The Point-LWW MOCK NCLEX

Which statement by the nurse accurately explains the need for a client with hypertension to obtain an annual eye exam?

"By examining the retina in your eyes, an ophthalmologist can detect changes in the arteries in your eyes."

The nurse is caring for a client on the orthopedic unit. When preparing the client for discharge, which instructions should the nurse reinforce after surgical repair of a hip fracture?

"Do not flex the hip more than 90°, do not cross your legs, and get help putting on your shoes."

Which statement by a client with sickle cell disease indicates further education is needed to reinforce the therapeutic regimen?

"I should take one baby aspirin daily to help prevent sickle cell crisis."

The nurse is reviewing a client's plan of care. The following statement appears on the client's plan of care: "Client will ambulate in the hall without assistance within 4 days." What does the nurse recognize this statement as an example of?

A client outcome

A 62-year-old male client with schizophrenia tells a nurse that he sexually molests his cousin. He tells the nurse that he's never told anyone and begs her to keep his secret. Which action should the nurse take?

Document the details of the conversation and notify the nursing supervisor.

A 2-year-old child comes to the emergency department with inspiratory stridor and a barking cough. What is the highest priority action by the nurse?

Establish and maintain the airway.

The nurse is planning to discharge a 24-year-old gravida 1, para 1, non-English-speaking Hispanic client. Which nursing intervention takes priority?

Locating a staff member who can interpret the discharge instructions.

A 76-year-old client with no debilitating conditions belongs to which geriatric population?

Middle-old

A client is in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?

Pick up the implant with long-handled forceps and place it in a lead-lined container.

A nurse is caring for a client admitted with a diagnosis of multiple myeloma. Which nursing intervention is most appropriate for this client?

Prevent bone injury.

The nurse cares for a client who is post-op bowel resection and has a nasogastric (NG) tube to low intermittent suction. Which care intervention should the nurse administer?

Provide meticulous mouth care as needed.

A client comes to the clinic and informs the nurse they may have been exposed to a family member with tuberculosis. The nurse administers the tuberculin skin test, and 2 days later the test is positive. What does the nurse determine the results mean?

The client had presence of infection at some point.

A 2-year-old child is diagnosed with bronchiolitis caused by respiratory syncytial virus (RSV). The client has an 8-year-old sibling. Which statement is correct?

The siblings should be separated to prevent the spread of the infection.

The nurse is preparing to administer an intramuscular (I.M.) injection to a 6-month-old infant. Which appropriate site would the nurse inject the infant? Vastus lateralis muscle Ventrogluteal area Deltoid muscle Gluteus maximus muscle

Vastus lateralis muscle Explanation: The nurse should administer an I.M. injection to a 6-month-old infant in the vastus lateralis muscle. The ventrogluteal area should be used only after the child has been walking for about a year. The deltoid and gluteus maximus muscles aren't appropriate injection sites in children.

A nurse is preparing a client for a stress test. Which is an appropriate nursing intervention?

Verify that a consent form has been signed.

A nurse reviews a client's medical record and notes that a physician ordered an indwelling urinary catheter due to client's urine retention. Which action should the nurse perform first?

Verify the client's identity.

The nurse must administer a liquid medication to an infant. Which step should the nurse take first?

Verify the physician's order.

Which of the following clients should the nurse question about their signed consent form for surgery?

a 54-year-old client with a fractured femur committed to a mental health unit

The nurse is caring for a client with acute renal failure. Rank in chronological order the phases of acute renal failure. Use all the options.

initial insult oliguric phase diuretic phase recovery phase

When caring for a neonate of a mother with diabetes, which physiologic finding is most indicative of a hypoglycemic episode?

jitteriness

A nurse is caring for a neonate with congenital hypothyroidism. Which data should the nurse anticipate ?

puffy eyelids

A client returns to the acute care unit after abdominal surgery. Which measure should the nurse perform first that will help reduce or prevent the incidence of atelectasis?

use of an incentive spirometer

The nurse is preparing to administer an immunization to a 2-month-old child. The child's parent states, "I am going to put off the immunizations because I hate to see my child hurt." Which response by the nurse is most appropriate?

"Although your baby will feel discomfort now, it will be short lived."

A licensed practical nurse (LPN) is assisting with the admission of a client to the medical-surgical unit. While gathering data about the client, the LPN asks the client if an advance directive has been prepared. The client responds, "I don't know what you mean." Which response by the nurse would be most appropriate?

"An advance directive is a document that states your wishes about health care."

A client comes to the clinic for right shoulder pain. The nurse observes bruises resembling fingerprints on several areas of the right arm and bruising on the back. The client has a history of similar injuries in the past. What questions would be important for the nurse to ask? Select all that apply.

"Are you in a relationship that makes you afraid or unsafe?" "People in relationships argue. What happens when you and your partner argue?" "If you are in danger now, would you like help in locating a shelter?"

The parents of a 9-year-old child in the terminal phase of a fatal illness ask the nurse for guidance in discussing death with their child. Which response is appropriate?

"At this developmental stage, most children have an adult concept of death and should be encouraged to discuss it."

A nurse is reinforcing home care instructions for a client who has recently had a skin graft. Which instruction is appropriate for the nurse to give the client?

"Cover the area when in direct sunlight."

The nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether the client is at risk for a TORCH infection, the nurse should ask: "Have you ever had osteomyelitis?" "Do you have any cats at home?" "Do you have any birds at home?" "Have you recently had a rubeola vaccination?"

"Do you have any cats at home?" Explanation: TORCH refers to Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes simplex virus, agents that may infect the fetus or neonate, causing numerous ill effects. Toxoplasmosis is transmitted to humans through contact with the feces of infected cats (which may occur when emptying a litter box), through ingesting raw meat, or through contact with raw meat followed by improper hand washing. Osteomyelitis, a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola aren't TORCH infections.

A client arrives at the clinic for a scheduled amniocentesis. Which question should the nurse ask?

"Have you emptied your bladder?"

An oncology clinic nurse is reinforcing prevention measures for oropharyngeal infections to a client receiving chemotherapy. Which statement by the client indicates an understanding of the nurse's teaching?

"I clean my teeth gently several times a day."

A client diagnosed with systemic lupus erythematous (SLE) is experiecing an exacerbation. Which statement made by the client indicates further education should be reinforced?

"I don't have to worry if I get strep throat."

A client is admitted to the behavioral health unit for treatment of pedophilia and tells the nurse that the client doesn't want to talk about sexual behaviors. Which response from the nurse is most appropriate?

"I know this must be difficult for you."

A client is admitted for pneumonia secondary to human immunodeficiency virus (HIV). The nurse asks unlicensed assistive personnel (UAP) to give the client a bed bath. The UAP is hesitant to bathe the client for fear that he or she will contract the virus. Which statements would be most appropriate for the nurse to include in the response? Select all that apply.

"I know you're frightened, but by taking proper precautions, there's little to no risk of acquiring HIV." "The use of personal protective equipment (PPE) may prevent the unintentional transmission of diseases in situations where you may come in contact with blood, body fluids, or secretions."

The nurse is reinforcing education for a client diagnosed with gastroesophageal reflux disease (GERD) regarding preventative measures to reduce symptoms. What statement made by the client requires further reinforcement?

"I should lie flat after I eat my meals."

A client needs to have a fecal occult blood test performed on three consecutive bowel movements. To prepare the client for this test, the nurse provides information about the required dietary restrictions. The nurse knows the teaching has been successful when the client makes which statement?

"I should not eat any poultry, red meat, and turnips for 4 days before I begin this test."

A nurse has instructed a client about taking ferrous sulfate liquid preparation. Which statement by the client indicates the need for additional education?

"I should take the iron with an antacid to prevent gastric distress."

Propranolol has been prescribed for a teen who has been diagnosed with hypertension. When discussing the medication with the teen, which statement indicates the need for further instruction?

"I should take this medication daily on an empty stomach."

Which statement by the client best indicates an understanding on how to prevent complications while taking warfarin?

"I should use a soft toothbrush."

A nurse is reinforcing education with a client who has hypertension. The nurse recognizes that the education has been effective when the client makes which statement? "I shouldn't adjust my medication without my health care provider's advice." "I can stop taking my medication when I no longer have headaches." "I should stop taking my medication if I have adverse effects." "I only have to take the medication when I feel bad."

"I shouldn't adjust my medication without my health care provider's advice." Explanation: Medication for blood pressure control must not be adjusted or stopped without primary care provider approval. Any medication changes require close monitoring of the client. Medication must be continued on a regular schedule, or the client's blood pressure will rise. Therefore, client teaching has been ineffective when the client states that (a) the medication may be discontinued when the headaches cease, or (b) medication should be taken when the client feels bad. If serious adverse effects occur, the client should notify the health care provider. Other medications can be substituted without the adverse effects.

The nurse is reinforcing discharge instructions to a client with chronic cholecystitis. Which response by the client indicates the education has been effective?

"I will take my anticholinergic medications as prescribed."

The nurse is reinforcing teaching instructions to a client with trigeminal neuralgia on how to minimize pain episodes. Which comments by the client would indicate correct understanding of instructions? Select all that apply.

"I'll chew food on the unaffected side." "I'll drink fluids at room temperature." "I'll perform mouth care after meals.

A 78-year-old client with type 2 diabetes needs a kidney transplant. The client's daughter volunteers to donate a kidney, but the client voices concerns about her daughter's health to the nurse. Which response by the nurse is appropriate?

"I'll notify your physician of your concerns and see if he can discuss the procedures with you."

A client with dependent personality disorder is working to increase self-esteem. Which statement by the client shows that the education was successful?

"I'm not just going to look at the negative things about myself."

When determining a client's knowledge of symptoms to report during pregnancy, which statements would indicate to the nurse that the client understands the information given? Select all that apply.

"If I have blurred or double vision, I should call the clinic immediately." "If it takes longer than two hours for the baby to move ten times, I should call my doctor."

A nurse is caring for a cleint with non-Hodgkin's lymphoma. Which statement indicates that the client diagnosed with non-Hodgkin's lymphoma needs further reinforcement from the education plan? "I know this all started when I felt that lump in my underarm." "Lymph tissue is in the spleen and bone and marrow." "Lymph tissue keeps the immune system in working condition." "If I stay healthy and eat right, I can cure this disease."

"If I stay healthy and eat right, I can cure this disease." Explanation: Non-Hodgkin's lymphoma cannot be cured by staying healthy. Medical treatments are prescribed to stop the disease progression. A lump can indicate a swollen lymph gland and maybe a sign of lymphoma. Lymph tissue is in the spleen and bone marrow. Lymph tissue makes lymphocytes and other immune system cells.

The nurse is meeting with a 17 year-old client who has recently tested positive for human immunodeficiency virus (HIV). The client states, "What information will be disclosed to others." What information should be provided by the nurse?

"In some jurisdictions laws may require you share this information with future sexual partners."

A 2-year-old child is admitted through the emergency department with a suspected diagnosis of Hirschsprung's disease (aganglionic megacolon). The parent asks about treatment of the disease. What would be an appropriate response from the nurse?

"Initially the child will have a temporary colostomy; later a second operation removes the abnormal part of bowel and reattaches the normal bowel down to the rectum."

A client asks the nurse why he needs to apply a cold pack on a sprained ankle. Which response would be most appropriate?

"It constricts local blood vessels and decreases swelling."

The nurse is providing teaching for a client with hepatitis A. Which statement by the client indicates the need to reinforce the teaching?

"It is all right to French kiss my partner."

A newly hired graduate nurse is caring for a client prescribed a carminative enema. When discussing the plan of care with the nurse mentor, which appropriate information would the graduate state that provides an understanding of a carminative enema?

"It is given into the rectum to help expel flatus to relieve distention."

A nurse is caring for a client with otosclerosis who is scheduled for stapedectomy. The client asks the nurse when the client's hearing will improve. Which response by the nurse is most appropriate?

"It might take as long as 6 weeks for your hearing to improve."

During admission data collection, the nurse asks the client about an advance directive. The client's family member states, "Why is this important when my mother is only here for a short stay?" Which response would the nurse give to help the client and family gain a better understanding of an advance directive? "You never know, something may happen even if it is a short stay." "It provides guidelines for making decisions in the event your mother is unable to make her medical decisions." "It makes sure that you do not create a scene in the case your mother becomes too sick to make medical decisions." "We ask everyone this question, no matter how long they stay."

"It provides guidelines for making decisions in the event your mother is unable to make her medical decisions." Explanation: An advance directive provides guidelines in the event the client becomes incapacitated and is unable to make his or her wishes known. The advance directive is asked of everyone but this response does not fully explain why it is asked. It is not used to prevent family members from making a scene in case the client is incapacitated. Telling the family member anything can happen is inappropriate and does not address the question.

A client who gave birth vaginally 16 hours ago states she doesn't need to void at this time. The nurse reviews the documentation and finds that the client hasn't voided for 7 hours. Which response by the nurse is indicated?

"It's common for you to have a full bladder even though you can't sense it."

The parents of a child diagnosed with leukemia have stated that they'll give aspirin to their child for pain relief. Which statement by the nurse about aspirin would be most accurate?

"It's contraindicated because it promotes bleeding tendencies."

The night nurse reports that a postpartum client is homeless, has poor hygiene, and has tested positive for the human immunodeficiency virus (HIV). The nurse assigned to care for the client requests that the assignment be changed because she's pregnant and doesn't want to risk exposure. Which response by the charge nurse indicates an understanding of the ethical responsibilities of a professional nurse?

"It's inappropriate to refuse this assignment; all clients should be treated equally."

A client diagnosed with major depression has started taking amitriptyline hydrochloride. The nurse is reviewing the instructions about this drug and potential adverse effects. The nurse determines that the client has a good understanding of the drug therapy based on which client statement?

"It's not unusual for this drug to make my mouth feel a bit dry."

A nurse is reinforcing education for the parents of a child who has been diagnosed with spina bifida. Which statement by the parents would indicate an understanding of spina bifida?

"Its presence indicates that many areas of the central nervous system (CNS) may not develop or function adequately."

After being admitted to the hospital with sickle cell crisis, a client asks a nurse how he can prevent another crisis. Which response by the nurse is best?

"Make sure that you drink plenty of fluids."

A nurse is caring for a client with newly diagnosed diabetes mellitus. Which information should the nurse reinforce in education sessions about dietary management of diabetes? "Eating too much sugar causes diabetes." "Sugar is primarily found in desserts." "A client with diabetes should stop eating sugary foods." "Meals should be eaten at consistent times each day."

"Meals should be eaten at consistent times each day." Explanation: Maintaining a regular eating pattern to avoid hunger and the temptation to snack on high-calorie foods is crucial for clients with diabetes. A client with type 1 diabetes needs to adjust insulin doses according to food intake throughout the day. A client with type 2 diabetes should limit total calories but should not skip meals. Diabetes results from inadequate insulin or improper insulin utilization to control glucose, not from eating too much sugar. Various amounts and forms of sugar are available in different foods, not just desserts. Clients with diabetes should be taught to scrutinize all food labels for sugar content. Not all sugars should be removed from a client's diet. For example, natural sugars found in fruits should be eaten, whereas concentrated sweets should be avoided.

The nurse is reinforcing education to a parent of a child with cerebral palsy. Which statement indicates that the education has been successful? "My child's muscles will get stronger." "My child's condition will get progressively worse." "My child will have low intelligence." "My child will need continual therapy to maintain functioning."

