one
What are the steps in order of priority for application of an ostomy appliance? Arrange the actions in the order they should be performed. All options must be used.
1. perform 2. remove 3. cleanse 4. assess 5. cut 6. press
A health care provider prescribes 3000 mL of 5% dextrose to be administered over a 24-hour period. The nurse prepares to set the infusion rate knowing that how many milliliters per hour are to be administered? Fill in the blank.
125
A client is scheduled for an oral cholecystography. The nurse should plan to obtain what type of diet for the evening meal before the test?
2
A client is seen in the health care clinic, and a diagnosis of conjunctivitis is made. The nurse reinforces discharge instructions to the client regarding care of the disorder while at home. Which statement by the client indicates a need for further teaching?
2
A client is seen in the urgent care center for complaints of chest pain 2 days ago. Since that time, the client has not been feeling well and fatigues easily. The nurse reviews the results of the laboratory tests and suspects myocardial infarction at the time of chest pain 2 days ago if which comes back positive?
2
A client is to receive medication via patient-controlled analgesia (PCA), and the nursing instructor asks the nursing student caring for the client to describe the use of the PCA. The instructor determines that the student needs further teaching about the PCA when the student makes which statement?
2
A client with Crohn's disease is seen by the health care provider, and a complete blood count (CBC) has been prescribed. The nurse reinforces instructions to the client who will be reporting to the laboratory in the morning to have the blood test drawn. The nurse gives the client which information about this test?
2
A client with ascites is scheduled for a paracentesis. The nurse is assisting the health care provider in performing the procedure. Which position should the nurse assist the client into for this procedure?
2
A licensed practical nurse (LPN) asks an unlicensed assistive personnel (UAP) to gather supplies in preparation for administering a tepid bath to a child with a fever. The LPN intervenes if the UAP obtains which unnecessary item(s)?
2
A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is important?
2
Intravenous (IV) lactated Ringer's (LR) solution is prescribed for a postoperative abdominal surgery client. A nursing student is caring for the client, and the nursing instructor asks the student about why this IV solution is prescribed? Which is a correct response by the student?
2
The chart describes characteristics of various types of enemas. Which type of enema has the highest risk of complications? Refer to chart.
2
The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the health care provider?
2
The medication prescribed is zidovudine (Retrovir), 0.2 g orally, three times daily. The medication label states zidovudine, 100-mg tablets. The nurse prepares to administer how many tablets for one dose? Fill in the blank.
2
The medication prescription reads phenytoin (Dilantin), 0.2 g orally, twice daily. The medication label states 100-mg capsules. The nurse prepares how many capsule(s) to administer one dose? Fill in the blank.
2
The nurse checks the client's surgical incision for signs of infection. Which is indicative of a potential infection?
2
The nurse evaluates that there is a need for further teaching on bowel elimination when the client makes which statement?
2
The nurse is administering mouth care to an unconscious client. The nurse should avoid doing which?
2
The nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which finding would indicate a sign of a potential complication?
2
The nurse is caring for a client with a diagnosis of gout. Which laboratory value should the nurse expect to note in the client?
2
The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which should be the initial action by the nurse?
2
The nurse is inserting an indwelling urinary catheter into the urethra of a client. As the nurse inflates the balloon, the client complains of discomfort. Which is the appropriate nursing action?
2
The nurse is reading a client's urinalysis report. The nurse interprets which item found on the report to be considered abnormal?
2
The nurse is reinforcing instructions about home safety measures to a parent. Which statement by the parent indicates a need for further teaching?
2
The nurse is reinforcing instructions to a client and family regarding home care following cataract removal from the left eye. The nurse should provide the client with which instruction regarding positioning in the postoperative period?
2
The nurse is reviewing the health care records of assigned clients. Which client is at risk for excess fluid volume?
2
The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit?
2
The nurse is reviewing the laboratory results of a client scheduled for surgery. Which laboratory result should indicate to the nurse that the surgery might be postponed?
2
The nurse reinforces what information to a client who is scheduled for an electromyogram (EMG)?
2
A client is receiving an enteral feeding that delivers 1.5 calories/mL. The feeding is infusing at 30 mL/hr via a feeding pump. Which is the maximal amount of calories the client should receive in an 8-hour period if the tube feeding is not interrupted? Fill in the blank.
360
The nurse is checking the remaining volume in a 1000-mL intravenous (IV) bag that is scheduled to infuse over 8 hours on an electronic infusion pump. The nurse has just noted at 11:00 am that the remaining IV fluid is at the 500-mL level. At 12:00 noon at which numerical level (mL) should the IV fluid be? Fill in the blank.
375
A child is diagnosed with viral conjunctivitis and antibiotic eye drops are prescribed for the child. The mother asks the nurse when the child can return to school. The nurse should make which response to the mother?
4
A client has been diagnosed as having syndrome of inappropriate antidiuretic hormone (SIADH) secretion following cranial surgery. The nurse interprets that this complication is not resolving if which urine specific gravity measurement is obtained?
4
A client has just undergone gastroscopy. Which is the essential postprocedure nursing intervention?
4
A client is admitted to the surgical unit postoperatively with a wound drain in place. Which nursing action should the nurse avoid in the care of the drain?
4
A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement?
4
A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. The nurse should tell the client which about the test?
4
A clinic nurse has given a client the materials needed to test the stool for occult blood as part of a routine screening for colorectal cancer. When the client asks the nurse whether there are any special precautions that must be followed in doing this test, the nurse tells the client to avoid eating which food for at least a day before performing the test?
4
A long-term care nurse about to give a daily dose of digoxin (Lanoxin) is told that a serum digoxin level drawn earlier in the day measured 2.7 ng/mL. The nurse should take which action?
4
Arterial blood gases (ABGs) are obtained on a client with pneumonia. The ABG results are pH, 7.50; Pco2, 30 mm Hg; HCO3-, 20 mEq/L; Po2, 75 mm Hg. The nurse interprets these results and determines that which acid-base conditions exists?
4
A health care provider prescribes 2000 mL of 5% dextrose in water to run over 24 hours. The drop (gtt) factor is 15 gtt/mL. The nurse plans to adjust the flow rate at how many drops per minute? Fill in the blank. Round answer to the nearest whole number.
21
A health care provider prescribes 1000 mL of normal saline (NS) to be infused over a period of 10 hours. The drop (gtt) factor is 15 drops (gtt) per mL. The nurse adjusts the flow rate at how many drops per minute? Fill in the blank.
25
A postoperative client has a prescription to receive an intravenous (IV) infusion of 1000 mL normal saline solution over a period of 10 hours. The drop (gtt) factor for the IV infusion set is 15 gtts/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank.
25
A client arrives in the emergency department complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL. How should the nurse correctly interpret these results?
3
A client is at risk for developing hypocalcemia. The nurse determines that the client is experiencing this electrolyte disturbance if which sign is noted?
3
A client is scheduled for an endoscopic retrograde cholangiopancreatography (ERCP). The nurse includes which intervention in the plan of care for the client?
3
A client scheduled for a pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. The nurse gives a response to the client that provides reassurance, based on which understanding?
3
A client who has undergone a barium enema is being readied for discharge from the ambulatory care unit. Which statement by the client indicates understanding of the discharge instructions?
3
A client's arterial blood gases reveal a pH of 7.51 and a bicarbonate level of 31 mEq/L. The nurse prepares for the administration of which medication that should be prescribed to treat this acid-base disorder?
3
A health care provider has prescribed phenobarbital sodium (luminal sodium), 25 mg orally twice daily, for a child with febrile seizures. The medication label reads as follows: "Phenobarbital sodium, 20 mg/5 mL." The nurse has determined that the dose prescribed is a safe dose for the child. How many milliliters per dose should the nurse administer to the child?
3
An older client complains of chronic constipation. Which instructions should the nurse give to the client?
3
The nurse is administering intramuscular iron to an assigned client. The nurse should take which action to avoid skin staining around the injection site?
3
The nurse is caring for a client recovering from hepatitis. The nurse recognizes the need to report which laboratory test result to the health care provider?
3
The nurse is caring for a group of clients. Which client is most likely to have a serum phosphorus level of 2.0 mg/dL?
3
The nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who underwent lumbar puncture. The nurse knows that a reported value of 0 is normal for which substance in CSF?
3
The registered nurse is preparing to insert a nasogastric (NG) tube in a client and asks the licensed practical nurse (LPN) to obtain supplies needed for the procedure. Which supply obtained by the LPN indicates a need for further teaching regarding this procedure?
3
Which arterial blood gas (ABG) result should the nurse anticipate in the client with profuse vomiting for 2 days?
3
The nurse is reviewing the laboratory results from the lumbar puncture performed on a client with a diagnosis of meningitis. Which finding is indicative of a bacterial infection? Select all that apply.
3. 4. 5.
A client with sickle cell anemia is being treated for sickle cell crisis. The health care provider prescribes morphine sulfate 2 mg. The concentration of the vial is 10 mg/mL of solution. How many milliliters of solution should the nurse administer? Fill in the blank.
0.2
A health care provider's prescription reads "cyanocobalamin (vitamin B12) 100 mcg intramuscular." The medication label reads "cyanocobalamin (vitamin B12), 0.5 mg/mL." The nurse administers how many milliliters to the client? Fill in the blank. Record the answer to one decimal place.
0.2
A health care provider has prescribed phytonadione 2.5 mg intramuscularly. The nurse reads the label on the medication vial and administers how many mL to the client? Refer to the figure and fill in the blank. Record your answer to two decimal places.
0.25
The nurse is preparing to administer 35 mg of a prescribed intramuscular (IM) dose of medication to a client. The medication label reads 50 mg/mL. How many milliliters should the nurse administer to the client? Fill in the blank.
0.7
A health care provider's prescription reads: tobramycin sulfate, 7.5 mg intramuscularly twice daily. The medication label states 10 mg/mL. How many milliliters (mL) will the nurse give to administer 1 dose? Fill in the blank. Record your answer to two decimal places.
0.75
A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery?
1
A client being seen in a health care provider's office has just been scheduled for a barium swallow the next day. The nurse writes down which instructions for the client to follow before the test?
1
A client has had a set of arterial blood gases drawn. The results are pH 7.34, Paco2 of 37, Pao2 of 79, HCO3- of 19. The nurse interprets that the client is experiencing which acid-base imbalance?
1
A client having preadmission testing before surgery has blood drawn for the determination of serum electrolyte levels. The nurse determines that which result warrants a call to the health care provider by the nurse?
1
A client is diagnosed with Haemophilus influenzae pneumonia. In addition to standard precautions, which other precautions should be instituted immediately by the nurse?
1
A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, Which is the initial nursing assessment?
1
A client who is recovering from a brain attack (stroke) has residual dysphagia. The licensed practical nurse has instructed the unlicensed assistive personnel (UAP) in feeding technique. The nurse should intervene if the UAP attempts to perform which activity?
