Random Nursing Questions
A client in sickle cell crisis has been hospitalized during her pregnancy. After giving discharge instructions, the nurse determines the client needs further teaching when she makes which statement?
"I will need to take an iron supplement even if my laboratory values are normal."
A Muslim client is scheduled to be discharged in 2 days, but insists on fasting until after dark. The nurse anticipates which explanation from the client?
"My religion requires me to fast all day until sunset."
A client is admitted for an exacerbation of irritable bowel syndrome who insists on being allowed to keep a head covering on at all times. The best response by the nurse is:
"Please help me to understand this practice."
The nurse facilitating the medication management group consistently notices that a particular client positions himself on the perimeter of the group. In order to be culturally mindful about the origin of this behavior, what question would the nurse ask the client?
"Where will you be comfortable sitting and still remain a part of the group?"
The nurse is developing a care management plan with a client who has been diagnosed with gastroesophageal reflux disease (GERD). What should the nurse should instruct the client to do? Select all that apply.
Avoid a diet high in fatty foods. Avoid beverages that contain caffeine. Avoid all alcoholic beverages.
What is the most important intervention for the nurse to implement while caring for a neonate with an omphalocele?
Carefully position and handle the omphalocele
A client at 24 weeks gestation comes to the clinic for a prenatal check-up and informs the nurse that she has been "seeing double." The nurse checks the urine and determines that there is 3+ proteinuria. What does the nurse determine is the potential priority problem?
Gestation hypertension
The nurse is teaching the parents of a child diagnosed with celiac disease? What is the nurse's priority goal?
Help the parents and child follow the prescribed dietary restrictions
A nurse is caring for a client receiving chemotherapy. Which assessment finding places the client at the greatest risk for an infection?
Stage 3 pressure ulcer on the left heel
A nurse is caring for a client who's ordered continuous ambulatory peritoneal dialysis (CAPD). Which finding should lead the nurse to question the client's suitability for CAPD?
The client has a history of diverticulitis.
The nurse is performing an admission assessment of a new client. When assessing potential cultural influences on the client's care, the nurse should address what domains? Select all that apply.
decision-making processes nutrition communication expressions of pain
The nurse is teaching the parents of a child with sickle cell disease. To instruct them on how to prevent sickle cell crisis, she should include which instruction?
Drink at least 2 quarts (2.3 liters) of fluids per day.
A physician treating a client in the cardiac care unit for atrial arrhythmia orders metoprolol, 25 mg P.O. two times per day. Metoprolol inhibits the action of sympathomimetics at beta1-receptor sites. Where are these sites mainly located?
Heart
While performing a cervical examination on a client in labor, a nurse's fingertips feel pulsating tissue. What is the most appropriate nursing intervention?
Leave the fingers in place and press the nurse call light
A school-age child, with a diagnosis of epilepsy, is admitted to the pediatric unit of a local hospital for evaluation of his anticonvulsant medications. As the nurse enters the child's room, the child begins to have a seizure. What is the priority nursing action?
Loosen any restrictive clothing
A nurse is performing an assessment of a postpartum client two hours after birth, and notes heavy bleeding with large clots. What should be the nurse's initial action?
Massaging the fundus firmly
A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention?
Monitor fetal heart tones
A client receiving a continuous infusion of lidocaine for ventricular dysrhythmias states "I am so tired. Even my vision is blurry." What is the nurse's best action?
Decrease the lidocaine infusion rate.
A client receiving intravenous heparin has developed hematuria and petechiae. What is the nurse's best action?
Administer protamine sulfate
The nurse is caring for an immune compromised client with a fungal infection of the scalp. What recommendation should the nurse make to prevent future problems?
Avoid sharing combs and brushes.
The family member of a client diagnosed with dissociative identity disorder (DID) asks a nurse if hypnotic therapy might help the client. How should the nurse respond?
"Yes, a client is often not consciously aware of alter personalities."
