Prep U Questions Exam 3

A client has a history of poorly controlled diabetes. Which health concern will the nurse discuss with the client? A) Erectile dysfunction B) Retarded ejaculation C) Sexually transmitted infections D) Premature ejaculation

A

A client with dehydration will have an increase in: A) aldosterone B) potassium C) albumin D) glucose

A

A nurse is caring for a client who is sleeping for abnormally long periods of time. This condition may be caused by injury to which body structure? A) Hypothalamus B) Thyroid C) Spinal cord D) Pancreas

A

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? A) "Fluid in the tissue space between and around cells." B) "Fluid outside cells." C) "Watery plasma, or serum, portion of blood." D) "Fluid inside cells."

A

Which of the following statements is an appropriate nursing diagnosis for a client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion? A) Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea B) Fluid Volume Deficit related to congestive heart failure, as evidenced by shortness of breath C) Fluid Volume Excess related to loss of sodium and potassium D) Congestive Heart Failure related to edema

A

A nurse reads a client's chart and sees that she may have dyspareunia. Which of the following would be priority assessments? Select all that apply. A) client's ability to use vaginal lubricants during sexual act B) history of hormonal imbalance C) physical assessment of internal and external genitalia D) history of neurologic disorders E) use of certain medications such as antihypertensives

A, B, C

A perimenopausal woman reports insomnia. Which intervention(s) will the nurse suggest to the client? Select all that apply. A) Eliminate caffeine and alcohol in the evening because both are associated with disturbances in the normal sleep cycle. B) Eat a small snack of protein and carbohydrate before bedtime. C) Discuss the use of a sleep aid with the health care provider. D) Exercise vigorously before bedtime to promote drowsiness. E) Nap frequently during the day to make up for the lost sleep at night.

A, B, C

The clinic nurse sees the client today and asks about his chief concern. The client describes to the nurse his inability to attain an erection. Which would be a priority for the nurse to assess? Select all that apply. A) If there is a history of diabetes B) Medications that the client is taking C) Specifics about the erectile problem D) Sleep history of the client E) The client's physical activity

A, B, C

The nursing instructor is talking with the junior nursing class about male reproductive issues. The instructor tells the students that the causes of erectile dysfunction include which of the following? Select all that apply. A) Diabetes B) Tadalafil C) Ingestion of vitamins D) Spinal cord trauma E) Alcoholism

A, D, E

The client has just returned from surgery. The client asks you for an extra dose of pain medication. What would be some signs that the client is in severe pain? Select all that apply. A) elevated respiratory rate B) elevated heart rate C) pallor (peripheral vasoconstriction) D) decreased temperature E) decreased blood pressure

A, E

A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning, the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement? A) Facilitate a change in the client's diet to ensure more carbohydrates at dinner. B) Assess the factors that the client believes contribute to the problem. C) Educate the client on relaxation techniques and reduce noise levels on the unit. D) Obtain a PRN order for a sedative hypnotic from the client's physician.

B

A client is diagnosed with narcolepsy. What is a characteristic of this disorder? A) restless leg syndrome B) uncontrollable desire to sleep C) waking during sleep D) decrease in the amount or quality of sleep

B

A client with peripheral neuropathy states, "Sometimes I get the worst pain from just a bedsheet brushing over my foot." What is the nurse's most appropriate action? A) Assess the passive range of motion of the client's foot. B) Document the client's allodynia. C) Document a nursing diagnosis of Pain (chronic) related to neuropathy D) Assess for further signs of hyperalgesia.

B

A male client comes to the clinic because he thinks that he has syphilis. Which test would the nurse expect the client to have done? A) Pap smear B) VDRL C) Wet preparation D) HPV

B

The parents of a boy 10 years of age are worried about his sleepwalking (somnambulism). What topic should the nurse discuss with the parents? A) sleep deprivation B) safety C) schoolwork D) privacy

B

The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade? A) 3+ B) 4+ C) 1+ D) 2+

C

The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate? A) isotonic B) hypotonic C) hypertonic D) plasma

C

The nurse is caring for a client who had a below-the-knee amputation of the left leg 8 months ago. The client is reporting left foot pain of 7 on a 1-to-10 scale. The pain began earlier today. How will the nurse document this type of pain? Select all that apply. A) referred B) somatic C) acute D) neuropathic E) visceral

C, D

A nurse is providing care to a client who has been vomiting for the past 2 days. The nurse would assess this client for which imbalance? Select all that apply. A) Respiratory acidosis B) Hypernatremia C) Hypokalemia D) Hypercalcemia E) Metabolic alkalosis

C, E

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? A) cryoprecipitate B) albumin C) granulocytes D) platelets

D

The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patterns? A) Newborns are inactive when awake. B) Newborns will nap two times per day. C) Newborns have shorter periods of REM sleep. D) Newborns sleep 16 to 17 hours per day.

D

Which medication would the nurse most likely see on the medication administration record (MAR) of a client with diabetic neuropathy? A) lorazepam B) morphine C) hydromorphone D) gabapentin

D

A nurse is collecting a sexual health history from an older adult woman who is postmenopausal. Which client statement requires further education by the nurse? A) "I have noticed I have less lubrication with sexual intercourse." B) "I have noticed that intercourse is much easier than before." C) "I have experienced orgasms that are longer than in the past." D) "I have had much more energy during the daytime hours."

a

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? A) Potassium B) Sodium C) Phosphorous D) Chloride

A

A 62-year-old client informs the nurse that the parent has been anxious and disoriented in the morning. The client also informs the nurse that the parent gets up frequently to use the bathroom. Which nursing intervention can decrease the disruption of sleep? A) Have your parent take diuretic medicine in the morning. B) Encourage your parent to take frequent naps during the day. C) Offer your parent iced tea before bed. D) Suggest your parent sleep without socks.

A

A client visits a community clinic reporting a foul-smelling vaginal discharge that is thin, foamy, and green in color; itching of vulva and vagina; and burning on urination. Which STI would the nurse suspect? A) Trichomonas vaginalis B) Acquired immunodeficiency syndrome (AIDS) C) Neisseria gonorrhoeae D) Chlamydia trachomatis

A

What name is given to the rhythmic biologic clock that exists in humans? A) circadian rhythm B) alert-unaware process C) yo-yo theory D) sleep-wake cycle

A

A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply. A) confusion B) ventricular dysrhythmia C) constipation D) respiratory muscle weakness E) abdominal distention

A, B, D

A client has the following arterial blood gas results:pH: 7.33PaCO2: 42 mm HgHCO3: 19 mEq/L (19 mmol/L)PaO2: 95 mm HgWhich imbalance would the nurse suspect? A) Metabolic alkalosis B) Metabolic acidosis C) Respiratory alkalosis D) Respiratory acidosis

B

A client in his 40s has asked the nurse how much sleep he should be getting in order to maximize his health and well-being. How should the nurse respond? A) "It's important to get a minimum of 8 hours sleep each night." B) "Most adults need between 7 and 9 hours, but everyone is different." C) "More sleep equals better health, so the more sleep you can fit into your schedule, the better." D) "Sleep needs depend a lot on age, and at your age, 6 to 7 hours usually suffice."