1
A client who takes theophylline for chronic obstructive pulmonary disease (COPD) is seen in the urgent care center for respiratory distress. Just before initiating treatment for the respiratory distress, a sample for a theophylline level is drawn. The nurse determines that the client may not be compliant with medication therapy if which result is obtained?
1
A client will undergo a barium swallow to confirm a diagnosis of a hiatal hernia. In preparation for the test, which instruction should the nurse provide the client?
1
A client with diabetes mellitus has a blood glucose level of 596 mg/dL on admission. The nurse anticipates that this client should be experiencing which type of acid-base imbalance?
1
A health care provider (HCP) has written a prescription for a preoperative client to have "enemas until clear." The nurse has administered three enemas and the client is still passing brown liquid stool. Which action should the nurse take next?
1
The nurse administers scopolamine as prescribed to a client in preparation for surgery. The nurse monitors the client for side effects related to the administration of this medication. Which should the nurse determine is an expected side effect of this medication?
1
The nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse tells the client that which food provides the least amount of potassium?
1
The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should assist the client to which position?
1
The nurse is admitting a client to the hospital who has been scheduled for gastrointestinal (GI) surgery. When asking the client whether the client takes over-the-counter medications, which statement should concern the nurse?
1
The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?
1
The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric tube. The nurse checks the residual and obtains an amount of 200 mL. Which action should the nurse take?
1
The nurse is preparing to reposition a dependent client who weighs more than 250 pounds. Which intervention is best for the nurse to consider when moving this client?
1
The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item?
1
The nurse is reading a health care provider's prescription and notes that a client is to receive a medication at 1:00 pm. Using the military time clock, the nurse administers the medication at which time? Refer to figure.
1
The nurse is reinforcing post-procedure teaching after a client underwent an upper gastrointestinal (GI) series. The nurse reminds the client that the stools will remain white for approximately how long?
1
The nurse is reinforcing teaching to a client about an upcoming colonoscopy procedure. The nurse should include in the instructions that the client will be placed in which position for the procedure?
1
The nurse is reviewing the laboratory results of a client hospitalized with a diagnosis of Crohn's disease. The client has a magnesium level of 1.3 mg/dL. Which is the most appropriate nursing intervention?
1
The nurse is reviewing the laboratory results of a female adult client suspected of having iron deficiency anemia. The nurse reviews the results and determines that which hemoglobin result is consistent with this diagnosis?
1
The nurse is told that the laboratory result for the serum digoxin level is 2.4 ng/mL. Which action should the nurse take?
1
The nurse is turning a postoperative client who had extensive spinal surgery on the previous day. Which turning intervention or position would be best for repositioning this client?
1
The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to carefully monitor which parameter during the next hour?
1
The nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem?
1
The nurse prepares to administer a prescribed dose of scopolamine (Transderm-Scōp). The nurse should monitor for which side effect of this medication?
1
The registered nurse (RN) tells a licensed practical nurse (LPN) that the health care provider has prescribed a hypotonic intravenous (IV) solution for a client. Which IV solution should the LPN obtain for administration to the client?
1
Which cardiovascular sign should the nurse expect to note in a client with a diagnosis of hypocalcemia?
1
Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L?
1
A client with new onset migraine headaches is being seen in the clinic. The client has a history of hypotension and diabetes mellitus. The nurse predicts that the client will experience undesirable cardiac side effects if the health care provider prescribes which medications? Select all that apply.
1. 2.
The nurse knows when preparing the Filipino American client for a surgical procedure it is important to assess for which culturally relevant influences? Select all that apply.
1. 2. 3. 4.
While caring for a client admitted to the hospital with suspected seizure activity, the client acknowledges the use of the herbal supplement ginkgo, to the nurse. Which follow-up questions by the nurse would be most appropriate? Select all that apply.
1. 2. 3. 4.
A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. Upon assessment, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Which interventions would the health care provider likely prescribe? Select all that apply.
1. 2. 3. 4. 5.
The nurse is preparing to provide mouth care to an unconscious client. The nurse collects which items to perform this procedure? Select all that apply.
1. 3. 4. 5.
An Appalachian family has brought a toddler to the emergency department with a fractured arm. The nurse knows that nonverbal communication is important to evaluate with assessing the family. Which factors are involved in non-verbal communication? Select all that apply.
1. 3. 4. 5. 6.
The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? Select all that apply.
1. 3. 4. 6.
The sister of a client with human immunodeficiency virus (HIV) asks the nurse to review once more what she needs to know in order to take care of her brother. Which instructions would be appropriate for the nurse to reinforce? Select all that apply.
1. 3. 6
The metabolic panel of a client reveals a calcium level of 6.5 mg/dL. Based on this laboratory finding, which additional data specific to this calcium level should the nurse collect? Select all that apply.
1. 4. 5. 6.
The nurse educator is describing the yin and yang theory of the ancient Chinese philosophy of Tao to a group of nursing students. The nurse educator explains that in this theory, foods are classified as hot and cold and are transformed into yin and yang energy when metabolized by the body. The nursing student understands this theory when the student makes which statement?
4
The nurse has provided instructions to a client scheduled for a mammography regarding the procedure. Which statement by the client indicates an understanding of the procedure?
4
The nurse is assigned to a hospitalized client with chronic pancreatitis. The nurse reviews the client's record and expects to note a serum amylase level that is most alike to which value?
4
The nurse is assisting in caring for a client in transfer from the postanesthesia care unit following nasal surgery. Nasal packing and a mustache dressing are in place. The nurse places the client in which position to best reduce swelling?
4
The nurse is assisting in monitoring a client who may be started on parenteral nutrition (PN). The nurse reviews the client's laboratory results and determines that the client is at risk of severe malnutrition if the albumin level report indicates which critical level?
4
The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use?
4
The nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which is the appropriate initial nursing action?
4
The nurse is encouraging an older incontinent client's participation in recreational therapy. What nursing intervention should the nurse consider performing first?
4
The nurse is monitoring a client for hypercalcemia. Which sign/symptom would the nurse note in hypercalcemia?
4
The nurse is planning to reinforce dietary teaching about foods that are low in potassium to a client receiving a potassium-retaining diuretic. The nurse should be sure to include which food on a list of foods that have low potassium content?
4
The nurse is preparing to suction a client through a tracheostomy tube. The nurse should avoid which action when performing this procedure?
4
The nurse is reinforcing instructions to a client following mastectomy who will be discharged with an axillary drain in place. The client will be receiving home care visits from a nurse to monitor drainage and perform dressing changes. Which statement by the client indicates a need for further teaching?
4
The nurse is reinforcing preprocedure instructions to a client scheduled for a barium swallow at 8:00 am. Which statement by the client indicates a need for further teaching?
4
The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit?
4
The nurse is told that the blood gas results indicate a pH of 7.50 and a PCo2 of 32 mm Hg. The nurse determines that these results are indicative of which acid-base disturbance?
4
The nurse reinforces teaching a client on how to administer enoxaparin (Lovenox) subcutaneously. The nurse determines that the client understands the correct procedure if the client does which on a return demonstration?
4
The nurse reviews the care plan for a client who is having difficulty sleeping. Which bedtime snack will help the client achieve a restful night's sleep?
4
The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating which pathophysiological process?
4
When positioning for a surgical procedure, the nurse understands that the client's respiratory system is most at risk for dysfunction when in which position?
4
The nurse determines that which herbal therapies can be prescribed for its use as an antispasmodic? Select all that apply.
4. 5.
When caring for the following group of clients, who does the nurse determine is at risk for development of metabolic alkalosis? Select all that apply.
4. 5.
The prescription reads to infuse an insulin drip at 12 mL/hr. There are 100 units regular insulin in 250 mL of normal saline. How many units of insulin will the client receive per hour? Fill in the blank.
4.8
The health care provider prescribes 1000 mL of 5% dextrose in water (D5W) to run at 125 mL/hr. The nurse calculates the infusion rate, knowing that it will take how many hours for 1 liter (L) to infuse? Fill in the blank.
8
The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse should tell the client to select which food item that is high in riboflavin?
1
Which laboratory results indicate a therapeutic drug level? Refer to chart. Select all that apply.
1. 3. 5.
The nurse is caring for a client with kidney failure. The nurse is told that the blood gas results indicate a pH of 7.30 and a HCO3- of 20 mm Hg, and that the client is experiencing metabolic acidosis. The nurse reviews the laboratory results and expects to note which?
2
The nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first?
4
The nurse is reviewing the arterial blood gas results of the client. Blood gas results indicate a pH of 7.30 and a Pco2 of 50 mm Hg, and the nurse has determined that the client is experiencing respiratory acidosis. Which additional laboratory values should the nurse expect to note in this client?
2
The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client. Which instructions should be included in the list? Select all that apply.
2. 4. 5. 6.
Which information should the nurse include when reinforcing client teaching regarding ostomy care? Select all that apply.
2. 4. 5. 6.
The hospice nurse is caring for five clients from various religious backgrounds. Which observations should the nurse expect for the clients of the various religious backgrounds? Select all that apply.
2. 5.
A client who has undergone barium enema is being readied for discharge. The nurse determines that the client has understood discharge instructions when the client makes which statement?
4
A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse trying to enhance the client's respiratory status should avoid performing which action?
4
The nurse is providing care to a Cuban-American client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. Which nursing action is most appropriate?
4
The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL. Based on this finding, what should be the nurse's first action?
4
The nurse is preparing to administer an intramuscular injection to a 1-year-old child. Which location should the nurse select to administer the medication?
4
The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal?
4
A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measure is necessary when caring for this client?
2
The nurse monitors a postoperative client for signs of complications. Which signs/symptoms should the nurse determine to be indicative of a potential complication?
1
A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing Allen's test before drawing the blood to determine the adequacy of which?
1
The nurse has reinforced postprocedure instructions to a client who has undergone a colonoscopy. The nurse determines that the client needs further teaching if the client makes which statement?
1
The nurse is reviewing the results of a client's serum laboratory studies. Which result indicates a deficiency of protein intake?
1
The medication prescribed is atropine sulfate, 0.4 mg. The medication label states atropine sulfate, 0.5 mg/0.5 mL. How many milliliters will the nurse prepare to administer to the client? Fill in the blank.
0.4
A health care provider's prescription reads atenolol (Tenormin) 0.025 grams orally daily. The medication bottle reads atenolol (Tenormin), 50-mg tablets. The nurse prepares how many tablet(s) to administer the dose? Fill in the blank.
0.5
A client presents in the emergency department reporting severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a weight loss of 7 pounds in the last week. At this time, which action would the nurse take?
1
A health care provider prescribes a 24-hour urine collection for vanillylmandelic acid (VMA). The nurse instructs the client in the procedure for the collection of the urine. Which statement by the client would indicate a need for further teaching?
1
A health care provider prescribes atenolol (Tenormin) 0.05 g orally daily. The label on the medication bottle states, atenolol 50-mg tablets. How many tablet(s) will the nurse administer to the client? Fill in the blank.
