.

The nurse is assessing a client who is taking hydrochlorothiazide (HCTZ). Which of the following questions would be essential for the nurse to ask the client? a. "Do bright lights hurt your eyes?" b. "Have you noticed any change in your appetite?" c. "How much water do you drink during the day?" d. "Do you have a dry cough?"

The correct answer is B. Hydrochlorothiazide may cause hypokalemia. Hypokalemia may be indicated by muscle cramps, abdominal distention, anorexia, and constipation. Asking the client about a change in appetite would be essential to help identify potential fluid and electrolyte imbalances. The client's intake of water has lower priority than identifying indications of fluid and electrolyte imbalances.

The nurse is reinforcing preoperative teaching with a client who has signed a surgical consent and is scheduled for a radical prostatectomy. Which of the following statements by the client would increase the risk for a charge of battery if the surgery is performed as scheduled? a. "I know that I may have pink-colored urine for several weeks after surgery." b. "I will be able to resume sexual activity within six weeks of surgery." c. "I should avoid becoming constipated after surgery." d. "I can donate my own blood for transfusion since this surgery can cause severe anemia."

The correct answer is B. Informed consent means that the client has received and understands the surgical procedure as well as the risks and benefits of treatment to include specific details regarding complications. Battery is touching a person without consent with or without harm to the client. A radical prostatectomy increases the risk for sexual dysfunction. The client's statement about resuming sexual activity indicates the client does not have a correct understanding of the surgical procedure and increases the risk of a charge of battery if the surgery proceeds without providing the client with additional information regarding sexual function after surgery.

The nurse is preparing to administer enoxaparin (Lovenox) as prescribed to a client. Which of the following actions would be appropriate for the nurse to take? a. Check the client's activated partial thromboplastin time (APTT) before giving the Lovenox. b. Inject the Lovenox at a 90 degree angle into the client's abdomen. c. Pull the plunger on the syringe backward to check for blood before injecting the Lovenox. d. Verify the client's current weight.

The correct answer is B. Lovenox is injected either at a 45 or 90 degree angle into the client's abdomen. The APTT is not routinely monitored when Lovenox is administered.

The nurse is preparing a client for discharge after the client had a colonoscopy with removal of a rectal polyp. Before the client is discharged, the nurse must a. measure the client's abdominal girth b. check the client's blood pressure c. determine if the client has expelled any flatus d. assess the client's gag reflex

The correct answer is B. Prior to discharging a client, the nurse must make sure that a client is not experiencing any complications. After a colonoscopy, the client is at risk for hemorrhage and bowel perforation. The nurse must check the client's blood pressure before the client is discharged. The client is not required to expel flatus prior to discharge.

The nurse is caring for a 72-year-old client who is receiving percutaneous endoscopic gastrostomy (PEG) tube feedings. The client has residual dysphagia and hemiparesis due to a cerebrovascular accident (CVA). The nurse observes that the client is having difficulty remaining alert and has the new onset of confusion. The nurse should immediately check the client's a. abdominal girth b. oxygen saturation level c. peripheral pulses d. gastric residual

The correct answer is B. Risk factors for pneumonia include immobility, advanced age, aspiration of gastric contents and a suppressed immune system. Geriatric-aged clients have a suppressed immune system and may not have typical fever and respiratory changes when an infection develops. Based on the history presented in the question, the nurse should immediately check the client's oxygen saturation level since a change in mental status may indicate hypoxia associated with aspiration pneumonia.

The parent of an 8-day-old infant watches television in the room while the home health nurse completes a weight check on the infant. The infant's weight is the same as the birth weight and the parent reports that the infant does not like to be touched. Which of the following additional observations of the infant by the nurse would indicate that child protective services must be contacted? a. dried formula on the chin b. reddened occiput c. cheesy substance in the axilla d. edematous breasts

The correct answer is B. The home health nurse must remain alert for indications of child maltreatment, such as failure to gain weight, avoidance of contact with the infant and indications of bruising that may indicate inappropriate aggression toward the infant. Child protective services must be contacted by law if the infant's occiput is reddened since this indicates pressure associated with the infant remaining in the supine position. Vernix caseosa is a cheesy substance that is normally present in the axilla and other skin folds of a newborn.