B

A client needs an intravenous fluid that will pull fluids into the vascular space. What type of fluid does the nurse prepare to administer as prescribed? A) Osmolar B) Hypertonic C) Isotonic D) Hypotonic

B

The clinic nurse is explaining the action of sildenafil (Viagra) to a client. The nurse should assess his medication regimen to determine if he is taking medications that are contraindicated with Viagra. Which of the following medications is contraindicated with Viagra? A) MAO inhibitors B) Nitrates C) Diuretics D) Amoxicillin

B

The nurse is assessing the pain of a preschooler. Which pain scales would be appropriate for the nurse to utilize? (Select all that apply.) A) CRIES Pain Scale B) COMFORT scale C) 0-10 Numeric Rating Scale D) FLACC Scale E) Wong-Baker Faces Scale

B, D, E

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate? A) 20 gtt/min B) 40 gtt/min C) 50 gtt/min D) 30 gtt/min

C

The nurse is reviewing the client's arterial blood gas results. The test reveals a pH of 7.52, a PaO2 level of 49 mm Hg (6.52 kPa) and an HCO3 level of 28 mEq/L (28 mmol/L), the nurse suspects the client is most likely experiencing which condition? A) Respiratory alkalosis B) Respiratory acidosis C) Metabolic alkalosis D) Metabolic acidosis

C

Which diagnostic test is used to diagnose a chlamydial infection? A) Pap smear B) Wet preparation with KOH C) Cervical culture D) Blood work

C

A nurse is changing a client's peripheral IV dressing. Which step is recommended in this procedure? A) Cleanse the site thoroughly with sterile saline or according to facility policy. B) Wipe or blot the site dry and allow it to dry completely before covering it. C) Observe clean technique to minimize the possibility of contamination. D) Apply chlorhexidine to the site in order to disinfect.

D

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. Which action should the nurse take? A) Increase the rate of infusion to restore blood volume more quickly. B) Reassure the client that the feelings are associated with anxiety and will pass. C) Confirm the shortness of breath by listening to the client's lungs. D) Stop the transfusion and notify the health care provider.

D

The nurse is performing an assessment for a client related to pain. In order to determine the need for pain medication, what should the nurse base the decision on? A) pain tolerance. B) level of consciousness. C) objective signs. D) temporal pattern.

D

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: A) hypokalemia. B) hypocalcemia. C) hypoglycemia. D) hypothyroidism.

A

A client has been reluctant to ask for breakthrough doses of the opioid prescribed, despite showing signs of pain. The client states to the nurse, "I don't want to become addicted to the medication." How should the nurse respond to the client's statement? A) "There's only an extremely small chance that you will become addicted to this drug." B) "If you start needing more doses to control your pain, then we'll address the question of addiction." C) "It's best to focus on controlling your pain and not worry about issues like addiction." D) "You could become addicted, but there are excellent resources available in the hospital to deal with that development."

A

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)? A) Metabolic alkalosis B) Respiratory alkalosis C) Metabolic acidosis D) Respiratory acidosis

A

A client is experiencing withdrawal from alcohol and admitted to the behavioral health unit. The client begins to have muscle weakness, tremors, hyperactive deep tendon reflexes, and a change in mental status. What should the nurse prepare to replace in this client? A) Magnesium B) Phosphorus C) Chloride D) Potassium

A

A client reports awakening during the night and does not feel as though restful sleep is achieved. The nurse reviews the medications the client is prescribed and identifies one of the medication that the client may take that may have an effect on sleep patterns. Which medication will the nurse discuss with the client? A) prednisone B) diltiazem C) metoprolol D) pantoprazole

A

A client taking a diuretic twice daily for treatment of hypertension reports being awakened often by a full bladder. What teaching regarding the diuretic will the nurse provide? A) Take it before 6:00 p.m. at night. B) Take it immediately before going to sleep. C) Skip the bedtime dose of medication. D) Take the second dose when awakening to urinate.

A

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs? A) An implanted central venous access device (CVAD) B) A midline peripheral catheter C) A peripheral venous catheter inserted to the cephalic vein D) A peripheral venous catheter inserted to the antecubital fossa

A

A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible? A) phlebitis B) air embolism C) thrombus formation D) pulmonary embolus

A

A client's partner expresses concern to the nurse about the client's snoring. Which assessment parameters will the nurse teach the couple to observe for the possibility of sleep apnea? A) Snoring with periods of irregular silence B) Varying patterns of snoring C) Light and occasional snoring D) Deep sleep, from which the client is not easily aroused

A

A male client presents to the clinic with reports of erectile dysfunction. Which statement by the nurse will assist in identifying the potential cause of the erectile dysfunction? A) "Do you take any medications such as antihypertensives, antidepressants, or illicit drugs?" B) "What are you doing immediately prior to your sexual encounters?" C) "Have you always had a hard time obtaining an erection?" D) "Have you had any discharge or pain with urination?

A

A nurse at the health care facility is caring for an older adult client who complains of sleeplessness. Which condition is a manifestation of depression in an older client? A) insomnia B) nightmares C) somnambulism D) nocturnal enuresis

A

A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action? A) Report this finding to the primary care provider and seek a decrease in the client's opioid dosing. B) Administer a dose of naloxone and report this finding to the primary care provider. C) Increase the frequency of the client's vital signs assessment to every 2 hours for the next 6 hours. D) Discontinue the client's pain medication until his or her level of consciousness improves.

A

A nurse is developing a plan of care for a dying client. Which physiologic basic human need should be addressed? A) personal hygiene B) spirituality C) risk for infection D) family support

A

A nurse is reviewing the medication administration record. Which order does the nurse question? A) a diuretic administered twice daily at 9 a.m. and 9 p.m. B) a diuretic administered once daily at 9 a.m. C) a diuretic administered twice daily at 9 a.m. and 5 p.m. D) a diuretic administered every other day at noon

A

The nurse is caring for a client who has a long history of using opioid pain medication. Which action will the nurse take to further assess the client's pain and provide pain relief? A) Acknowledge the pain as the client reports it and administer pain medication as prescribed. B) Report the client to the health care provider for seeking drugs. C) Observe the client's behavior when the nurse is not with the client. D) Take the client's vital signs often to observe for changes that may indicate pain.

A

The nurse is providing care for a client with a peripheral intravenous catheter in situ. What intervention should the nurse implement in the care of this IV? A) Change the site every three to four days. B) Insert the largest gauge possible to maximize flow and minimize the risk of occlusion. C) Flush the catheter every six hours with hypertonic solution if the IV is not in constant use. D) Clean the insertion site daily using sterile technique.

A

The nurse observes the sleep pattern of an obese client with cardiac disease and notes occasional periods of apnea. Which action should the nurse take? A) Assess the client's vital signs and pulse oximetry. B) Call a code blue, as the client is not breathing. C) Ask a peer to come and observe the sleep pattern. D) Review the client's medical record for sleep disturbances.

A

What is the rationale for using CPAP to treat sleep apnea? A) Positive air pressure holds the airway open. B) Alternating waves of air stimulate breathing. C) Negative air pressure holds the airway closed. D) Delivery of oxygen facilitates respiratory effort.

A

What term is used to describe painful intercourse? A) Dyspareunia B) Vulvodynia C) Dysmenorrhea D) Impotence

A

Which of the following statements best describes the relationship between biologic sex and gender identity? A) Sex is chromosomally determined, while gender is a psychosocial construct. B) Biologic sex and gender identity are both modifiable by surgery and medical interventions. C) Biologic sex is genetically determined but gender identity is chosen during adolescence. D) Biologic sex and gender identity are considered synonymous in nursing practice.

A

Which statement by the client indicates acceptance of dying? A) "I have finalized all my financial arrangements for my family." B) "I just want to live long enough to see my child get married." C) "I need to take out a life insurance policy right now." D) "Everyone dies; death is a part of life and I have to accept it."

A

Which statement made by a client with terminal illness indicates acceptance of the diagnosis? A) "I do not feel like watching football tonight. I just want to be alone." B) "Even if I die, my family will be fine. They do not need me anymore." C) "After all I have done for the church, I end up getting cancer!" D) "Please, let me make it through the night and I will be a better person."