"My child will need continual therapy to maintain functioning." Explanation: The child with cerebral palsy needs continual treatment and therapy to maintain or improve functioning. Without therapy, muscles will get progressively weaker and more spastic. Although some children with cerebral palsy have an intellectual disability, many have normal intelligence.

A client is being discharged home with a diagnosis of hypertrophic cardiomyopathy (HCM). Which statement by the client best demonstrates an understanding of this disease process?

"Since this is a hereditary disorder, my family members should probably be evaluated for similar symptoms."

A nurse is reviewing infection-control measures with a group of unlicensed assistive personnel (UAP). Which statement made by one of the group members indicates learning goals have been met?

"Standard precautions should be used when performing client care."

A geriatric client is admitted to acute care following a fall. The client is only able to provide a name during the admission phase. The caretaker reports that the client is usually alert and oriented and expresses concern about the client's confusion. Which response is most appropriate?

"Stress related to an unfamiliar situation can cause short-term confusion in older adult clients."

After a nurse reinforces education with an adolescent about syphilis, which statement by the adolescent indicates the need for further education? "The disease is divided into four stages: primary, secondary, latent, and tertiary." "Affected persons are most infectious during the first year." "Syphilis is easily treated with penicillin or doxycycline." "Syphilis is rarely transmitted sexually."

"Syphilis is rarely transmitted sexually." Explanation: About 95% of the cases of syphilis are transmitted sexually. There are four stages to syphilis, although some people may only experience the first three stages. Affected persons are most contagious in the first year of the disease. The drug of choice for treating syphilis is penicillin or doxycycline.

A child ingests a caustic toilet bowl cleaner during a visit to a friend's house. The child's caregiver tells the nurse about feelings of guilt. What would be an appropriate response by the nurse?

"Tell me more about your feelings."

The nurse is gathering data from a newly admitted client. The client states, "I have been taking my high blood pressure medicine, but not like I am prescribed to take it." Which response is appropriate for the nurse to make in response to this information?

"Tell me what you mean by not taking the medicine as prescribed."

A child diagnosed with chickenpox is asked to stay home from school to avoid infecting other children. The caregiver of the child asks the nurse, "When is the infectious period?" What statement made by the nurse is most accurate?

"The client is infectious 1-2 days before the rash appears and until the blisters are crusted."

A newly hired graduate nurse asks her preceptor, "What is a common goal of discharge planning in all care settings?" How does the preceptor correctly respond?

"The goal is teaching the client how to perform self-care activities."

Preoperatively, the health care practitioner orders antiembolism stockings for a client scheduled for open heart surgery. The client asks the nurse what is the purpose of antiembolism stockings. How does the nurse appropriately responds?

"The stockings will reduce or prevent edema in your legs and feet."

Which statement would the nurse include when reinforcing education for a parent about salmon patches (stork bites)? "They're benign and usually fade in adult life." "They're usually associated with syndromes of the neonate." "They can cause mild hypertrophy of the muscle associated with the lesion." "They're treatable with laser pulse surgery in late adolescence and adulthood."

"They're benign and usually fade in adult life." Explanation: Salmon patches occur over the back of the neck in 40% of neonates and are harmless, needing no intervention. Laser pulse surgery is not recommended for salmon patches because they typically fade on their own in adulthood. Portwine stains are associated with Sturge-Weber syndrome. Port-wine stains found on the face or extremities may be associated with soft tissue and bone hypertrophy.

A 2-year-old child's parent informs the nurse of a concern that the child may have attention deficit hyperactivity disorder (ADHD) because "my child has so much energy, doesn't pay attention for long, and is always getting into things." Which response by the nurse would be best? "This behavior is normal. The child is exploring and learning about the world." "You should talk to your pediatrician. You have definite concerns." "Keep intake of sugar and sugary treats to a minimum." "I'd suggest going to a child psychologist for evaluation."

"This behavior is normal. The child is exploring and learning about the world." Explanation: It's normal for a 2-year-old child to eagerly explore the environment for new sensory experiences. Talking to the pediatrician is inappropriate because the nurse is assuming a corrective, parental role toward the parent without addressing concerns. Restricting the child's intake of sugar and sugary treats is incorrect because the nurse is making assumptions and recommendations that don't relate to the parent's concerns. Suggesting evaluation by a psychologist reinforces the parent's fear that something is wrong with the child.

During a prenatal visit, the nurse measures a client's fundal height at 19 cm. The client asks what does this mean. How should the nurse respond? "This measurement indicates that the fetus has reached approximately 12 weeks." "This measurement indicates that the fetus has reached approximately 19 weeks." "This measurement indicates that the fetus has reached approximately 24 weeks." "This measurement indicates that the fetus has reached approximately 28 weeks."

"This measurement indicates that the fetus has reached approximately 19 weeks." Explanation: The fundal height measurement in centimeters equals the approximate gestational age in weeks, until week 32. Thus, fundal height at 12 weeks is 12 cm; at 24 weeks, 24 cm; and at 28 weeks, 28 cm.

On admission to the psychiatric unit, a client with major depression reports that a family member is physically abusive and requests that the nurse not release any personal information to anyone. When the allegedly abusive family member calls the unit and demands information about the client's treatment, what is the nurse's best response?

"To protect clients' confidentiality, I can't give any information, including whether your relative is receiving treatment here."

A nurse is providing care for a pregnant client who asks how she can best deal with her fatigue. Which instruction would the nurse most likely reinforce with the client?

"Try to get more rest by going to bed earlier."

The nurse is reinforcing education for a client diagnosed with genital herpes. Which educational instructions should the nurse include to best prevent spread of the disease? Select all that apply.

"Use a separate towel to pat lesions dry and another to dry other parts of the body." "It is important to inform your partner of the disease."

A client and spouse are seeking treatment for infertility after having difficulty becoming pregnant. Which statement made by the client does the nurse determine is causing the most "stressful aspect of treatment"?

"We have to schedule sexual intercourse with our busy lives."

A homosexual client tells the nurse that "my family is not supportive." What is the best response by the nurse?

"What do you mean by not supportive?"

A 1-year-old infant is pale, but the physical examination is normal. Blood studies reveal a hematocrit of 24% (0.24). Which question by the nurse to the parents would be most useful in helping to establish a diagnosis of anemia?

"What's the infant's usual daily diet?"

A 1-year-old infant is pale, but the physical examination is normal. Blood studies reveal the infant's hematocrit is 24%. Which question by the nurse to the parents would be most useful in helping to establish a diagnosis of anemia?

"What's the infant's usual daily diet?"

An older adult client fractured a hip after a fall in the home and surgical correction is not an option due to comorbid factors. The client states to the nurse, "How will I ever get better? Which response by the nurse is best?

"What's your biggest concern right now?"

The parents of a 14-year-old child who underwent an atrial septal repair 5 days ago have asked if a few family members can visit. Which response by the nurse is appropriate?

"While controlling infection and promoting rest are important, a few visitors would not be a problem at this stage of recovery."

The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47 years. Following the American Cancer Society guidelines, what information would be the most important for the nurse to give the women? "All women should perform breast self-examination two to three times yearly." "Every woman should have a mammogram every 2 years beginning at age 40." "After the age of 50, you should have a hormonal receptor assay once yearly." "Women older than age 40 should have a mammogram and clinical examination every year."

"Women older than age 40 should have a mammogram and clinical examination every year." Explanation: The American Cancer Society guidelines state, "Women older than age 40 should have a mammogram annually and a clinical examination at least annually [not every 2 years]; all women should perform breast self-examination monthly [not annually]." The hormonal receptor assay is done on a known breast tumor to determine whether the tumor is estrogen- or progesterone-dependent.

The nurse is reinforcing education to an adolescent about sexually transmitted infection (STI). What statement made by the client indicates that further education is required? "You always know when you have gonorrhea." "The most common STI in kid's my age is chlamydia infection." "Most of the girls who have chlamydia don't even know it." "If you have symptoms of gonorrhea, they can show up a day or a couple of weeks after you got the infection to begin with."

"You always know when you have gonorrhea." Explanation: Gonorrhea can occur with or without symptoms. There are four main forms of the disease: asymptomatic, uncomplicated symptomatic, complicated symptomatic, and disseminated disease. All of the other statements by the adolescent about STIs are accurate.

A client is at her ideal weight when she conceives. During a prenatal visit 2 months later, she asks the nurse how much weight she should gain during pregnancy. What is the nurse's best response? "You should gain less than 10 lb." "You should gain 10 to 15 lb." "You should gain 16 to 24 lb." "You should gain 24 to 32 lb."

"You should gain 24 to 32 lb." Explanation: For a client entering pregnancy in her ideal weight range, a gain of 24 to 32 lb (11 to 15 kg) is adequate to meet her needs and the needs of her fetus. Weight gain below the recommended range predisposes the client to complications during pregnancy, labor, and delivery.

A client is prescribed haloperidol. When reinforcing the teaching plan about the drug, which instruction would the nurse emphasize?

"You should report feelings of restlessness or agitation at once."

An older adult client's husband tells the nurse he's concerned because his wife insists on talking about events that happened to her years ago. The nurse finds the client alert, oriented, and answering questions appropriately. Which statement made to the husband is correct?

"Your wife is reviewing her life."

A child is admitted with a diagnosis of croup. Which characteristic signs would the nurse monitor in this client? Select all that apply.

"barking" cough severe respiratory distress increased heart rate

A client arrives to the clinic with reports of a rash. The nurse observes the client and documents the lesion as a papule. What is the best way for the nurse to document this finding? 0.5-cm fluid filled lesion 0.5-cm red, flat pinpoint rash 0.5-cm elevated area 0.5-cm wheal

0.5-cm elevated area Explanation: Papules are elevated up to 0.5 cm, and nodules and tumors are masses elevated more than 0.5 cm. Erosions are characterized by loss of the epidermal layer. Macules and patches are nonpalpable, flat changes in skin color. Fluid-filled lesions are vesicles and pustules.

A client is ordered a dose of epoetin alfa to treat anemia related to chemotherapy. The recommended dose is 150 units/kg. The client weighs 60 kg. The vial is labeled 10,000 units/mL. How many milliliters of epoetin alfa should the nurse administer? Record your answer using one decimal place.

0.9

A health care provider's order reads: amoxicillin 500 mg capsules × 2 PO now, followed by 500 mg PO every 6 hours. How many grams of amoxicillin will the nurse administer as the initial dose? Record your answer as a whole number.

1

At a health fair, a woman, age 43, with a family history of osteoporosis asks the nurse how much calcium she should consume. The nurse tells her that the recommended daily calcium intake for premenopausal women is:

1,000 to 1,200 mg.

The nurse determines that a postpartum client's perineal pad weighs 100 g. The nurse should document this client's blood loss as: 50 ml 100 ml 150 ml 200 ml

100 ml Explanation: One gram of weight is approximately equivalent to 1 ml of fluid. Therefore, the blood loss estimate for a perineal pad weighing 100 g would be approximately 100 ml.

The physician prescribes an infusion of 2,400 ml of I.V. fluid over 24 hours, with half this amount to be infused over the first 10 hours. During the first 10 hours, the client should receive how many milliliters of I.V. fluid per hour?

120 ml/hour

Which of the following is the recommended immunization schedule for diphtheria, tetanus, acellular pertussis (DTaP)? Birth, 2 months, 6 months, 15 to 18 months, and 10 to 12 years 1 month, 2 months, 6 months, 15 to 18 months, and 4 to 6 years 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years Birth, 3 months, 6 months, 12 months, and 4 to 6 years

2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years Explanation: According to the American Academy of Pediatrics, the DTaP vaccine should be administered at 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years (before the start of school). The other options are incorrect.

The nurse is caring for a client who underwent internal fixation of the right hip. Before administering the client's warfarin, the nurse checks the laboratory report for the client's International Normalized Ratio (INR) results. Which indicates the therapeutic range for this client?

2.0 to 3.0

The nurse is caring for a child with a urinary tract infection. The health care provider has ordered cephalexin 125 mg by mouth every 8 hours. Cephalexin is available 250 mg per 5 mL. How many milliliters should the nurse administer per dose? Record your answer using one decimal place.

2.5

A 22 lb (10 kg) child is diagnosed with Kawasaki disease and started on gamma globulin therapy. The health care provider orders an IV infusion of gamma globulin, 2 g/kg, to run over 12 hours. How many grams should the nurse give the client? Record your answer using a whole number.

20

A client sustained burns to the entire back and left arm. Using the Rule of Nines, calculate the percentage of burns on this client's body.

27%

A client is diagnosed with genital herpes simplex. Concerned about spread of the virus to others, the nurse questions the client about recent sexual activity. What is the average incubation period for localized genital herpes simplex infection?

3 to 7 days

The nurse receives a health care provider's order to administer 1,000 mL of intravenous (IV) normal saline solution over 8 hours to a client who recently had a stroke. What should the drip rate be if the drop factor of the tubing is 15 gtt/mL? Record your answer using a whole number.

31

The nurse measures a client's temperature at 102° F. What is the equivalent Centigrade temperature?

38.9° C

A nurse is to administer 1,000 ml of normal saline over 6 hours to a client in labor. The drip factor of the IV administration set is 15 drops/ml. What is the rate of the infusion?

42 drops/minute

The health care provider prescribes 60 mEq of potassium chloride liquid as a one-time dose. The pharmacy supplies a liquid containing 20 mEq/15 ml. How many milliliters will the nurse administer? Record your answer using a whole number.

45

A nurse is teaching a women's group about ovarian cancer. Which client is at the highest risk for this disease?

45-year-old client who has never been pregnant

A 10-year-old client with asthma is prescribed 2 mg of albuterol syrup four times per day. The syrup comes in a dosage strength of 2 mg/5 ml. How many milliliters of syrup should the nurse administer? Record your answer using a whole number.

5

A client undergoing treatment for an anxiety disorder is being cared for by a nursing student. The nursing faculty asks the student When is such a disorder considered chronic and generalized? What timeframe does the student provide about the existence of the client's "excessive anxiety and worry about two or more life circumstances"?

6 months

The nursing instructor asks a nursing student approximately how much time is required for the blastocyst to reach the uterus for implantation. What timeframe does the student provide to the instructor?

7 days

A client is 33 weeks' pregnant and has had diabetes since age 21. When checking the fasting blood glucose level, which value would indicate the client's disease is controlled? 45 mg/dL (2.5 mmol/L) 85 mg/dL (4.7 mmol/L) 120 mg/dL (6.67 mmol/L) 136 mg/dL (7.56 mmol/L)

85 mg/dL (4.7 mmol/L) Explanation: The recommended fasting blood glucose level in the pregnant client with diabetes is 60 to 95 mg/dL (3.33 to 5.28 mmol/L). A fasting blood glucose level of 45 mg/dL (2.5 mmol/L) is low and may result in symptoms of hypoglycemia. A blood glucose level below 120 mg/dL (6.67 mmol/L) is recommended for 2-hour postprandial values. A blood glucose level above 136 mg/dL (7.56 mmol/L) in a pregnant client indicates hyperglycemia.

A nurse is caring for the following clients who have a history of genital herpes infection. Which client is most at risk for an outbreak of genital herpes?

A client who reports genital pruritus and paresthesia

A nursing assistant is assisting a nurse with feeding clients. Which client should the nurse assign to the nursing assistant?

A client with bilateral blindness

Which of the following effects is an advantage of the antipsychotic medication risperidone?

A lower incidence of extrapyramidal effects

The nurse assesses a neonate with esophageal atresia for signs of dehydration. Which finding should the nurse expect to see?