The nurse is conducting a staff development conference regarding internal disasters. The nurse should state that if building evacuation is required, priority should be given to evacuating clients who are a. receiving continuous oxygen b. ambulatory c. comatose d. sitting in wheelchairs

The correct answer is B. The nurse must establish evacuation plans in case of an internal disaster. Priority is given to evacuating the ambulatory clients. This can be accomplished by having a staff member lead the clients to the designated exit.

The nurse has been reassigned to the emergency department (ED) due to a staff shortage. The nurse is assigned to irrigate a superficial stab wound but the nurse has never performed a wound irrigation. To help prevent a charge of negligence, the nurse should initially a. refuse to irrigate the client's wound b. review the procedure for wound irrigation c. ask another staff member to help d. ask the nursing supervisor to come to the ED

The correct answer is B. The nurse must possess the appropriate knowledge, skills and abilities to safely provide care to assigned clients. When a nurse is asked to float to an unfamiliar area and complete an unfamiliar task, the nurse should review the procedure for wound irrigation. The nurse can be charged with negligence if the task is not completed according to the agency policy. The nurse is responsible for the correct performance of an assigned task by the nurse or if delegated to another staff person. Asking for help would be appropriate after the nurse reviews the procedure.

The nurse is reviewing home safety with a 79-year-old client. Which of the following should the nurse identify as a safety hazard for the client that needs to be corrected? a. an unopened can of a liquid nutritional supplement is sitting next to the gas stove b. a bottle of paint thinner is stored next to a can of cooking oil c. a towel soaked with alcohol is sitting next to the washing machine d. a tube of denture adhesive is stored next to a tube of toothpaste

The correct answer is B. The nurse should remain alert to safety hazards in a client's home. Storing potentially toxic chemicals with food items is a safety hazard.

The nurse is reinforcing teaching with a client who is receiving chemotherapy. The nurse should reinforce that which of the following vitamins may increase the risk for bleeding? a. vitamin B 6 b. vitamin C c. vitamin E d. vitamin K

The correct answer is B. Vitamin C can increase the risk for bleeding.

The nurse is assessing a client who is at 39 weeks gestation and reports the onset of contractions 12 hours ago. The nurse observes a linear bruise on the client's legs and the client reports this occurred when she fell down 2 steps on the front porch. Which of the following questions would be essential for the nurse to ask the client? a. "When did you fall?" b. "Do you have any other injuries?" c. "Are you being mistreated by someone you love?" d. "How many prenatal vitamins are you taking each day?"

The correct answer is C. A client who is pregnant is at risk for domestic violence. Linear bruises on the legs is an injury that is not consistent with the client's report of the injury. It would be essential for the nurse to ask the client about being mistreated by another person.

The nurse is confirming an appointment with a client who is scheduled for her first Papanicolaou smear. Which of the following statements would be appropriate for the nurse to make? a. "This test will help to determine if you have any sexually transmitted diseases." b. "A vaginal irrigation can be done the morning of the test." c. "Do not use any vaginal medications for at least twenty-four hours before the test." d. "An over-the-counter analgesic will help minimize cramping during the test."

The correct answer is C. A client who is scheduled for a Papanicolaou smear is instructed to not douche or use any vaginal medications prior to the test to help ensure reliability of the results.

The nurse has reinforced teaching with a client with bacterial conjunctivitis. Which of the following statements by the client would indicate a correct understanding of the teaching? a. "I need to sleep in a different bed than my spouse until this infection resolves." b. "I can wear my contact lenses after twenty-four hours of treatment." c. "I should clean my eyes using a different section of my washcloth for each eye." d. "I will rest in bed until the redness is gone."

The correct answer is C. A client with bacterial conjunctivitis needs to know methods to control the infection. This includes wiping each eye with a separate section of a washcloth to help prevent cross-contamination. Contact lenses should not be worn until the infection is resolved (typically after 7 days).

The nurse is admitting a client with a metastatic brain tumor who just had a craniotomy. Which of the following actions should the nurse take first? a. Assess the client's level of consciousness. b. Assess the client's vital signs. c. Determine if the client has an advance directive. d. Determine if the client has family members in the waiting room.