A

The nurse is caring for a client that is at the end of life. After the client is pronounced dead, what actions by the nurse are essential components of care? Select all that apply. A) Placing identification tags on the client's dentures or other prostheses B) Removing all tubes according to agency policy, unless an autopsy is to be performed C) Arranging for family members to view the body before it is discharged to the mortician D) Washing the client's body E) Placing identification on the wrist

A, B, C

The nurse is conducting an assessment on a newly admitted 18-year-old client. When questioned about sexual preference, the client appears slightly confused and confesses to not being sure. Which is an appropriate response(s) from the nurse? Select all that apply. A) "What has happened to cause you to question yourself?" B) "What have you done to help you try to determine this?" C) "Have you discussed this with your family?" D) "What types of activity do you enjoy doing the most?" E) "What do your friends think your preference is?

A, B, C

A client with type AB blood has experienced a precipitous drop in hemoglobin levels due to a gastrointestinal bleed and now requires a blood transfusion. Which blood types may this client safely receive? Select all that apply. A) B B) O C) A D) AB

A, B, C, D

The nurse is caring for four clients. Which client does the nurse identify as the most likely to have undertreated pain? Select all that apply. A) 60-year-old with early onset dementia B) 29-year-old who has a speech impediment C) 41-year-old who is from a different country D) 34-year-old with schizophrenia E) 18-year-old with a broken ulna F) 53-year-old with recurrent pancreatitis

A, B, C, D

A client is alert but nonverbal after a motor vehicle accident. Which action(s) will the nurse include in the assessment of pain for this client? Select all that apply. A) Communicating with the client in writing B) Using the Wong Baker FACES pain rating scale C) Checking for loss of function of the extremities D) Observing for grimacing and other signs of pain E) Performing vital signs

A, B, C, D, E

The client experiences intractable chronic pain from cancer. The nurse is developing a care plan to provide the client adequate pain relief. What principle(s) will guide the treatment plan? Select all that apply. A) Give oral medications for pain relief. B) Assess the client's pain experience at every visit. C) Administer pain medications around the clock. D) Remind the client about limitations of the pain medications. E) Contact the health care provider if the client reports unrelieved pain.

A, B, C, E

The nurse is caring for a client receiving epidural opioids . What side effects of the medication should the nurse assess for? Select all that apply. A) Urinary retention B) Pruritis C) Infection D) Hypertension E) Nausea

A, B, C, E

A 5-year-old client reports abdominal pain. Which action(s) will the nurse take to assess the pain? Select all that apply. A) Use the Wong-Baker FACES pain rating scale. B) Observe the client. C) Use the numeric rating scale. D) Ask the client to describe the pain. E) Ask the parents if the client is in pain.

A, B, D

The client is actively dying and has a prescription for Do Not Resuscitate. The nonresponsive client is mouth breathing and has noisy respirations. The client is incontinent of urine and feces. The family is at the bedside. What interventions would be appropriate for the nurse to perform to meet the needs of the client and the family? Select all that apply. A) Elevate the head of the bed to a semi-Fowler's position. B) Encourage the family to reminisce about positive, enjoyable events that the client and family shared together. C) Provide ice chips for the family to administer to the client. D) Cleanse the client's mouth every shift and PRN E) Insert a catheter for the client's urinary incontinence.

A, B, D

The nurse anticipates a dying client to exhibit which signs of impending death? Select all that apply. A) restlessness B) incontinence C) flushed extremities D) loss of sensation E) increased body temperature F) Cheyne-Stokes respirations

A, B, D, F

A hospice nurse is assessing a client with end-stage chronic obstructive pulmonary disease (COPD). Which assessment findings would suggest that the client is dying? Select all that apply. A) jaundiced skin B) Cheyne-Stokes respirations C) decreased pain D) regular but slow heart rate E) decreased urine output

A, B, E

The client has a sodium level of 131 mEq/L and has been placed on fluid restrictions of 1,000 mL per day. What interventions would the nurse include in the plan of care to assist the client in adhering to the fluid restriction? Select all that apply. A) Offer the client fluids in small containers. B) Remove the water pitcher from the client's bedside. C) Provide hard candies for the client to suck on. D) Limit frequent oral hygiene for the client. E) Provide a moisturizer for the lips and mouth.

A, B, E

The community health nurse is preparing for a family planning clinic. The nurse identifies which factors that influence contraceptive choices? Select All That Apply A) Age B) Religious beliefs C) Economic status D) Culture E) Level of education F) Marital status G) Desire for future pregnancy

A, B, E, F, G

A client reports throbbing pain caused by a laceration that occurred to the finger while cutting vegetables. Which terminology should the nurse use to document this pain? Select all that apply. A) acute B) chronic C) cutaneous D) somatic E) neuropathic

A, C

The nurse is teaching a client with terminal cancer who is interested in hospice care. Which home hospice benefits will the nurse explain? Select all that apply. A) The nurse and physician are on call 24 hours, every day of the week. B) Medications to treat cancer are provided. C) Pain will be managed with medication, if needed. D) Homemaker services can be included. E) Counseling services are available.

A, C, D, E

A 28-year-old male comes to the clinic for an evaluation. The client complains of a penile discharge. After completing an assessment, the nurse suspects that the client has a chlamydia infection based on which finding? Select all that apply. A) Testicular pain B) Painful lesion on the penis C) Burning on urination D) Painful vesicles around the genitals E) Swollen testes

A, C, E

A client has voiced concerns about her inability to fall asleep. When reviewing her history, what information would the nurse expect to find? Select all that apply. A) history of hyperthyroidism B) exercises 30 to 60 minutes daily C) drinks coffee with all meals D) works 30 hours per week E) smokes 1 pack of cigarettes daily

A, C, E

A nurse is caring for a client who has been diagnosed with a disturbed sleep pattern. Which measures should the nurse implement to promote sleep? Select all that apply. A) Assisting with progressive relaxation B) Administration of diuretics C) Providing a back massage D) Increasing the intake of stimulating chemicals E) Promoting daytime exercises

A, C, E

The nurse is developing a discharge teaching plan for clients taking opioid pain medication. Which of the following should the nurse include? Select all that apply. A) Avoid alcohol. B) Take medication on an empty stomach. C) Do not smoke without someone else present. D) Avoid dairy products. E) Do not drive while taking pain medication.

A, C, E

The nurse is working in the emergency department when a male client states, "I have been exposed to gonorrhea from a sexual partner and I think I have it." What symptoms should the nurse assess in this client that correlate with the client's suspicions of infection? Select all that apply. A) Increased frequency of urination B) Vesicles around the penis C) Difficulty urinating D) Chancre sore on the penis E) Purulent penile discharge

A, C, E

The nurse has entered the room of a newly admitted client and observed a continuous positive airway pressure (CPAP) on the client's bedside table. Which action(s) will the nurse take to assess the client's use of the CPAP machine? Select all that apply. A) Examine the fit of the mask. B) Provide education about the importance of CPAP. C) Explore the client's understanding of disinfection. D) Discuss the client's habit of using the CPAP. E) Elicit the client's understanding of sleep apnea.

A, D

A nurse is inspecting the IV access site of a client receiving intravenous therapy. The nurse suspects that the IV has infiltrated based on which finding at the site? Select all that apply. A) Coolness B) Redness C) Warmth D) Swelling E) Pallor

A, D, E

What signs of complications and their probable causes may occur when administering an IV solution to a client? Select all that apply. A) Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV. B) Bleeding at the site when the IV is discontinued indicates an infection is present. C) Engorged neck veins, increased blood pressure, and dyspnea occur when a thrombus is present. D) A pounding headache, fainting, rapid pulse rate, increased blood pressure, chills, back pains, and dyspnea occur when an air embolus is present. E) Redness, swelling, heat, and pain at the site may indicate phlebitis. F) Local or systemic manifestations may indicate an infection is present at the site.