A sunken anterior fontanel

A clinical nurse specialist (CNS) is orienting a new licensed practical nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. A well-informed new graduate would know the greatest likelihood of an acute hemolytic reaction would occur when giving:

A-positive blood to an A-negative client.

A 19-year-old client with cystic fibrosis is admitted to the hospital in acute respiratory distress. The client's mother tells a nurse that the client has been unable to get out of bed for the past month. While assessing the client, the nurse notes a stage II pressure ulcer on the client's sacrum. Which action is most important to include in the client's plan of care?

Accurately document the appearance, size, location, and odor of the wound, and consult a wound care nurse.

The physician diagnoses leukemia in a child, age 4, who reports being tired and sleeps most of the day. Which nursing diagnosis reflects the nurse's understanding of the pathophysiology behind leukemia?

Activity intolerance related to anemia

Which nursing diagnosis should the nurse expect to see in a plan of care for a client in sickle cell crisis?

Acute pain related to sickle cell crisis

For which rationale, when administering a Z-track injection, the nurse measures the correct medication dose and then draws a small amount of air into the syringe?

Adding air prevents the drug from flowing back into the needle track.

A client arrives in the emergency department reporting squeezing, substernal pain that radiates to the left shoulder and jaw. The client also reports nausea, diaphoresis, and shortness of breath. What nursing action is a priority?

Administer O2, attach a cardiac monitor, take vital signs, and administer aspirin and sublingual nitroglycerin.

A client is admitted with acute osteomyelitis that developed after an open fracture of the right femur. When planning this client's care, the nurse should include which measure?

Administering large doses of I.V. antibiotics as prescribed

The nurse documents, "The client described her husband's abuse in an emotionless tone and with a flat facial expression." When reviewing the documentation, the nurse recognizes this statement is describing which aspect of the client's disposition?

Affect

A client with chronic renal failure must restrict her fluid intake to 500 ml daily. Despite having reached the limit, the client is insisting that she have more fluid. Which intervention by a nurse is appropriate?

Allow her to have a piece of hard candy.

An elderly client, age 75, is admitted to the health care setting. In what manner will the nurse modify this client's data collection? Shortening it Talking in a loud voice Addressing the client by his first name Allowing extra time for this task

Allowing extra time for this task Explanation: When collecting data on an elderly client, the nurse should allow extra time to compensate for aging-related physiologic changes, should address the client respectfully rather than by his or her first name, and should give simple instructions. Talking in a loud voice is demeaning and assumes that the client has difficulty hearing, which may not be the case.

A client has an abnormal result on a Papanicolaou test. After admitting that she read her chart while the nurse was out of the room, the client asks what dysplasia means. Which definition should the nurse provide?

Alteration in the size, shape, and organization of differentiated cells

A nurse participating in planning care for a client who is in labor expects to monitor the client's blood pressure frequently. Why is this action important? Decreased blood pressure is a sign of maternal pain. Alterations in cardiovascular function affect the fetus. Blood pressure decreases at the peak of each contraction. Decreased blood pressure is the first sign of preeclampsia.

Alterations in cardiovascular function affect the fetus. Explanation: During contractions, blood pressure increases and blood flow to the intervillous spaces changes, compromising the fetal blood supply. Therefore, the nurse should frequently monitor the client's blood pressure to determine whether it returns to precontraction levels and allows adequate fetal blood flow. During pain and contractions, maternal blood pressure usually increases. Similarly, preeclampsia causes blood pressure to increase, not decrease.Alterations in cardiovascular function affect the fetus. Explanation: During contractions, blood pressure increases and blood flow to the intervillous spaces changes, compromising the fetal blood supply. Therefore, the nurse should frequently monitor the client's blood pressure to determine whether it returns to precontraction levels and allows adequate fetal blood flow. During pain and contractions, maternal blood pressure usually increases. Similarly, preeclampsia causes blood pressure to increase, not decrease.

The nurse is observing a new mother interact with her baby for the first time approximately 1 hour after the baby's birth. Upon receiving the baby, the mother begins to undress her baby. Which of the following should the nurse do?

Anticipate and support the behavior as a normal part of bonding.

Which scenario requires the licensed practical nurse (LPN) to notify the registered nurse (RN) immediately?

Apical pulse rate of 90 beats/minute with a radial pulse rate of 70 beats/minute

The nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do?

Apply an ice pack to her perineum.

A 10-year-old child falls, injures the left shoulder, and is taken to the emergency department. While the child waits to be seen by the primary health care provider, what is the priority nursing action?

Apply ice to the injured shoulder.

The nurse intervenes in the care of a client who is experiencing a postoperative wound evisceration. Which action should the nurse perform first?

Apply sterile saline moistened gauze over the area.

In the client with burns on the legs, which nursing intervention helps prevent contractures?

Applying knee splints

A nurse observes a coworker administering a medication several hours after it had been scheduled. When confronted, the coworker simply makes a dismissive joke and then charts the medication as given at the scheduled time. What should the witnessing nurse do? Place the actions in chronologic sequence. All options must be used.

Approach the coworker in a calm and professional manner. Request a private meeting to discuss the incident. Express concern and clearly inform the nurse the behavior is unethical. Encourage the nurse to take responsibility for these actions. Report the incident to the nurse-manager if resistance is noted.

A client is admitted for right leg vein ligation and stripping for varicose veins. Which nursing intervention postoperatively should the nurse include?

Ask the client to elevate the legs when sitting.

A nurse enters a postpartum client's room to collect data and observes the perineal pad is completely saturated with lochia rubra. Which action by the nurse is the priority?

Ask the client when she last changed her perineal pad.

A 2-month-old with a history of hydrocephalus is admitted to the pediatric unit with pneumonia. The infant's respiratory status deteriorates and the physician explains to the family that the infant requires intensive care. The grandmother convinces the parents to refuse transfer and institute comfort measures. Which action should the nurse take?

Ask to speak to the parents privately without the grandmother present.

The nurse is caring for a patient with diabetes who is lethargic and has developed rapid, deep respirations. Which action should the nurse take?

Assess glucose level.

Which is the highest priority performed by the nurse prior to completing this nursing action?

Assess stomach residual.

During the first 24 hours after a client is diagnosed with addisonian crisis, which task should the nurse perform frequently?

Assess vital signs.

The nurse is caring for a client placed in traction to treat a fractured femur. Which nursing intervention has the highest priority?

Assessing the extremity for neurovascular integrity

A primigravid client is admitted to the labor and delivery area in the early first stage of labor. She is breathing with each contraction. Which action taken by the nurse helps the client deal with the pain of labor? Assist the client to a supine position with the legs in the stirrup. Assist the client to practice Kegel exercise. Assist the client in performing effleurage. Encourage client to push with each contraction.

Assist the client in performing effleurage. Explanation: Effleurage, gentle massage of the abdomen and thigh, is soothing to the mother during labor. Kegel exercises tighten the pelvic floor muscles, needed after birth and not during labor. Pushing before the cervix is fully dilated can cause swelling and tearing of the cervix. Supine position can cause compression of the abdominal vessels, leading to hypotension.

A client with a history of epilepsy is admitted to the medical-surgical unit. While assisting the client from the bathroom, the nurse observes the start of a tonic-clonic seizure. Which nursing interventions are appropriate for this client? Select all that apply.

Assist the client to the floor. Turn the client to the side. Place a pillow under the client's head.

A nurse is caring for a client with active tuberculosis who is homeless. The client is almost ready for discharge; however, the nurse is concerned about the client's ability to follow the medical regimen. Which nursing intervention would best promote adherence with the treatment plan after discharge?

Assist with referring the client to a social worker for discharge.

A nurse is assigned the care of an 87-year-old client with multiple ulcerations, which require dressing changes. The nurse is also assigned the care of a 50-year-old client, who is ordered to receive 2 units of packed red blood cells. Which task can the nurse delegate to the nursing assistant?

Assisting the clients with bathing

The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?

Asymmetry

The nurse is reinforcing education regarding insulin injections with an 11-year old child with diabetes Type I. Which guideline is appropriate to follow?

At age 11, the child should be old enough to give injections independantly.

A 2-year-old returns from surgery after a bowel resection as a result of Hirschsprung disease. A temporary colostomy is in place. Which immediate postoperative nursing intervention would have priority?

Auscultate lung sounds.

For a client with an endotracheal (ET) tube, which nursing action is most essential?

Auscultating the lungs for bilateral breath sounds

A nurse tells a client in labor, "If I were you, I'd ask the doctor for something for pain; you shouldn't have to suffer during labor." Which ethical principle is the nurse promoting?

Autonomy

When caring for a toddler, the nurse should understand that a child in this age-group works to achieve which developmental task?

Autonomy

A child with a Wilms tumor has had surgery to remove a kidney and has received chemotherapy. The nurse should include which instructions at discharge?

Avoid contact sports.

A client who has had a pacemaker inserted is ready for discharge. What information should the nurse reinforce in the discharge instructions to the client?

Avoid exposure to magnetic resonance imaging (MRI) equipment.

The nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis?

Avoid internal rotation of the affected leg.

When teaching a client with peripheral vascular disease about foot care, the nurse should include which instruction? Avoid using cornstarch on the feet. Avoid wearing canvas shoes. Avoid using a nail clipper to cut toenails. Avoid wearing cotton socks.

Avoid wearing canvas shoes. Explanation: The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, which may, in turn, cause skin irritation and breakdown. Both cotton socks and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nail clippers.

The nurse is identifying a unit of packed red blood cells with a coworker before administration. The client's blood type is AB negative. Which blood type can safely be administered to this client?

B negative

The nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?

Baked beans, hamburger, and milk

The nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor. What information should the nurse provide to the parents? Select all that apply.

Be sure to keep the monitor on a flat surface away from other appliances. Develop a plan in case of a power failure. The parents should take a CPR course.

Which intervention by the nurse would be most helpful when discussing hypospadias with the parents of an infant with this defect?

Be there to listen to the parents' concerns.

An infant, age 3 months, undergoes surgical repair of a cleft lip. After surgery, the nurse should use which equipment to feed the infant?

Bulb syringe with tubing

The nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?

By supplying a magic slate or similar device

The nurse should include which in-home management instruction for a child who's receiving desmopressin acetate for symptomatic control of diabetes insipidus?

Call the health care provider for an alternate route of desmopressin acetate when the child has an upper respiratory infection (URI) or allergic rhinitis.

A 45-year-old client receiving radiation therapy for thyroid cancer reports mouth and throat pain. While inspecting the mouth and throat, the nurse notices white patches and ulcerations in the oral mucosa. What do these findings suggest?

Candidiasis

The nurse is caring for a terminally ill client with cancer who is receiving hospice services with an advance directive. Which nursing action is a priority?

Care for elimination needs.

A client suspected of having a pulmonary embolus is scheduled for a lung scan. What is the most important action for the nurse prior to the procedure?

Check all allergies of the client.

A client in the third trimester of pregnancy is having contractions 5 minutes apart that began suddenly. The nurse identifies that it is the client's seventh month. The client is admitted directly to the obstetrics department. Which intervention has priority? Call the obstetrician. Time the contractions. Check fetal heart tones. Call the client's spouse.

Check fetal heart tones. Explanation: The nurse should check fetal heart tones and assess the client's vital signs. The client should be placed on a monitor to check contractions and for continuous fetal monitoring. The obstetrician and spouse should be notified as soon as possible.

The nurse is initiating an intravenous (IV) access for a client who needs an infusion of normal saline solution. Which nursing action should the nurse perform before the venipuncture?

Check for latex allergy before applying the tourniquet.

A client who's aphasic and has left-sided paralysis after sustaining a stroke is scheduled for debridement of a left leg ulcer. Whenever passive range-of-motion (ROM) exercises are performed on the left leg, the client grimaces and moans. Which action should the nurse take before the physician performs the debridement?

Check the client's medication administration record to see when he last received pain medication and administer a dose, if appropriate, before debridement.

A nurse caring for a client during the fourth stage of labor observes that the client has changed pads four times in the past hour and is reporting dizziness. What initial actions should the nurse take? Select all that apply.

Check vital signs. Notify the RN. Check the fundal height.

The nurse is caring for a terminally ill school-age child. Which resource might be most helpful in caring for this child?

Child life specialist

During a mental status examination, a client may be asked to explain such proverbs as "Don't cry over spilled milk." What about the client's ability to think is being assessed by the health care practitioner?

Client's ability to think abstractly

A child is to receive phenytoin, 5 mg/kg by mouth each day. When teaching the parents about the medication regimen, the nurse should use which approach? Conduct brief education sessions, provide written materials during each visit, and repeat information as appropriate. Ask the parents to spend an entire day at the facility so they can learn every detail about their child's care. Call the parents at home and explain everything, allowing time for them to ask questions. Send the parents the drug packaging insert so they can become familiar with the medication.

Conduct brief education sessions, provide written materials during each visit, and repeat information as appropriate. Explanation: Effective teaching methods include providing simple instructions in short sessions, providing written materials, repeating information, and allowing time for questions. The other options are ineffective teaching strategies that may be overwhelming for the parents and frustrating for the nurse.

A client is placed on oxygen therapy via a nasal cannula. Which should be the first action by the nurse?

Confirm the health care provider's order for oxygen.

The nurse is aware that Standard Precautions represent the first tier of Centers for Disease Control guidelines for isolation precautions. Which is the nurse's primary responsibility when following Standard Precautions?

Consider all body substances potentially infectious.

A client tells a nurse that her ileoconduit appliance won't adhere to her skin. The nurse inspects the site and notes that the area around the stoma is red, moist, and tender to touch. How should the nurse intervene?

Consult the wound-ostomy nurse.

The nurse is caring for a 10-year-old child with cystic fibrosis. The child's parents tell the nurse that they're having difficulty coping with their child's disease. Which action would be most appropriate for the nurse to take?

Consulting with the social worker to help the family find appropriate resources

A nursing home resident is admitted to the hospital for evaluation and treatment of chronic diarrhea. The nurse plans to place the client on isolation precautions. Which type of isolation precautions should be observed with this client? Select all that apply.

Contact Standard

After a 33-year-old male client displays violent behavior, he is placed in restraints. Which intervention by the nurse takes priority for this client?

Continuously monitoring the client

After undergoing a right lower lobectomy for treatment of lung cancer, a 75-year-old client returns to his room with a chest tube in place. Several hours later a nurse finds the client out of bed barely able to speak, with the chest tube removed. Which action should the nurse take immediately?

Cover the insertion site with an occlusive dressing, call for assistance, and remain with the client.

A child admitted with pneumonia has a history of cystic fibrosis (CF). Which statement made by the parents best demonstrates an understanding of cystic fibrosis? It is a genetic disorder carried on the X chromosome. Cystic fibrosis (CF) is an inherited disease characterized by an abnormality in the body's salt, water- and mucus-making cells. In cystic fibrosis only one defective gene or set of genes is passed by one parent. It is a chronic disease, but it is not progressive.

Cystic fibrosis (CF) is an inherited disease characterized by an abnormality in the body's salt, water- and mucus-making cells. Explanation: Cystic fibrosis (CF) is an inherited disease characterized by an abnormality in the body's salt, water- and mucus-making cells. In recessive disorders such as cystic fibrosis, both parents must pass the defective gene or set of genes to the child. Dominant disorders are characterized by only one defective gene or set of genes passed by one parent. Sex-linked genetic disorders are carried on the X chromosome. It is a chronic disease and is progressive.