1
A health care provider prescribes digoxin (Lanoxin), 0.125 mg by mouth (PO) daily, for a client with heart failure. The medication label states 0.125 mg per tablet. How many tablet(s) will the nurse administer to the client? Fill in the blank.
1
Calcitriol (Rocaltrol) is prescribed for the client with hypocalcemia. The nurse instructs the client to avoid excessive amounts of which food item that interfere with calcium absorption?
1
The client has just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of postprocedure care?
1
The nurse is assigned to care for a client who has a nasogastric (NG) tube and is receiving tube feedings. When implementing nursing care for the client, the nurse remembers which information?
1
The nurse is assigned to care for a client who is Chinese. The nurse enters the room and following a greeting and introduction to the client, the nurse begins to discuss the plan of care for the day. During the discussion, the client turns away from the nurse. The nurse should take which action?
1
The nurse is caring for an adult client with respiratory distress syndrome. A review of the arterial blood gas results indicates that the client is experiencing respiratory alkalosis. The nurse should then examine the results of serum electrolytes to see whether which electrolyte imbalance is present?
1
A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply.
1. 2. 3. 4.
Which factors contribute to the problem of stress incontinence? Select all that apply.
1. 2.
The nurse is caring for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On data collection, the nurse notes that the client is severely dysphagic. The nurse should include which in the plan of care? Select all that apply.
1. 2. 3.
Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply.
1. 2. 3. 4
A client receiving iron supplements (ferrous sulfate) is complaining of constipation and the stool that is passed is black. Which information is appropriate for the nurse to share with the client? Select all that apply.
1. 2. 3. 4.
A pulmonary angiography is scheduled for a client suspected of having a pulmonary embolism. The nurse understands that which action is an appropriate preprocedure care intervention? Select all that apply.
1. 2. 3. 4.
The client has a three-way closed continuous catheter irrigation system. Which information should be included in the documentation for this client? Select all that apply.
1. 2. 3. 4.
The nurse has just received report on a newly admitted client who is cognitively impaired and experiencing pain. Which data collection techniques should be included in this client's plan? Select all that apply.
1. 2. 3. 5
The nurse is caring for a new immigrant from the Philippines who is in labor. The client is 4 cm dilated and 30% effaced. This is her first child. The mother is grimacing. Her pulse, respiratory rate, and blood pressure are elevated. The nurse offers to check on a prescription for an epidural. The mother declines. The nurse hypothesizes the client declines the epidural for which reasons? Select all that apply.
1. 5.
A health care provider's prescription reads "meperidine hydrochloride (Demerol) 125 mg by the intramuscular route stat." The medication vial reads 100 mg/mL. How many milliliters of the medication should the nurse draw into the syringe for injection? Fill in the blank. Record answer to two decimal places.
1.25
Morphine sulfate, 2.5 mg subcutaneously, is prescribed for a client postoperatively. The medication label reads 2 mg/mL. How many milliliters should the nurse administer? Fill in the blank.
1.25
The nurse is caring for a client with chronic cancer pain who is requesting pain medication. The health care provider's prescription reads MS Contin (morphine sulfate) 0.6 mg/kg orally every 4 hours as needed for pain. The client weighs 110 pounds. The liquid morphine sulfate available is 10 mg/5 mL. How many milliliters should the nurse administer?
15
A client is seen in the clinic for a physical examination. Laboratory studies are performed and reveal that the hemoglobin and hematocrit are low, indicating the need for further diagnostic studies and a blood transfusion. The client is a Jehovah's Witness and refuses to have a blood transfusion. Which should be an appropriate action by the clinic nurse?
2
A client is suspected of having a myocardial infarction. The nurse should expect elevations in which isoenzyme value reported with the creatine kinase (CK) level?
2
A client undergoing diagnostic testing for cancer is scheduled for magnetic resonance imaging (MRI). The nurse reinforces to the client which information about the procedure?
2
A health care provider has prescribed phenobarbital sodium (Luminal Sodium), 25 mg orally twice daily for a child with febrile seizures. The child's weight is 7.2 kg. The safe pediatric dosage is 1 to 6 mg/kg/day. What should the nurse determine about the medication dosage?
2
A health care provider prescribes atenolol (Tenormin) 0.05 g by mouth daily. The label on the medication bottle states atenolol 25-mg tablets. How many tablets will the nurse administer to the client? Fill in the blank.
2
A health care provider prescribes tetracycline hydrochloride (Sumycin) 0.5 g orally 4 times daily. The medication label on the bottle of medication reads tetracycline hydrochloride 250 mg tablets. The nurse prepares how many tablet(s) to administer one dose? Fill in the blank.
2
A tuberculin skin test is administered to an individual infected with human immunodeficiency virus (HIV). Seventy-two hours later, the nurse checks the test site and documents the results as positive, indicating that the individual has been exposed to tuberculosis. Which findings did the nurse identify to make this interpretation?
2
An anxious client is experiencing respiratory alkalosis from hyperventilation as a result of anxiety. The nurse should do which action to help the client experiencing this acid-base disorder?
2
The nurse is caring for a client with respiratory insufficiency. The arterial blood gas results indicate a pH of 7.50 and a PCo2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note?
2
The nurse is collecting data from a client with a suspected diagnosis of gastric ulcer. The client tells the nurse that oral antacids are taken frequently throughout the day. The nurse continues to collect data from the client, understanding that the client is at risk for which acid-base disturbance?
2
The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium?
2
The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which nursing action should be performed?
2
The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level should be noted with which condition?
2
The nurse reviews the client's laboratory data. Which data warrant an immediate call to the health care provider? Refer to chart.
2
The nurse volunteering at the health screening clinic reinforces instructions to a 22-year-old client that diet and exercise should be used as tools to keep the total cholesterol level under at least which level?
2
The nurse has just confirmed that a client has been scheduled for a mammogram for the following week. The nurse reinforces that the client should take which action? Select all that apply.
2. 3.
The nurse is completing the laboratory requisition that will accompany an arterial blood gas (ABG) specimen sent to the laboratory for analysis. The nurse understands that which data will be needed by the laboratory for adequate evaluation of the specimen? Select all that apply.
2. 3. 4 5.
A client has arrived back to the nursing unit from special procedures with an epidural catheter in place for pain control. The nurse is revising the plan of care to reflect the epidural catheter and the interventions needed to prevent infection at the site. Which interventions should the nurse include in the plan of care? Select all that apply.
2. 3. 4.
The nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Which instructions should the nurse place on the list? Select all that apply.
2. 3. 4.
A client is to receive 1000 mL of 5% dextrose in water over a period of 125 mL/hr. The drop (gtt) factor is 10 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.
21
A 24-year-old Chinese American is breastfeeding her infant girl. The client's mother asked the nurse not to include cold foods on her daughter's tray because they are not good for the baby. The nurse responds by telling the client that she can have what she wants; it is not up to her mother. This response demonstrates which cultural characteristic?
3
Sulfisoxazole (Gantrisin), 1 g orally four times daily, is prescribed for an adolescent with a urinary tract infection. The medication label reads, "500-mg tablets." The nurse has determined that the prescribed dose is safe. How many tablets per dose should the nurse administer to the adolescent?
3
The nurse determines that the client understands the proper fitting of the crutches when he states that which amount of space should be between the axilla and the top crutch pad?
3
The nurse has reinforced instructions to a client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further teaching if the client makes which statement?
3
The nurse is assigned to care for an Asian-American client. The nurse develops a plan of care based on which belief?
3
The nurse is assisting in the care of a group of clients on the nursing unit. The nurse determines that a client with which diagnosis is the one who has the least likely risk for developing third-spacing of body fluid?
3
The nurse is assisting to admit a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe enough, the client will be at risk for which acid-base imbalance?
3
The nurse is caring for a client who is scheduled for surgery. The client is concerned about the surgical procedure. Which action should alleviate the client's fears and misconceptions about surgery?
3
The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid-base imbalance?
3
The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which prescribed medication should the nurse prepare to assist in administering to the client?
3
The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of U waves. The nurse checks the client and then reviews the results of the client's recent electrolyte results. The nurse expects to note which electrolyte value?
3
The nurse is reinforcing instructions to a client who is to have a gallium scan about the procedure. The nurse should include which item as part of the instructions?
3
A client has been admitted to the hospital with a diagnosis of severe nausea and vomiting. The client has an indwelling intravenous (IV) catheter. The client's morning laboratory results show a serum blood sodium level of 130 mEq/L and a serum blood chloride level of 92 mEq/L. Which intravenous fluids will provide free water, sodium, and chloride to the client? Select all that apply.
3. 4.
The nurse is caring for a Hispanic client who reports that she is a practicing Roman Catholic. Which actions by the nurse demonstrate spiritual and cultural sensitivity? Select all that apply.
3. 4.
A client has had a bone scan procedure. The nurse determines that the client understands the elements of follow-up care if the client states which postprocedural care?
4
A client has returned to the nursing unit following abdominal hysterectomy. To most effectively gather data on the client's postoperative bleeding, the nurse would implement which intervention?
4
A client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level. When reviewing the client's results, the nurse determines that which requires a call to the health care provider for intervention?
4
A client with hepatic cirrhosis has been consuming a diet with optimal amounts of protein. The nurse determines that the client's consumption of dietary protein has been most effective if the total protein level is which value?
4
A client with leukemia who had a bone marrow aspiration is thrombocytopenic. The nurse gives which instruction to the family as the client is discharged to home?
4
A health care provider prescribes laboratory studies on an infant born to a human immunodeficiency virus-(HIV-) positive woman to determine the presence of HIV infection. Which laboratory study should the nurse expect to be prescribed?
4
The nurse educator is providing an in-service education to the nursing staff regarding transcultural nursing care. A staff member asks the nurse educator to describe the concept of acculturation. Which response is appropriate?
4
The nurse has admitted a client to the clinical nursing unit following a right mastectomy. The nurse plans to place the right arm in which position?
4
The nurse has assisted with obtaining a blood specimen for arterial blood gas (ABG) analysis. The nurse avoids doing which to properly obtain and send the specimen?
4
The nurse is assisting in preparing a client for discharge to home. Daily cold therapy has been prescribed for the client, and the nurse reinforces instructions about this treatment. Which statement by the client indicates adequate understanding of cold therapy treatment?
4
The nurse is assisting in the care of a client receiving codeine sulfate for pain. The nurse should make note of which finding to detect an adverse effect of this medication?
4
The nurse is assisting the health care provider in performing a lumbar puncture. The nurse prepares for the procedure by placing the client in which position?
4
The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional signs/symptoms should the nurse expect to note in this client if hyponatremia is present?
4
The nurse is reviewing the laboratory studies of a client receiving epoetin alfa (Epogen). When should the nurse expect to note a therapeutic effect of this medication?