A charge nurse is developing the client care assignments for the shift. Which client is most appropriately assigned to a licensed practical nurse (LPN)?
A client who experienced a cerebral vascular accident and has a do-not-resuscitate (DNR)
After unsuccessful CPR efforts, the nurse must prepare an Islamic client for the morgue. Which nursing action should the nurse take?
Asking the client's family if they want to perform the ritualistic washing
A 40-year-old client with schizophrenia lives in a rooming house. At the weekly nursing clinic he reports creatures eating at his skin while scratching vigorously. Which intervention should be done first?
Assess the physical problems
An alert and oriented client comes to the emergency department after hitting his head in a motor vehicle accident. What should the nurse do first?
Immobilize the client's head and neck
A nurse is assigned with an ancillary staff member to care for a group of cardiac clients. Which client should the nurse address first?
The client who suffered an acute myocardial infarction (MI) who is complaining of constipation.
A client has been admitted with severe burns. Lactated Ringer's has been ordered to infuse via a pump. Why is this solution being used?
To prevent signs of hypovolemic shock and restore circulation
A client has a history of heart failure and has been prescribed furosemide, digoxin, and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of:
digoxin toxicity.
A client with chest pain is prescribed intravenous nitroglycerin. Which assessment is of greatest concern for the nurse initiating the nitroglycerin drip?
Blood pressure is 88/46 mm Hg.
After teaching a primigravid client at 24 weeks' gestation, who has received permission from the primary care provider to make a 6-hour automobile trip to visit her parents, about precautions to take during the trip, which client statement indicates the need for further teaching?
"I will sleep for 1 hour at the halfway point of the trip."
A client in a semiprivate room is diagnosed with pediculosis corpus. A nurse will initiate treatment after moving the client to another room. The client's roommate asks the nurse for information about the client. What should the nurse say?
"I'm sorry, but I can't share confidential information."
What is the nurse's priority action in caring for a client who has just had a liver biopsy?
Monitor vital signs
The nurse is providing care for a diverse group of clients. The nurse should consider the possible role of cultural norms if which clients avoid eye contact during interactions with the nurse? Select all that apply.
a client who is Native American an older adult client who identifies as Japanese
The nurse is caring for a client with esophageal varices. The nurse should discuss which laboratory report finding with the health care provider (HCP)?
elevated PT/INR
A nurse is making a home visit to a pregnant client at 20 weeks' gestation who is a member of the local Hmong community. The nurse is assisting the client with meal planning to promote optimal nutrition during her pregnancy. Based on the nurse's understanding of the client's culture and food preferences, which foods would the nurse suggest? Select all that apply.
fish cheese eggs
A client is being admitted to the substance abuse unit for alcohol detoxification. As part of his intake interview, a nurse asks when he had his last alcoholic drink. He says that he had his last drink 6 hours before admission. Based on this response, the nurse should expect early withdrawal symptoms to peak:
in 1 to 2 days.
After administering the prescribed medications, which of the following clients requires immediate intervention?
A client taking digoxin who has a morning potassium level of 3.0 mEq/L.
The team on an antepartum unit consists of two registered nurses (RN), one licensed vocational nurse (LVN), and one nursing assistant. Which one of the following conditions would be appropriate to assign the LVN?
A client with gestational hypertension
A client admitted with acute pyelonephritis now reports having a severe migraine, but declines PRN analgesics. What should the nurse discuss with this client? (Select all that apply.)
Ask the client which migraine treatments are helpful when at home. Alternative therapies such as relaxation or music can help.
A client comes to the physician's office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun's damaging rays. Which instruction best prevents skin damage?
"Apply sunscreen even on overcast days."
Radiation therapy is instituted for a client with Hodgkin's disease. After 1 week, the radiation site becomes red and irritated. Which statement indicates that the client treated the area appropriately at home?
"I applied nothing to the area; I just kept it dry."