The correct answer is C. A client with cancer who had a craniotomy is at risk for multiple potentially life-threatening postoperative complications. The nurse should first determine if the client has an advance directive so that appropriate actions can be planned if an emergency occurs during the shift. An advance directive provides information about how staff members should respond if a life-threatening emergency develops. The client's level of consciousness has lower priority based on the information presented in the question.

The nurse is planning care for a client who was recently diagnosed with hypothyroidism. Which of the following should the nurse include in the client's plan of care? a. showing the client how to monitor urinary output b. encouraging the client to rest until symptoms resolve c. teaching the client about high fiber foods d. demonstrating foot care to the client

The correct answer is C. A client with hypothyroidism often experiences constipation. The nurse should teach the client about high fiber foods to help regulate bowel movements. Hypothyroidism does not affect urinary output.

The nurse is preparing to administer a prescribed medication to a client with severe Alzheimer's disease. The client is not wearing an identification bracelet. Which of the following actions would be most appropriate for the nurse to take? a. Monitor the client's response when the name is stated. b. Compare the name on the medication record with the name on the foot of the bed. c. Return the medication to the medication cart. d. Ask another licensed staff member to confirm the client's identity.

The correct answer is C. A client with severe Alzheimer's disease is unable to provide reliable information. Based on the 5-rights of medication administration, if the client is not wearing an identification bracelet, the nurse should return the medication to the medication cart until a new bracelet is obtained.

The nurse has reinforced teaching with the spouse of a client who will start prescribed donepezil (Aricept). Which of the following statements by the spouse would indicate a correct understanding of the teaching? a. "Water exercises are not permitted while this medication is taken." b. "Memory loss is reversed when this medication is taken daily." c. "This medication should not be discontinued abruptly." d. "Elevated blood glucose levels are common when the medication is first started."

The correct answer is C. Aricept is used to stabilize and slow memory loss associated with dementia. This medication should not be discontinued abruptly.

The nurse is talking with a client who will begin chemotherapy for leukemia. Which of the following statements would be correct for the nurse to make? a. "Your urine will have high levels of the chemotherapy particles after the first treatment so make sure that you flush your toilet at least twice after urinating." b. "You should avoid contact with young children until the chemotherapy treatments are completed." c. "Try taking the prescribed antiemetic at regular time intervals rather than when nausea occurs." d. "Wear loose fitting clothing to help prevent skin irritation associated with chemotherapy."

The correct answer is C. Chemotherapy can cause severe nausea and vomiting. A client should try taking the prescribed p.r.n. antiemetic at regular time intervals to help prevent nausea and vomiting. Radiation therapy may cause skin reactions so the client should wear loose fitting clothing to help minimize irritation.

The nurse in the long-term care facility is caring for the following assigned clients. The nurse would increase the risk of a charge of false imprisonment if the nurse administers a. a sedative prescribed p.r.n. to a client with moderate Alzheimer's disease who is agitated at sundown b. a sedative prescribed p.r.n. to a client with an inoperable brain tumor who is too restless to sleep c. an opioid analgesic prescribed p.r.n. to a client with metastatic bone cancer who refuses to sleep during the night d. a skeletal muscle relaxant prescribed p.r.n. to a client with fibromyalgia who reports skin sensations of crawling bugs

The correct answer is C. False imprisonment is confining or restricting a client's movement by using physical or verbal constraint without the client's consent. Administering medications to control a client's behavior for the convenience of staff is a form of false imprisonment, such as administering an analgesic to a client who refuses to sleep at night.

The nurse is caring for a client with chronic low back pain. The client reports pain rated 8 on a scale of 0 (no pain) to 10 (severe pain). The client received a prescribed oral analgesic 5 minutes ago. Which of the following actions by the nurse may enhance the client's comfort? a. turning the client onto the left side with both knees flexed to the chest b. elevating the client's legs above the level of the heart while lying in bed c. placing a rolled towel behind the client's back while sitting d. assisting the client to lay on the abdomen with the arms raised above the head

The correct answer is C. Nonpharmacologic methods to enhance the comfort of a client with low back pain include sitting with a pillow to support the back, resting supine with pillows under the legs and resting in the lateral position with a pillow between the knees. If there is leg pain, the painful leg is flexed while the client is in the lateral position.