A, E, F

A client with a sleep disorder experiences cataplexy. Which is a feature of this condition? A) nightmare or vivid hallucinations experienced during sleep time B) sudden loss of motor tone that may cause the person to fall asleep; usually experienced during a period of strong emotion C) irresistible urge to sleep, regardless of the type of activity in which the client is engaged D) skeletal paralysis that occurs during the transition from wakefulness to sleep

B

A couple have presented to the healthcare provider for a follow up visit following the husband's uncomplicated myocardial infarction (MI) one week ago. The nurse determines that education on resuming intimate sexual contact should be discussed. What timeline regarding sexual intercourse should the nurse be sure is included in the discussion? A) three weeks if no symptoms of chest pain B) three months if no symptoms of chest pain C) one week if no symptoms of chest pain D) one month if no symptoms of chest pain

B

A factory worker has a work schedule involving rotating work hours between days, evenings, and nights. The client tells the nurse about being a "morning person" and not sleeping well when working the night shift. Which information will the nurse teach the client about sleep hygiene? A) Talk to your health care provider about obtaining a prescription for a sleep aid. B) Modify the sleep environment to simulate quiet and darkness. C) Apply for a promotion to a day shift supervisor position. D) Increase your caffeine intake on days when you feel fatigued.

B

A hospital client's pain is being treated with epidural analgesia. Which nursing action would pose a threat to the client's safety? A) Palpating the client's abdomen during a head-to-toe assessment B) Administering an oral dose of morphine to treat the client's breakthrough pain C) Administering a glycerin suppository to treat the client's constipation D) Feeding the client food and fluids while in a semi-Fowler's (partially upright) position

B

A middle-age adult man has just started an exercise program. What would the nurse teach him about timing of exercise and sleep? A) Exercising immediately before bedtime enhances ability to sleep. B) Exercising within 2 hours of bedtime can hinder ability to sleep. C) The fatigue from exercise may be a hindrance to sleep. D) The time of day does not matter; exercise facilitates sleep.

B

A new mother is discussing her 6-month-old infant's sleep habits and expresses concern about the infant obtaining too much sleep. The mother reports the infant's circadian cycle as listed above. The best statement by the nurse is: A) "You need to awaken your infant during the midnight to 6 a.m. time period." B) "Your infant is obtaining the average hours of sleep per day for an infant." C) "Your infant requires more time asleep during the day hours." D) "Your infant is actually obtaining too little sleep for one day."

B

A nurse assesses a client who was administered an opioid analgesic and finds the client unresponsive to shaking and stimulation. Which is the nurse's immediate plan of action? A) Contact the health care provider B) Administer naloxone C) Call a code blue D) Notify the family

B

A nurse implements a back massage as an intervention to relieve pain. What theory is the motivation for this intervention? A) Prostaglandin stimulation B) Gate-control theory C) Large/small fiber theory D) Neuromodulation

B

A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area? A) Face B) Sacral area C) Hands D) Abdomen

B

A nurse is caring for a client newly diagnosed with sleep apnea. Which should the nurse teach the client about the most important reason why the continuous positive air pressure (CPAP) device should be used during sleep? A) "Using the CPAP will increase your energy during the day by allowing you to sleep at night." B) "The CPAP assures you get enough oxygen throughout the night." C) "The CPAP prevents you from snoring so your spouse can sleep." D) "By maintaining the oxygen in your body during sleep other health problems can be avoided."

B

A nurse is caring for a client who is prescribed continuous positive airway pressure (CPAP) for sleep apnea. Which action will the nurse take? A) Insert a nasal catheter B) Apply a CPAP mask while sleeping. C) Place the client in an oxygen tent D) Administer transtracheal oxygen via nasal pillow.

B

A nurse is explaining premenstrual syndrome to a female client. The client demonstrates understands when stating what may occur in the premenstrual phase? A) Blurred vision B) Headache C) Calmness D) Water loss

B

A nurse working the night shift assesses a client's vital signs at 4 a.m. (0400). What would be the expected findings, based on knowledge of NREM sleep? A) Increased TPR and BP B) Decreased TPR and BP C) No change from daytime readings D) Highly individualized, cannot predict

B

A patient calls the clinic and tells the nurse they have a foamy, greenish, and itchy vaginal discharge. The patient asks the nurse what the significance of this discharge is. What is the best response by the nurse? A) Drainage is caused by vaginal dryness. B) The patient may have trichomoniasis. C) Drainage is physiologic and normal. D) The patient may have chlamydia.

B

A terminally ill client asks the nurse what assisted suicide is. Which response is best for the nurse to provide? A) "It is withdrawing medical treatment with the intention of causing a client's death." B) "It is when a lethal combination of drugs is made available to the client wishing to die." C) "It is best if you talk to your doctor about that since assisted suicide is illegal in all states." D) "It is when the clinician administers a lethal dose of medication to cause the client's death."

B

An 82-year-old client is newly admitted to an assisted living facility. Which intervention promotes safety at night for the client? A) administering diuretics at bedtime B) using a night light in the bathroom C) leaving the door open to the nursing hallway D) leaving a bright light on in the bathroom

B

The nurse caring for a client receiving opioid therapy notes that the client's respirations are 7. What is the first action by the nurse? A) Begin cardiac compressions. B) Administer naloxone. C) Tell the client loudly to breath D) Take the client's blood pressure.

B

The nurse identifies that a client is in stage 3 sleep. What assessment finding by the nurse is indicative of this stage? A) anxiety B) enuresis C) diaphoresis D) shortness of breath

B

The nurse is admitting a client that has obesity and is diagnosed with obstructive sleep apnea (OSA). The client states, "I just wake up a lot and don't feel rested but it's not a big deal." What education should the nurse provide about the complications related to OSA? A) OSA can cause you to have seizures. B) OSA contributes to hypertension and heart disease. C) OSA can cause a condition called respiratory alkalosis D) OSA is the cause of depression.

B

The nurse is assessing an older adult client that reports feeling fatigued and tired throughout the day. What intervention by the nurse will assist with the client's report of fatigue? A) Inform the client that taking frequent naps during the day will help B) Have the client further evaluated for depression C) Encourage the client to drink or eat more foods with caffeine during the day D) Encourage the client to increase the amount of fluids during the evening hours

B

The nurse is performing an intake assessment of a 60-year-old client who admits to having a nightcap of 4 to 6 ounces of scotch whisky each night. What effect might this alcohol be having on the client's sleep? A) shorter sleep cycles B) decreased REM sleep C) increased amount of total sleep D) increased stage IV NREM sleep (delta sleep)

B

Which example best supports the diagnosis of Sexual Dysfunction: Dyspareunia? A) A 39-year-old alcoholic woman is no longer interested in having sex with her partner. B) A 50-year-old woman in the process of menopause has pain and burning during intercourse. C) A 50-year-old woman with a history of stroke is afraid to have sex with her partner for fear it will elevate her blood pressure. D) A client with a colostomy believes she cannot have a sexual relationship with her husband because he will be repulsed by her stoma.