After explaining to a multigravid client at 36 weeks' gestation who is diagnosed with severe hydramnios about the possible complications of this condition, which client statement indicates the need for further instruction?
"I can continue to work at my job at the automobile factory until labor starts."
A Japanese couple are experiencing labor. During the admission process, the husband tells the nurse that the wife will not receive any pain medication during the process. The husband then waits in the waiting room. As the birthing process continues, the nurse asks the wife if she needs pain medication. She declines the offer and reminds the nurse by saying, "My husband told you I cannot have any pain medicine." What is the nurse's best response to the client?
"I want to advocate for you and assist with the pain during this process."
A nurse is providing instruction to a 38-year-old male client undergoing treatment for anxiety and insomnia. The practitioner has prescribed lorazepam 1 mg/po/tid. The nurse determines that teaching has been effective when the client states:
"I'll avoid coffee."
A client reports to a physician's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?
"If I notice tingling in my lips or mouth, gargling may help the symptoms."
The nurse is caring for a group of clients in an acute medicine setting. What statement by a client would most warrant a referral to spiritual care, with the client's permission?
"It feels like one round of bad news after another for me, like I am being punished."
A client has had sucralfate prescribed as treatment for peptic ulcer disease. Which statement indicates that the client understands how to take the medication?
"It is important that I take this drug on an empty stomach."
A client on vacation experiences severe allergy symptoms, headache, and sinusitis (without respiratory distress). This client adamantly declines any supportive medications when offered. The nurse questions the client and learns the client receives weekly acupuncture treatments for these symptoms. The nurse's best response is:
"Let us try this until you can have acupuncture."
The client who experiences residual arm pain after a fall has been referred to an acupuncture treatment center. What is the nurse's best response to the client's question, "How is acupuncture supposed to help me?"
"Pain is relieved by releasing endorphins, which balance the flow of energy."
A client with chronic pain comes to the clinic for an evaluation. During the visit, the client asks the nurse about possibly using acupuncture for pain relief. Which response by the nurse would be most appropriate?
"Restoring the energy balance in your body could help with pain relief."
Which of the following client statements should the nurse evaluate as indicating the client's correct understanding of the causes of coronary artery disease (CAD)?
"The leading cause of CAD is atherosclerosis."
A nurse is planning the care for a client with a pressure ulcer. Which statements should the nurse include in the client's nursing care plan? Select all that apply.
"Use pressure-reduction devices." "Reposition every 1 to 2 hours." "Teach the family how to care for the wound." "Clean the area around the ulcer with mild soap."
A nurse is providing education to the family of a client scheduled for discharge. The client, who has severe cognitive impairments, is a recent quadriplegic. The family has questions about the need to perform range-of-motion of exercises with the client. What information should the teaching session include? Select all that apply.
"Use sheepskin pads in the bed and wheelchair." "Friction and shear increase a paralyzed client's risk of pressure ulcers."
The nurse is caring for a client admitted to the emergency department after being found lying on the bathroom floor with several empty pill bottles around her. While waiting for a psychiatric consult, the nurse discovers that the client's boyfriend has recently broken up with her. Which response is most likely is to build and maintain a therapeutic relationship within the emergency department?
"What can I do to help while you are here?"
A client receiving chemotherapy for metastatic colon cancer is admitted to the hospital because of prolonged vomiting. Assessment findings include irregular pulse of 120 bpm, blood pressure 88/48 mm Hg, respiratory rate of 14 breaths/min, serum potassium of 2.9 mEq/L (2.9 mmol/L), and arterial blood gas—pH 7.46, PCO2 45 mm Hg (6.0 kPA), PO2 95 mm Hg (12.6 kPa), bicarbonate level 29 mEq/L (29 mmol/L). The nurse should implement which prescription first?
5% Dextrose in 0.45% normal saline with KCl 40 mEq/L at 125 mL/h
A client with preeclampsia is prescribed magnesium sulfate to prevent seizure activity. The nurse is reviewing the results of the client's serum magnesium level and determines that the client's level is therapeutic based on which result?