The nurse is teaching a client who is to start total parenteral nutrition (TPN). The client asks the nurse how the decision is made to use TPN compared to nasogastric (NG) tube feedings. Which of the following statements would be correct for the nurse to make? a. "Total parenteral nutrition is more cost effective for a client than NG tube feedings since the nutritional value is higher quality." b. "Nasogastric tube feedings cause a client to have more oral infections than TPN." c. "Total parenteral nutrition is chosen when a client is not able to absorb nutrients from the intestinal tract." d. "Nasogastric tube feedings are beneficial for clients who do not have a gag reflex but who require enteral nutrition for less than a month."

The correct answer is C. TPN is provided when a client is not able to absorb nutrients through the gastrointestinal tract, such as with inflammatory bowel disorders, cancer and malnutrition. TPN requires regular laboratory tests to determine the appropriate components based on evaluation of the client's changing nutritional needs. There is no evidence to support that TPN is more cost effective than NG feedings. NG tube feedings are administered when a client's protective reflexes are intact, such as the gag reflex and is used when the client needs nutritional support for less than 5 days. In addition, the client's gastrointestinal tract must be able to absorb the nutrients.

The nurse is reviewing the laboratory test results of an adult client who had an annual physical examination. Which of the following laboratory test results is within the normal range? a. white blood cell (WBC) count, 23,000/cu mm b. glycosylated hemoglobin (HgbA1C), 8.2% c. serum potassium, 3.7 mEq/L d. urine specific gravity, 1.000

The correct answer is C. The normal serum potassium level is 3.5 to 5 mEq/L; HgbA1C less than 6% is normal or less than 7% indicates glycemic control for a client with diabetes mellitus; a normal WBC is 5,000 to 10,000/cu mm; and the urine specific gravity is typically between 1.010 to 1.025.

The nurse has completed discharge teaching with a 76-year-old client with dysphagia who will be discharged with percutaneous endoscopic gastrostomy (PEG) tube feedings. Which of the following statements by the client would indicate that the client is at increased risk for injury after discharge and would require intervention by the nurse? a. "I will coil the PEG tube under my clothing when I am gardening outdoors." b. "I plan to clamp the PEG tube when I resume my swimming classes next month." c. "I will keep the PEG tube feeding bags on top of my refrigerator." d. "I can fill the PEG tube feeding bag with enough formula to last eight hours."

The correct answer is C. The nurse must be able to identify a client's risk for injury in the home. A client who is 76 years old is at risk for falls and should be discouraged from reaching overhead to get frequently needed objects. Storing the PEG tube feeding bags on top of the refrigerator is a risk that requires intervention by the nurse. The feeding bags can be filled with enough formula to last 8 hours without risk to the client.

The nurse is assessing a client who is taking prescribed levothyroxine (Synthroid) and who has a low thyroid-stimulating hormone (TSH) level. The nurse should assess the client's a. nails for thickening b. skin for breakdown c. neck veins for distention d. pedal pulses for symmetry

The correct answer is C. The nurse should understand common manifestations of thyroid disease and risks for a client with thyroid disease. A client who is on Synthroid is at risk for hyperthyroidism. A low TSH is an indication of excess Synthroid and the client is at risk for dysrhythmias and heart failure. The nurse should assess the client's neck veins for distention.

The nurse is reviewing the record of a 62-year-old female client who was just admitted. The client had a cerebrovascular accident (CVA) and also has osteoporosis. The client receives continuous percutaneous endoscopic gastrostomy (PEG) tube feedings and the client's prescribed medications are administered via the PEG tube. Which of the following prescribed medications should the nurse clarify before administering the medication to the client? a. oxybutynin (Ditropan) b. paroxetine (Paxil) c. warfarin sodium (Coumadin) d. estrogen (Premarin)

The correct answer is D. A cerebrovascular accident may be caused by hemorrhage or thrombus. The nurse should clarify the prescription for Premarin since a history of thrombus is a contraindication for Premarin. Coumadin can be administered via the PEG tube and is not contraindicated based on the information presented in the question.