4
The prescription reads to give ondansetron hydrochloride 0.15 mg/kg of body weight 30 minutes before receiving chemotherapy. The client weighs 132 pounds. How many milligrams (mg) of ondansetron hydrochloride will the nurse administer? Fill in the blank.
9
A client is having trouble remembering his prescribed medication regimen. Which statement by the nurse is therapeutic?
4
A Hispanic-American mother brings her child to the clinic for an examination. Which is most important when gathering data about the child?
4
Which statement made by the nursing student indicates a need for further teaching by the nursing instructor on the concept of ethnocentrism?
3
The nurse is preparing a small dose of a medication for administration to an infant. The nurse selects which syringe for preparing the medication? Refer to figure.
2
The nurse is caring for a client with a nasogastric tube who has prescriptions to have the tube irrigated once every 8 hours. The nurse ensures that which solution is placed in the client's room to be used for the irrigation when the client's serum electrolyte results indicate a potassium level of 4.5 mEq/L and a sodium level of 132 mEq/L?
3
A health care provider prescribes phenytoin (Dilantin) 0.1 g orally twice daily. The medication label states, 100-mg capsules. How many capsule(s) will the nurse prepare to administer the dose? Fill in the blank.
1
The nurse is caring for a client who has a wound infection. Contact precautions are being followed. Which are correct actions by the nurse when using personal protective equipment (PPE)? Select all that apply.
1. 2. 3. 6.
A client is scheduled for a myelogram, and the nurse reinforces a list of instructions to the client regarding preparation for the procedure. Which instructions should the nurse include in the list? Select all that apply.
1. 2. 4.
The nurse is providing directions to the unlicensed assistive personnel (UAP) regarding clients' hygiene needs. Which is the priority order in which the UAP should assist the clients? Arrange the actions in the order that they should be performed. All options must be used.
1. a confused 2. bed rest 3. dehydration 4. independent
The nurse is preparing to bathe a client who has mild Alzheimer's dementia and requires minimal help with hygiene. Which is the priority order of nursing interventions? Arrange the actions in the order that they should be performed. All options must be used.
1. develop 2. allow 3. address 4. provide 5. document
A health care provider prescribes potassium chloride (KCl) elixir, 20 mEq orally daily. The medication label states potassium chloride (KCl), 30 mEq/15 mL. How many milliliters should the nurse prepare to administer the dose? Fill in the blank.
10
A client who currently underwent abdominal surgery experiences an evisceration. Which statement made by the client supports this diagnosis?
2
A client with heart disease who is taking digoxin (Lanoxin) complains of having no appetite. The nurse notes that the client also has a low serum potassium (K+) level. The nurse checks the results of the digoxin level obtained this morning, anticipating that the level will fit which characterization?
2
A client with tuberculosis, whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. What should the nurse tell the client?
2
A health care provider writes a prescription to apply a heating pad to a client's back. The nurse implements the prescription and avoids which action?
2
The nurse reinforces postoperative liver biopsy procedures to a client. Which should the nurse tell the client?
3
A client is to have an upper gastrointestinal (GI) series. Which nursing action should be done concerning the procedure?
3
A client originally was prescribed oral sertraline (Zoloft) 25 mg daily for depression. The dose has been gradually increased in an effort to control the symptoms. The current dose is 75 mg daily. The medication label reads 25 mg/tablet.To receive the correct dose, the nurse instructs the client to take how many tablets once daily? Fill in the blank.
3
The nurse checks the food on a tray delivered for an Orthodox Jewish client and notes that the client has received a cheeseburger and potato fries with whole milk as a beverage. Which action should the nurse take?
3
The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. Which is the next nursing action?
3
The nurse is assigned to care for a group of clients on the clinical nursing unit. Which client is least likely to develop third spacing of fluids?
3
The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions in regard to avoiding the use of herbal medications?
3
The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do with the aspirated residual?
3
A child is receiving edetate calcium disodium (calcium EDTA) for the treatment of lead poisoning. Which laboratory result would be important to monitor during treatment?
4
A client has been diagnosed with pernicious anemia. In planning care for the client, the nurse anticipates that the client will be treated with which?
4
A client who takes theophylline (Theo-24) for chronic obstructive pulmonary disease (COPD) is seen in the health care clinic. A theophylline level is drawn, and the nurse determines that the client is compliant with the medication regimen if which laboratory result is reported?
4
A client with hypertension has been prescribed a low-sodium diet. The nurse teaching this client about foods that are allowed should include which food in a list provided to the client?
4
The nurse determines that sodium polystyrene sulfonate (Kayexalate) has been effective in a client if which laboratory result is noted?
4
The nurse is inquiring about the client's use of complementary and alternative medicines (CAMs). The nurse should be most concerned with the client who uses which CAMs? Select all that apply.
3. 4.
The nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.
3. 4. 5
The client is having a lumbar puncture (LP) performed. The nurse should place the client in which position for the procedure?
4
A client is scheduled to receive digoxin (Lanoxin), 0.125 mg by mouth. The licensed practical nurse (LPN) reads the medication label and notes that each tablet contains 0.25 mg.The LPN should perform which action?
1
The nurse has just been told by the health care provider that a prescription has been written to administer an iron injection to a client. The nurse anticipates giving the medication by which method?
1
A client has been placed on neutropenic precautions. Which information is appropriate when explaining what this means? Select all that apply.
1. 2. 4.
A client is in respiratory alkalosis induced by gram-negative sepsis. The nurse assists in implementing which measure as the effective means to treat the problem?
1
The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client? Select all that apply.
1. 2. 4.
A client is receiving standard oral anticoagulant therapy with warfarin (Coumadin). The result of a newly drawn international normalized ratio is 3.8 seconds. The nurse anticipates carrying out a prescription to do which action?
1
Atropine sulfate, 0.2 mg given intramuscularly, is prescribed for a child. The medication label reads as follows: "0.4 mg/mL." The nurse has determined that the prescribed dose is safe. How many milliliters should the nurse administer to the child? Fill in the blank.
0.5
The medication prescribed is prochlorperazine 5 mg intramuscularly, every 4 hours as needed. The medication label states prochlorperazine 10 mg/mL. The nurse prepares how much medication to administer the dose? Fill in the blank.
0.5
A health care provider prescribes meperidine hydrochloride (Demerol) 15 mg intramuscularly for a client in pain. The medication label states, meperidine hydrochloride (Demerol) 25 mg per mL. How many milliliters will the nurse administer to the client? Fill in the blank.
0.6
The medication prescribed is heparin sodium 650 units subcutaneously, every 12 hours. The medication vial reads heparin sodium 1000 units/mL. The nurse prepares how many milliliters to administer one dose? Fill in the blank.
0.65
The medication prescribed is atropine sulfate, 0.4 mg intramuscularly, immediately. The medication label states atropine sulfate, 0.3 mg/0.5 mL. The nurse prepares how much medication to administer the dose? Fill in the blank and round answer to one decimal place.
0.7
The medication prescribed is meperidine hydrochloride (Demerol), 35 mg intramuscularly. The medication label states meperidine hydrochloride (Demerol), 50 mg/mL. The nurse plans to prepare how much medication to administer the dose? Fill in the blank.
0.7
The medication prescribed is hydromorphone hydrochloride (Dilaudid), 3 mg intramuscularly, every 4 hours as needed. The medication label reads hydromorphone hydrochloride (Dilaudid), 4 mg/1 mL. The nurse should prepare to administer how many mL to the client? Fill in the blank.
0.75
A client presents to the emergency department with lethargy; deep, regular respirations; and a fruity odor to the breath. The client's arterial blood gas (ABG) results are pH of 7.25, Pco2 of 34 mm Hg, Po2 of 86 mm Hg, and HCO3- of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance?
1
A client underwent creation of an ileostomy 2 days ago. The nurse checks the client for signs of which acid-base disorder that can occur in a client with an ileostomy?
1
A client was diagnosed with acute pancreatitis 10 days ago. The nurse interprets that the episode of acute pancreatitis is fully resolved if the serum lipase level drops to which value?
1
A client with a history of cardiac disease is scheduled for a dose of furosemide (Lasix). Which serum potassium level warrants a call to the health care provider by the nurse before administering the furosemide?
1
The nurse is assisting in performing an arterial blood gas (ABG) analysis on a client. The nurse initially implements which intervention after the blood gas is drawn to minimize the risk for uncontrolled bleeding?
1
The nurse is assisting in the care of a client for whom an arterial blood gas (ABG) must be drawn. The nurse notes that the person who draws the blood sample from the radial artery performs Allen's test first. The nurse understands that this is being done to determine the adequacy of which circulation?
1
The nurse is assisting in the care of a client who had an ileostomy created a few days ago. Owing to the normally high output of drainage from this type of ostomy, the nurse monitors the client for which sign?
1
The nurse is assisting in the care of a group of clients on the clinical nursing unit. The nurse monitors the fluid balance of a client who has which diagnosis and is most at risk for fluid volume deficit?
1
The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned client is at risk for excess fluid volume?
1
The nurse reviews the client's laboratory results. Which abnormal findings would the nurse report to the health care provider? Select all that apply.
1. 2. 4. 5.
A client is complaining about pain when voiding. The health care provider prescribes a clean-catch urine specimen. In order of priority, the nurse should instruct the client to take which steps to collect the specimen? Arrange the actions in the order they should be performed. All options must be used.
1. instruct to wash hands 2. seperate 3. wipe 4. initiate voiding 5. stop stream 6. cover collection
The medication is an intramuscular dose of 400,000 units of penicillin G benzathine (Bicillin). The medication label reads penicillin G benzathine (Bicillin) 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Fill in the blank and record the answer using one decimal place.
1.3
Fentanyl 75 mcg intravenous push (IVP) has been prescribed by the health care provider. The medication ampule reads fentanyl 50 mcg/mL. The nurse should prepare how many milliliters to administer the correct dose? Fill in the blank and record your answer using one decimal place.
1.5
A health care provider has prescribed a liquid oral suspension of amoxicillin (Amoxil). The prescription reads 0.25 gram (g) orally 3 times daily. How many milliliters (mL) should the nurse administer to the client per dose? Refer to the figure. Fill in the blank.
10
A client's preoperative vital signs are temperature 98.6° F orally, apical pulse 80 beats per minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which action should the nurse take first?
2
A gastric analysis is prescribed for a client with a suspected diagnosis of tuberculosis (TB). The nurse understands that the test is relevant in confirming this diagnosis because of which related fact?
2
A health care provider's prescription reads "ketorolac (Toradol), 30 mg intramuscular every 6 hours as needed." The medication label reads "ketorolac (Toradol), 15 mg/mL." The nurse prepares to administer how many milliliters to the client? Fill in the blank.
2
A health care provider's prescription reads as follows: "Ampicillin, 125 mg intramuscular every 6 hours." The medication label reads, "1 gram when reconstituted with 7.4 mL of bacteriostatic water." How many milliliters should the nurse draw up for one dose?