6.8 mEq/L (3.4 mmol/L)
The nurse is assigned to care for four clients. Which client should the nurse assess first?
A client admitted one hour ago with new-onset atrial fibrillation who is receiving IV diltiazem
Which client, diagnosed with pneumonia, is most likely to have community-acquired pneumonia?
A client newly admitted to a long-term care facility
2/10/2017 1100 56-year-old client presents with sudden onset of stroke-like symptoms that started 45 minutes prior to admission. Presenting National Institute of Health Stroke Scale (NIHSS) Score = 20. Head CT negative for blood. Past medical history includes hypertension treated with an ACE inhibitor. Alteplase 68 mg IV, given over one hour. At the end of the alteplase infusion, the nurse notes that the client's tongue was swollen. What is the nurse's priority action?
Administer antihistamines, intravenous corticosteroids, and or epinephrine
A nurse and an unlicensed assistive personnel (UAP) are caring for four clients together on the telemetry unit. Which of the following nursing actions can safely be delegated to the UAP?
Applying electrodes in the correct position for ECG monitoring.
A float nurse is assigned to a surgical unit. The nurse is receiving 2 clients from the post anesthesia care unit (PACU) at the same time. When delegating tasks to other PACU personnel who are not known to the nurse, which question would be most important to ask?
Are you comfortable in performing the tasks being assigned?
A client in home hospice care verbalizes to her caregiver that she wants to meet with her minister. The caregiver, who does not want the minister to visit or to interact with the minister because of her different values and beliefs, asks the home health nurse how to handle this situation. To prevent further disagreement between the client and caregiver, what is the best recommendation for the nurse to implement?
Arrange for an alternative caregiver to be available for the client when the minister visits.
The mother of a two-year-old with epiglottitis states that she needs to pick up her older child from school. The two-year-old child begins to cry and appears more stridorous. What is the nurse's priority action?
Ask the mother if there's anyone else who can meet the older child
An amniotomy is performed on a client in labor. What is the priority nursing intervention following this procedure?
Assess fetal heart tones
The nurse is assessing a laboring client. The client suddenly screams and exclaims, "My baby is coming." What is the priority action by the nurse?
Assess for crowning
A nurse is caring for a client that received a colostomy 2 days ago. Which is the priority intervention?
Assess the drainage from the stoma.
A female client with anorexia nervosa is receiving care from her family after successfully completing the refeeding stage of treatment. Which nursing intervention takes priority at this time?
Assisting the family to work on the issues of autonomy and separation
The nurse is caring for a client who has been newly diagnosed with systemic lupus erythematosus (SLE). Which information would be included in a teaching plan that focuses on home care? Select all that apply.
Avoid exposure to sunlight. Keep exercise to a minimal level. Avoid over-the-counter (OTC) medications unless approved by the physician. Take rest periods as needed.
A client, recovering from a spinal cord injury, has a great deal of spasticity. Which medication would the nurse anticipate to relieve spasticity?
Baclofen
What is the nurse's priority to regulate the temperature of a neonate?
Block radiant, convective, conductive, and evaporative losses
A nurse calls the unit manager to report that her purse has been stolen from the locked break room. The nurse says she thinks she knows which of the staff stole the purse. Which actions by the nurse manager would be appropriate? Select all that apply.
Call hospital security to initiate an investigation. Ask the nurse to document all the facts related to the missing purse. Alert nursing administration that a staff's purse has been stolen. Ask other staff to report any suspicious activity they may have observed.
A neonate is admitted to the nursery following a long and difficult labor. Admission vital signs are temperature 96.5° F (35.8° C), heart rate 168 beats/minute, and respiratory rate 64 breaths/minute. After placing the neonate under the radiant heater, the nurse should take which action?
Check the neonate's blood glucose level.