B

Which sexually transmitted infection has the following characteristics: thin, foamy, greenish vaginal discharge that causes itching of the vulva and vagina? A) Herpes simplex 1 B) Trichomoniasis C) Nonspecific vaginitis D) Herpes simplex 2

B

Which statement accurately describes the process known as grief reaction? A) Reactions to grief are similar for all people. B) Reactions to grief may differ from client to family. C) Reactions to grief follow all stages of the grieving process. D) Reactions to grief and dying are different.

B

A client has been admitted with fluid volume excess related to right-sided heart failure. Which assessment data would the nurse expect related to the fluid volume excess? Select all that apply. A) blood pressure 100/48 mm Hg B) distended neck veins C) crackles in the lungs D) excessive urination E) poor skin turgor

B, C

A client who suffered multiple trauma in a motor vehicle accident is receiving care in an orthopedic trauma unit. The client has a documented history or opioid addiction and the hospital's advanced pain control team has become involved in his pain control plan. Which of the following are aspects of addiction? Select all that apply. A) Presence of an unusually low pain threshold B) Compulsive use of a particular drug C) The need to use opioids for purposes other than pain relief D) The use of more than 30 mg of morphine or 15 mg of hydromorphone in a 24 hour period E) The need for increasing size or frequency of opioid doses to achieve pain relief

B, C

The nurse is caring for a client who reports throbbing pain at the site of a recent laceration from a pocketknife. How will the nurse document this type of pain? Select all that apply. A) somatic B) acute C) cutaneous D) neuropathic E) chronic

B, C

A nurse is working with an older adult client who has been diagnosed with onset insomnia and informs the nurse about waking at least once during the night. What actions by the nurse can help promote adequate sleep? Select all that apply. A) The nurse teaches the client that shorter, unbroken sleep periods are not normal. B) The nurse helps the client come up with a bedtime routine that can be implemented each night. C) The nurse advises the client to exercise no closer than 6 hours to bedtime. D) The nurse encourages the client to remove the television from the bedroom. E) The nurse encourages the client to minimize caffeine intake several hours prior to bedtime.

B, C, D, E

The hospice nurse is educating a client's family on the physical signs of approaching death. The nurse identifies that the education has been effective when the family says they will know that death is imminent when they see which related symptoms? Select all that apply. A) Increased body temperature B) Bowel incontinence C) Cyanosis of dependent areas D) Restlessness E) Irregular respiratory rate

B, C, D, E

The nurse is providing instructions to a client who has been prescribed a patient controlled analgesia (PCA) pump postoperatively. The nurse will include which information in the client instructions? Select all that apply. A) "It is best to press the button only when you are experiencing extreme pain." B) "The device is set up to deliver a predetermined dose each time you press the button." C) "You will be asked to rate your pain frequently to reassess your need for this device." D) "You will hear a bell sound when the infuser delivers the medication." E) "You should be the only person pressing the button on this device." F) "You will be monitored closely to ensure you do not administer yourself an overdose."

B, C, D, E

Which nursing interventions would be anticipated with hospice care? Select all that apply. A) Administer prescribed chemotherapy to treat invasive liver cancer. B) Ease respiratory function by providing oxygen via nasal cannula. C) Administer prescribed morphine for pain control. D) Administer prescribed antiemetics to control nausea. E) Insert a Foley catheter to prevent incontinence.

B, C, D, E

A client reports periodic difficulty falling asleep. Which teaching will the nurse provide? Select all that apply. A) Sleep in on weekends to catch up from weekday lack of sleep. B) Decrease caffeine intake. C) Adhere to a regular schedule for waking and going to sleep. D) Take intermittent daytime naps to feel refreshed. E) Go on a daily walk.

B, C, E

Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply. A) Monitoring edema B) Intravenous therapy C) Nutrition management D) Hypervolemia management E) Electrolyte management F) Fluid restriction

B, C, E

During an orientation class for new RN graduates, the nurse educator identifies which conditions as potential risks for clients to experience sleep pattern disturbance? Select all that apply. A) glaucoma B) depression C) constipation D) type 1 diabetes mellitus E) substance use F) stroke

B, C, E, F

A 54-year-old man is recovering from an outbreak of Herpes zoster on his left chest. He tells the nurse that even his shirt touching him causes a horrible pain on the left side of the chest. What term would best describe the client's pain? A) Chronic pain B) Somatic pain C) Hyperalgesia D) Nociceptive pain

C

A client is hypotensive secondary to hypovolemia resulting from dehydration. Based on the nurse's knowledge about intravenous solutions, the nurse would expect the physician to prescribe which type of solution? A) Hypertonic B) Volume expander C) Isotonic D) Hypotonic

C

A client is prescribed escitalopram, diuretics, and pseudoephedrine. The client states, "I'm tired all the time." What does the nurse understand may be happening to this client? A) Mental illness creating insomnia B) Excessive exercises decreasing the quality of sleep C) Decrease in R.E.M. sleep due to prescribed medications D) Increase in daytime napping

C

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of: A) colloid solution. B) interstitial fluid. C) electrolytes. D) nonelectrolytes.

C

A client tells the nurse that she is experiencing stabbing pain in her mouth, gums, teeth, and chin following brushing her teeth. These are symptoms of: A) postherpetic neuralgia. B) complex regional pain syndrome. C) trigeminal neuralgia. D) diabetic neuropathy.

C

A nurse educates a young couple on putting their newborn on his back to sleep. What is the rationale for this information? A) Supine position makes changing diapers and feeding difficult. B) Supine position may alter the size and shape of the infant's head. C) Prone position increases the risk for sudden infant death syndrome. D) Prone position decreases the risk for sudden infant death syndrome.

C

A postoperative client who reported a pain level of 8 was medicated with an IV opioid 20 minutes ago. The client now reports a pain level of 9. Which would be the nurse's best action? A) Direct the client in relaxation exercises B) Reevaluate the client's pain level in 1 hour C) Administer a nonopioid medication D) Document the client's pain level

C

A specially trained nurse has inserted a PICC line. What would be done next? A) Place the client on restricted oral fluids. B) Explain the procedure to the client and family. C) Send the client to the radiology department. D) Start administration of prescribed fluids.

C

A woman reports pain with intercourse. Which client medications should the nurse check for that contribute to dyspareunia? A) Antihypertensives B) Antibiotics C) Antihistamines D) Calcium supplements

C

After the death of a terminally ill spouse, a client reports frequent headaches and loss of appetite. The client states, "How am I going to live without him?" What type of grief is the client experiencing? A) Anticipatory grief B) Unresolved grief C) Inhibited grief D) Abbreviated grief

C

Based on the circadian cycle, the body prepares for sleep at night by decreasing the body temperature and releasing which chemical? A) norepinephrine B) serotonin C) melatonin D) dopamine

C

The action of ibuprofen is to: A) enhance the endorphins of the CNS. B) close the gate of the A-delta fibers. C) have an antiprostaglandin effect on the CNS. D) provide narcotic pain relief.

C

The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority? A) Compare the client's current assessment with previous admission assessment B) Educate the client/caregiver about signs of impending death C) Examine the effectiveness of the current pain regimen D) Assess the client's serum albumin level

C

The nurse is caring for an older client with chronic pain due to osteoarthritis, hypertension, and mild dementia. The client reports blurred vision, and the spouse states, "I'm worried. Today I noticed that there was blood in the stool, and there is more confusion than usual." What is the priority nursing action? A) Document the client's symptoms. B) Perform a physical assessment. C) Ask the client and caregiver for a medication history. D) Report increased confusion.