2
A hospitalized child with leukemia has received chemotherapy by the intravenous (IV) route, and a discharge to home is being planned. Laboratory values indicate that the child is neutropenic. During the course of the chemotherapy, the IV infiltrated and the child has a small open area at the site of infiltration that is being treated daily by cleansing and the application of a topical antibiotic. The nurse reinforces instructions to the mother regarding the signs of infection at this affected site. Which statement by the mother indicates that the mother understands the instructions?
2
A normal saline 0.9% intravenous (IV) solution is prescribed for a client. The IV is to run at 100 mL/hr. The nurse prepares the solution, understanding that which is a characteristic of this type of solution?
2
The medication prescribed is digoxin (Lanoxin), 0.25 mg orally, daily. The medication label reads digoxin (Lanoxin), 0.125 mg/tablet. The nurse should prepare how many tablet(s) to administer the dose? Fill in the blank.
2
The medication prescribed is levodopa 1 g orally, daily. The medication label states levodopa, 500-mg tablets. The nurse prepares to administer how many tablets at the evening dose? Fill in the blank.
2
The nurse is taking care of a client preoperatively. The client is NPO and tells the nurse that he takes detemir insulin (Levemir) and aspart insulin (NovoLog) at 0700 daily. The client's surgery is scheduled for 0900. Which is the best action for the nurse to take?
2
The nurse caring for a Chinese-American client plans to use communication according to Chinese-American cultural beliefs and practices. Which techniques are considered disrespectful in the Chinese-American's view of communication? Select all that apply.
2. 3. 4.
The nurse knows that spatial behavior is related to territoriality in many Latino cultures. Which client needs are associated with territoriality? Select all that apply.
2. 3. 4. 5.
The nurse is told in a report that the client has hypocalcemia and a positive Chvostek's sign. Which signs should the nurse expect to note during the data collection? Select all that apply.
2. 3. 5.
The nurse is planning to administer an oral glucose tolerance test (OGTT) to a client to rule out or confirm diabetes mellitus. The nurse knows that the client needs more information when the client makes which statement? Select all that apply.
2. 3. 6.
The nurse determines that which clients are at high risk for metabolic acidosis? Select all that apply.
2. 4. 6.
Which laboratory result would verify the diagnosis of bacterial meningitis?
3
A health care provider prescribes phenobarbital (Luminal), 10 mg by mouth daily. The medication bottle is labeled 15 mg/5 mL. How many milliliters (mL) will the nurse administer? Fill in the blank. Record your answer using one decimal place.
3.3
A health care provider prescribes 3000 mL of 0.9% normal saline to run over 24 hours. The drop (gtt) factor is 15 gtt/mL. The nurse plans to adjust the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.
31
A health care provider prescribes 3000 mL of 5% dextrose in water (D5W) to run over a 24-hour period. The drop (gtt) factor is 15 drops (gtt) per 1 mL. The nurse adjusts the flow rate to run at how many gtt per minute? Fill in the blank. Record your answer to the nearest whole number.
31
The health care provider prescribes 1000 mL of 0.45% normal saline to run over 8 hours. The drop (gtt) factor is 15 gtt/mL. The nurse plans to adjust the flow rate to how many gtt/min? Fill in the blank. Round your answer to the nearest whole number.
31
The health care provider's prescription reads "phenytoin (Dilantin) 0.2 g orally, twice daily." The medication label states 100-mg capsules. How many capsule(s) should the nurse plan to administer over a 24 hour period? Fill in the blank.
4
The nurse assists the health care provider in performing a lumbar puncture on a 3-year-old child with leukemia suspected of central nervous system (CNS) disease. In which position should the nurse place the child during this procedure?
4
The nurse informs a client that a Papanicolaou smear will be done at the next scheduled clinic visit, and the nurse provides instructions to the client regarding preparation for this test. Which statement by the client indicates an understanding of the procedure?
4
The nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which action should the nurse plan to take first?
4
The nurse is assisting in the care of a client who is at risk for hyponatremia. The nurse should monitor this client for which symptoms of this electrolyte imbalance?
4
The nurse is reinforcing instructions provided to a client with a continuous passive motion (CPM) machine. The nurse determines that the client needs further teaching when the client states that he should perform which action?
4
The nurse is reinforcing instructions to a client about the use of an incentive spirometer in the postoperative period. The nurse should include which information in discussions with the client?
4
The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing?
4
The nurse prepares the client for irrigation of an abdominal wound. Refer to video. Click on the Question Video button to view a video showing preparation procedures. After preparation, the nurse should appropriately don which article (s) to perform the procedure?
4
The nurse reinforces instructions to a client who is to return to the health care provider's office in 1 week for a patch test to identify the allergen causing the dermatitis. The nurse provides which instruction to the client?
4
The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. Which should the nurse observe for on the cardiac monitor as a result of this laboratory value?
4
The nurse reviews a client's serum sodium level and notes that the level is 150 mEq/L. The health care provider prescribes dietary instructions for the client based on the sodium level. Which food item should the nurse instruct the client to avoid?
4
The nurse who is caring for a client with kidney failure notes that the client is dyspneic, and crackles are heard on auscultation of the lungs. Which additional signs/symptoms should the nurse expect to note in this client?
4
The nursing instructor is providing a session on cultural beliefs related to health and illness. Following the session, the instructor asks a nursing student to describe the beliefs of an African-American client with regard to illness. Which statement describes the beliefs of an African-American client with regard to illness?
4
When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should plan to do which action in the initial care of this wound?
4
Which ostomy location would most likely need to be irrigated? Refer to figure.
4
The nurse is explaining The Joint Commission's (TJC's) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves which action?
1
Which identifies the route of transmission of tuberculosis (TB)?
3
The nurse is assisting in caring for a client with severe hyponatremia resulting from hypervolemia. The client is being treated with an intravenous hypertonic saline. The nurse determines that the treatment measures are effective when the laboratory results reveal which sodium level?
3
The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding preventing the transmission of the infection to the other children in the family and the other household members. Which instructions should the nurse reinforce to the mother?
3
When reinforcing instructions to an oriented client and the client's family regarding how to use the patient controlled analgesia (PCA) pump with both a basal and demand dose, the nurse should include which instructions? Select all that apply.
1. 2. 3. 5.
The nurse is preparing to initiate a tube feeding for a client, and the health care provider has prescribed the use of an electronic feeding pump. The nurse brings the pump to the bedside to plug the pump cord into the wall and discovers that there is no available outlet in the wall socket. Which action should the nurse implement?
2
The nurse is reviewing laboratory results and notes that the client's International Normalized Ratio (INR) is 2.2. The nurse should realize this test is performed to monitor the effectiveness of which medication?
2
A health care provider's prescription reads potassium chloride 20 mEq in 1000 mL normal saline and infuse at 100 mL/hr. The nurse assisting in caring for the client determines that the client will receive how many milliequivalents (mEq) of potassium every hour? Fill in the blank.
2
A health care provider's prescription reads theophylline 100 mg orally every 6 hours. The medication label reads 50-mg capsules. How many capsules will the nurse give to administer one dose? Fill in the blank.
2
An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse should plan to do which as a first step for the prevention of future injury?
2
The medication prescribed is metoclopramide hydrochloride (Reglan) 10 mg intramuscularly times one dose. The medication label reads metoclopramide hydrochloride (Reglan), 5 mg/mL. The nurse prepares how much medication to administer the dose? Fill in the blank.
2
The nurse is assigned to assist in caring for a client who has had an autograft placed on the anterior lower extremity. Which activity should the nurse include in the plan of care?
2
The nurse is assigned to care for a client with a peripheral intravenous (IV) infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown?
2
A postoperative client has been receiving morphine sulfate every 3 to 4 hours for pain. The nurse should be sure to implement which measure to reduce the risk of adverse effects from this medication?
4
A transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with pain, and the nurse provides information to the client about the TENS unit. Which statement by the client indicates the need for further teaching?
4
The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside?
4
The nurse is assigned to care for a client experiencing episodes of postural hypotension. Which action should the nurse take to ensure safety while transferring the client from the bed to the chair?
4
The nurse is assisting in preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that surgery is necessary. Considering the client's religious preferences, the nurse documents which information?
4
A client was transferred to the nursing unit from the coronary care unit after experiencing a myocardial infarction (MI). When reviewing the client's serum creatinine phosphokinase (CPK) levels recorded in the chart, the nurse knows that an elevation of which enzyme was due to the MI?
1
A licensed practical nurse (LPN) is providing follow-up teaching after a client underwent an upper gastrointestinal (GI) series with Gastrografin used for contrast. The nurse instructs the client that which may occur from the Gastrografin?
1
A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that additional counseling is necessary when the client makes which statement?
1
The health care provider's prescription reads "levothyroxine (Synthroid), 100 mcg orally daily." The medication label reads "levothyroxine, 0.1 mg/tablet." The nurse prepares to administer how many tablet(s) to the client? Fill in the blank. Record your answer using one decimal place.
1
The nurse determines that an adult male client admitted with dehydration and a hematocrit level of 56% has received adequate fluid volume replacement if which repeat hematocrit level is noted?
1
The nurse is assigned to assist in caring for a client who is receiving parenteral nutrition with fat emulsion. The nurse is instructed to monitor the client for signs of fat overload. The nurse monitors for which signs and symptoms of this complication?
1
The nurse is caring for a postoperative client who had a pelvic exenteration. The health care provider has changed the client's diet from nothing by mouth (NPO) to clear liquids. The nurse checks which before administering the clear liquids?
1
The nurse is assigned to reinforce instructions to a client and the family about the management of home intravenous (IV) infusion therapy. The nurse begins the process by teaching the client and family principles related to what actions first?
3
The nurse is caring for a client scheduled for magnetic resonance imaging (MRI). Which instruction does the nurse reinforce to the client?
3
The health care provider's prescription reads "levothyroxine (Synthroid), 150 mcg orally daily." The medication label reads "levothyroxine, 0.1 mg/tablet." The nurse prepares to administer how many tablet(s) to the client? Fill in the blank. Record your answer using one decimal place.
1.5
The nurse is caring for a client with cirrhosis who is experiencing fluid overload. The nurse would determine that this problem is resolving if which data are obtained by the nurse?
2
The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. The nurse should take which step next?
2
The nurse is assisting in providing surgical instructions to a preoperative client. Which instruction would be most appropriate to include in the preoperative plan of care?
4
The nurse is caring for a client following a total hip replacement. The client has been diagnosed with iron deficiency anemia. The nurse instructs the client to increase intake of which foods?
4
The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?
4
A client who has received sodium bicarbonate in large amounts is at risk for developing metabolic alkalosis. The nurse checks this client for which signs and symptoms characteristic of this disorder?
4
The nurse is caring for a postoperative client who is being monitored by pulse oximetry. Which is an expected measurement determined by the pulse oximeter?
1
A health care provider has prescribed prochlorperazine 4 mg intramuscularly for a client who is vomiting. The nurse reads the label on the medication vial and administers how many milliliters (mL) to the client? Fill in the blank. Refer to the figure.
