Transition to Practice EXAM 2

A client has a precipitous delivery attended only by the nurse. What nursing intervention has the highest priority? A. ensure an adequate airway in the newborn B. massage the uterine fundus until it is firm C. clamp and cut the umbilical cord D. assess for signs of placental detachment

A

A client presents to the community health clinic with reports of generalized weakness, muscle cramps, nausea, vomiting, and diarrhea. Based on these symptoms, the nurse anticipates that the client may have which problem? A. Hyperkalemia B. Hyponatremia C. Vitamin D deficiency D. Hypoparathyroidism

A

A female client is heterozygous for blue eyes, a recessive trait. Her male partner is homozygous for brown eyes, a dominant trait. What color eyes will their four children have? A. Brown B. Blue C. Some will have blue, and some will have brown D. Cannot be determined

A

A high school senior is complaining of a persistent cough and admits to smoking 10-15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement? A. encourage the student to associate with non-smokers only while attempting to stop smoking B. tell the student that he is still young and should continue to try various smoking cessation methods C. describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness D. provide the student with the latest research data describing the long-term effects of tobacco use

A

A male client, who has a 3 year history of type 2 diabetes that is controlled by diet, is being discharged post-myocardial infarction with a prescription of nitroglycerin tablets for chest pain and regular insulin for treatment of his diabetes. Following teaching, the client tells the nurse that he will make sure he keeps his nitroglycerin bottle in his pants pocket at all times; that he eats and drinks a snack before going to bed; and that he checks his blood glucose before eating in the morning. This client requires further teaching on which subject? A. storing nitroglycerin B. fluid intake C. blood glucose monitoring D. diabetic diet

A

A middle-aged male client received a liver transplant 5 days ago. In the last 36 hours, he has developed a rash beginning on his palms, along with abdominal pain and nausea. It has been determined that the immune response is caused by the new organ. What is the most likely diagnosis of his condition? A. graft-versus-host disease B. Acute transplant rejection C. Hyperacute organ rejection D. T-cell mediated graft rejection

A

A new mother asks the nurse why her infant son has yellow liquid coming out of his eyes. Which explanation is correct? A. an antibiotic ointment is placed in each newborn's eyes to prevent infection B. conjunctivitis neonatorum is common in newborns C. this type of question should be discussed with your pediatrician D. most infants have drainage from their eyes which usually resolves within 2-3 days of life

A

A newborn is brought to the admissions nursery by the nurse and the father of the baby. The baby weighs 9 pounds 3 ounces and measures 21 inches head to toe. Which description is a correct assessment of this infant? A. above average in weight but average in length B. above average in weight and length C. above average in weight but below average in length D. macrosomia with an average length

A

A nurse is caring for a client with diabetes insipidus. Which laboratory values should the nurse review? A. Antidiuretic hormone and urine osmolality B. Serum glucose and serum potassium levels C. Blood urea nitrogen D. Creatinine clearance

A

A young adult client was diagnosed with an acute subdural hematoma following a mountain biking accident. Which pathophysiologic process most likely underlies his diagnosis? A. Blood has accumulated between the dura and subarachnoid space B. Vessels have burst between the client's skull and dura C. A traumatic lesion in the frontal or temporal lobe has resulted in increased intracranial pressure D. Blood has displaced cerebrospinal fluid in the ventricles as a consequence of the coup-contrecoup injury

A

About mid-morning, a 10-year-old child reports to the school nurse complaining of nausea, dizziness, and chills. Further assessment reveals that this child is sweating profusely and has a blood glucose level of 57 mg/dL. Based on these assessment findings, which food is best for the nurse to encourage the child to eat? A. peanut butter crackers B. chocolate bar C. soft drink D. piece of bubble gum

A

An intensive care nurse is monitoring the vital signs of a client experiencing hypothermia. What is the priority assessment? A. Respirations B. Heart rate C. Blood pressure D. Temperature

A

Current assessment findings for a client who is withdrawing from barbiturates are: blood pressure 135/90; temperature 97.6F; pulse 98 beats/min; respiratory rate 22 breaths/minute. The client is also experiencing insomnia, restlessness, confusion, and pronounced muscle twitching. What action should the nurse take? A. notify the health care provider of the client's status B. assess vital signs q 15 minutes until stable C. place the client in a vest-type restraining jacket D. encourage the client to take a warm bath to help relax