What would be important environmental assessments for the home care nurse to explore with a client who is being discharged home?
Checking access to the home with a walker, access and safety measures in the bathroom, and access to food preparation in the kitchen, and ensuring safety in the sleeping environment
A client with a history of cocaine abuse is receiving intravenous therapy and exits the hospital "to visit a friend." The client returns to the nursing unit 1 hour later, agitated, aggressive, combative, and reporting "chest pain." Place the nurse's actions in priority order from first to last. All options must be used.
Contact the security department. Obtain an ECG. Obtain a urine sample. Initiate a referral to obtain drug rehabilitation counseling.
What is a priority for the nurse developing a plan with a client admitted to the hospital with an acute exacerbation of rheumatoid arthritis?
Continuing to work on a positive self image because joint deformities are common in this disease
A hospital client has told the nurse that his religion involves the burning of incense and has asked permission to do so on the unit. The nurse is aware that this practice would violate the hospital's fire regulations. What is the nurse's best action?
Dialogue with the client about alternative rituals or the possibility of performing the ritual outdoors.
The nurse is admitting a hospital client who does not speak English and who is accompanied by the client's school-aged child. The client appears to be in pain, but the nurse is unable to assess the character or history of the client's pain. How should the nurse best communicate with the client?
Enlist the help of a hospital interpreter; ask the son to translate if none is readily available.
A nurse from a surgical unit is asked to work on the pediatric unit during a staffing shortage. The surgical nurse has not worked in pediatrics for 10 years and is not familiar with the unit. The surgical nurse approaches the nurse manager and claims not to be competent to work on the pediatric unit. What should the nurse manager do?
Find another nurse to cover the unit and send the nurse back to the surgery unit.
Liquid oral iron supplements have been prescribed for a child. What is the most important information for the nurse to provide to this child's parents?
Give the medicine via a dropper or through a straw
A mother calls the health clinic and tells the nurse that she found her toddler with an open and empty bottle of acetaminophen. The mother asks the nurse what she should do. What is the nurse's priority intervention?
Give the mother instructions on how to call poison control
A client is scheduled for amniocentesis. What priority intervention should the nurse implement?
Have the client void
An infant in the newborn nursery goes into cardiac arrest and needs to be resuscitated. The resuscitation cart was not restocked properly by the nurses on the unit after an earlier arrest, and critical supplies are missing. The baby sustains brain damage as a result of delays in obtaining needed supplies. How does the nurse manager address this situation?
Hold the nurses responsible because hospital procedure was not followed.
A client arrives at the emergency department with severe chest pain and shortness of breath. The client is diaphoretic, pale, and weak. Suddenly, the client collapses and becomes unresponsive. What is the priority action by the nurse?
Initiate chest compressions before ventilations.
A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?
Irrigate the wounds with water.
In the hospital setting, the daughter of a man who is dying tells the nurse, "It is hard to just sit with my father for hours and not say or do anything." As the nurse responds to the daughter's statement, what issue is most important for the nurse to focus on during their discussion?
Know that being present with the person is important.
A laboring client in the latent stage of labor begins reporting pain in the epigastric area, blurred vision, and a headache. Which medication would the nurse anticipate for these symptoms?
Magnesium sulfate
The nurse is caring for a client with gestational trophoblastic disease (GTD). Which of the following interventions will the nurse include in the client's plan of care? Select all that apply.
Measure fundal height. Administer ondansetron IV.
A 4-month-old infant has been carried into the emergency department after falling off his parents' bed and hitting his head on the floor. What should the nurse do next?
Move the family to an area where an assessment can be completed and call for a physician.
A nurse who works in a community-based clinic is implementing primary prevention with the clients who use the clinic. What should the nurse include in primary prevention activities?
Obtaining a rubella titer on a woman who is planning to start a family
A nurse is working with an unlicensed assistive personnel (UAP). Which clients should the nurse assign to the UAP? Select all that apply.