A child with diabetes insipidus receives desmopressin acetate (DDAVP). When evaluating for therapeutic effectiveness, the nurse would interpret which finding as a positive response to this drug?

Decreased urine output

A child, age 4, with a recent history of nausea, vomiting, and diarrhea is admitted to the pediatric unit with a diagnosis of gastroenteritis. During data collection, the nurse detects tenting. This finding supports a nursing diagnosis of:

Deficient fluid volume related to dehydration.

A nurse is reinforcing education for a client on how to perform tracheostomy care. What is the most important principle of client education that the nurse needs to utilize?

Determine the client's readiness to learn new information.

How can breast cancer prevention programs best serve women who are at risk and come from lower socioeconomic backgrounds? Provide access to health insurance. Increase support services. Increase access to health care. Develop screening and educational programs.

Develop screening and educational programs. Explanation: Breast cancer prevention programs can best serve at-risk women from lower socioeconomic backgrounds by developing screening and educational programs tailored to their needs. Without increasing educational awareness and screening, improving access to insurance, heath care, and support services won't help these women. According to the National Breast and Cervical Cancer Early Detection Program, research shows that without better screening and education programs, women with low incomes are 3 to 7 times more likely to die from cancer than women with higher incomes.

Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the client's medication drawer. What priority action should the nurse implement?

Discard the syringe to avoid a medication error.

A client who retired six weeks ago, has been diagnosed with an adjustment disorder with mixed anxiety and depression. What can the nurse reinforce to help the client adapt well to the stress? Select all that apply. Remain hopeful about the past. Avoid social supports, such as friends and loved ones. Do something that gives you a sense of accomplishment. Find a support group geared toward your situation. Live a healthy lifestyle including a healthy diet and regular physical activity.

Do something that gives you a sense of accomplishment. Find a support group geared toward your situation. Live a healthy lifestyle including a healthy diet and regular physical activity. Explanation: A client with a sense of accomplishment, living a healthy lifestyle including a healthy diet and regular physical activity and having a support group will improve resilience and adaptation to the stress of retirement. The client needs to be hopeful about the future and stay connected to social support such as friends and family.

An adult client scheduled for surgery chooses to waive the right to informed consent. What should the nurse do?

Document that the client waived the right in the medical record.

During a clinic visit, the nurse notes that a 3-year-old preschooler, who measured 27 inches at the age of 2, now measures 29.5 inches. Based on the preschooler's measurement, how would the nurse proceed? Notify the health care provider. Document the finding. Wait 5 minutes and measure the toddler again. Explain to the caregiver that the toddler is not growing fast enough.

Document the finding. Explanation: The preschooler grows 1½ to 2½ inches/year, so the nurse should document the finding. Because the preschooler's measurement is in the expected range, there is no need to notify the health care provider or wait 5 minutes and measure the client again. It is inappropriate to explain to the caregiver that the preschooler is not growing fast enough.

One day after a client gives birth, the nurse performs a postpartum assessment. The nurse finds a moderate amount of lochia rubra on the client's perineal pad. Which action should the nurse?

Document this as a normal finding

A nurse is reinforcing education to a client with prostatitis who is receiving co-trimoxazole double strength. Which education is appropriate for this client?

Drink six to eight glasses of fluid daily while taking this medication.

A client taking a new prescription for propranolol calls the clinic to report a weight gain of 3 lb (1.36 kg) within 2 days, shortness of breath, and swollen ankles. What is the nurse's best action?

Due to fluid accumulation, have the client assessed for worsening heart failure by the health care provider.

A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head?

Elevated 30 degrees

The nurse is caring for a breastfeeding client on her second postpartum day. The breast is enlarged, firm, and warm to touch. Which action is the nurse expected to take?

Encourage the client to breast feed the baby more frequently and regularly.

A nurse caring for a client during the first 24 hours following delivery notes normal lochia. Which of the following should the nurse include in the care of this client?

Encourage the client to increase fluid intake.

The nurse is caring for a child who has recently been diagnosed with a cardiovascular disorder. The child's parents do not seem to be accepting of the diagnosis and the changes the diagnosis will make in their lives. What initial action by the nurse will be most therapeutic?

Encourage the parents to discuss their feelings about the loss of their child's health.

The nurse is caring for a 14-year-old child in skeletal traction for treatment of a fractured femur. The child is expected to be hospitalized for several weeks. When assisting with the plan of care, which nursing actions take into account the need to achieve developmental milestones in adolescence? Select all that apply. Encourage visitation of friends during hospitalization. Allow parents to make all stressful decisions for the adolescent. Provide for privacy, especially during ADLs and toileting. Encourage the parents to stay with the adolescent at all times. Arrange for in-hospital schooling so the child does not fall behind while hospitalized.

Encourage visitation of friends during hospitalization. Provide for privacy, especially during ADLs and toileting. Arrange for in-hospital schooling so the child does not fall behind while hospitalized. Explanation: According to the Erikson theory of personal development, an adolescent is in the stage of identity versus role confusion. During this stage, the body is changing as secondary sex characteristics emerge. The adolescent tries to develop a sense of identity, and peer groups take on more importance. School performance is important. Adolescents often have an increased anxiety about missing school. When adolescents are hospitalized, they are separated from the peer group. Hospitalized adolescents fear invasion of privacy and altered body image. Adolescents want to be respected as individuals separate from the parents and need to be included in the decision-making process.

When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is appropriate?

Encouraging increased fluid intake

The parents of a pediatric client are waiting in the surgical family lounge while their son undergoes emergency surgery. A physician enters the family lounge and tells another family that surgery for their family member was unsuccessful. What should the nurse do to best serve these families?

Escort the family who received the discouraging news to a private area.

The nurse finds an adult client collapsed in the hallway. Which action should the nurse take first when arriving to assist this client?

Establish unresponsiveness.

A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder-retraining program?

Evaluate present elimination patterns.

Yesterday, a client with schizophrenia began treatment with haloperidol. Today, the nurse notices that the client is holding his head to one side and is reporting neck and jaw spasms. What should the nurse do?

Evaluate the client for adverse reactions to haloperidol.

A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action?

Explain that these are expected problems for the latter stages of pregnancy.

A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action? Make an appointment because the client needs to be evaluated. Explain that these are expected problems for the latter stages of pregnancy. Arrange for the client to be admitted to the birth center for delivery. Tell the client to go to the hospital; she may be experiencing signs of heart failure from a 45% to 50% increase in blood volume.

Explain that these are expected problems for the latter stages of pregnancy. Explanation: The nurse must distinguish between normal physiologic reports of the latter stages of pregnancy and those that need referral to the health care provider. In this case, the client indicates normal physiologic changes related to the growing uterus and pressure on the diaphragm. These signs aren't indicative of heart failure. The client does not need to be seen or admitted for delivery at this time.

The client is receiving an infusion of cytarabine through a peripheral IV catheter when he reports burning at the insertion site. The nurse notes no blood return from the catheter, but she sees redness at the IV site. The client is most likely experiencing which complication?

Extravasation

A client with a diagnosis of bulimia nervosa is working on relationship issues. Which nursing intervention is most important?

Facilitate the client's ability to identify feelings about relationships.

A client in labor is attached to an electronic fetal monitor (EFM). Which of the following data provided by an EFM most reliably indicates adequate uteroplacental and fetal perfusion?

Fetal heart rate variability within an acceptable range

A 6-year-old child with a history of varicella and aspirin intake is brought to the emergency department. The nurse suspects Reye's syndrome. Which data collection findings are consistent with this syndrome?

Fever, decreased level of consciousness (LOC), and impaired liver function

A client undergoing prenatal blood testing is found to be positive for human immunodeficiency virus (HIV). Which action would be most appropriate for the nurse to do?

Follow facility policy for documenting and communicating HIV status.

A client is treated in the emergency department for a Colles' fracture sustained during a fall. What is a Colles' fracture?

Fracture of the distal radius

The nursing instructor is demonstrating a head-to-toe assessment. Which plane would the instructor use to divide the body longitudinally into anterior and posterior regions?

Frontal plane

A nurse places electrodes on a collapsed individual who was visiting a hospitalized family member. Based on the data, which intervention should the nurse do first?

Gather information on the client's airway, breathing, and circulation.

The nurse is to administer the morning dose of NPH insulin to a client with type 1 diabetes. The client is alert and oriented; before administering the medication, the nurse obtains a glucose reading of 52. What should the nurse do at this time?

Give the client breakfast and then recheck the glucose level.

A client begins clozapine therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The nurse instructs her to return for weekly white blood cell (WBC) counts to assess for which adverse reaction?

Granulocytopenia

A dystonic reaction can be caused by which medication?

Haloperidol

Which of the following techniques is most effective in preventing nosocomial infection transmission when caring for a preschooler?

Hand washing

What should a male client older than age 50 do to help ensure early identification of prostate cancer?

Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly.

Initial client assessment information includes blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate 22 breaths/minute, and reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones. Based on these findings, the nurse would expect the client to have which concerns?

Headache, blurred vision, and facial and extremity swelling

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

Helicopod

The nurse is gathering data from an older adult client with a fracture. Identify the location of the most common fracture in older adults to cause death within 1 year of sustaining the fracture.

Hip

A nurse is preparing a lecture for a prenatal class. Which hormone would the nurse include in the presentation as being responsible for maintaining pregnancy during the first 3 months?

Human chorionic gonadotropin (hCG)

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which of the following problems?

Hypercapnia, hypoventilation, and hypoxemia

When obtaining the vital signs of a client with multiple traumatic injuries, the nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?

Increased intracranial pressure (ICP)

For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone. When caring for this client, the nurse should monitor for which adverse drug reactions?

Increased weight, hypertension, and insomnia

A client in labor tells the nurse, "I'm noticing that I have a clear, milky discharge from both of my breasts." Based on the client's statement, which action by the nurse would be most appropriate? Tell the client that her milk is starting to come in because she's in labor. Complete a thorough breast examination, and document the results in the chart. Perform a culture on the discharge, and inform the client that she might have mastitis. Inform her that the discharge is colostrum, normally present after the fourth month of pregnancy.

Inform her that the discharge is colostrum, normally present after the fourth month of pregnancy. Explanation: After the fourth month of pregnancy, colostrum may be noticed. The breasts normally produce colostrum for the first few days after birth. Milk production begins 1 to 3 days postpartum. A clinical breast examination isn't usually indicated in the intrapartum setting. Although a culture may be indicated, it requires advanced assessment as well as a medical order.

Which documentation is most important when preparing a preschool-age child for surgery?

Informed consent

A client, age 23, is diagnosed with type 1 diabetes. The physician prescribes 15 units of U-100 regular insulin and 35 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. The nurse checks the medication order, assembles the appropriate equipment, washes her hands, rotates the NPH insulin vial, puts on disposable gloves, and cleans the stoppers. To draw the two insulin doses into the single U-100 insulin syringe, which sequence should the nurse use?

Inject 35 units of air into the NPH vial; inject 15 units of air into the regular insulin vial and withdraw 15 units of regular insulin; and withdraw 35 units of NPH.

A 13-year-old boy visits the school nurse because he's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the child may have scoliosis. The nurse should first: send the child home to recover. inspect the child for uneven shoulder height or uneven hip height. arrange for the child to have spinal X-rays as soon as possible. ask the child's mother to take him to a physician immediately.

Inspect the child for uneven shoulder height or uneven hip height. Explanation: Before deciding on any specific intervention, the school nurse should perform a basic assessment for scoliosis, including inspecting for uneven shoulder or hip height. The nurse will then have more specific information to give to the parent. The parent bears responsibility for seeking further medical care for the child.

Which of the following would be appropriate for a client with arterial blood gas (ABG) values of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3- 24 mEq/L, and PaO2 94 mm Hg?

Instruct the client to breathe into a paper bag.

An adolescent female client has begun menstruation. The nurse teaches the client about dietary intake of which nutrient?

Iron

A 4-year-old client has just returned from surgery. He has a nasogastric (NG) tube in place and is attached to intermittent suction. The child says to the nurse, "I'm going to throw up." What should the nurse do first?

Irrigate the NG tube to ensure patency.

A client who has a pulmonary embolism has the potential to develop chest pain. What would be the nurse's best explanation for this when reinforcing education for the client?

It is pleuritic pain due to inflammation.

Which characteristic of the fascia can cause it to develop compartment syndrome?

It is unable to expand.

A 4-year-old child had a subungual hemorrhage of the toe after a jar fell on the foot. Which statement regarding the rationale for using electrocautery to treat the injury is most accurate?

It's used to relieve pain and reduce the risk of infection.

The nurse has just administered a drug to a child. Which organ is most responsible for drug excretion in children?

Kidneys

Which of the following nutritional deficiencies may delay wound healing?

Lack of vitamin C

The mother of a preschooler with spina bifida tells the nurse that her daughter sneezes and gets a rash when playing with brightly colored balloons and that recently she had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to which of the following?

Latex

The nurse is caring for a preschool aged child who has been prescribed a preoperative intramuscular (IM) injection at 07:00. To elicit the child's cooperation in administering this medication, the nurse should use which approach?

Let the preschooler choose which leg to use for the injection.

A client is diagnosed with prehypertension. Which of the following would most likely be included in the client's treatment plan? Diuretics Lifestyle modification instructions Beta-adrenergic blockers Angiotensin-converting enzyme (ACE) inhibitors

Lifestyle modification instructions Explanation: Prehypertension signals the need for teaching about lifestyle modifications to prevent hypertension. Lifestyle modifications may include dietary changes, adopting relaxation techniques, regular exercise, smoking cessation, limiting intake of alcohol, and restricting sodium and saturated fat intake. Diuretics, beta-adrenergic blockers, and ACE inhibitors are used to treat hypertension.

The nurse must apply a wet-to-dry dressing over an ulcer on a client's left ankle. How should the nurse proceed?

Lightly pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound.

A male client is receiving digoxin and furosemide to treat heart failure. He reports feeling weak and having muscle cramps. His apical pulse is 76 beats/minute; respirations, 16 breaths/minute; and blood pressure, 148/86 mm Hg. What action should the nurse take?

Look at the chart for his last potassium level and contact the physician.

A client who reportedly consumes 1 qt of vodka daily is admitted for alcohol detoxification. To try to prevent alcohol withdrawal symptoms, the nurse expects the health care practitioner to most likely prescribe which drug?

Lorazepam

A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the client's right arm, and the left arm and hand should be elevated as much as possible to prevent which condition?

Lymphedema

A client with advanced cancer of the mouth has a swollen, necrotic, and weeping tongue. Which nursing intervention should be a priority in planning care?

Maintain a patent airway.

A neonate returns from the operating room after surgical repair of a tracheoesophageal fistula and esophageal atresia. Which intervention is most important for the nurse to perform?

Maintain a patent airway.

A nurse is caring for a client who just had surgery. What is the nurse's highest priority for this client?

Maintain a patent airway.

A client is admitted with chronic obstructive pulmonary disease (COPD). Which nursing actions should the nurse perform for this client? Select all that apply.

Maintain adequate airway for client. Educate client on smoking and other triggers. Teach pursed lips breathing technique to client . Assess pulse oximetry .

A client reports difficulty breathing and a sharp pain in the right side of the chest. The respiratory rate measures 40 breaths/minute. The nurse should assign highest priority to which goal of care?

Maintaining effective respirations

A 75-year-old client who was admitted to the hospital with a stroke informs the nurse that he doesn't want to be kept alive with machines. He wants to make sure that everyone knows his wishes. Which action should the nurse take?

Make arrangements for the client to receive information about advance directives.