C

The nurse is preparing a care plan for a client receiving opioid analgesics. Which factors associated with opioid analgesic use will the nurse include in the plan of care? A) Assessing for impaired urinary elimination B) Observing for diarrhea C) Preventing constipation D) Observing for bowel incontinence

C

While conducting a sexual history, the nurse asks a client about protection from sexually transmitted infections (STIs). Which question would be most appropriate for the nurse to ask? A) "Have you or your partner experienced erectile dysfunction?" B) "Do you find sex satisfying?" C) "Have you had any sexually transmitted infections and if so, which ones?" D) "Are you comfortable with the way you are currently expressing yourself sexually?"

C

Which clients would the nurse identify that are at risk for the development or presence of sexual dysfunction? Select all that apply. A) a 25-year-old male client in traction B) a 19-year-old male who is still a virgin C) a 30-year-old female experiencing PMS D) a 52-year-old male with a history of hypertension E) a 49-year-old male diagnosed with an enlarged prostate (BPH) F) a postmenopausal female client

C, D, F

A 13-year-old female client comes in for a sports physical for school. During the exam, the client mentions she has a great boyfriend. Which question should the nurse prioritize with this client? A) Which sport are you participating in? B) Have you tried any recreational drugs? C) Do your parents know you smoked a cigarette? D) Have you received a human papillomavirus (HPV) vaccination?

D

A client has a prescription to restrict fluids. What is one comfort measure nurses can implement for this client to alleviate a common problem? A) back rubs B) hair care C) chewing gum D) oral hygiene

D

A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client? A) Increase and decrease the serum level of the analgesic as needed. B) Do not provide analgesia if there is any doubt about the likelihood of pain occurring. C) Treat the pain only as it occurs to prevent drug addiction. D) Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen.

D

A client that is post-menopausal reports painful intercourse for the last two months. When performing an assessment of the client, what data should the nurse obtain? A) the communication pattern between the client and her partner B) the history of any sexual abuse, rape, or incest C) the client's knowledge of anatomy and sexual response D) the use of antihistamines, tranquilizers, or alcohol

D

A critical care nurse is aware of the legislation that surrounds organ donation. When caring for a potential organ donor, the nurse is aware that: A) clients must have an organ donor card to donate organs. B) non-heart-beating cadavers are not potential organ donors. C) nursing focus should be directed at organ donation once it is decided to withdraw life support. D) hospitals are mandated to notify transplantation programs of potential donors.

D

A man 68 years of age comes to the clinic complaining that he is having difficulty obtaining an erection. When reviewing the client's history, what might the nurse note that contributes to impotence? A) Lack of exercise B) Past history of infection C) Increasing age D) History of hypertension

D

A maternity nurse is instructing new parents on the proper sleeping position for their newborn child. In what position does the nurse instruct the parents to place the infant? A) Side-lying position B) High-Fowler's position C) Prone position D) Supine position

D

A nurse is assessing an adult client with back pain. The client is unable to speak English. Which pain scale is most appropriate for the nurse to use in assessing the client's pain? A) FLACC scale B) Payen behavioral pain scale C) PAINAD scale D) 0 to 10 numeric rating scale

D

A nurse is caring for a client with insomnia. Which teaching will the nurse provide to help the client improve sleep? A) "Limit fluids in the evening." B) "Watch television in bed before sleep." C) "Eat a heavy meal for dinner." D) "Create a bedtime routine."

D

A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage? A) Midbrain B) Medulla C) Cerebral cortex D) Hypothalamus

D

A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid? A) Atropine B) Epinephrine C) Diphenhydramine D) Naloxone

D

An older adult client experiences the death of a spouse. Which behavior by the client exemplifies the grief stage of reorganization? A) Voices disbelief regarding the death of the spouse B) Shares pictures of the spouse and talks about the spouse continuously C) Adopts frequent phrases and mannerisms of the deceased D) Appears sad and reaches out to adult children for support

D

During a well-check visit of a toddler, the parent mentions that the child is exhibiting sexual behaviors. Which information on growth and development of a toddler will the nurse discuss with the parent? A) Discourage interest in other children's bodies. B) Delay modeling a positive body image until early adolescence. C) Refrain from discussing anything about sexuality until early adolescence. D) Acknowledge that masturbation is normal.

D

The client has been in the intensive care unit for several days. The client appears to be sleeping throughout the night. The nurse records the data listed above. The nurse evaluates that rapid eye movement (REM) sleep is occurring at: A) 0400. B) 0200. C) 0300. D) 0100.

D

The client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to: A) apply a facial mask that will deliver positive air pressure. B) take a prescribed sedative before trying to sleep. C) insert an oral appliance prior to attempting sleep. D) anticipate sleeping overnight at a health care center.

D

The emergency room nurse is caring for a client who will need a lumbar puncture. The health care provider prescribes lidocaine 2.5% and prilocaine 2.5% cream (EMLA) to decrease the pain associated with the procedure. When should the nurse administer the cream? A) Thirty minutes prior to the procedure B) Immediately after the procedure C) Just prior to the procedure D) One hour prior to the procedure

D

The nurse assessing an adolescent's need for further information regarding sexual health should ask which question? A) "Have you ever been diagnosed with a sexually transmitted infection?" B) "Are you involved in an intimate relationship at this time?" C) "How many sexual partners have you had?" D) "What questions or concerns do you have about your sexual health?"

D

The nurse is assessing a client with a history of sleep apnea who is noncompliant regarding wearing the continuous positive airway pressure (CPAP) apparatus. Which statement made by the client indicates understanding of risks related to noncompliance? A) "Not wearing CPAP at night may cause my blood pressure to become low and I may fall." B) "There is no reason why I should wear the mask other than because the doctor says I should." C) "Wearing the mask when I sleep may cause me to gain weight as I will sleep more." D) "I know if I do not wear the CPAP the oxygen in my blood may drop and damage my heart."

D

The nurse is caring for a client suspected of being infected with human papillomavirus (HPV). Which clinical manifestation observed by the nurse would correlate with this suspicion? A) Foul-smelling, thin, grayish white vaginal discharge B) Single, painless genital lesion 10 days to 3 months after exposure C) Purulent discharge with reports of burning when urinating D) Pale, soft, papillary lesions on the genitalia and perianal area

D

The nurse is conducting an assessment on a 42-year-old female client. The client admits to having unprotected sex with multiple individuals over the years. Based on the data collected during the assessment (Temp 103, BP 128/84, Pulse 88, RR 16, Generalized reticular rash, swollen lymph nodes, hair falling out, tired all the time), which disorder should the nurse suspect this client has? A) Herpes simplex virus (HSV) B) Gonorrhea C) Chlamydia D) Syphilis

D

The nurse is preparing to provide education to a group of high school students on sexually transmitted infection (STI) prevention. The nurse knows that this age group often uses oral-genital stimulation as a way to prevent pregnancy. Which concept should the nurse make sure to convey to the group? A) use of public restrooms increases the risk of contracting HIV B) avoid multiple partners to reduce the risk of being infected C) oral-genital contact is safe with use of a barrier method D) skin-to-skin contact can spread herpes and genital warts

D

The nurse is providing care for a confused client who no longer is able to make health care decisions. Which document will the nurse review on the client's medical record to determine the designated person to make decisions on the client's behalf? A) Health care provider's progress notes B) Advance directive form C) Living will form D) Durable power of attorney form

D

The nurse learns during the assessment of a client that the client has difficulty falling asleep, wakes up early, and does not feel refreshed in the morning. This client is most likely experiencing: A) increased sleep. B) ineffective coping. C) activity intolerance. D) disturbed sleep pattern.