A

The RN charge nurse is making client assignments. Which client should the charge nurse assign to the graduate nurse who has just finished orientation? a. The client with a cystectomy who had a creation of an ileal conduit b. The client on continuous hemodialysis who is awaiting a kidney transplant c. The client diagnosed with renal trauma secondary to a motor vehicle accident The client who has had abdominal surgery and whose wound has eviscerated

A

The RN primary nurse is caring for clients on the renal unit. Which task is most appropriate for the RN to delegate to the UAP? a. Instruct the UAP to calculate the clients' urinary intake and output b. Request the UAP to double-check a unit of blood that is being administered c. Tell the UAP to change the surgical dressing on the client with a kidney transplant d. Ask the UAP to transfer the client from the renal unit to the intensive care unit

A

The charge nurse is making assignments in the day surgery center. Which client should be assigned to the most experienced nurse? a. The 24-year-old client who had a circumcision and is being prepared for discharge b. The client scheduled for a cystectomy who is crying and upset about the surgery c. The client diagnosed with kidney cancer who is receiving two units of blood d. The client who has end-stage renal disease and had an arteriovenous fistula created

A

The charge nurse is making client assignments for a neurological medical floor. Which client should be assigned to the most experienced nurse? a. The elderly client who is experiencing a stroke in evolution b. The client diagnosed with a transient ischemic attack 48 hours ago c. The client diagnosed with Guillain-Barre syndrome who reports leg pain d. The client diagnosed with Alzheimer's disease who is wandering in the halls

A

The clinic nurse is making assignments for the large family practice clinic. Which task should be assigned to a staff nurse who is 4 months pregnant? a. Have the staff nurse answer the telephone calls from clients b. Instruct the staff nurse to work in the radiology department c. Tell the staff nurse to work in the front desk triage area d. Assign the staff nurse to work in the oncology clinic

A

The critical care RN charge nurse is making client assignments for the shift. Which client should the charge nurse assign to the graduate nurse who just completed orientation? a. The client diagnosed with amyotrophic lateral sclerosis on a ventilator who is dying and whose family is at bedside b. The client diagnosed with a closed head injury and increasing intracranial pressure receiving IV mannitol c. The client diagnosed with a C-5 spinal cord injury who is experiencing spinal shock and is on dopamine d. The client diagnosed with a seizure disorder who has been experiencing status epilepticus for the past 24 hours

A

The nurse is administering medications to clients on a surgical unit. Which medication should the nurse administer first? a. Morphine IV infusion to the client who is 8 hours postoperative and is reporting pain, rating it as 7 b. Vancomycin intravenous piggyback to the client diagnosed with an infected abdominal wound c. Pantoprazole intravenous piggyback to the client who is at risk for developing a stress ulcer d. Furosemide intravenous push to the client who has undergone surgical debridement of the right lower limb

A

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? a. Sweating and pallor b. Bradycardia and indigestion c. Double vision and chest pain d. Abdominal pain and cramping

A

The nurse is teaching the client about his prescribed prednisone. Which statement, if made by the client indicates that further teaching is necessary? a. "I can take aspirin or my antihistamine if I need it." b. "I need to take the medication every day at the same time." c. "I need to avoid coffee, tea, cola, and chocolate in my diet." d. "If I gain 5 pounds or more in a week, I will call my doctor."

A

The nurse on a medical unit has just received the evening shift report. Which client should the nurse assess first? a. The client diagnosed with renal vein thrombosis who has a heparin drip infusion and a PTT of 92 b. The client on peritoneal dialysis who has a clear dialysate draining from the abdomen c. The client on hemodialysis whose right upper arm fistula has an audible bruit d. The client diagnosed with cystitis who is reporting burning on urination

A

The nurse on the cardiac unit is reviewing client laboratory results and notes that a client's potassium level is 6.1 mEq/L. The nurse removes the banana from the client's meal tray. What information should the nurse provide regarding this action? A. "Your potassium level is high, so I need you to let me know if you feel numbness, tingling, or weakness." B. "Your potassium level is higher than it should be, which brings a risk of changes in kidney function." C. "I need to monitor you for signs of high potassium; tell me if you feel that your heart is beating quickly." D. "The amount of potassium in your blood is too high, but I will change your intravenous fluids."