The home health nurse is talking with family members about the nutritional needs of a client who is receiving mechanical ventilation. Which of the following statements would be correct for the nurse to make? a. "Increased protein needs can be met by offering the client a liquid fruit-flavored gelatin beverage." b. "The caloric needs for the client are lower than the needs of a healthy client who is the same age." c. "Water-soluble vitamins are lost during suctioning so they need to be replaced with an oral supplement." d. "Eating high carbohydrate meals can cause the client's oxygen saturation level to fall."

The correct answer is D. A client on mechanical ventilation is at risk for imbalanced nutrition. The client needs to be on a diet that has increased protein, calories, vitamins and minerals. However, a high carbohydrate intake can cause increased carbon dioxide production and result in a low oxygen saturation level.

The nurse is assessing a client who had a colonoscopy an hour ago. The client reports feeling weak and dizzy and the client's blood pressure has changed from 118/70 mm Hg to 104/56 mm Hg. Which of the following actions should the nurse take first? a. Notify the client's primary health care provider b. Check the client's temperature c. Auscultate the client's bowel sounds d. Elevate the client's legs above the level of the heart

The correct answer is D. A client who had a colonoscopy is at risk for bowel perforation and hemorrhage. The onset of weakness, dizziness and a decreasing blood pressure indicates possible hypovolemia and the nurse should elevate the client's legs above the level of the heart to help maintain cerebral tissue perfusion.

The nurse is assessing a client who had a total hip arthroplasty 2 days ago. The nurse observes that the client's pulse is increased, the client reports feeling anxious and has pain in the operative leg. The nurse's initial response should be based on an understanding that the client may have a. a wound infection b. a dislocated hip prosthesis c. atelectasis d. a pulmonary embolism

The correct answer is D. A client who had a hip prosthesis is at risk for deep vein thrombosis and pulmonary embolism. A pulmonary embolism may be indicated by the development of tachycardia and anxiety. The nurse's initial response should be based on an understanding of pulmonary embolism since this is a potentially life threatening condition. A wound infection is not life-threatening and should not be the basis for the nurse's first response.

The nurse has taught a client who just had drainage of a pilonidal cyst. Which of the following statements by the client would indicate a correct understanding of the teaching? a. "I need to rest with my legs elevated on pillows." b. "I should refrain from sexual activity until the pain is gone." c. "I cannot use any rectal medications until this is healed." d. "I should sit in a warm tub of water several times a day."

The correct answer is D. A client who had a pilonidal cyst drained should sit in a warm tub of water to help enhance healing. The client may be more comfortable by sitting on cushioned surfaces which minimize pain in the region of the coccyx.

The nurse is assessing a client with heart failure who is taking prescribed hydrochlorothiazide (HydroDIURIL). The client states, "I do not know where I am. I don't feel good." The nurse should immediately review the results of which of the following laboratory tests? a. erythrocyte sedimentation rate (ESR) b. serum protein c. uric acid d. blood urea nitrogen (BUN)

The correct answer is D. A client who is on HydroDIURIL is at risk for renal dysfunction. The onset of confusion and malaise may indicate that the client has renal dysfunction. The nurse should immediately check the results of the client's BUN.

The nurse is assessing a client who reports frequent sore throats and swollen glands beneath the jaw. The nurse observes that the client is 20% above the ideal body weight and that the client's weight has fluctuated by about 4.5 kg (10 lb) during the past few months. Which of the following questions would be essential for the nurse to ask the client? a. "Have you noticed any change in your vision?" b. "How often do you eat?" c. "What type of beverages do you enjoy?" d. "Do you feel any heart palpitations?"

The correct answer is D. A client with a binge-purge eating disorder may have frequent sore throats and a chipmunk facial appearance due to swelling of the parotid glands. The nurse should ask the client about palpitations since a client with a binge-purge eating pattern is at risk for cardiac dysrhythmias.

The nurse is helping to evaluate the effectiveness of bumetanide (Bumex) for a client with heart failure. Which of the following questions would provide the best information from the client? a. "Do your clothes fit differently?" b. "Do you have any ringing in your ears?" c. "How often during the day does your mouth feel dry?" d. "How many pillows do you use under your head while sleeping?"

The correct answer is D. A client with heart failure may report difficulty sleeping unless the head is supported on several pillows at night. To determine the effectiveness of Bumex, a diuretic, the nurse should ask about the number of pillows used during the night to sleep.