D

The nurse prepares to assess a client who is presenting to the infertility clinic for her first appointment. What should the nurse include when obtaining data from the client? A) Age at onset of menses B) Premenstrual symptoms C) Recent untreated urinary tract infection (UTI) D) History of an untreated sexually transmitted infection (STI)

D

The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system? A) Abdominal distention B) Paralytic ileus C) Vomiting D) Diarrhea

D

What independent nursing action can be used to facilitate sleep in hospitalized clients who are on bed rest? A) changing the bed with fresh linens B) administering prescribed sleep medications C) encouraging naps during the daytime D) giving a back massage

D

Which client likely faces a risk for the nursing diagnosis of Disturbed Sleep Pattern: Difficulty Remaining Asleep? A) a client who requires blood glucose checks four times daily B) a client whose physical therapy has been scheduled for 4:30 p.m. C) a client whose opioid analgesics result in central nervous system depression D) a client who receives IV antibiotics every 3 hours

D

Which natural chemical does the body produce at night to decrease wakefulness and promote sleep? A) serotonin B) endorphins C) dopamine D) melatonin

D

A 16-year-old girl tells the nurse that her friend has genital warts and asks the nurse how to make sure that she does not get them. Which of the following should the nurse recommend? A) "If your male partner doesn't have genital warts, you will not get them." B) "Douching will help to prevent them." C) "Get the human papillomavirus vaccine." D) "Have the Norplant system implanted in your arm."

c

The client has vancomycin 250 mL intravenously prescribed daily. The vancomycin is to be administered over 90 minutes through an IV administration pump. How many mL/hr would the nurse set the IV administration pump to administer the vancomycin? Record your answer using a whole number.

167

A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving? A) A hypotonic solution B) Packed red blood cells C) A hypertonic solution D) An isotonic solution

A

A client with renal disease requires IV fluids. It is important for the nurse to: A) place the fluids on an electronic device. B) catch the rate up when it falls behind. C) check the intravenous rate once a shift. D) administer the fluids through the dialysis access.

A

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? A) cardiac irregularities B) metabolic acidosis C) increased intracranial pressure (ICP) D) muscle weakness

A

A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance? A) Hyperphosphatemia B) Hypokalemia C) Hypermagnesemia D) Hyponatremia

A

The nurse is assessing a client who was hospitalized due to a fall with brief loss of consciousness. Which sign(s) alerts the nurse that the client is severely dehydrated? Select all that apply. A) The client reports dizziness when standing up from a chair. B) The client has been working outside in warm temperatures. C) The client has dark-colored urine with a noticeable odor. D) The client reports having increased saliva production. E) The client reports a loss of 3 lb (1.4 kg) over the past 2 weeks.

A, B, C

The client is to receive two units of packed red blood cells (PRBC) for anemia following surgery. The nurse is preparing to administer the first unit. What interventions would the nurse take to administer the PRBC safely? Select all that apply. A) Wear clean gloves when spiking the blood container with the administration set. B) Obtain baseline vital signs prior to beginning the transfusion. C) Check that informed consent has been obtained from the client. D) Verify client identification and blood product information with a second nurse. E) Prime the blood administration set with a dextrose solution. F) Set the IV infusion pump to administer the unit in 1 hour.

A, B, C, D

The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? Select all that apply. A) Reduce infusing fluid volume as ordered. B) Ask provider to order a low-salt diet. C) Treat the underlying condition that contributes to increased fluid volume. D) Administer furosemide as ordered. E) Increase oral intake to flush excess fluids.

A, B, C, D

The nurse is caring for a client who is being discharged with total parenteral nutrition (TPN) to be delivered via peripherally inserted central catheter (PICC). When teaching the client about care and management of the PICC line at home, what point(s) will the nurse include? Select all that apply. A) "Contact your health care provider if you see yellow or greenish drainage at the PICC site." B) "If you have a cold or flulike symptoms, wear a mask when you are preparing to give yourself TPN." C) "It is common to see redness at the PICC insertion site occasionally." D) "PICC lines tend to be less comfortable than other types of central lines. Some pain can be expected." E) "Ensure that you have washed your hands thoroughly before handling the PICC line."

A, B, E

The nurse is monitoring intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the I&O record? Select all that apply. A) 100 mL from melted ice chips B) barbecue sandwich C) infusion of intravenous solution D) serving of jello E) bowl of chili F) cup of ice cream

A, C, D, F

A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? A) "I've had a GI virus for the past 3 days with severe diarrhea." B) "I've been taking antacids almost every 2 hours over the past several days." C) "I was breathing so fast because I was so anxious and in so much pain." D) "I've had a fever for the past 3 days that just doesn't seem to go away."

B

A client with chronic anemia is admitted for the administration of blood. What would the nurse expect the physician to order? A) Whole blood B) Packed cells C) Platelets D) White blood cells E) D5W 1000 mL

B

Which individual with diarrhea for three days is most likely to suffer from fluid and electrolyte imbalance? A) Adolescent B) Infant C) School-age child D) Young adult

B

Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing? A) hemolytic reaction B) febrile reaction C) allergic reaction D) circulatory overload

B

A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? Select all that apply. A) distended neck veins B) heart rate 128/bpm C) crackles in the lungs D) blood pressure 100/48 mmHg E) poor skin turgor

B, D, E

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status? A) daily BUN and serum creatinine monitoring B) daily electrolyte monitoring C) daily weights D) output measurements

C

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? A) 75 mL/hr for the first 15 minutes, then 200 mL/hr B) As fast as the client can tolerate C) 1 unit over 2 to 3 hours, no longer than 4 hours D) 200 mL/hr

C

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action? A) Slow the rate of IV fluids. B) Elevate the arm. C) Remove the IV. D) Apply a warm compress.

C

A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells? A) granulocytes B) normal saline solution C) plasma D) albumin

C

A client has a physician's order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose? A) treat the client's infection B) administer blood products C) provide protein supplements D) replace fluid and electrolytes

D

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? A) Give the client a glass of orange juice with added sugar. B) Encourage fluid intake. C) Allow nothing by mouth. D) Start an IV of normal saline as prescribed.

D

A student is learning how to administer intravenous fluids, including accessing a vein. What is the most potentially harmful risk posed for the client when accessing the vein? A) minor bleeding B) discomfort C) pain D) infection

D

A nurse assessing the IV site of a client observes swelling and pallor around the site, and notes a significant decrease in the flow rate. The client reports coldness around the infusion site. What IV complication does this describe? A) sepsis B) thrombus C) infiltration D) speed shock

C

The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client? A) O negative B) B positive C) AB negative D0 A positive

A

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client? A) increased cardiac output B) renal failure C) excessive use of laxatives D) diaphoresis

B

A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison? A) 1,500 mL B) 2,300 mL C) 2,600 mL D) 1,800 mL

C

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? A) Decreased oxygen levels B) Increased potassium levels C) Increased sodium levels D) Decreased potassium levels

D

A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client? A) hypertonic solution B) isotonic solution C) colloid solution D) hypotonic solution

A

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? A) Avoid salty or excessively sweet fluids. B) Eat crackers and bread. C) Use an alcohol-based mouthwash to moisten your mouth. D) Use regular gum and hard candy.

A

A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 4.5 mg/dL (2.6 mEq/L)Based on these levels, the nurse would identify which imbalance? A) hypokalemia B) hypercalcemia C) hypermagnesemia D) hyponatremia

A

A nurse is teaching a client regarding a newly implanted venous access system. Which statement by the nurse is incorrect? A) "You won't have to endure any more needlesticks." B) "Implanted catheters have a self-sealing port." C) "The implanted venous access is hidden under the skin." D) "The catheter will need to be flushed periodically with heparin."