A neonate weighs 7 lb, 3 oz at birth. When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb and an axillary temperature of 98° F (36.7° C) and observes the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should provide what suggestions to the mother? Select all that apply.

Make sure that the newborn's temperature is maintained within normal range. Observe the stool for amount and characteristic. Encourage early and frequent feedings.

A 4-year-old girl has a urinary tract infection (UTI). When teaching the parents how to help her avoid recurrent UTIs, the nurse should emphasize which preventive measure? Wiping her perineum from back to front after she uses the toilet Administering prophylactic antibiotics Giving her a warm bath for 15 minutes daily Making sure she avoids bubble baths

Making sure she avoids bubble baths Explanation: The child should avoid bubble baths because oils in the bubble bath preparation may irritate the urethra, contributing to UTIs. Girls and women should wipe the perineum from front to back, not back to front, to avoid contaminating the urinary tract with fecal bacteria. Although antibiotics are used to treat UTIs, they aren't given prophylactically. No evidence suggests that warm baths help prevent UTIs.

A client with amebiasis, an intestinal infection, is prescribed metronidazole. The nurse is providing information about adverse reactions of this drug. Which information should the nurse include in his or her teaching plan?

Metallic taste

While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse to apply?

Moist sterile saline gauze

The nurse is assisting with the care of an infant following surgical repair of esophageal atresia and tracheoesophageal fistula. Which nursing intervention takes the highest priority during the first 24 hours following the surgical repair?

Monitor for excessive secretions.

The nurse is caring for an adolescent client receiving a selective serotonin reuptake inhibitor (SSRI) as part of the treatment plan for anorexia nervosa. Which action is a priority intervention related to the SSRI therapy?

Monitor for suicidal thoughts.

A client with pancreatitis has been receiving total parenteral nutrition (TPN) for the past week. Which nursing intervention helps determine if TPN is providing adequate nutrition?

Monitor the client's weight every day.

What is an appropriate nursing intervention for a client with a soft wrist restraint?

Monitoring circulatory status every 15 minutes if the client is agitated, or every 2 hours if the client is calm

When caring for a client who has had a cesarean section, which of the following actions is appropriate?

Monitoring pain status and providing necessary relief

The nurse is planning sex and contraceptive education for adolescents. Which factor should the nurse consider? Neither sexual activity nor contraception requires planning. Most teenagers today are knowledgeable about reproduction. Most teenagers use pregnancy as a way to rebel against their parents. Most teenagers are open about contraception, but inconsistently use birth control.

Most teenagers are open about contraception, but inconsistently use birth control. Explanation: Adolescents receive most of their information on reproduction and sexuality from their peers, who generally do not have correct information. Teenagers generally become pregnant because they fail to use birth control for reasons other than rebelling against their parents. Contraception should always be part of sex education and requires planning. Most teenagers today are open about discussing contraception and sexuality, but they may get caught up in the moment of sexuality and forget about birth control measures.

A client with Crohn's disease is admitted to a semiprivate room late in the afternoon. The next day, the client reports that he was not able to sleep during the night because the hallway lights bothered him. He asks that he be moved to a bed next to a window. What should the nurse do?

Move him to the next available window-side bed.

The nurse sees an unauthorized person reading a client's medical record outside a client's room. Which action should the nurse take?

Notify the nursing supervisor and approach the individual.

A nurse is caring for a client who sustained a gunshot wound to the leg during a jewelry store robbery. The client is in police custody and receiving treatment in the emergency department. A member of the media asks the nurse about the client's condition. How should the nurse respond?

Notify the nursing supervisor so she can obtain a formal statement from the physician about the client's condition for the media.

The LVN/LPN suspects narcotic diversion when a particular nurse volunteers to administer medication to clients when they call for pain medication and the clients continue to report pain. What should the nurse do?

Notify the nursing supervisor.

A client newly diagnosed with diabetes mellitus is experiencing difficulty with self-administration of insulin. Despite further teaching, the client shows little improvement. What action by the nurse is most appropriate?

Notify the physician of the client's lack of progress and request a diabetes education department consult.

While being escorted to an operating room, a client is extremely anxious and says, "I really don't know what they're going to do to me today. The physician said I have a lump in my breast and that's all I know." Which action is appropriate for the nurse to take?

Notify the physician upon arrival at the operating room.

An adult client was admitted with myasthenia gravis. While reviewing the client's chart, the licensed practical nurse (LPN)/licensed vocational nurse (LVN) noticed the medication administration record (MAR). Based on the information, what should the nurse do next?

Notify the registered nurse and question the morphine sulfate.

A child is diagnosed with diabetes insipidus has developed a viral illness including congestion, nausea, and vomiting. What instructions should the nurse reinforce?

Obtain an alternate route for desmopressin acetate administration.

When planning a program to educate adolescents about acquired immunodeficiency syndrome (AIDS), which action might lead to better acceptance of the program?

Obtain peer educators to provide information about AIDS.

When planning a program to educate adolescents about acquired immunodeficiency syndrome (AIDS), which action might lead to better acceptance of the program? Survey the community to evaluate the level of education. Obtain peer educators to provide information about AIDS. Set up clinics in community centers and supply condoms readily. Invite health care providers to host workshops in community centers.

Obtain peer educators to provide information about AIDS. Explanation: Peer education programs have shown that teens are more likely to pose questions to peer educators than to adults, and that peer education can change personal attitudes and the perception of the risk of HIV infection. The other approaches would be helpful but wouldn't necessarily make the outreach program more successful.

A client with chronic anxiety disorder reports chest pain. Which nursing intervention is most appropriate?

Obtain vital signs.

A client in active labor is sweating profusely and has minimal urine output. Which of the following is how the nurse should intervene?

Offer the client ice chips and ask the charge nurse to notify the physician of the low urine output

Which intervention should be included in the plan of care for a 6-month-old infant with mild dehydration related to diarrhea and vomiting?

Oral electrolyte replacement solutions, breast milk, or lactose-free formula

The nurse is caring for multiple clients that have been determined to be at risk for falls. Which intervention(s) should the nurse institute to prevent falls? Select all that apply.

Orient client to the nurse call system and encourage its use. Ensure the nurse call system is within reach. Keep hospital bed in low position.

A client seeks care for low back pain of 2 weeks' duration. Which data collection finding suggests a herniated intervertebral disk?

Pain radiating down the posterior thigh

The nurse prepares to administer a client's morning medication. Which action should the nurse take first?

Perform hand hygiene.

The nurse is caring for a child with a seizure disorder. Which nursing intervention would be included to support the goal of avoiding injury, respiratory distress, or aspiration during a seizure?

Place a hand under the child's head for support.

A nurse is reinforcing education with a parent on how to reduce the baby's risk of developing otitis media. Which instruction should the nurse be sure is included in the teaching plan?

Place the baby in an upright position when giving a bottle.

Which intervention prevents a 17-month-old child with spastic cerebral palsy from going into a scissoring position?

Place the child on the hip.

A child has just returned to the pediatric unit following ventriculoperitoneal shunt placement for hydrocephalus. Which intervention would the nurse perform first?

Place the child on the side opposite the shunt.

A 2-year-old child is admitted to the pediatric unit with the diagnosis of bacterial meningitis. Which nursing action would be appropriate for the nurse to perform first?

Place the toddler in respiratory isolation.

The nurse is caring for an unconscious client who suffered a stroke 4 days ago. When providing oral hygiene for this client, the nurse must take which essential action?

Placing the client in a side-lying position

The nurse is caring for a 10-year-old client with cardiac failure who is on bed rest. The client is crying because of boredom. Based on the client's developmental growth, which appropriate action would the nurse implement to eliminate this client's boredom?

Play a game of checkers with the client.

Two staff nurses on the urology unit are responsible for the unit schedule. The holidays are nearing, and many staff members would like to take vacation days. Which method might fairly solve the holiday staffing problem?

Poll the staff to find out their preferences.

A client is receiving oxygen by way of a nasal cannula at a rate of 2 L/minute. How can the nurse promote oxygenation in this client? Select all that apply.

Position client in Fowler's position. Decrease anxiety in the client. Set the line marked "2" so it cuts the ball in half.

Which steps should the nurse follow to insert a straight urinary catheter?

Prepare the client and the equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows.

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for adverse effects of heparin, especially bleeding. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that's specific to heparin. Which agent fits this description?

Protamine sulfate

Which nursing intervention is the best way to help reduce the occurrence of poisoning in children?

Provide education to those who care for children.

The nurse is caring for a client who is in the panic level of anxiety. Which action is the nurse's highest priority?

Provide for the client's safety needs.

A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and gives birth. Which priority intervention should be included in the plan of care for the neonate during the first 24 hours?

Provide frequent early feedings with formula.

A 32-year-old homeless client is referred to an outpatient treatment program for delusional behavior. A nurse notes during the history-taking process that the client eats only one meal a day, which is high in fat and contains no vegetables. The client also states that she rarely eats fruit. Which approach can the nurse use to help the client eat more nutritious meals?

Provide the client with a nutritional lunch and arrange for the nutritionist and psychiatrist to see the client after lunch.

A client is scheduled for an endoscopy. On admission, the nurse asks the client if he has an advance directive, and the client states, "No." What should the nurse do next?

Provide the client with information about an advance directive.

A girl, age 15, is 7 months pregnant. When teaching parenting skills to an adolescent, the nurse knows that which teaching strategy is most effective?

Providing a one-on-one demonstration and requesting a return demonstration, using a live infant model

A nurse is caring for a client with candidiasis. What information should the nurse obtain from the client? Select all that apply. Recent antibiotic use Menopause Use of corticosteroids Use of oral contraceptives Use of over the counter herbal medications

Recent antibiotic use Use of corticosteroids Use of oral contraceptives Explanation: The use of antibiotics increases the risk of candidiasis. Small numbers of the fungus Candida albicans commonly inhabit the vagina. Because corticosteroids decrease host defense, they increase the risk of candidiasis. Candidiasis is rare before menarche and after menopause. The use of hormonal contraceptives increases the risk of candidiasis. OTC herbal medications do not increase the incidence of candidiasis.

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse assists with formulating a nursing diagnosis of Risk for injury. Which "related- to" phrase is appropriate for the nurse to add to complete the nursing diagnosis statement?

Related to impaired balance

A 68-year-old client with end-stage chronic obstructive pulmonary disease (COPD) has discharge orders that include home oxygen therapy. The client exhibits anxiety about becoming dependent on supplemental oxygen. How can a nurse help allay the client's anxiety?

Remain with the client during an education session taught by the respiratory therapist, and reinforce teaching after the session.

A nurse is caring for a confused client with a fractured hip who is trying to get out of bed. Which action should the nurse take first?

Reorient the client to the surroundings.

The licensed practical nurse (LPN) is assigned to care for a 4-year-old child who had a Harrington rod inserted the day before and notices the client is receiving antibiotics by a syringe pump. The nurse is IV certified, but uncomfortable because they are unfamiliar with the equipment. What would be the best course of action?

Request in-service education for use of the syringe pump.

Four clients on an orthopedic unit are scheduled to attend physical therapy at the same time. Facility policy dictates that each client be escorted to therapy in a wheelchair or on a stretcher. When it's time for therapy, only three wheelchairs are available. One of the four clients is learning crutch-walking and is scheduled for discharge in the morning. What should the nurse do to ensure the clients' safety and timely arrival to physical therapy?

Request that a physical therapist accompany the client to therapy while he uses the crutches.

An incarcerated client is admitted to the hospital after sustaining multiple contusions and a fractured femur in an assault. After surgical repair of the femur, the client develops paralytic ileus. A nasogastric (NG) tube and cleansing enemas are prescribed. The client has a prison guard assigned to his bedside. How should a nurse proceed to implement a physician's orders?

Request that the guard remain outside the client's door during the prescribed procedures.

An older adult client who has chronic respiratory disease comes to the clinic for a 6- month check. The nurse informs the client that it's time for the pneumococcal and flu vaccines. What would be the nurse's best explanation to the client for these injections? All clients are recommended to have these vaccines. These vaccines produce bronchodilation and improve oxygenation. These vaccines help reduce the tachypnea these clients experience. Respiratory infections can cause severe hypoxia and possibly death in clients with chronic respiratory diseases.

Respiratory infections can cause severe hypoxia and possibly death in clients with chronic respiratory diseases. Explanation: It's highly recommended that clients with respiratory disorders be given vaccines to protect against respiratory infection. Infections can cause respiratory failure, and these clients may need to be intubated and mechanically ventilated. The vaccines have no effect on respiratory rate or bronchodilation.

The nurse is caring for a child with symptomatic aortic stenosis. Which instruction should be provided to the child and parents.

Restrict exercise.

A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?

Restricting fluids

The nurse is assisting with the discharge of a client with acute pyelonephritis. What should the nurse be sure to include in the client instructions? Avoid taking any dairy products. Return for follow-up urine cultures. Stop taking the prescribed antibiotics when the symptoms subside. Recurrence is unlikely because of treatment with antibiotics.

Return for follow-up urine cultures. Explanation: The client needs to return for follow-up urine cultures because bacteriuria may be present but may not produce symptoms. Intake of dairy products will not contribute to pyelonephritis. Antibiotics must be taken for the full course of therapy regardless of symptoms. Pyelonephritis commonly recurs as a relapse or new infection, usually within 2 weeks of completing therapy.

The nurse is developing a teaching plan for a client receiving clozapine. The nurse should stress the importance of which aspect of follow-up care?

Routine complete blood count (CBC) with differential

When talking to the parents of a neonate with congenital hypothyroidism, the nurse should encourage which action? Seek professional genetic counseling. Retrace the family tree for others born with this condition. Talk to relatives who have gone through a similar experience. Wait until the neonate is 1 year of age before obtaining counseling.

Seek professional genetic counseling. Explanation: Seeking professional genetic counseling is the best option for parents who have a neonate with a genetic disorder, such as congenital hypothyroidism. Retracing the family tree and talking to relatives will not help the parents become better educated about the disorder. Education about the disorder should occur as soon as the parents are ready, so they will understand the genetic implications for future children.

The nurse has an order to administer an intramuscular (I.M.) injection using the Z-track technique. When carrying out this order, what nursing intervention should the nurse implement?

Simultaneously withdraw the needle and release the skin.

A client is admitted to the emergency department with complaints of double vision, difficulty swallowing, dry mouth, and muscle weakness. A nurse also observes that the client has drooping eyelids and slurred speech. He states that he recently ate home-canned green beans. The nurse suspects exposure to botulism. What type of infection control precaution is necessary?

Standard precautions

A client receiving total parental nutrition is prescribed a 24-hour urine test. The nurse delegates the collection of the specimen to the unlicensed assistive personnel (UAP). The nurse is aware that the UAP is collecting the specimen correctly when he or she initiates the collection in which instance?

Start after a client's known voiding that empties the bladder

A nurse is gathering data on a client receiving an enteral feeding who suddenly states, "I feel very faint and sweaty." What is the nurse's immediate action?

Stop the feeding.

A nurse is caring for a 10-year-old child hospitalized for treatment of acute osteomyelitis. The child's left leg is immobilized in a splint. What is the nurse's most appropriate action?

Support and handle the leg gently during turning and repositioning.

A client was admitted with a brain tumor. Which vital signs would the nurse expect to notice?

T, 99° F (37.2° C); P, 52; R, 12; BP, 176/86

A client with hypothyroidism (myxedema) is receiving levothyroxine, 25 mcg P.O. daily. Which finding should the nurse recognize as an adverse drug effect?