Older adult client who had hip replacement surgery and needs to walk in the hall with a walker. Adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours.
A nurse and an LPN are working in the labor and birth unit. Of the activities that must be done immediately, which should the nurse assign to the LPN?
Perform a straight catheterization for protein analysis.
A nurse is developing a care plan for a client with disseminated intravascular coagulation (DIC). Which nursing intervention should the nurse include?
Place a pressure-reducing mattress on the client's bed.
A nurse is caring for a client exhibiting mild contractions and a cervical dilation of 4 cm. Using an external fetal monitor, the nurse observes variable decelerations. Which action should the nurse take first?
Place the client on her left side
A young woman is admitted for surgical treatment of genital lesions. What should the nurse identify as an important part of care for this client?
Provide a chaperone or assistant in her care whenever possible.
A nurse notes the following laboratory values for a client receiving chemotherapy: white blood cell count 6000/µL, red blood cell count (RBC) 3.7 million cells/cm3, hematocrit 35%, platelet count 80,000 mm3. Which order would the nurse question?
Rectal temperatures every 4 hours
The nurse is reviewing the lab report for a client in hospice care with breast cancer and brain metastasis. According to the information in the chart, what should the nurse do next?
Report the elevated calcium level immediately.
A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse?
Report the incident to risk management
A nurse suspects an infant may have a tracheoesophageal fistula or esophageal atresia. What is the most important intervention by the nurse?
Report the suspicion to the health care provider
The nurse is caring for a client who has been intubated. What is the nurse's priority intervention?
Reposition the endotracheal (ET) tube every 24 hours
A client has been diagnosed with dementia related to chronic and heavy alcohol consumption. In a family meeting with the client, discharge plans are being discussed. Which points should the nurse share with the family and client? Select all that apply.
Safety alarms on the doors will keep the client from wandering off. As the need for supervision increases, it may be necessary for the client to be placed in an extended-care facility.
A client presents at the health care provider's office with gray-brown burrows with epidermal curved ridges and follicular papules of the skin. The health care provider diagnoses scabies. Which teaching points would a nurse review with the client? Select all that apply.
Scabies is transmitted by close person-to-person contact or contact with infected linens and clothing. Severe itching of the affected areas, especially at night, is a common finding. All of the client's linens and clothing should immediately be washed in hot water.
A client with chronic back pain is admitted to the medical-surgical floor and is receiving multiple pain medications and an antidepressant for pain control. The physician's orders include a physical therapy consult for ambulation and back strengthening, magnetic resonance imaging (MRI) of the lumbar spine, and a computed tomography (CT) scan of the abdomen. How should the nurse schedule therapy and diagnostic tests?
Schedule the MRI of the lumbar spine first, then the physical therapy consult, and then the CT scan.
Which nursing assessment data would be given priority for a child with clinical findings related to tubercular meningitis?
Signs of increased intracranial pressure (ICP)
The nurse is ambulating a client. The client experiences chest pain after ambulating 50 feet. What is the nurse's priority intervention?
Sit the client down
A client with heart failure has been receiving an I.V. infusion at 125 ml/hour. Now the client is short of breath and the nurse notes bilateral crackles, jugular vein distention, and tachycardia. What should the nurse do first?
Slow the I.V. infusion.
A client was admitted to the hospital 2 weeks ago following an ischemic stroke. Following the early introduction of stroke rehabilitation, he has seen significant improvements in both his medical status and activities of daily living (ADLs). This morning, however, his nurse notes that the client has been coughing since eating a minced and pureed breakfast. Auscultation of the chest reveals coarse crackles. Which of the following practitioners should the nurse liaise with to obtain a swallowing assessment?
Speech therapist.
A client has a tracheostomy. Which nursing action would prevent complications of suctioning?
Sterility of suction catheter
To reduce the risk of laryngeal cancer in employees in a factory that uses respiratory irritants, what instructions should the nurse give the employees? Select all that apply.