A

The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet? a. Rice b. Oatmeal c. Rye toast d. Wheat bread

A

Upon discharge, the nurse observes the infant safety seat is correctly installed in the parent's vehicle. Which level of prevention does this describe? A. Primary B. Secondary C. Tertiary D. Quarterly

A

What action by the LPN requires intervention by the critical care RN charge nurse? a. The LPN has the trough drawn after hanging the aminoglycoside b. The LPN changes out a sharps container that is over the fill line c. The LPN asks another nurse to observe wastage of a narcotic d. The LPN inserts an indwelling urinary catheter into the client

A

When examining the wound of a client who had abdominal surgery yesterday, the nurse finds that the wound edges are close together, there is no sign of redness, and there is a slight amount of bright red blood oozing from the incision. What action should the nurse take? A. record these findings in the client's record B. observe closely for possible dehiscence C. notify the health care provider that the client's wound is producing sanguineous drainage D. increase the IV fluid rate and encourage the client to eat more ice chips

A

Which behavior warrants intervention by the clinical manager in the medical-surgical outpatient clinic? a. The UAP discussing a client's condition in the waiting room b. The LPN is talking to a client over the phone about laboratory tests c. The RN is triaging phone messages during their lunch break d. The UAP is taking vital signs for the client being placed in a room

A

Which nursing task should the RN staff nurse on the renal unit assign to the LPN? a. Insert an indwelling urinary catheter before surgery b. Turn and reposition the client every 2 hours c. Measure and record the urine in the bedside commode d. Feed the client who choked on food during the last meal

A

While conducting a routine health assessment of a woman who recently immigrated to the U.S. from China, the nurse notes that the client make little direct eye contact, is deferential to health care personnel, and avoids sharing her personal thoughts and feelings. What action should the nurse take? A. continue the interview process and record the findings B. refer the client to a psychiatric outpatient clinic C. determine if there is a family history of emotional disorders D. encourage the woman to attend citizenship classes

A

Which biological practices are federally regulated for health care workers? Select all that apply. A. Standard precautions B. N-95 tuberculosis standard C. Blood-borne pathogen standard D. Biological product exposure limit E. Resource Conservation and Recovery Act F. As Low As Reasonably Allowable standard

A,B,C,E

The nurse is educating a group of clients about why routine screening for open-angle glaucoma is important. What information should the nurse include? Select all that apply. A. Open-angle glaucoma is an asymptomatic condition B. Increasing intraocular pressure damages the optic nerve C. Surgical intervention is required as soon as it is identified D. The chance for cure is increased if diagnosed early in the disease E. Early intervention can prevent vision loss

A,B,E

The nurse is reviewing the prescriptions for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. a. Maintain NPO status b. Encourage coughing and deep breathing c. Give small, frequent high-calorie feedings d. Maintain the client in a supine and flat position e. Give hydromorphone intravenously as prescribed for pain f. Maintain IV fluids at 10 mL/hr to keep the vein open

A,B,E

Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select all that apply. a. Providing a low-fat, well-balanced diet b. Teaching the child effective hand washing techniques c. Scheduling playtime in the playroom with other children d. Notifying the health care provider if jaundice is present e. Instructing the parents to avoid administering medications unless prescribed f. Arranging for indefinite home schooling because the child will not be able to return to school

A,B,E

A client with a diagnosis of Addisonian crisis is being admitted to the ICU. Which findings will the interprofessional health care team focus on? Select all that apply. a. Hypotension b. Leukocytosis c. Hyperkalemia d. Hypercalcemia e. Hypernatremia

A,C

The rural emergency department nurse is triaging victims at the site of a disaster. The victims are tagged using a color code system. Which client should be evacuated first? Rank in order of priority. a. The client assigned a red tag who is alert and diagnosed with a sucking chest wound b. The client assigned a green tag who cannot stop crying and can't answer questions c. The client assigned a yellow tag whose abdomen is hard and tender to the touch d. The client assigned a black tag with full-thickness burns on more than 60% of the body e. The client assigned a white tag who has no injuries and is comforting the victims

A,C,B,D,E

A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. a. Administer stool softeners as prescribed b. Instruct the client to limit fluid intake to avoid urinary retention c. Encourage a high fiber diet to promote bowel movements without straining d. Apply cold packs to the anal-rectal area over the dressing until the packing is removed e. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding

A,C,D

The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion and has a serum sodium of 118 mEq/L. Which health care provider prescriptions should the nurse anticipate receiving? Select all that apply. a. Initiate an infusion of 3% NaCl b. Administer intravenous furosemide c. Restrict fluids to 800 mL over 24 hours d. Elevate the head of the bed to high-Fowler's e. Administer a vasopressin antagonist as prescribed

A,C,E

Which contextual factors are considered external environmental influences in the framework for occupational health programs and services? Select all that apply. A. Economics B. Workforce C. Technology D. Interventions E. Socio-economic status F. Legislation/regulation

A,C,F

A brain-injured client is unresponsive to speech, pupils are dilated and do not react to light. The client is breathing regularly at a respiratory rate of 45 breaths per minute. In response to a noxious stimulus, the arms and legs extend rigidly. What is the client's level of impairment? A. Obtundation B. Coma C. Brain death D. Vegetative state

B

A client at 13 weeks' gestation is scheduled for an amniocentesis in one week. The nurse knows that the primary reason for conducting this procedure is to obtain what information? A. level of fetal lung maturity B. presence of genetic disorders C. quantification of alpha-fetoprotein levels D. determination of gestational age

B

A client has a living will and an advance directive specifying no intubation or CPR. The client's spouse and children tell the nurse privately that they want the client resuscitated if the need arises. How should the nurse respond? A. nurses use their best judgment based on the client's condition B. the health care team must honor the written wishes of the client C. notify the health care provider of the family's wishes, so a decision can be made D. every effort must be made to honor the family's wishes about their loved one

B

A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? a. Warm the client b. Maintain a patent airway c. Administer thyroid hormone d. Administer fluid replacement

B

A client who has been admitted to the ICU with a diagnosis of pericardial effusion begins to experience severe tachycardia. Upon assessment, the nurse finds that his central venous pressure is increased, he has jugular vein distention, his systolic blood pressure has dropped, and there is a narrow pulse pressure. His heart sounds appear to be very muffled. Which complication is the client most likely experiencing? A. Pericarditis B. Cardiac tamponade C. Myocardial infarction D. Thrombosis

B

A client who uses nonsteroidal anti-inflammatory drugs (NSAIDs) has been taking misoprostol. The nurse determines that the misoprostol is having the intended therapeutic effect if which finding is noted? a. Resolved diarrhea b. Relief of epigastric pain c. Decreased platelet count d. Decreased white blood cell count

B

A client with Crohn's disease is scheduled to receive an infusion of infliximab. What intervention by the nurse will determine the effectiveness of treatment? a. Monitoring the leukocyte count for 2 days after the infusion b. Checking the frequency and consistency of bowel movements c. Checking serum liver enzyme levels before and after infusion d. Carrying out a Hematest on gastric fluids after the infusion is completed

B

A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting glucose level has been 180-200 mg/dL. Which medication, if added to the client's regimen, may have contributed to the hyperglycemia? a. Atenolol b. Prednisone c. Phenelzine d. Allopurinol

B

A health care worker has developed an allergic response to latex. What most common allergic response is the health care worker likely to develop? A. Airway obstruction B. Contact dermatitis C. Angioedema D. Rhinorrhea

B

A nurse is performing the initial assessment of an older adult client for an exacerbation of chronic obstructive pulmonary disease (COPD). Which information would be best characterized as a symptom? A. Oxygen saturation is 83% by pulse oximetry B. Client notes increased work of breathing when lying supine C. Auscultation of diminished breath sounds in lower lung fields bilaterally D. Respiratory rate is 31 breaths per minute

B

A young adult female is resting after a 1 minute episode during which she lost consciousness while her muscles contracted and extremities extended. This was followed by rhythmic contraction and relaxation of her extremities. She was incontinent of urine during this time. What has the client most likely experienced? A. Myoclonic seizure B. Tonic-clonic seizure C. Absence seizure D. Pseudoseizure

B

After the sudden death of a severely injured client while in transport by helicopter, the flight nurse discovers the oxygen tank that was attached to the oxygen supply. was empty during the transport. What action should the flight nurse take? A. replace the empty tank without reporting the situation to any members of the agency B. complete an adverse occurrence report and submit it to the nurse manager C. send an anonymous letter explaining the situation to the family of the client D. advise the flight crew of the situation, then suggest that no other discussion be held