Tachycardia

The nurse is obtaining vital signs for a client with a seizure disorder. Which method would the nurse use to obtain the most accurate measure?

Take an axillary temperature instead of an oral temperature.

The nurse suspects that a client is not swallowing the administered dose of an anxiolytic medication and is concerned that the client may be disposing of it in the trash. Which action should the nurse take first?

Talk with the client about the concerns.

The nurse is caring for a preschool child just diagnosed with impetigo. What is the most important action the nurse should take to prevent the spread of impetigo to others? Cover the area. Isolate the child at home. Apply an antibacterial ointment. Teach child and family good handwashing techniques.

Teach child and family good handwashing techniques. Explanation: Handwashing is the most important action that a nurse or client can take to prevent the spread of infection. Covering the area or applying an antibacterial ointment does not stop the spread of infection, nor does isolating the child.

Which assessment finding indicates that the infant latch during breast-feeding needs further intervention?

The baby's lips smack.

One day after an appendectomy, a 9-year-old client rates his pain at 4 out of 5 on the pain scale but is playing video games and laughing with his friend. Which of the following would the nurse document on the child's chart?

The child rates pain at 4 out of 5. Pain medication administered as prescribed.

When using a Snellen alphabet chart, the nurse records the client's vision as 20/40. What does this evaluation determine for the client?

The client can see at 20 feet what the person with normal vision sees at 40 feet.

A nurse is caring for a 25-year-old client with end-stage testicular cancer who has been referred to hospice care. Which of the following criteria excludes the client from hospice care?

The client entered a clinical trial through the National Cancer Institute.

A nurse is caring for a client with end-stage testicular cancer who has been referred to hospice care. Which criterion excludes the client from hospice care?

The client entered a clinical trial through the National Cancer Institute.

A client with Alzheimer's disease is being treated for injuries from a recent fall and malnutrition. The nurse determines a need to place the client closer to the nurse's station based on which finding?

The client has a tendency to wander.

A client's prenatal history shows the client to be a 23-year-old gravida 4, para 2. The nurse has correctly interpreted this information when making which statement?

The client has been pregnant four times and delivered two live-born children.

Upon admission to a long-term care facility, a client is administered a Mantoux test. The nurse reads the test in 48 hours and observes a 5-mm induration. What does this indicate to the nurse?

The client has produced an immune response to the tuberculosis bacteria.

A client diagnosed with a pleural effusion has been on supplemental oxygen for 24 hours and is still having dyspnea with decreased breath sounds on the left. The client's condition is worsening. Which procedure will the nurse prepare the client for?

The client is incompetent. Compelling reasons exist to overrule the client's wishes.

When reviewing a client's chart, the nurse sees the progress note. Which statement about the client's condition is most accurate?

The client may not be motivated to change their behavior or their lifestyle.

A client who is being treated in the emergency department with a diagnosis of status asthmaticus is prescribed beta-adrenergic agents and intravenous (I.V.) corticosteroids. What does the nurse identify as an indication that the treatment is not working?

The client needs to be intubated.

After having a transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded?

The client reports bladder spasms and the urge to void.

Teaching for women in their childbearing years who are receiving antipsychotic medications should include which of the following facts?

The client should continue using contraception during periods of amenorrhea.

A nurse is caring for a client with fluid volume excess. Which nursing care outcome is desired for this client?

The client will have clear breath sounds in all lung fields.

A nurse is preparing to care for a client with Ménière disease. Which priority outcome should the nurse implement?

The client will not fall when attempting to stand during the 07:00 to 15:00 shift.

Parents of an adolescent are concerned that their child has been irritable, hasn't been sleeping for 6 months, and is not engaging in social activities. Which outcome developed by the health care team would be appropriate for this client?

The client will obtain appropriate mental health services.

A client experiencing alcohol withdrawal is upset about going through detoxification. Which of the following goals should the nurse determine as priority?

The client will work with the nurse to remain safe.

The nurse is caring for a client with human immunodeficiency viirus (HIV) and reinforcing education regarding disease prevention. What is the importance of disease prevention for this client? The client's personal behavior has a direct link to the maintenance of health. The client is only infected with the virus and does not have to be concerned with illness at this time. If the client maintains optimal health, acquired immune deficiency will not occur. The external environment affects the outcomes of most disease processes.

The client's personal behavior has a direct link to the maintenance of health. Explanation: Linking health and personal behavior is extremely important to disease prevention, especially when the client is immunocompromised. By promoting healthy behaviors, the client can delay disease progression so the client should be concerned with disease progression. Even with the maintenance of optimal health, the ability to develop AIDS is great. The external environment does not effect most disease process but may have some contributing factors.

The nurse is reinforcing the correct use of crutches to a client in the emergency. Which should the nurse include?

The crutches should end 2 in (5 cm) below the axilla.

The nurse is caring for a 6-week-old infant with laboratory results indicating fluid and electrolyte imbalance. Which nursing consideration is most important?

The infant has immature kidney function.

The newly hired graduate nurse asks the nurse preceptor what is the only advantage of using a floor stock system. Which rationale does the preceptor give the graduate nurse?

The nurse can implement medication orders quickly.

The infection control nurse is making rounds to ensure that airborne precautions are being observed while caring for clients with tuberculosis. Which action by the staff nurse requires further education?

The nurse dons a surgical isolation mask when entering the client's room.

The nurse inadvertently gives a client a double dose of a prescribed medication. After discovering the error, whom should the nurse notify?

The prescriber

An unconscious client is admitted to the emergency department. The nurse suspects which source is the cause of airway obstruction in this client, as it is the most common source of airway obstruction in the unconscious victim?

The tongue

A nursing faculty is preparing a lecture on the foundation of nursing knowledge. Which framework for nursing education and clinical practice would faculty include in the lecture?

Theoretical and conceptual models

The parent of an 8-year-old client tells the nurse that when the child plays with other children, the child does not seem to interact with them, but simply plays alongside. What does the nurse determine about the child? This is solitary play typical of infants, not preschool children. This is a parallel play typical of toddlers, not preschool children. This is associative play typical of preschool children, not school-aged children. This is cooperative play typical of adolescents, not school-aged children.

This is a parallel play typical of toddlers, not preschool children. Explanation: Playing alongside, but not interacting with the other child, is an example of parallel play, which is typical of toddlers. School-aged children typically engage in cooperative play where they follow organized rules and have a defined leader and followers. Solitary play, typical of infants, is when the child is focused on own activity, even when playing in the presence of other children. Associative play where children play together, but without organization or leaders and followers, is typical of preschool play.

A local elementary school has requested scoliosis screening for its students from the hospital's community outreach program. Which information should be provided to the school? These students are too young to screen; instead, older students should be screened. These students are too old to screen and will no longer benefit from screening for scoliosis. Scoliosis screening requires sophisticated equipment and cannot be done in school. This is an appropriate request and arrangements will be made as soon as possible.

This is an appropriate request and arrangements will be made as soon as possible. Explanation: Screening for scoliosis should begin at age 8 and should be performed yearly thereafter. Screening for scoliosis involves inspection of the spine and use of a scoliometer, both of which can be done in a school setting.

A client with acne vulgaris is seeking treatment. The nurse will reinforce education on nightly apply of which medication?

Tretinoin

A client, age 36, with schizophrenia believes the room is bugged by the Central Intelligence Agency and that his roommate is a foreign spy. The client has never had a romantic relationship, has no contact with family members, and hasn't been employed in the last 14 years. Based on Erikson's theories, the nurse should recognize that this client is in which stage of psychosocial development?

Trust versus mistrust

The nurse finds the family member of a client in the nutrition room standing in a puddle of water holding the microwave door, shaking. What should the nurse do first?

Unplug the microwave.

A child, age 5, is brought to the pediatrician's office for a routine visit. When inspecting the child's mouth, the nurse expects to find how many teeth? Up to 10 Up to 15 Up to 20 Up to 32

Up to 20 Explanation: A child may have up to 20 deciduous teeth by age 5. The first tooth usually erupts by age 6 months; the last, by age 30 months. Deciduous teeth usually are shed between ages 6 and 13.

The nurse educator is preparing an in-service about urinary incontinence in the elderly. Which information should the nurse share with her colleagues describing urinary incontinence in the elderly?

Urinary incontinence is not a disease.

Which statement by the nurse would be the best response to parents who want to know the first indication that their child's acute glomerulonephritis is improving?

Urine output will increase.

Which information should the nurse include when reinforcing instructions for a client about using vaginal medications?

Use a water-soluble lubricant when inserting a suppository.

The parents of a 2-year-old child with chronic otitis media are concerned that the disorder has affected their child's hearing. Which behavior suggests that the child has a hearing impairment?

Using gestures to express desires

A client with hypothyroidism is prescribed levothyroxine 0.05 mg by mouth daily before breakfast. As the nurse gives the client the medication, the client states, "What dose am I getting? I've been taking 0.15 mg every day for years." Which action by the nurse is most appropriate?

Verify the dose against the health care provider's prescription in the client's medical record.

A client with advanced breast cancer is prescribed tamoxifen. When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately?

Vision changes

An 11-year old girl with reports of dysuria is suspected of having a urinary tract infection. Which findings on the laboratory report are consistent with a urinary tract infection?

WBCs: 20 per high-power field

An 11-year-old girl comes into the health care provider's office reporting dysuria. Which findings on the laboratory report are consistent with a urinary tract infection?

WBCs: 20 per high-power field

A client with diabetes who had a stroke has right-sided paralysis and incontinence and is in the rehabilitation center. Which action should be the nurse's priority in caring for the client?

Wash the client's skin with soap and water, gently patting it dry.

A nurse is reinforcing education for a client with allergies about anaphylaxis. What should the nurse be sure to include in this discussion?

Wear a medical identification bracelet.

A client has a tumor of the posterior pituitary gland. The nurse assisting with the development of the plan of care should include which nursing interventions? (Select all that apply.)

Weigh the client daily. Measure urine specific gravity. Monitor intake and output.

A family expresses concern that a relative who stopped using amphetamines 3 months ago is acting paranoid. Which explanation by the nurse is best?

When a person uses amphetamines, paranoid tendencies may continue for months.

Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding signals a significant problem during this procedure?

White blood cell (WBC) count of 20,000/mm3

A preschooler goes into cardiac arrest. When performing cardiopulmonary resuscitation (CPR) on a child, how should the nurse deliver chest compressions?

With the heel of one hand

After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical-surgical unit. Postoperatively, how should the nurse position the client?

With the leg on the affected side abducted

A child with leukemia has just completed a course of methotrexate therapy. How soon should the nurse expect to see signs of bone marrow depression in this client?

Within 2 weeks

A pregnant client at 26 weeks' gestation undergoes a glucose tolerance test. The nurse identifies the need for further action based on which results?

a 1-hour glucose level of 160 mg/dL (8.88 mmol/L) during a 3-hour glucose tolerance test

Which client would be most at risk for secondary Parkinson disease caused by pharmacotherapy?

a 30-year-old client with schizophrenia taking chlorpromazine

A nurse is taking care of four clients. Which client should the nurse see first?

a 33-year-old client with a recent diagnosis of Guillain-Barré syndrome

A nurse reviews the health history of four clients. Which client is at greatest risk for the development of colorectal cancer?

a 52-year-old client with a family history of polyposis

A toddler is brought to the emergency department with sudden onset of abdominal pain, vomiting, and stools that look like red currant jelly. To confirm intussusception, the suspected cause of these findings, the nurse expects the physician to order:

a barium enema.

A woman in her eighth month of pregnancy is having dinner with her husband at their favorite restaurant. The woman suddenly begins choking on a piece of chicken. The client's husband yells out, "Please somebody help us!" A licensed practical nurse is sitting at the next table and offers to help. Which action would the nurse most likely perform?

a chest thrust

The charge nurse is making assignments for nurses working on a medical surgical unit. Which clients could be assigned to the licensed practical nurse (LPN)? Select all that apply.

a client in need of tracheostomy dressing a client in need of Foley catheterization a client on tube feeding who needs the nasogastric tube checked for patency a diabetic client who needs reinforcement of teaching on insulin administration

A nurse is caring for a 15-year-old pregnant adolescent who is taking an iron supplement. After reviewing instructions for taking the iron supplement, the nurse determines that the teaching was successful when the client tells the nurse that she will take the supplement with which fluid to help increase the absorption of iron?

a glass of orange juice

The nurse evaluates a client who is 36-hours postoperative. Which sign or symptom indicates to the nurse that the client is experiencing a complication?

a warm, erythematous tender incision

An agitated client with left-sided heart failure reports increasing shortness of breath and coughs up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of which disorder?

acute pulmonary edema

Which intervention does the nurse determine has the most impact in delaying the development of acquired immunodeficiency syndrome (AIDS) once a client has been infected with human immunodeficiency virus (HIV)?

adherence with the complete therapeutic regimen

A client receiving haloperidol reports a stiff jaw and difficulty swallowing. The nurse's first action is to:

administer an as-needed dose of benztropine I.M. as ordered.

Which instructions should the nurse include when reinforcing education to the parents about caring for a child with chickenpox?

administer antipruritics as ordered

Which nursing intervention is most effective in maximizing tissue perfusion for a child in vaso-occlusive crisis?

administer oxygen as prescribed

A nurse is caring for a client with left-sided heart failure. Which intervention takes priority in this client's care?

administering diuretics

An adult who has never had mumps reports that he was just notified that a child of a family with whom he stayed recently has been diagnosed with mumps. Which treatment should the man receive? IV antibiotics ice packs to the scrotum application of a scrotal support administration of gamma globulin

administration of gamma globulin Explanation: Gamma globulin provides passive immunity to mumps. Antibiotic therapy is used in the treatment of bacterial orchitis. Ice and a scrotal support are used as comfort measures in the treatment of orchitis.

A 5-year-old child sustained third-degree burns to the right upper extremity after tipping over a frying pan. Which skin structures would the nurse include when explaining a third-degree burn to the child's parent?

all skin layers and nerve endings

The nurse is preparing to administer morning care to a 24-month-old admitted with respiratory syncytial virus bronchiolitis. Keeping in mind the extent to which a child in this age-group can help to meet his own hygiene needs, the nurse can expect to:

allow the toddler to bathe as much of himself as he can with supervision.

A 4-year-old girl is admitted to the hospital to rule out a diagnosis of leukemia. Which would be the best room assignment for the nurse to select for this child?

alone in a private room

An LVN/LPN working on a busy unit decides to delegate some tasks to the unlicensed assistive personnel (UAP). Which client tasks can be delegated to the UAP? Select all that apply.

ambulation of a client intake and output measurement positioning a client

Which client is at the greatest risk for developing sensory overload?

an 80-year-old client in the intensive care unit (ICU)

A client who is hospitalized with scleroderma signs a document that provides instructions concerning the provision of care if the client is unable to make their own treatment decisions. The document is known as:

an advance directive

A pregnant client is screened for tuberculosis during at the first prenatal visit. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. The nurse determines that the result is positive based on which finding?

an indurated wheal larger than 10 mm in diameter appearing in 48 to 72 hours

The nurse is reinforcing education to the parents of a child with leukemia about the three main consequences. What should the nurse inform the parents they should monitor for?

anemia, infection, and bleeding tendencies

A client has not voided for 10 hours following an inguinal hernia repair. Which factor may place a surgical client at risk for urine retention?

anticholinergic medication before surgery

A nurse working in the postanesthesia care unit is caring for multiple postoperative clients . Which task chould be delegated to unlicensed assistive personnel (UAP)?

apply sequential compression device to the client's leg

A mother brings her 2-month-old infant to the clinic for a well-baby checkup. To best assess the interaction between the mother and infant, the nurse should observe them: as the infant plays. as the infant sleeps. as the mother feeds the infant. as the mother rocks the infant.

as the mother feeds the infant. Explanation: The nurse can best assess mother-infant interaction during feeding, such as by observing how closely the mother holds the infant and how she looks at the infant's face. These behaviors help reveal the mother's anxiety level and overall feelings for the infant. The infant's posture and response during feeding provide clues to the infant's comfort level and feelings. Sleeping doesn't provide an opportunity for mother-infant interaction. Although playing and rocking may provide clues about mother-infant interaction, they aren't the best activities to assess. During playing, for instance, the mother may interact with the infant at a distance. Rocking promotes closeness but not interaction; the mother can rock the infant while talking to someone else or staring off into the distance.