Stop smoking. Limit alcohol use.
Which recommendation would be most helpful to suggest to a primigravid client at 37 weeks' gestation who has leg cramps?
Straighten the knee and flex the toes toward the chin.
The nurse is attending a family meeting where a recent immigrant's treatment plan is being discussed. The client is a retired English teacher and defers to the oldest son when the care team asks the client questions. How should the nurse best interpret the client's action?
The client's action may reflect cultural and familial norms.
A client on the adolescent psychiatric unit was admitted with a diagnosis of body dysmorphic disorder. The client has not been able to attend school or his/her part-time work over the past year as a result of certain body obsessions. Recently, the client shaved the hair all over his/her body, claiming, "It is all growing weird." What component of therapy would be most important for the nurse to apply to this client?
The client's body image is real to the client.
A nurse is caring for a client with a nursing diagnosis of fluid volume deficit related to impaired thirst mechanism. Which outcome would the nurse determine as most appropriate for this client?
The client's intake and output are balanced.
A 62-year-old client who has smoked 2 packs of cigarettes per day for the last 10 years is admitted with a diagnosis of lung cancer. She reports having "no appetite" and exhibits symptoms of anorexia. The client is 5 feet, 8 inches (173 cm) tall and weighs 112 lb (50.8 kg). The client is now scheduled for a left lung lobectomy. The nurse should include which factor when planning to prevent postoperative pulmonary complications?
The client's weight relative to her height is low.
The registered nurse (RN) is referred to a client's home when a husband and wife have been confirmed to have scabies. The family asks, "How will we get rid of this?" When instructing on the proper procedure to wash contaminated clothing and sheets, which nursing instruction is a priority?
Use hot water throughout wash cycle.
Which physical assessment data would alert the nurse to a possible mild toxic reaction in a client receiving lithium?
Vomiting and diarrhea
The nurse is caring for a client with peripheral artery disease who has just returned from having a percutaneous transluminal balloon angioplasty. Which finding requires immediate attention from the nurse?
a change in the intensity of the pulse from the baseline
A primigravid client visits the clinic for a routine examination at 35 weeks' gestation. The client's blood pressure is near the baseline of 120/74 mm Hg with no proteinuria or evidence of facial edema. The client asks the nurse, "What should I take if I get an occasional headache after looking at my computer at work all day?" The nurse instructs the client that she can occasionally take which over-the-counter medication?
acetaminophen
A client, diagnosed with asthma, is experiencing an anaphylactic reaction to a medication. After administering initial emergency care, the nurse would:
administer bronchodilators.
Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution?
anaphylactic reaction
A parent asks the nurse if medications can cause Reye syndrome. The nurse's most appropriate response is that Reye syndrome has been connected to:
aspirin.
A charge nurse is making assignments for a team that includes two registered nurses (RNs) and one unlicensed assistive personnel (UAP). One client requires a nurse to perform several complex procedures. The charge nurse should:
assign fewer clients to the RN managing this client's care.
The nurse teaches a client who has recently been diagnosed with hypertension about following a low-calorie, low-fat, low-sodium diet. Which menu selection would best meet the client's needs?
baked chicken, an apple, and a slice of white bread
The nurse is preparing to administer the last dose of ceftriaxone before discharge to a 1-year-old but finds the the IV has occluded. The nurse should:
contact the prescriber to request a prescription change.
The wife of a client with alcohol dependency tells the nurse, "I am tired of making excuses for him to his boss and coworkers when he cannot make it into work. I believe him every time he says he is going to quit." The nurse recognizes the wife's statement as indicating which behavior?
enabling
A client discusses with the nurse the possibility of using alternative therapies for management of hypertension and diabetes. Which is an expected alternative therapy used by the client?
ginseng
The client with hepatitis A is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. The most appropriate goal for this client is to:
gradually increase activity tolerance.