A

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate? A) "Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein." B) "Infiltration occurs when an IV is improperly placed, and phlebitis indicates circulatory overload." C) "Infiltration is a localized blood clot, and phlebitis occurs when an IV is improperly placed." D) "Infiltration is the inflammation of the vein, while phlebitis is a localized irritation."

A

A student has joined the marching band at high school. The band begins practicing outside during hot summer weather. Which health promotion information will the school nurse teach the students? A) The student should drink large amounts of water on practice days. B) The hot weather will help the student prepare for the marching season. C) With heat, endurance decreases as time increases on the field. D) The exercise will have minimal effect on fluid and electrolytes.

A

A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing? A) Metabolic alkalosis B) Respiratory alkalosis C) Respiratory acidosis D) Metabolic acidosis

A

Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance? A) increased respiratory rate B) hypoventilation C) renal retention of H ions D) increased excretion of bicarbonate ions by the kidneys

A

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as: A) hyponatremia. B) hypernatremia. C) hyperkalemia. D) hypokalemia.

A

The nurse is calculating the infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtt [drops]/1mL. What is the infusion rate? A) 42 gtt/min B) 20 gtt/min C) 125 gtt/min D) 25 gtt/min

A

The nurse is performing an assessment for an older adult client admitted with dehydration. When assessing the skin turgor of this client, which area of the body will be best for the nurse to assess? A) sternum B) hand C) thigh D) abdomen

A

A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation? A) Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV. B) Discontinue the IV and relocate it to another spot. C) Call the physician and ask if anti-inflammatory drugs should be administered. D) Cleanse the site with alcohol and apply transparent polyurethane dressing over the entry site.

B

A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which actions should the nurse perform to avoid further complications and provide relief to the client? A) Call for help. B) Discontinue the IV promptly. C) Elevate the affected arm. D) Administer oxygen.

B

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern? A) Milk B) Banana C) Turkey D) Yogurt

B

A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information? A) Report the exact milliliter of intake to the physician's office nurse. B) Compare the total intake and output of fluids for the 24 hours. C) Ensure that the information is included in the verbal end-of-shift report. D) Compare the client's intake with the normal range of adult fluid intake.

B

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation? A) Check all clamps on the tubing and check tubing for any kinking. B) Notify the primary care provider immediately for possible fluid overload. C) Place the client in the Trendelenburg position to keep the client's airway open. D) Notify the primary care provider immediately because these are signs of speed shock.

B

Cross-matching of blood is ordered for a client before major surgery. What does this process do? A) determines a person's blood type B) determines compatibility between blood specimens C) specifies the donor and the recipient of the blood D) predicts the amount of needed blood replacement

B

During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first? A) Prepare to give an antihistamine. B) Stop the transfusion immediately. C) Administer oxygen. D) Infuse saline at a rapid rate.

B

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking? A) diminished cognitive ability and hypertension B) muscle cramping and tetany C) muscle weakness, fatigue, and constipation D) nausea, vomiting, and constipation

B

Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert? A) Muscle weakness, fatigue, and constipation B) Muscle weakness, fatigue, and dysrhythmias C) Nausea, vomiting, and constipation D) Diminished cognitive ability and hypertension

B

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response? A) "This surgery has a very low chance of hemorrhage, so you will not need blood." B) "Let me refer you to the blood bank so they can provide you with information." C) "Unfortunately, your own blood cannot be reinfused during surgery." D) "We now have artificial blood products, so giving your own blood is not necessary."

B

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding? A) pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) B) pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) C) pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l) D) pH: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l)

B

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. Which action should the nurse take to help alleviate the edema? A) Deeply massage the legs B) Elevate the legs C) Direct the client to remain on bed rest D) Request additional salt be added to the diet

B

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's: A) high magnesium. B) low calcium. C) high sodium. D) low potassium.

B

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? A) hypotonic B) isotonic C) hypertonic D) colloid

B

A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump? A) The pump compresses the tubing to infuse the solution at a precise, preset rate. B) The pump stops pushing the fluid in the client's vein when the needle is displaced. C) The pump will continue to infuse fluid even when the needle is displaced. D) The pump will sound an audible and visual alarm warning the nurse of the situation.

C

An older adult client with hypokalemia is being discharged to the home of a caregiver. Which information should the nurse include in the family teaching? A) Include more canned vegetables in the diet. B) Include more cheese in the diet. C) Include more bananas in the diet. D) Include more bread in the diet.

C

The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr A) 60 gtt/min B) 600 gtt/min C) 100 gtt/min D) 160 gtt/min

C

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate? A) 103 gtts/hr B) 13 mL/hr C) 83 mL/hr D) 100 mL/hr

C

The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing? A) hypotonic, followed by isotonic B) hypotonic C) hypertonic D) isotonic

C

The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client? A) A positive B) AB negative C) O negative D) B positive

C

The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome? A) Bowel motility will be restored within 24 hours after beginning supplemental K+. B) Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet. C) ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. D) ECG will show no cardiac dysrhythmias within 24 hours after beginning supplemental K+.

C

A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which fluid and electrolyte imbalances? A) fluid volume deficit and alkalosis B) fluid volume deficit and acidosis C) fluid volume excess and alkalosis D) fluid volume excess and acidosis

D

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? A) 1,000 B) 3,750 C) 500 D) 3,000

D

A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate? A) Give the client a fluid containing additional sodium to enhance the feeling of fullness. B) Have the client use an alcohol-based mouthwash every 2 hours to reduce the thirst sensation. C) Apply a petroleum-based gel to the client's lips to prevent cracking. D) Offer the client sugar-free candy to help combat thirst.

D

A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which action should the nurse perform? A) Weigh the client before and after meals. B) Weigh the volume of IV fluid before instilling. C) Weigh the client without soiled incontinence pads. D) Weigh the client's wet linen or dressing.

D

A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires: A) an access route to administer medications intravenously. B) intravenous fluids to be administered on an outpatient basis. C) an access route to replace fluids in combination with blood products. D) replacement of fluids for those lost from vomiting and diarrhea.

D

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? A) febrile reaction: fever develops during infusion B) allergic reaction: allergy to transfused blood C) bacterial reaction: bacteria present in the blood D) hemolytic transfusion reaction: incompatibility of blood product

D

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is: A) fluid volume deficit. B) myocardial infarction. C) atelectasis. D) fluid volume excess.

D

The health care provider is concerned that the client has hypokalemia. During the physical examination, which question should the nurse ask the client? A) "Have you been experiencing chest pain?" B) "Have you been having diarrhea?" C) "Have you been experiencing difficulty breathing?" D) "Have you been experiencing muscle weakness or leg cramps?"

D

The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland? A) potassium and chloride B) potassium and sodium C) chloride and magnesium D) calcium and phosphorus

D

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level? A) Tetany B) Fluid volume excess C) Pulmonary embolus D) Cardiac dysrhythmias

D

The nurse is preparing to administer fluid replacement to a client. Which action should the nurse take first? A) Regulate the rate of administration. B) Calculate the number of drops per minute. C) Check for the availability of an IV pump. D) Verify the prescription for type of solution and amount of infusion.

D

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? A) a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today B) a 60-year-old who is 3 days post-myocardial infarction and has been stable. C) a 47-year-old who had a colon resection yesterday and is reporting pain D) a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

D

Which fluid should be administered slowly to prevent circulatory overload? A) dextrose 5% B) 0.45% NaCl C) 0.9% NaCl D) 5% NaCl

D

While obtaining a health history from a client, which question is most appropriate for the nurse to ask the client to assess fluid balance? A) "How often do you usually have a bowel movement?" B) "How much coffee do you drink during a typical day?" C) "How often do you experience leg cramps? D) "How much do you typically urinate during the day?"

D