The nurse is caring for a client who had an abdominal hysterectomy 48 hours ago. The client reports abdominal pain rated 8 on a scale of 0 (no pain) to 10 (severe pain). Which of the following medications prescribed p.r.n. would be appropriate for the nurse to administer to the client? a. ketorolac (Toradol) b. metoclopramide (Reglan) c. bisacodyl (Dulcolax) d. meperidine hydrochloride (Demerol)

The correct answer is D. Demerol should be administered for moderate to severe pain. A pain scale is used to determine the severity of pain and a rating of 8 indicates moderate to severe pain.

The nurse is participating in a disaster drill. The nurse is advised that a chemical spill occurred on the third floor of a large business. The nurse should understand that during the disaster drill priority should be given to the client with a. a bone protruding from the foot b. blood oozing from a hand c. red sclerae d. a dry cough

The correct answer is D. Maslow's hierarchy is used to establish priorities during a disaster. A chemical spill releases caustic fumes into the air. A client with a dry cough may have chemical burns in the airway and should receive priority. Blood oozing from a hand has lower priority than profuse bleeding.

The nurse is teaching the parent of a 4-hour-old, full term infant about feeding the infant. The parent has decided to only formula-feed the infant. Which of the following statements would be correct for the nurse to make? a. "Burp your infant often during the feeding." b. "The baby should sleep on the abdomen after eating." c. "Unopened cans of formula should be stored in the refrigerator." d. "You can prefill bottles with about two ounces of formula."

The correct answer is D. Principles of newborn feeding include filling the bottles with enough formula for each feeding, typically 2 to 3 ounces the first week of life; burping the infant after approximately 1/2 ounce of formula, placing the infant on the back after eating and storing unopened cans of formula in a cabinet.

The nurse is caring for a client who is receiving a dose of prescribed vancocin (Vancomycin) via IV piggyback. The nurse observes that the client's vital signs remain within the client's baseline and the client has facial flushing. Which of the following actions would be appropriate for the nurse to take? a. Obtain the emergency cart. b. Stop the infusion. c. Slow the rate of flow. d. Inform the client that this is normal.

The correct answer is D. Red man's syndrome may occur with vancomycin and this causes a flushed appearance to the face or neck. The client should be reassured that this is a common, non life-threatening side effect.

The nurse is assessing a 35-year-old client who has scheduled an annual physical examination. The client reports a history of mild pregnancy-induced hypertension (PIH) during two pregnancies and that both infants weighed over 4.0 kg (9 lb). Before the primary health care provider examines the client, the nurse should give priority to a. reviewing the client's record for a recent echocardiography report b. reviewing the client's record for a recent electrocardiography (EKG) report c. obtaining a urine specimen from the client d. checking the client's capillary glucose level

The correct answer is D. Risk factors for type 2 diabetes mellitus include giving birth to an infant that is large-for-gestational age. Based on the client's history and age, the nurse should give priority to checking the client's capillary glucose level. The client's history does not indicate a risk for urinary problems therefore obtaining a urine specimen is not a priority.

The charge nurse has completed the shift assignments for nursing assistants. Which of the following statements by the charge nurse would provide the best directions to help ensure that the task is completed as assigned? a. "The client with right-sided hemiparesis must be assisted to walk in the hallway." b. "Make sure that the client with Alzheimer's disease is assisted to the bathroom several times this shift." c. "Snacks are in the refrigerator for clients who are receiving insulin." d. "The client with multiple sclerosis needs to get out of bed for each meal."

The correct answer is D. The charge nurse must provide specific, detailed information to nursing assistants to help ensure that the client care assignment is completed appropriately and within the required time frame. Informing the nursing assistant that the client needs to get out of bed for each meal is specific. The charge nurse needs to be more specific regarding when snacks should be given to clients who are receiving insulin.

The nurse is reviewing the laboratory test results of a client who had a transurethral resection of the prostate (TURP) 2 days ago. Which of the following laboratory test results is within the normal range? a. white blood cell (WBC) count, 3,000/cu mm b. red blood cell (RBC) count, 4.0 million/cu mm c. hemoglobin (Hgb), 20.0 grams/dl d. hematocrit (HCT), 46%

The correct answer is D. The normal hematocrit for a male is 42 to 52 %; WBC 5,000 to10,000/cu mm; RBC, 4.7 to 6.1 million/cu mm; and Hgb 14 to 18 grams/dl.