A client with Alzheimer's disease begins supplemental feedings through a gastrostomy tube to provide adequate calorie intake. What should the nurse be most concerned about with this client?

aspiration

The nurse is caring for a client who has been diagnosed with narcolepsy. Which actions may assist the client in managing this condition? Select all that apply.

avoid smoking follow a regular schedule for sleep and rest limit caffeine intake

A family meeting is held with a client who uses alcohol. While listening to the family, which unhealthy communication pattern might be identified?

avoidance of issues that cause conflict

A client with rheumatoid arthritis is about to begin aspirin therapy to reduce inflammation. When teaching the client about aspirin, the nurse discusses adverse reactions to prolonged aspirin therapy. These include:

bilateral hearing loss.

A client with renal insufficiency is admitted with a diagnosis of pneumonia, episodes of hypotension, and is receiving intravenous antibiotics. Which laboratory value should the nurse monitor?

blood urea nitrogen (BUN) and creatinine levels

A client comes to the clinic with back pain that has been unrelieved by continuous ibuprofen use over the past several days. Current prescription medications include captopril and hydrochlorothiazide. Which laboratory value should the nurse report?

blood urea nitrogen (BUN) of 26 mg/dL and serum creatinine of 2.35 mg/dL

A licensed practical nurse (LPN) is delegating responsibilities to a certified nursing assistant (CNA) on a busy postpartum unit. Which task would be appropriate for the LPN to delegate to the CNA?

bottle-feeding a 24-hour-old neonate

A health care provider and nurse are discussing treatment options with a client diagnosed with severe ulcerative colitis symptoms. Which potential complication requires frequent assessment?

bowel perforation

The nurse receives a call from the laboratory with lab values. Which lab value represents the highest priority for the nurse?

calcium, total 32 mg/dL (8 mmol/L)

The nurse is gathering data from a client who has the potential to have impaired neurovascular function from a cast application. What data are important for the nurse to gather to make sure there is not neurovascular impairment?

capillary refill, movement, pulses, warmth

A nurse is reviewing a newly admitted client's chart. Based on this progress notes entry, the nurse knows these data are consistent with which condition? Cherry-red skin indicates exposure to high levels of carbon monoxide.

carbon monoxide poisoning

The nurse is gathering data from a child suspected of ingesting paint chips from an old home. Which system does the nurse closely monitor for serious effects?

central nervous system (CNS)

An otherwise healthy adolescent has meningitis and is receiving IV and oral fluids. The nurse should monitor this teen's fluid balance to decrease the risk of what complication?

cerebral edema

The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:

changes from previous self-examinations.

The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover: cancerous lumps. areas of thickness or fullness. changes from previous self-examinations. fibrocystic masses.

changes from previous self-examinations. Explanation: Women are instructed to examine themselves to discover changes that have occurred in the breast. Only a physician can diagnose lumps that are cancerous, areas of thickness or fullness that signal the presence of a malignancy, or masses that are fibrocystic as opposed to malignant.

A nurse is caring for a client who is receiving enteral feedings through a feeding tube. Which action takes priority in this client's care?

checking placement of the tube

The nurse is reinforcing education about treatments for the parents of a child diagnosed with pneumonia. What does the nurse identify as the best action to help in promoting a clear airway?

chest physiotherapy

While gathering data about a child's skin integrity, the nurse observes a papular pruritic rash with some vesicles. The rash is profuse on the trunk and sparse on the distal limbs. What does the nurse correlate this finding with?

chickenpox

In which group is it most important for the client to understand the importance of an annual Papanicolaou (Pap) test?

clients infected with the human papillomavirus (HPV)

A client on the behavioral health unit spends several hours per day organizing and reorganizing the closet, repeatedly checking to see if clothing is arranged in the proper order. How does the nurse interpret this behavior?

compulsion

A primigravida client is 16 weeks pregnant. Which client instruction would be most important to reinforce in order to prevent toxoplasmosis? cooking meats thoroughly keeping dogs outside washing all vegetables having antibody titers routinely drawn

cooking meats thoroughly Explanation: Undercooked fresh meats that contain cysts with toxoplasmosis can cause infection. Cats, not dogs, carry toxoplasmosis. Toxoplasmosis is not carried on vegetables. Antibody titers do not prevent toxoplasmosis.

The nurse cares for a client who is recovering from general anesthesia. Which finding indicates to the nurse that the client is experiencing a complication?

decreased bibasilar breath sounds

The client is being evaluated for hypothyroidism. The nurse should stay alert for:

decreased body temperature and cold intolerance.

When collecting data on an infant diagnosed with pyloric stenosis, which finding should the nurse anticipate?

decreased bowel sounds

The nurse is caring for a client with a cognitive disorder. Which characteristic does the nurse observe that correlates with a cognitive disorder?

deficit in memory

When observing a neonate with congenital hypothyroidism, the nurse would be alert for which complication as the most serious consequence of this condition?

delayed central nervous system development

A client experiences polydipsia and voiding large amounts of waterlike urine with a specific gravity of 1.003. What do these clinical manifestations indicate to the nurse?

diabetes insipidus

A nurse collecting data on a post-craniotomy client finds the urinary catheter bag with 1,500 mL the first hour and the same amount for the second hour. Which complication should the nurse suspect as a cause of this amount of output?

diabetes insipidus

A nurse cares for a client that reports sexual dysfunction. Which condition should the nurse consider as one of the most common causes of sexual dysfunction?

diabetes mellitus

A nurse is providing care for a pregnant client in her second trimester. A 1-hour oral glucose tolerance test results show that the client has a blood glucose level of 160 mg/dL. Which intervention would the nurse anticipate as being included in the client's multidisciplinary plan of care?

dietary management

A client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse knows that this client should avoid arm exercise because it may:

dislodge the autografts.

A nurse is removing an indwelling urinary catheter. Which nursing action reflects the best technique?

document the time of removal

The nurse is gathering data from a client that is diagnosed with Kawasaki disease. What data does the nurse determine is associated with this diagnosis?

dry, cracked lips, strawberry tongue

A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test?

encourage increased oral fluid intake

The nurse is caring for a client who has undergone an open surgical procedure for hiatal hernia repair. Which nursing intervention is a priority?

encouraging incentive spirometer use

A client with a diagnosis of borderline personality disorder is admitted to the unit after slashing their wrist. When assisting with the planning of care, which goal is most appropriate for this client?

establish a therapeutic relationship with the client

The nurse assists in developing a list of nursing diagnoses for a client. This list should include:

factors influencing the client's problem.

The nurse is caring for a client with hypothyroidism. Which client data would the nurse expect to collect?

fatigue, cold intolerance, weight gain, and constipation

A 1-month-old infant is admitted to the pediatric unit and diagnosed with bacterial meningitis. Which findings by the nurse support the diagnosis?

fever, change in feeding pattern, vomiting, or diarrhea

Which finding is common when gathering data from a child with a total anomalous pulmonary venous return defect?

frequent respiratory infections

The nurse is caring for a geriatric client with a history of falls. While evaluating the client's risk of fall, the nurse should collect:

gait and balance information.

A nurse is caring for a client with lower back pain who is scheduled for myelography using a water-soluble contrast dye. After the test, the nurse should place the client in which position?

head of the bed elevated 45 degrees

When gathering data from a client admitted with hypertension, the nurse should expect the client to report which symptom?

headache

A child diagnosed with leukemia is suspected to have metastasis to the brain. What symptoms observed by the nurse will correlate with this suspicion?

headache and vomiting

The nurse is observing a normal cardiac rhythm strip obtained from an adult client. Which characteristic leads to this normal finding?

heart rate of 88 beats/minute

A nurse is transferring a client from a bed to a chair. Which action should the nurse take during client transfer?

help the client dangle the legs

The nurse is caring for a neonate whose mother is infected with hepatitis B. The nurse would inform the mother that her child will receive which treatment? hepatitis B vaccine at birth and age 1 month hepatitis B immune globulin at birth; no hepatitis B vaccine hepatitis B immune globulin within 48 hours of birth, and hepatitis B vaccine at age 1 month hepatitis B immune globulin within 12 hours of birth, and hepatitis B vaccine at birth, age 1 month, and age 6 months

hepatitis B immune globulin within 12 hours of birth, and hepatitis B vaccine at birth, age 1 month, and age 6 months Explanation: Hepatitis B immune globulin should be given as soon as possible after birth but within 12 hours. Neonates should also receive hepatitis B vaccine at regularly scheduled intervals. This sequence of care is considered superior to the other treatment options.

The nurse is caring for a client with suspected parathyroid dysfunction. Which laboratory results support a diagnosis of primary hyperparathyroidism?

high parathyroid hormone and high calcium levels

The nurse is reinforcing education for a client with uric acid calculi. Which type of diet should the nurse inform the client to avoid?

high purine

The physician diagnoses type 1 diabetes in a client who has classic manifestations of the disease and a random blood glucose level of 350 mg/dl. In addition to dietary modifications, the physician prescribes insulin. Initially, most clients receive the least antigenic form of insulin. Therefore, the nurse expects the physician to prescribe:

human insulin.

A client with diabetes delivers a 9-lb, 6-oz (4,250 g) neonate. The nurse should be alert for which condition in the neonate?

hypoglycemia

A nurse is receiving the chart of an adolescent client who has been admitted to the unit. When reading the progress notes above, the nurse sees a laboratory result that indicates a condition consistent with a diagnosis of bulimia nervosa. Which condition does the nurse suspect?

hypokalemia

Which combination of adverse effects should the nurse carefully monitor when administering IV insulin to a client diagnosed with diabetic ketoacidosis?

hypokalemia and hypoglycemia

According to Erikson, an adolescent who's suffering from gender dysphoria can't progress through which developmental task?

identity versus role confusion

A nurse is caring for a neonate and is using measures to help maintain the neonate's temperature. Which intervention would be most effective in helping to prevent evaporative heat loss? administering warm oxygen controlling the drafts in the room immediately drying the neonate placing the neonate on a warm, dry towel

immediately drying the neonate Explanation: Immediately drying the neonate decreases evaporative heat loss from his moist body from birth. Placing the neonate on a warm, dry towel decreases heat loss through conduction. Controlling the drafts in the room and administering warm oxygen help reduce heat loss through convection.

The nurse is instructing unlicensed assistive personnel (UAP) on how to properly position a client who underwent total hip replacement. The nurse explains that the client's hip needs to be in which position?

in an abducted position

A client with a recent fracture is suspected of having compartment syndrome. Which findings does the nurse recognize correlate with this diagnosis?

inability to perform active movement; pain with passive movement

The nurse is planning care for a client who is argumentative and demanding, calling the nurse frequently. What is the nurse's best intervention?

include the client in the decision-making process

A client is scheduled to have a cholecystectomy. In the preoperative teaching, the nurse explains that incentive spirometry will be used after surgery. Which information will the nurse include when conducting the postoperative teaching? Select all that apply.

increase alveolar inflation promote lung expansion promote deep breathing

When children are more physically active, which change in the management of the child with diabetes should the nurse expect?

increased food intake

Which finding will the nurse most likely observe when performing a health screening of an older adult female client who has loss of bone density?

increased thoracic curvature of the spine

A nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, where in the eye should the nurse instill the eyedrops?

into the conjunctival sac

A client presents to the emergency department with weight gain, lethargy, and goiter. When reviewing laboratory values, in which major mineral would the nurse anticipate this client to be deficient?

iodine

During the admission process, the nurse evaluates a client with rheumatoid arthritis. To assess for the most obvious disease manifestations first, the nurse checks for:

joint abnormalities.

During the admission process, the nurse evaluates a client with rheumatoid arthritis. To assess for the most obvious disease manifestations first, the nurse checks for: muscle weakness. joint abnormalities. painful subcutaneous nodules. gait disturbances.

joint abnormalities. Explanation: Joint abnormalities are the most obvious manifestations of rheumatoid arthritis. A systemic disease, rheumatoid arthritis attacks all connective tissue. Nonarticular connective tissue, such as collagen in the lungs, heart, muscles, vessels, pleura, and tendons, may be involved diffusely. Vasculitis may affect the eyes, nervous system, and skin, causing thrombosis and ischemia. Although muscle weakness may occur from limited use of the joint where the muscle attaches, such weakness isn't the most obvious sign of rheumatoid arthritis; also, it occurs only after joint abnormalities arise. Subcutaneous nodules, although common in rheumatoid arthritis, are painless. The disease may cause gait disturbances, but these follow joint abnormalities.

A primigravida client is in labor. Her cervix is 5 cm dilated and 75% effaced; the fetus is at 0 station. The client requests medication to relieve the discomfort of contractions, and the health care provider prescribes an epidural regional block. When assisting with the procedures, which position should the nurse help the client to assume when the epidural is administered?

lateral

A client addicted to alcohol begins individual therapy with a nurse. Which goal should be a priority for the client?

learning to express feelings

The nurse is caring for a client diagnosed with leukemia who is going to have a chemotherapy treatment. Which test would the nurse expect to be done to evaluate the client's ability to metabolize chemotherapeutic agents?

liver function studies

A pregnant client in the latent stage of labor begins reporting pain in the epigastric area, blurred vision, and a headache. The client has a history of hypertension during pregnancy. The nurse anticipates the administration of which medication?

magnesium sulfate

A nurse is about to give a backrub to a client after a complete bed bath. How should the nurse proceed?

massage gently in areas directly over pressure points

A nurse prepares to care for a client who has just transferred from the emergency department to the medical-surgical floor. Which is the most effective action that the nurse should take to prevent microbial transmission?

meticulous hand hygiene

A nurse is caring for a neonate diagnosed with fetal alcohol syndrome (FAS). When gathering data on this neonate, which craniofacial change would the nurse most likely find?

microcephaly

Which complementary therapy might calm a 4-year-old who has separation anxiety when the child's parents leave the hospital?

music therapy

A nurse who is part of the multidisciplinary team is assigned to care for four neonates and is reviewing each neonate's plan of care. The nurse would closely monitor which neonate considered to be at highest risk for developing hyperbilirubinemia?

neonate with ABO incompatibility

A client arrives at the emergency department after falling on ice outside of the senior citizens' housing facility and sustaining a right hip fracture. Which finding would be most important for the nurse to evaluate?

neurovascular compromise

A client who has chronic bronchitis has asked the nurse to identify things that will help to promote better oxygenation. Which of the following lifestyle factors does the nurse identify as affecting a client's oxygenation? Select all that apply.

nutrition physical exercise anxiety

A nurse is reinforcing discharge instructions to a client after treatment for a severe allergic reaction from a bee sting. What instructions should the nurse include? Select all that apply.

obtain diphenhydramine to take following a bee sting fill the prescription for injectable epinephrine to carry with you

A client has just returned from the postanesthesia care unit (PACU) after undergoing internal fixation of a left femoral neck fracture. The nurse should place the client in which position?

on the client's back with two pillows between the legs

Six months after the death of her infant son, a client is diagnosed with dysfunctional grieving. Which behavior would the nurse expect to find?

overactive without a sense of loss

The parents of a 6 month old diagnosed with a terminal brain tumor have chosen palliative care. Which interventions will be provided for this infant? Select all that apply.

pain management and comfort measures parental support enabling the parents to participate in the infant's care

A client in the fifth month of pregnancy is having a routine clinic visit. When gathering data from the client, the nurse would be alert for which common second trimester condition? mastitis metabolic alkalosis physiologic anemia respiratory acidosis

physiologic anemia Explanation: Hemoglobin level and hematocrit decrease during pregnancy as the increase in plasma volume exceeds the increase in red blood cell production. The result is physiologic anemia. Mastitis is an infection in the breast characterized by a swollen, tender breast and flulike symptoms. This condition is most commonly seen in breast-feeding clients. Alterations in acid-base balance during pregnancy result in a state of respiratory alkalosis, compensated by mild metabolic acidosis.