0.8
The nurse is caring for an African-American client. The nurse enters the room and, following a greeting and introduction to the client, begins to describe the procedure for a prescribed soapsuds enema. The client turns away from the nurse. Which nursing action is appropriate?
1
The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?
1
The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently?
1
The nurse receives the culture test results for a Hispanic client who developed a bloodstream infection from a central venous device. The culture report indicates that the infection is exogenous. The client asks the nurse how she could have contracted this infection. Which should the nurse include in the explanation of potential sources of infectious organisms? Select all that apply.
1. 2. 5.
A nursing student is asked to identify the practices and beliefs of the Amish society. Which should the student identify? Select all that apply.
1. 2. 5. 6.
A client is to be monitored for residual urine every 8 hours. Which are appropriate nursing actions for the nurse to complete this task? Select all that apply.
1. 3.
The nurse is preparing a client for the administration of a tuberculin skin test. The nurse determines that which body areas are appropriate for intradermal injections? Select all that apply.
1. 3. 4.
The nurse is caring for a Jewish client who follows a kosher diet. Which foods should the nurse use in planning meals for the client? Select all that apply.
1. 3. 4. 5.
The nurse is discharging a postoperative female client who had a urinary tract infection (UTI) after surgery. Which essential issues about UTIs should the nurse reinforce in the discharge instructions? Select all that apply.
1. 3. 4. 5.
A CD4+ count has been prescribed for a child with human immunodeficiency virus (HIV) infection. The mother asks the nurse about the purpose of the test and why the test needs to be done if it is already known that the child has HIV. The nurse should reinforce which information to the mother? Select all that apply.
1. 3. 4. 5. 6.
A client is 3 days postoperative from gastric surgery and still has a nasogastric tube in place. The client is at risk to develop which electrolyte imbalances? Select all that apply.
1. 3. 5.
The nurse working in a human immunodeficiency virus (HIV)/acquired immunodeficiency (AIDs) clinic is reviewing modes of transmission for HIV for a new nurse to the clinic. Which potential modes of HIV transmission should the nurse review? Select all that apply.
1. 3. 5. 6.
Penicillin V potassium 250 mg orally every 8 hours is prescribed for a child with a respiratory infection. The medication label reads: Penicillin, 125 mg per 5 mL. The nurse has determined that the dosage prescribed is a safe dose for the child. How many milliliters (mL) will the nurse administer to the child per dose? Fill in the blank.
10
The nurse is preparing to administer 30 mEq of liquid potassium chloride (KCl) to an adult client. The label on the medication bottle reads 40 mEq/15 mL. The nurse prepares how many milliliters of KCl to administer the correct dose of medication? Fill in the blank. Round your answer to the nearest whole number.
11
A client is to receive 1000 mL of 5% dextrose in water (D5W) at a rate of 100 mL/hr. The drop (gtt) factor is 10 drops (gtt) per mL. The nurse adjusts the flow rate to deliver how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.
17
Ampicillin sodium 250 mg in 50 mL of normal saline (NS) is being administered over a period of 30 minutes. The drop (gtt) factor is 10 drops (gtt) per mL. The nurse is asked to check the flow rate of the infusion. The nurse determines that the infusion is running at the prescribed rate if the infusion is delivering how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.
17
The nurse is asked to regulate the flow rate of an intravenous (IV) solution being administered to a client. The IV bag contains 50 mL of solution and the solution is to be administered over 30 minutes. The administration set has a drop factor of 10 drops (gtts)/mL. The nurse should regulate the roller clamp on the infusion set to deliver how many drops per minute? Fill in the blank. Round answer to the nearest whole number.
17
A client diagnosed with bipolar disorder is prescribed oral lorazepam (Ativan) 4 mg daily to help manage his manic behavior. The medication label reads 2 mg/mL. To ensure the correct dose, the nurse administers how many milliliters per dose? Fill in the blank.
2
A client has an intravenous infusion (IV) started before surgery for a right below-the-knee amputation. In addition to the intravenous infusion, blood is drawn and a surgical skin preparation is done. The nurse anticipates that the client is likely to experience which psychosocial problem in the preoperative period?
2
A client has been admitted for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?
2
A client has been treated for dehydration and pneumonia. The nurse evaluates that the client's dehydration has been successfully treated if the blood urea nitrogen (BUN) level drops to which value?
2
A client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client for which symptom that correlates with this client's fluid imbalance?
2
A client with history of seizure disorder is having a routine serum phenytoin level drawn. The nurse who receives a telephone report of the results notes that the client's blood level of the medication is within the normal range if which value is reported?
2
The nurse hangs a 1000-mL intravenous (IV) bag of 5% dextrose in water (D5W) at 0700. The IV is to infuse at 100 mL/hr, and the nurse places a time tape on the IV bag. At noon the nurse should expect that the infusion line on the IV bag would be at which point? Refer to figure.
2
The nurse is assigned to collect data from a Hispanic-American client during the hospital admission. On initial meeting of the client, the nurse should plan to do which?
2
The nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which information about the client is of least priority during the data collection?
2
The nurse is obtaining the intershift report for a group of assigned clients. The nurse plans to monitor which client for signs of hyperkalemia because of the physiology associated with the health problem?
2
The nurse is preparing a client scheduled for a bone marrow aspiration, and the client asks the nurse whether the procedure will be painful. The nurse should make which response to the client?
2
The nurse is preparing a session regarding nutrition for a group of culturally diverse pregnant women. The nurse determines that the priority nursing intervention includes which action?
2
The nurse is preparing to administer medication through a nasogastric (NG) tube that is connected to suction. Which indicates the accurate procedure for medication administration?
2
The nurse is providing eye care to an unconscious client. Which action does the nurse take with a clean, wet cotton ball to cleanse the eye?
2
A health care provider prescribes 1000 mL of normal saline to be infused over a period of 12 hours. The drop (gtt) factor is 15 drops (gtt)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.
21
A health care provider prescribes a bolus of 500 mL of 0.9% normal saline (NS) to run over 4 hours. The drop (gtt) factor is 10 drops (gtt) per 1 mL. The nurse plans to adjust the flow rate at how many gtt per minute? Fill in the blank. Record your answer to the nearest whole number.
21
The intravenous prescription is 1000 mL of 0.9% NaCl (normal saline) to run over 12 hours. The drop factor is 15 gtts/1 mL. The nurse plans to adjust the flow rate to how many gtts/minute? Fill in the blank and record the answer to the nearest whole number.
21
A 3-year-old child is hospitalized because of persistent vomiting. Which condition should the nurse expect to occur in this child?
3
Penicillin G procaine (Wycillin), 1 million units intramuscularly, has been prescribed for the child with a throat infection. The child's weight is 62 pounds. The safe pediatric dosage for a child that weighs greater than 60 pounds is 600,000 to 1,200,000 units daily. Which should the nurse determine about the medication dosage?
3
Penicillin V 250 mg orally every 8 hours, is prescribed for a child with a respiratory infection. The child's weight is 45 pounds. The safe pediatric dosage is 25 to 50 mg/kg/day. Which statement accurately describes the prescribed dosage for this child?
3
The nurse assists a health care provider with the insertion of a Miller-Abbott tube. After insertion of the tube, the nurse should assist the client to which position?
3
The nurse is reviewing the preoperative prescriptions of a client with a colon tumor who is scheduled for abdominal perineal resection. The nurse notes that the health care provider has prescribed neomycin sulfate (Mycifradin) for the client. Which is the rationale for prescribing this medication?
3
The nurse reinforces preoperative teaching to a client who will wear an abdominal binder postoperatively following abdominal surgery. Which instruction should the nurse reinforce in the preoperative teaching plan?
3
The nurse reviews an assigned client's laboratory report and notes a serum potassium level of 5.5 mEq/L. The nurse should determine that this is an expected finding if the client had which health problem?
3
The nurse reviews the arterial blood gas results of a client and notes that the results indicate a pH of 7.30, Pco2 of 52 mm Hg, and HCO3- of 22 mEq/L. Which interpretation does the nurse correctly make about these results?
3
The registered nurse reviews the results of the arterial blood gases with the licensed practical nurse (LPN) and tells the LPN that the client is experiencing respiratory acidosis. The LPN should expect to note which on the laboratory result report?
3
A nursing student is discussing cultural issues in a clinical conference. The nursing instructor asks the student to describe ethnocentrism. Which statement by the student indicates a lack of understanding of the issue of ethnocentrism?
4
Etidronate (Didronel), an antihypercalcemic medication, is prescribed for a client. Which information should the nurse reinforce when instructing the client about taking this medication?
4
Penicillin G procaine, 1,000,000 units given intramuscularly, is prescribed for an adolescent with an infection. The medication label reads as follows: "1,200,000 units/2 mL." The nurse has determined that the prescribed dose is safe. How many milliliters per dose should the nurse administer to the adolescent?
4
The nurse is caring for a child following a cleft palate repair who has wrist restraints in place. The nurse assists in preparing a plan of care and determines that which nursing intervention should receive highest priority regarding the restraints?
4
The nurse is caring for a client who is nervous and is hyperventilating. The nurse should monitor the client for signs of which acid-base imbalance?
4
A client with a history of seizure disorder is taking phenytoin (Dilantin). The nurse reviews the laboratory results of the phenytoin level and determines that the client has been noncompliant with medication therapy if which laboratory result is noted?
1
A client with a seizure disorder is taking phenytoin (Dilantin). A sample for a serum phenytoin level is drawn, and the nurse determines that the next dose of the medication may be administered if which laboratory result is noted?
1
A health care provider's prescription reads ciprofloxacin (Cipro) 0.5 g orally twice daily. The medication label reads ciprofloxacin 500 mg tablets. The nurse prepares how many tablet(s) to administer 1 dose? Fill in the blank.
1
A health care provider's prescription reads triazolam (Halcion), 125 mcg orally at bedtime daily. The medication bottle is labeled triazolam, 0.125-mg tablets. The nurse prepares how many tablet(s) to administer 1 dose? Fill in the blank.
1
The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which questions should the nurse ask the client? Select all that apply. Refer to video. Click on the Question Video button to view a video showing preparation procedures.
1. 2. 4. 6.
A client is admitted to the hospital with a diagnosis of suspected myocardial infarction (MI). The nurse is reviewing the laboratory results performed on the client. Which documented laboratory result specifically indicates the presence of an MI?
1
A client with arthritis is scheduled for a surgical knee joint replacement. The client will be admitted to the hospital on the day of the surgical procedure, and the nurse is reinforcing instructions to the client regarding preparation for the surgical procedure. Which statement by the client indicates an understanding of the preoperative instructions?
1
A health care provider's prescription reads atenolol (Tenormin), 0.025 g orally daily. The medication bottle reads atenolol, 25-mg tablets. The nurse prepares how many tablet(s) to administer the dose? Fill in the blank.
1
A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?