A charge nurse is completing client assignments on a neurologic unit. One full-time nurse from the unit, two floating nurses, and one agency nurse are present for the shift. The charge nurse should assign the unit's full-time nurse to care for the client who:
had a craniotomy 24 hours earlier for a brain hemorrhage.
A client was discharged from an alcohol rehabilitation program on clonazepam 0.5 mg three times a day. Several months later he reports having insomnia, shakiness, sweating, and one seizure. The nurse should first ask the client if he:
has stopped taking the clonazepam suddenly.
A group of nurses are working to develop a program to address risk reduction strategies for major causes of mortality in the community. The community is made up largely of African Americans. To ensure that the program addresses the health needs of this population, the group would develop strategies focusing on which condition as the priority?
heart disease
The client has had a gastric resection, and is having difficulty clearing the airway of mucus. The nurse should determine if the client has:
incisional pain.
The nurse is assessing a middle-aged client with cancer who has lost 1 lb (0.5 kg) in 4 weeks. The client is taking ondansetron for nausea and now has a temperature of 101° F (38.3° C). The fever is indicative of:
infection.
A client in a long-term nursing care facility who decides to be placed on hospice care expresses to the nurse, "I have outlived my family and friends; I have lost hope and there is no need for me to continue on." What underlying client concerns would the nurse first address with this client?
loneliness and feelings of isolation
A 34-year-old multiparous client at 16 weeks' gestation who received regular prenatal care for all of her previous pregnancies tells the nurse that she has already felt the baby move. How does the nurse interpret this finding?
normal because multiparous clients can experience quickening between 14 and 20 weeks' gestation
A client receiving chemotherapy for cancer has an elevated serum creatinine level. The nurse should next:
notify the HCP.
To help prevent hip flexion deformities associated with rheumatoid arthritis, the nurse should help the client assume which position in bed several times a day?
prone
The nurse is conducting a health assessment of an older adult. The client tells the nurse about cramping leg pain that occurs when walking for 15 minutes; the pain is relieved with rest. The lower extremities are slightly cool to touch and pedal pulses are palpable +1. The nurse should instruct the client to:
seek consultation from the health care provider (HCP).
A 29-year-old woman is concerned about her personal risk factors for malignant melanoma. She is upset because her 49-year-old sister was recently diagnosed with the disease. After gathering information about the client's history of sun exposure, the nurse's best response would be to explain that:
some melanomas have a familial component and she should seek medical advice.
The grandmother of an Asian client with a diagnosis of Zika virus is distressed and tells the nurse, "My granddaughter must be served cold foods because she has a hot illness and we must get her body in balance." When the nurse consults the dietitian, what foods would be suggested for inclusion in the client's daily meals? Select all that apply.
steamed fish green vegetables citrus fruits
A cerclage procedure is performed on a client at 20 weeks' gestation who is diagnosed with cervical incompetence. When preparing the discharge teaching plan, the nurse should expect to instruct the client to monitor herself for which problem?
symptoms of infection
While admitting a client to the alcohol treatment program, the nurse asks the client how long she has been drinking, how much she has been drinking, and when she had her last drink. The client replies that she has been drinking about a liter of vodka a day for the past week and her last drink was about an hour ago. This information helps the nurse to determine which factor?
the severity of withdrawal symptoms
The single parent of a young teenager is being treated for complicated bronchitis at a small rural hospital. The mother does not live in the area and has a poor command of English. The facility is experiencing delays in accessing a translator. In considering whether to allow the teenager to translate medical information for his mother, the nurse should consider that:
these circumstances may allow the child to translate.
A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation?
urine output of 30 mL/h
A client at risk for lung cancer asks about the reason for having a computed tomography (CT) scan as part of the initial exam. What is the nurse's best response? "A CT scan is:
useful for distinguishing small differences in tissue density and detecting nodal involvement."
In providing discharge teaching for the client after a modified radical mastectomy, the nurse should instruct the client to avoid:
working in her rose garden.