The nurse is completing oral care on a client who is comatose. Which of the following actions would be appropriate for the nurse to take? a. Brush the client's tongue with a medium bristle toothbrush. b. Use one moist gauze pad to gently wipe both cheeks inside of the client's mouth. c. Irrigate the client's mouth with normal saline after flossing the client's teeth. d. Turn the client onto the side with the head slightly lower than the shoulders.

The correct answer is D. The nurse completes oral care on a client who is comatose by turning the client onto one side with the head slightly lower than the shoulders. This helps to prevent aspiration. The client's tongue, roof of the mouth and cheeks are each cleaned with a separate gauze pad to minimize cross-infection. Oral irrigation is not performed due to the risk of aspiration.

The nurse has been advised that a client is being admitted with severe diarrhea. There are no private rooms available on the unit. It would be most appropriate for the nurse to assign the client to share the room with a client a. who is receiving total parenteral nutrition (TPN) b. with an open abdominal wound c. who is receiving percutaneous endoscopic gastrostomy (PEG) tube feedings d. with acute pancreatitis

The correct answer is D. The nurse is required to assist in determining the correct room assignments for clients based on an understanding of infection control procedures. A client with severe diarrhea requires contact precautions as does the client with acute pancreatitis. It would be most appropriate for these two clients to share a room. Clients with open wounds and who are receiving TPN or PEG feedings would not be appropriate roommates for the client with severe diarrhea based on the choices given.

The nurse is reinforcing teaching with a client who will start warfarin sodium (Coumadin) due to the new diagnosis of atrial fibrillation. Which of the following statements would be appropriate for the nurse to make? a. "Multiple vitamin supplements are recommended while you take Coumadin." b. "Orange juice should be limited since this contains a high amount of vitamin K." c. "Avoid using antibacterial soap on your skin." d. "You should get a shower chair to use in your bathtub."

The correct answer is D. The nurse must be able to identify a client's risk for injury in the home. A client with atrial fibrillation may develop dizziness during activities. In addition, the client is at risk for potentially life-threatening bleeding due to the therapeutic effects of Coumadin. It would be appropriate for the nurse to recommend that the client get a shower chair to use in the bathtub.

The nurse is preparing to change the dressing on a client's triple lumen central venous catheter. Which of the following actions would be correct for the nurse to take? a. removing the client's old dressing using sterile gloves b. lowering the client's head before removing the dressing c. applying triple-antibiotic ointment to the catheter insertion site d. putting on a face mask after opening the prepackaged dressing kit

The correct answer is D. The nurse should put on a face mask when the dressing is changed on a client's central venous catheter. It would be appropriate to put on the mask after the dressing kit has been opened. The client's head should be turned away from the catheter insertion site when the dressing is removed.

The nurse is present when an adult client stops eating, grabs the throat and falls to the floor. The nurse should immediately a. open the client's mouth b. get a stretcher c. start abdominal thrusts d. determine if the client can speak

The correct answer is D. The question should increase the nurse's suspicion that the client has an obstructed airway. The nurse should immediately determine if the client can speak.

The nurse is conducting a staff development conference regarding death and dying. The nurse should indicate that a school-aged child typically views death as a. a deep sleep b. punishment c. a part of mortality d. final

The correct answer is D. The school-aged child typically views death as final.

The nurse is working in an immunization clinic. The nurse should inform parents that the varicella vaccine is recommended at a. 2 months of age b. 4 months of age c. 9 months of age d. 12 months of age

The correct answer is D. The varicella vaccine is recommended at 12 months of age.

The nurse is admitting an adult client with a wound infection. The client has a prescription for intravenous vancomycin. The nurse should ask the nursing assistant to closely monitor the client's a. voice tone and quality b. gait c. daily weight d. intake and output

The correct answer is D. Vancomycin can cause elevated blood urea nitrogen (BUN) and creatinine levels as well as diarrhea. The nurse should ask the nursing assistant to closely monitor the client's intake and output.