3
A client is complaining of abdominal pain and nausea. The prescription is as follows: give hydroxyzine (Vistaril) 25 mg intramuscularly and meperidine (Demerol) 25 mg intramuscularly, stat. Hydroxyzine (Vistaril) is available 50 mg/mL. Meperidine (Demerol) is available in 25 mg/0.5 mL. The nurse should combine the doses in one syringe for administration to the ventrogluteal muscle. How many milliliters should the nurse administer in total? Fill in the blank.
1
A client has just delivered an 8 lb 8 oz infant boy after a prolonged labor. The pediatrician prescribes ampicillin 50 mg to be given by the intramuscular route to the newborn every 8 hours. The nurse is initiating the first dose. Ampicillin is available in powder form for injection. The directions on the bottle indicate reconstitution with 0.9 mL of sterile diluent for a concentration of 125 mg/mL. How many milliliters (mL) should the nurse prepare to administer the first dose? Fill in the blank.
0.4
A health care provider prescribes meperidine hydrochloride (Demerol), 40 mg intramuscularly stat, for a postoperative client in pain. The medication label states meperidine hydrochloride, 50 mg/mL. How many milliliters (mL) will the nurse prepare to administer to the client? Fill in the blank.
0.8
A 24-hour urine specimen for creatinine and electrolytes has been prescribed for a hospitalized client to evaluate kidney function. The nurse explains the procedure to the client. The client voids at 0900, and the urine is discarded. The client voids at 1200 and the urine is measured and placed in the collection container. At which time the next day should the 24-hour urine collection be complete? Fill in the blank with the correct military time.
0900
A client has a serum sodium level of 129 mEq/L because of hypervolemia. The nurse consults with the health care provider to determine whether which measure should be instituted?
1
A client is determined to be in respiratory alkalosis by blood gas analysis. The nurse should monitor this client for signs of which electrolyte disorder that could accompany the acid-base imbalance?
1
A licensed practical nurse (LPN) is assisting in the care of a client receiving a continuous intravenous (IV) infusion of heparin sodium for deep vein thrombosis (DVT). The LPN notes that the result of a newly drawn activated partial thromboplastin time (aPTT) level is 90 seconds. The client's baseline before the initiation of therapy was 30 seconds. The LPN should take which action?
1
A pediatric client with a ventricular septal defect repair is placed on a maintenance dose of digoxin (Lanoxin). The safe dose is 0.03 mg/kg/day, and the client's weight is 7.2 kg. The health care provider (HCP) prescribes the digoxin to be given twice daily. How much digoxin should the nurse administer to the client at each dose?
1
A registered nurse (RN) is discussing the overall fluid balance of an assigned client. The RN records that the client's insensible fluid loss is approximately 500 mL/day. The licensed practical nurse (LPN) recalls that the RN is referring to fluid losses occurring through which areas?
1
The client is to receive a Fleet enema. Which is the best position for administering an enema? Refer to figure.
1
The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child. The results indicate an area of induration measuring 8 mm. Which correct interpretation should the nurse make about these results?
1
The licensed practical nurse (LPN) is assisting in the care of a client who overdosed on aspirin (acetylsalicylic acid) 24 hours ago. The LPN should report to the registered nurse (RN) which findings associated with an anticipated acid-base disturbance?
1
The medication prescription states to administer acetaminophen (Tylenol), 650 mg orally for a temperature of more than 38° C. The medication bottle states Tylenol (acetaminophen), 325 mg tablets. The nurse takes the client's temperature and notes that it is 101° F. The nurse plans to take which action?
1
The nurse caring for a male client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's laboratory results and notes a hematocrit level of 30%. Which action should the nurse take?
1
The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is non-reddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 cells/mm3. Which interpretation does the nurse make of these findings?
1
The nurse consults with a dietitian regarding the dietary preferences of an Asian-American client. Which food should the nurse suggest to include in the diet plan?
1
The nurse is caring for a client following a total abdominal hysterectomy. The nurse anticipates that which postoperative outcome will be the priority in the first 24 hours following surgery?
1
The nurse is caring for a group of clients on a clinical nursing unit. The nurse checks for signs of deficient fluid volume. Which client is at risk for this fluid imbalance?
1
The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation?
1
The nurse is monitoring the status of the postoperative client. The nurse should become most concerned with which sign(s) that could indicate an evolving complication?
1
The nurse is preparing a client for surgery. Which would be a component of the plan of care?
1
The nurse is preparing the client for transfer to the operating room (OR). The nurse should take which action in the care of this client at this time?
1
The nurse is preparing to administer an acetaminophen (Tylenol) suppository to a child. The nurse plans which action?
1
The nurse is reinforcing discharge instructions to a Chinese client regarding prescribed dietary modifications. During the teaching session the client continually turns away from the nurse. Which nursing action is most appropriate?
1
The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL. The nurse understands which condition causes this serum calcium level?
1
The nurse working the 3:00 to 11:00 pm shift notes that a client with coronary artery disease (CAD) has a prescription for serum lipid levels to be drawn in the morning. The nurse places the client on which dietary preparation to ensure accurate test results?
1
The skin surrounding a postoperative client's abdominal wound is becoming irritated in the area where the dressing tape is being reapplied with each dressing change. Which is the appropriate nursing action?
1
The student nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action would be appropriate?
1
Which statement by the client should cause the nurse to suspect that the thyroid test results drawn on the client this morning may be inaccurate?
1
A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Which interventions would the health care provider likely prescribe? Select all that apply.
1. 2. 3. 4. 5.
A client has been diagnosed with functional incontinence. Which interventions are appropriate to care for this type of incontinence? Select all that apply.
1. 2. 3. 6.
A client arrives at the clinic complaining of a severe headache. The client states "It's a 10/10 headache. I took 600 mg of Ibuprofen (Motrin) over the past few hours, and it has not decreased the pain." The nurse suspects that the client is experiencing a migraine but wants to validate the suspicion by asking which questions? Select all that apply.
1. 2. 4. 5.
A seriously ill client in the hospital tells the nurse that he thinks he has lost some of his ability to hear over the past few days. The nurse reviews the medications the client is currently receiving. Which medications are known to be ototoxic? Select all that apply.
1. 2. 5.
Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory results warrant a call to the health care provider (HCP)? Select all that apply.
1. 2. 5.
The nurse is caring for a Southeast Asian woman who presented to the emergency department with complaints of a headache and nausea. The client is accompanied by her adult son. Upon examination, the nurse notes long pale red welts on both arms. Which actions should the nurse take next? Select all that apply.
1. 2. 5.
The nurse is caring for an older Orthodox Jewish client whose condition is terminal. The nurse is implementing a plan of care and wishes to communicate this plan with the family and client. The nurse should be aware of which end-of-life religious practices when planning and communicating with the client and family? Select all that apply.
1. 2. 5.
The nurse is reviewing the serum magnesium results for a group of clients. Which results warrant a call to the health care provider by the nurse? Select all that apply.
1. 4. 5.
The nurse is reviewing the laboratory results of several clients receiving pharmacologic therapy. Which laboratory test results indicate a therapeutic value and that the nurse can safely administer the medication as prescribed? Select all that apply.
1. 5. 6.
The nurse on a medical unit is instructing the unlicensed assistive personnel (UAP) regarding toileting needs of the assigned clients. Which is the order of priority in which the unlicensed assistive personnel (UAP) should assist these clients? Arrange the actions in the order that they should be performed. All options must be used.
1. admitted 2 days 2. admitted 5 days 3. dementia 4. ambulatory
The nurse is using a bladder scanner to determine a client's post-void residual (PVR). Which priority order should the nurse employ to perform this procedure? Arrange the actions in the order that they should be performed. All options must be used.
1. assist 2. turn 3. press the gender 4. apply 5. plce 6. press and hold
A client is complaining of back discomfort and does not want any pain medication. The nurse has decided to administer a back massage to the client. The nurse should perform the actions in which priority order? Arrange the actions in the order they should be performed. All options must be used.
1. check 2. collect 3. verify 4. perform 5. help 6. dim 7. administer
A client has a continuous catheter irrigation postoperatively after having a transurethral resection of the prostate. The nurse notes that fluid is entering the bladder, but none appears to be draining. In priority order, which actions should the nurse take? Arrange the actions in the order they should be performed. All options must be used.
1. ensure drainage 2. bladder distention 3. bladder spasm 4. review I and O
An adult client has had serum electrolytes drawn. The nurse receiving the results by telephone from the laboratory should be most concerned with which result?
3
An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is the most important to provide to the client?
3
An ultrasound of the gallbladder is scheduled for the client with a suspected diagnosis of cholecystitis. Which should the nurse explain to the client about this test?
3
A client who has been prescribed indomethacin (Indocin) for gout is asked to provide a stool sample for guaiac testing. The nurse explains that the purpose of the test is to make which determination?
2
A client with a tentative diagnosis of gastroesophageal reflux is going to undergo ambulatory pH monitoring. The nurse assists in the procedure and should bring which item to the bedside?
2
The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed, and the serum calcium level is 12.0 mg/dL. Based on this laboratory value, the nurse should take which action?
2
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?
2
The nurse is observing a nursing student preparing to obtain a throat culture on a client suspected of having a beta-hemolytic Streptococcus infection. Which action indicates the need for further teaching regarding collecting this specimen? Select all that apply.
2. 4.
A 70-year-old client who has been treated for cellulitis of the leg asks the nurse how to improve resistance to infection. Which measures should the nurse reinforce in the teaching plan? Select all that apply.
2. 4. 5. 6.
Cloxacillin sodium 100 mg orally every 8 hours is prescribed for a child with an elevated temperature who is suspected of having a respiratory tract infection. The child weighs 17 pounds. The safe pediatric dosage is 50 mg/kg/day. Which statement accurately describes the prescribed dosage for this child?
3
The intravenous prescription is 3000 mL of 5% dextrose (D5W) to run over a 24-hour period. The drop factor is 10 gtts/1 mL. The nurse plans to adjust the flow rate to how many gtts/minute? Fill in the blank and record the answer to the nearest whole number.
21
The health care provider prescribes a three-way bladder irrigation of normal saline to be infused at a rate of 200 mL per hour, which infused without problem. There is 1850 mL in the collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine output for the shift? Fill in the blank.
250
The nurse is calculating a client's 24-hour fluid intake. The client consumed coffee (8 oz), water (8 oz), and orange juice (6 oz) for breakfast; soup (4 oz) and iced tea (8 oz) for lunch; and milk (10 oz), tea (8 oz), and water (8 oz) for dinner. The client also consumed 24 oz of water during the day. How many milliliters of fluid did the client consume in the 24-hour period? Fill in the blank.
2520
The health care provider prescribes ibuprofen (children's Motrin) 5 mg per kg for a child who weighs 13 pounds. How many milligrams (mg) should the nurse administer to the child? Fill in the blank. Record your answer using one decimal place.
29.5
A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take?