A client arrives in the emergency department with a nosebleed. What is the first action by the nurse?

pinch the nares together at the bridge of the nose

The nurse is caring for a client with acute pulmonary edema. To immediately promote oxygenation and relieve dyspnea, the nurse should:

place the client in high Fowler's position.

A client diagnosed with major depression states, "Everything is my fault, and I would be better off dead." Which priority intervention would the nurse implement?

place the client on suicide precautions

When collecting data on a neonate for signs of diabetes insipidus, a nurse should recognize which symptom as a sign of this disorder?

polyuria and polydipsia

An emergency department nurse suspects neglect in a 3-year-old child admitted for failure to thrive. What behavior in the child should the nurse look for that might indicate signs of neglect?

poor hygiene and weight loss

Which nursing intervention should the nurse give highest priority to when caring for an unconscious client?

positioning the client with the head of bed at a 15 to 30 degree angle

A nurse is obtaining data from a 3-year-old child with nuchal rigidity. Which sign would be documented on the chart to support this condition?

positive Kernig's sign

A client is admitted to the cardiac unit with a diagnosis of heart failure. The health care provider prescribes furosemide and digoxin to manage the condition. Which laboratory value should be monitored during hospitalization?

potassium

A student nurse is performing wound care while the instructor observes. Which observation by the instruction requires immediate intervention of the student nurse's action?

pouring solution directly onto a sterile field barrier

A client whose gestational diabetes is poorly controlled throughout her pregnancy goes into labor at 38 weeks' gestation and gives birth. When assisting with implementing the plan of care for this neonate, which intervention would be the priority during the neonate's first 24 hours?

providing frequent early feedings with formula

A client is suspected of having a pulmonary embolus. Which test should the nurse prepare the client for that is definitive?

pulmonary angiogram

A client who is 27 weeks' pregnant arrives at the health care provider's office reporting fever, nausea, vomiting, malaise, unilateral flank pain, and costovertebral angle tenderness. About which condition does the nurse anticipate reinforcing education?

pyelonephritis

The nurse is reinforcing nutritional information with a client with a leukocyte (WBC) count of 2,500/µL (2.50 × 109/L). What food should the nurse be sure to have the client avoid? white bread raw carrot sticks stewed apples well-done steak

raw carrot sticks Explanation: The normal leukocyte (WBC) is 4.500 /(4.50 × 109/L) to 11,000/ (11.00 × 109/L). A WBC count of 2,500/ (2.50 × 109/L) is low, making the client prone to infection. A low-bacteria diet is indicated, which excludes raw fruits and vegetables.

A nurse is caring for 10-year-old child with sickle cell anemia admitted for vaso-occlusive crisis. Which would be the most appropriate activity for the nurse to provide for the child?

reading

The nurse is caring for a client with esophageal varices. What is a priority intervention when caring for this client?

recognizing hemorrhage

The nurse is assisting with the development of a plan of care for a client with illness anxiety disorder. What would be an appropriate goal for this client?

relieving the fear of serious illness

A nurse is assisting with the development of a plan of care for a client who has undergone electroconvulsive therapy (ECT). Which intervention would most likely be included?

reorienting the client to time and place

A client comes to the emergency department with status asthmaticus. Based on the documentation note shown, the nurse suspects that the client has what abnormality?

respiratory alkalosis

After reviewing the client's maternal history of receiving magnesium sulfate during labor, which condition should the nurse anticipate as a potential problem in the neonate?

respiratory depression

The nurse is obtaining data from a new client in the cardiovascular clinic. When asking about childhood diseases and disorders associated with structural heart disease, the nurse should consider which finding significant? croup rheumatic fever severe staphylococcal infection medullary sponge kidney

rheumatic fever Explanation: Childhood diseases and disorders associated with structural heart disease include rheumatic fever and severe streptococcal (not staphylococcal) infections. Croup—a severe upper airway inflammation and obstruction that typically strikes children ages 3 months and 3 years—may cause latent complications, such as ear infection and pneumonia. However, it doesn't affect heart structures. Likewise, medullary sponge kidney, characterized by dilation of the renal pyramids and formation of cavities, clefts, and cysts in the renal medulla, eventually may lead to hypertension but doesn't damage heart structures.

A client who wanders is admitted to a restraint-free facility. Which nursing interventions can be implemented to avoid restraint use? Select all that apply.

schedule diversional activities take client on daily walks place client in a room close to the nurses' station

A 59-year-old client is scheduled for cardiac catheterization the next morning. His physician prescribed secobarbital sodium, 100 mg by mouth at bedtime, for sedation. Before administering the drug, the nurse should know that:

sedatives reduce excitement; hypnotics induce sleep.

The nurse is providing care to a pregnant client with preeclampsia. Magnesium sulfate has been ordered. The nurse understands that this drug is being given to prevent which condition?

seizures

Which clinical manifestations should a nurse expect to see in a child in stage V of Reye syndrome?

seizures, flaccidity, and respiratory arrest

A client with a narcissistic personality disorder states to the nurse, "I don't care what you say. I know much more about nursing than you ever will!" What nursing intervention is essential at this time?

set limits for socially acceptable client behavior

A client informs the nurse that the client has difficulty sleeping. About which conditions does the nurse question the client to determine factors that inhibit adequate sleep patterns? Select all that apply.

shift work sleep apnea caffeine intake in the evening Excessive worry or anxiety

When caring for an older adult client, the nurse should expect to find which normal age-related changes that may affect client education? reduced intelligence electrolyte imbalances slowed reaction time increased vein elasticity

slowed reaction time Explanation: Slowed reaction time is a normal age-related change in older adult clients. Although the client's intelligence should remain intact, aging may slow learning speed. Electrolyte imbalances are abnormal findings in clients of any age. With age, vein elasticity usually decreases, not increases.

A confused client is brought to the emergency room. The client's has a heart rate of 108/minute and blood pressure 102/68 mm Hg. The family states the client has been taking lithium for manic episodes. Which laboratory results would be most concerning to the nurse?

sodium 150 mEq/L (150 mmol/L), hemoglobin 19.2 g/dL (192 g/L), blood urea nitrogen (BUN) 38 mg/dL (13.57 mmol/L)

Which approach should be used with a client with paranoid personality disorder who misinterprets many things the health care team says?

speak in simple messages without details

A nurse notes that a client frequently coughs while eating. The licensed practical nurse (LPN) reports this finding to the registered nurse and discusses possible options to address this problem. Based on the discussion, which health team member would the LPN expect to become involved?

speech therapist

A client is treated in the emergency department with reports of dyspnea, cough, and sharp pain that increases with exertion. The nurse auscultates diminished breath sounds, and the health care provider prescribes a chest x-ray. What does the nurse suspect this will indicate?

spontaneous pneumothorax

During data collection of a newly admitted client, the nurse observes a reddened area on the left heel. The nurse applies pressure to the reddened area and notes that it does not blanch when pressure is relieved. When documenting the findings, which appropriate stage would the nurse assign to this pressure sore?

stage I

A nurse is reinforcing the teaching plan for a postpartum client diagnosed with mastitis. The nurse determines that the client has understood the information when she states which organism as most likely responsible?

staphylococcus aureus

The client refused an injection, but the nurse administered it anyway. The client wants to sue the nurse. The attorney informs the client that this lawsuit must be filed within two years. What is this time frame called?

statute of limitation

A client in labor is prescribed oxytocin and asks the nurse, "What's this medication for?" The nurse would incorporate knowledge of which action in the response?

stimulates labor and prevents hemorrhage

The nurse is planning a health teaching session for parents of a toddler. When describing a toddler's typical eating pattern, the nurse should mention that many children of this age exhibit: consistent table manners. an increased appetite. strong food preferences. a preference for eating alone.

strong food preferences. Explanation: A toddler typically exhibits strong food preferences, eating one type of food for several days and excluding others. A toddler can't be expected to use consistent table manners. Generally, the appetite decreases during the toddler stage because of a slowed growth rate. A toddler typically enjoys socializing during meals and often imitates others.

A client with antisocial personality disorder tells a nurse, "Life has been full of problems since childhood." Which condition would the nurse explore in the assessment?

substance abuse

A 13-year-old with structural scoliosis has Cotrel-Dubousset rods inserted. Which position would be best during the post-operative period?

supine in bed

Which symptom is the most common manifestation of severe combined immunodeficiency disease (SCID)?

susceptibility to infection

A client who has just given birth to a full-term neonate is handed the neonate by the nurse. Which factor is most likely to promote attachment between parents and their neonate? verbalization of desire by the parents to bond with the neonate completion of parental education about the importance of bonding sustained physical contact with the neonate immediately after birth history of attachment with previous birth experiences

sustained physical contact with the neonate immediately after birth Explanation: The neonate's first period of reactivity, which occurs in the first hour after birth, is the ideal time for attachment. During this period, the parents can touch, hold, talk to, examine, and feed the neonate. Although parental desire and education can contribute to effective attachment, the parents must ideally make early physical contact for attachment to occur. Attachment during previous births may aid in attachment now, but early interaction with this neonate is still necessary.

The nurse is reinforcing education for the parents of a child with growth hormone deficiency. Which sport does the nurse suggest as the most beneficial for the child? Select all that apply.

swimming gymnastics

A nurse is caring for a 1-day postpartum client. The progress note above informs the nurse that the client is in which phase of the postpartum period?

taking in

A client tells the nurse "my cowaorkers are sabotaging my computer." When the nurse asks questions, the client becomes argumentative. Which intervention would be most appropriate for the nurse to implement?

talk with the client about the realistic situations

Four children, each 6 months of age, arrive at the clinic for diphtheria-pertussis-tetanus (DPT) immunization. Which child can safely be immunized at this time? the child with a temperature of 103° F (39.4° C) the child with a runny nose and cough the child taking prednisone for the treatment of leukemia the child with difficulty breathing after the last immunization

the child with a runny nose and cough Explanation: Children with cold symptoms can safely receive DPT immunization. Children with a temperature more than 102° F (38.9° C), serious reactions to previous immunizations, or those receiving immunosuppressive therapy shouldn't receive DPT immunization.

A nurse wants to use a waist restraint for a client who wanders at night. Which intervention should be considered before applying the restraint?

the client's reason for getting out of bed

The nurse is caring for a neonate that was born to a mother with gestational diabetes. What site will be used to puncture the neonate's foot in order to monitor the neonate's glucose level?

the lateral aspect of the heel

A client with bipolar disorder has abruptly stopped taking prescribed medication. Which behavior would indicate the client is experiencing a manic episode?

thoughtless spending

A nurse gathers data on a client who has developed a paralytic ileus. Which type of bowel sounds should the nurse anticipate hearing?

three to four peristaltic sounds per minute

Which reason best accounts for the physical symptoms in a client with a somatic symptom disorder?

to prevent or relieve symptoms of anxiety

When presenting an informational series on infant safety, which appropriate development milestone for the 4-month-old infant would the nurse stress could jeopardize the infant's safety? responds readily to sound grabs feet and pulls to the mouth turns from abdomen to back drops objects to pick up another one

turns from abdomen to back Explanation: The ability to turn from abdomen to back puts the infant at risk for falling: parents must be careful not to leave the infant unattended with the crib's side rails down, on the sofa, or on the changing diaper table. The other three responses are not additional risks for the infant.

The nurse is assisting with a care plan for a client admitted with Alzheimer's dementia. The family reports that the client has to be watched closely for wandering behavior at night. Which nursing action will be of the greatest importance?

using a bed check monitor device

A client who has difficulty sleeping is asked to keep a sleep diary. Which information should the nurse instruct the client to keep in this diary?

usual bedtime

The nurse is reviewing the medical record of a client who is 6 weeks postpartum and came for a follow up appointment with her health care provider. The client's uterus is enlarged and soft, and she is experiencing vaginal bleeding. Based on the findings, which condition would the nurse most likely suspect?

uterine subinvolution

A client with Bipolar I disorder is experiencing mania. How will the nurse best communicate with this client?

verbalize self-confidence in own abilities

A school nurse is obtaining data from a student at an elementary school. Which finding would lead the nurse to suspect impetigo?

vesicular lesions that ooze, forming crusts on the face and extremities

A client with peptic ulcer disease is prescribed aluminum-magnesium complex. When teaching about this antacid preparation, the nurse should instruct the client to take it with:

water.

Which finding would concern the nurse who's caring for an infant after a right femoral cardiac catheterization?

weak right dorsalis pedis pulse

A postpartum client decides to bottle-feed her neonate. To prevent breast engorgement, the nurse should recommend that she:

wear a supportive, well-fitting brassiere.

A postpartum client decides to bottle-feed her neonate. To prevent breast engorgement, the nurse should recommend that she: express milk manually. take antilactation drugs. take hot showers. wear a supportive, well-fitting brassiere.

wear a supportive, well-fitting brassiere. Explanation: A proper brassiere helps prevent breast engorgement by providing support and acting as a barrier to breast stimulation. Ice pack application helps reduce swelling. Antilactation drugs are no longer recommended because a rebound effect may occur after they're discontinued; also, they're expensive and may cause adverse effects. Manual milk expression and hot showers stimulate the breasts, triggering milk production and prolonging the discomfort of engorgement.

When collecting data on a client who has just been admitted to the medical-surgical unit, the nurse discovers scabies. To prevent scabies infection in other clients, the nurse should:

wear gloves when providing care and isolate the client's bed linens until the client is no longer infectious.

A nurse is preparing to reinforce education with a client who uses alcohol. What client data would be most important for the nurse to obtain?

willingness to learn

The nurse is to give a client a 325-mg aspirin suppository. The client has diarrhea and is in the bathroom. The best nursing approach at this time would be to:

withhold the suppository and notify the client's physician.

A physician is administering a medication by intraosseous infusion to a child. Intraosseous drug administration is typically used for a child who is:

younger than age 3 in an emergency situation when I.V. access isn't available.

A school-age child experiences symptoms of excessive polyphagia, polyuria, and weight loss. The physician diagnoses type I diabetes mellitus and admits the child to the facility for insulin regulation. The physician prescribes an insulin regimen of insulin (Humulin R) and isophane insulin (Humulin N) administered subcutaneously. How soon after administration can the nurse expect the regular insulin to begin to act?

½ to 1 hour