3
A client diagnosed with schizophrenia who is being prepared for discharge has been prescribed oral risperidone (Risperdal) 6 mg daily. The medication label reads 2 mg/tablet. To ensure the correct dose, the nurse instructs the client to take how many tablets once daily? Fill in the blank.
3
A client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely the result of which factor in the client's history?
3
A client has a history of mild renal insufficiency. Which serum creatinine level should the nurse determine is consistent with this problem?
3
A client has a prescription to receive purified protein derivative (PPD) 0.1 mL intradermally (tuberculin skin test). The nurse prepares to administer the PPD and obtains a tuberculin syringe with a 26-gauge, 5/8-inch needle. Which technique should the nurse use to insert the needle?
3
A client has been diagnosed with metabolic alkalosis. Which laboratory value(s) is most important for the nurse to monitor for this client?
3
A client has been taking prednisone for 3 years to treat symptoms of lupus erythematosus. She is scheduled for abdominal hysterectomy because of menorrhagia. The nurse plans care realizing that postoperatively the client is at risk for which condition?
3
A client with atrial fibrillation who is receiving maintenance therapy with warfarin sodium (Coumadin) has a prothrombin time (PT) of 30 seconds. The nurse anticipates that which will be prescribed?
3
A client with chronic pain has been taught how to operate a transcutaneous electrical nerve stimulation (TENS) unit. Which action by the client shows understanding of the appropriate use of the device when the level of stimulation is uncomfortable?
3
A client with diabetes mellitus calls the clinic nurse to report that the blood glucose level is 150 mg/dL. After obtaining further data from the client, the nurse determines that the client ate lunch approximately 2 hours ago. How should the nurse interpret the data?
3
A client with diabetes mellitus has a glycosylated hemoglobin A (HbA1c) level of 8%. Which instruction does the nurse plan to reinforce to the client based on this test result?
3
A health care provider has written a prescription for calcium carbonate for the client with hypocalcemia. The nurse preparing to administer the medication schedules the medication to be given at which time?
3
A lethargic, pale child is brought to the health care provider's office with symptoms of periorbital edema and reduced quantity of urine output. The urine is cloudy and smoky in color. The nurse asks the mother if the child has had any recent infections, to which the mother responds that the child had a very sore throat a few weeks ago. The health care provider suspects that the child might have acute poststreptococcal glomerulonephritis. Which laboratory test would rule out a past streptococcal infection in the child?
3
Diphenhydramine hydrochloride (Benadryl) 25 mg orally every 6 hours is prescribed for a child with an allergic reaction. The child weighs 25 kg. The safe pediatric dosage is 5 mg/kg/day. What should the nurse determine about the medication dosage?
3
Diphenhydramine hydrochloride (Benadryl), 25 mg orally every 6 hours, is prescribed for a child with an allergic reaction. The child weighs 25 kg. The safe pediatric dosage is 5 mg/kg/day. Which conclusion should the nurse infer?
3
During a surgical procedure, the nurse prevents a client's extremities from dangling over the sides of the table, knowing that this action may cause what?
3
Morphine sulfate, 2.5 mg, is prescribed for a child. The safe pediatric dose is 0.05 to 0.1 mg/kg/dose. The child weighs 50 kg. Which statement describes the prescribed dosage for this child?
3
The nurse checks a client's skin turgor and documents that the client exhibits normal fluid balance. Which finding should the nurse have noted?
3
The nurse evaluates that the older client has a need for further teaching on how to promote sleep when the client makes which statement?
3
The nurse in the health care provider's office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. Which statement is appropriate for the nurse to tell the client?
3
The nurse is assigned to care for a client who has just returned to the nursing unit following a renal biopsy. The nurse plans to do which action to properly care for this client for the remainder of the shift?
3
The nurse is assisting in caring for a client who is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The nurse is monitoring the client for signs of hyperkalemia. Which sign/symptom should be noted in the client if hyperkalemia is present?
3
The nurse is checking postoperative prescriptions and planning care for a 110-pound child after spinal fusion. Morphine sulfate, 8 mg subcutaneously every 4 hours as needed (PRN) for pain, is prescribed. The pediatric drug reference states that the safe dosage is 0.1 to 0.2 mg/kg/dose every 2 to 4 hours. What should the nurse determine about the medication dosage?
3
The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse reports the information to the health care provider and anticipates that the provider will prescribe which?
3
The nurse is monitoring the fluid balance of a client with human immunodeficiency disease (HIV). Because loss of subcutaneous adipose tissue and muscle atrophy occur in such clients, the nurse understands that which will provide a reliable indicator of fluid balance?
3
The nurse is monitoring the laboratory results of a client preparing to receive chemotherapy. The nurse determines that the white blood cell count (WBC) is normal if which result is present?
3
The nurse is planning to reinforce instructions to the Hispanic-American client about nutrition and dietary restrictions. When developing the plan for the instructions, the nurse is aware of which related fact?
3
The nurse is planning to reinforce nutrition instructions to an African-American client. When reviewing the plan, the nurse is aware that which food is a common dietary practice of clients with African-American heritage?
3
The nurse is preparing to care for a client following a lumbar puncture. The nurse plans to place the client in which position immediately after the procedure?
3
The nurse is preparing to deliver a food tray to a client whose religion is Judaism. The nurse checks the food on the tray and notes that the client has received a roast beef dinner with whole milk as a beverage. Which action should the nurse take?
3
The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief?
3
The nurse is preparing to hang an intravenous (IV) solution of 1000 mL 5% dextrose in lactated Ringer's to flow at 80 mL/hour. The nurse time-tapes the bag with a start time of 07:00. After making hourly marks on the time-tape, the nurse notes that the completion time for the bag would be what?
3
The nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions that which could cause a false-negative result?
3
The nurse is reading the health care provider's (HCP's) progress notes in the client's record and sees that the HCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?
3
The nurse is reinforcing instructions to a Native-American client regarding the procedure for collecting a urine sample. The nurse observes that the client continually stares at the floor during the instructional session. The nurse interprets this as being indicative of which behavior?
3
The nurse is reinforcing instructions to a female client regarding the procedure for collecting a midstream urine sample. Which statement by the client indicates an understanding of the procedure?
3
Which equipment should the nurse plan to have at the bedside when initiating a clear liquid diet for a postoperative client who has had general anesthesia?
3
Which is the most appropriate catheter for a male client with severe urinary retention, a history of urinary tract infections, and a stage 4 decubitus on the coccyx? Refer to chart.
3
Why should the nurse who is focusing on facilitating positive outcomes regarding health care services become familiar with the cultural beliefs and practices of a childbearing woman?
3
A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, "I don't feel any better than I did before surgery." Which response by the nurse is most appropriate?
4
A client has a prescription to have radial arterial blood gases (ABGs) drawn. Before drawing the sample, an Allen test will be performed. In performing the Allen test, which blood vessel(s) should the nurse occlude?
4
A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing?
4
A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22 mm Hg, and a PCo2 of 30 mm Hg. Which action should the nurse take?
4
A client has the following laboratory values: pH of 7.55, HCO3- of 22 mm Hg, and a Pco2 of 30 mm Hg. Which action should the nurse take?
4
A client is admitted to the hospital with a diagnosis of malnutrition. The nurse is told that blood will be drawn to determine whether the client has a protein deficiency. Which laboratory data indicates that the client is experiencing a protein deficiency?
4
A client is scheduled for a digital subtraction angiography. The nurse supports the client's understanding that the test is directed toward which outcome?
4
A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data and then checks the client's skin turgor by doing which? Refer to video. Click on the Question Video button to view a video showing preparation procedures.
4
A client who had knee surgery 4 days ago reports to the home health nurse that he has not had a bowel movement since before the surgery. Which question would assist the nurse in the collection of data regarding the client's problem?
4
A client who has fallen from a roof and fractured his ribs has arterial blood gas results of: pH 7.48, PaCO2 32 mm Hg, PaO2 89 mm Hg, and HCO3- 22 mEq/L. How does the nurse interpret the client's blood gas results?
4
A client with a history of gastrointestinal bleeding has a platelet count of 300,000 cells/mm3. Which action by the nurse is most appropriate after reading this report?
4
The nurse is caring for a client following an abdominal hysterectomy performed 1 day ago. An intravenous (IV) line is infusing and a nasogastric (NG) tube is in place and attached to low intermittent suction. The nurse monitors the client and notes that the bowel sounds are absent. The nurse should perform which action?
4
The nurse is caring for a client whose magnesium level is 4 mg/dL, and the client is being treated for the magnesium imbalance. The nurse interprets that the electrolyte imbalance is resolving if which sign or symptom is no longer present?
4
The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom is an indication of this electrolyte imbalance?
4
The nurse is caring for a client with diabetic ketoacidosis and observes that the client is experiencing abnormally deep, regular, rapid respirations. How should the nurse correctly document this observation in the medical record?
4
The nurse is caring for a client with kidney failure. The laboratory results reveal a magnesium level of 3.6 mg/dL. Which sign does the nurse expect to note in the client, based on this magnesium level?
4
The nurse is caring for a postoperative client who has a drain inserted into the surgical wound. Which action should the nurse avoid in the care of the drain?
4
The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A wound drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change?
4
The nurse is comparing the use of nalbuphine (Nubain) versus meperidine (Demerol) for pain management for a pregnant client. Which statement is true with regard to the use of nalbuphine or meperidine?
4
The nurse is encouraging a client who is incontinent to participate in recreational therapy. Which nursing intervention should the nurse consider performing first?
4
The nurse is explaining the concept of a time-out in the perioperative area. Which statement best describes the purpose of a time-out?
4
The nurse is explaining the concept of time-out in the perioperative area to a group of nursing students. What is the purpose of a time-out?
4
A health care provider prescribes digoxin (Lanoxin) 0.5 mg orally daily for a client with heart failure. The medication label states, 0.25 mg per tablet. How many tablet(s) will the nurse administer to the client? Fill in the blank.
2
A health care provider prescribes 1000 mL of 0.9% normal saline (NS) to run over 8 hours. The drop (gtt) factor is 10 drops (gtt) per 1 mL. The nurse adjusts the flow rate to run at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.
21
A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week, yet is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern about not being able to continue the tube feedings at home. Which nursing response would be appropriate at this time?
4
A licensed practical nurse (LPN) is administering medications to a client with chronic rheumatoid arthritis. The client has difficulty swallowing, and the film-coated form of diflunisal is prescribed. Which action by the LPN is most appropriate?
4
A licensed practical nurse (LPN) is asked to prepare an intravenous (IV) infusion of 1000 mL 5% dextrose in lactated Ringer's at 80 mL/hr to be administered to an assigned client. The LPN time-tapes the bag with a start time of 09:00. After making hourly marks on the time-tape, the LPN notes that which time would mark the completion time for the bag?
4
The nurse is preparing to begin a continuous tube feeding on a client with a nasogastric tube. In which position should the nurse place the client for safe administration of the tube feeding?
4