B

An overweight adolescent girl has been to the school nurse three times in the last two months complaining of vaginal and urinary tract infections. What action should the nurse take first? A. counsel the girl regarding hygiene B. ask if she is going to the bathroom frequently C. teach the girl the importance of practicing safe sex D. encourage the girl to see the school counselor

B

Restoration of the integrity of myelin sheaths would likely result in a slowing or stopping of the progression of which disease process? A. Amyotrophic lateral sclerosis B. Multiple sclerosis C. Duchenne muscular dystrophy D. Diabetic neuropathy

B

The RN primary nurse and LPN are caring for a client diagnosed with a stroke. Which intervention should the RN assign to the LPN? a. Feed the client who is being allowed to eat for the first time b. Administer the client's anticoagulant subcutaneously c. Check the client's neurological signs and limb movement d. Teach the client to turn the head and tuck the chin to swallow

B

The RN staff nurse and unlicensed assistive personnel (UAP) are caring for clients on a surgical unit. Which action by the UAP warrants immediate intervention? a. The UAP empties the indwelling catheter bag for the client with transurethral resection of the prostate (TURP) b. The UAP assists a client who received an IV narcotic analgesic 30 minutes ago to ambulate in the hall c. The UAP provides apple juice to the client with a nephrectomy who has just been advanced to a clear liquid diet d. The UAP applies moisture barrier cream to the elderly client diagnosed with urinary incontinence who has an excoriated perianal area

B

The blood pressure readings obtained by a UAP are consistently different from those obtained by other staff members. What action should the charge nurse take first? A. counsel the UAP about the inaccurate blood pressure readings B. observe the UAP performing blood pressure measurements C. make staff members aware of the possible errors in blood pressure readings D. ask the education department to provide additional training for the UAP

B

The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light because the UAP is involved in a personal phone call. Which action should the nurse take first? A. page the unit manager to address the situation B. close the demographic screen on the computer C. instruct the UAP to end the phone call immediately D. send a UAP into the client's room to relieve the nurse

B

The critical care nurse is caring for a client diagnosed with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. Two hours later, which data would warrant immediate intervention by the nurse? a. The client has purposeful movement when the nurse rubs the sternum b. The client extends the upper and lower extremities in response to painful stimuli c. The client is aimlessly thrashing in the bed when a noxious stimuli is applied d. The client is able to squeeze the nurse's hand on a verbal request

B

The nurse administers dopamine IV infusion at 3 mcg/kg/min to a critically ill, hypotensive client. What is the intended effect of this treatment? To increase __. A. blood pressure to 140/80 B. urine output to 55 mL/hr C. pulse to 132 beats/min D. respirations to 24 breaths/min

B

The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data should the nurse expect to obtain when asking the parents about the child's symptoms? a. Watery diarrhea b. Projectile vomiting c. Increased urine output d. Vomiting large amounts of bile

B

The nurse has just received the shift report. Which client should the nurse assess first? a. The client diagnosed with Guillain-Barre syndrome who has ascending paralysis to the knees b. The client diagnosed with a C-6 spinal cord injury who has autonomic dysreflexia c. The client diagnosed with Parkinson's disease who is experiencing a pill rolling tremor d. The client diagnosed with Huntington's disease who has writhing, twisting movements of the face

B

The nurse is caring for an 8-month-old male client with hemophilia A. The parents ask about the likelihood that their future children would be born with the condition. What is the nurse's best response? A. I cannot determine since the pattern of inheritance is unknown and you need to seek genetic counseling B. If you have another son there is a 50% chance that he will also have hemophilia C. There is a 50% chance that your next child will have hemophilia, but the severity varies and it could be a mild form D. Since you have already had a son with hemophilia, the chance that you will have another child with the condition is unlikely

B

The nurse is caring for the following clients on a medical unit. Which client should the nurse assess first? a. The client diagnosed with acute glomerulonephritis who has oliguria and periorbital edema b. The client diagnosed with benign prostatic hypertrophy who has blood oozing from the intravenous site c. The client diagnosed with renal calculi who is complaining of flank pain rated as a 5 on a scale of 1 to 10 d. The client diagnosed with nephrotic syndrome who has proteinuria and hypoalbuminemia

B

The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider? a. Stoma is beefy red and shiny b. Purple discoloration of the stoma c. Skin excoriation around the stoma d. Semi-formed stool noted in the ostomy pouch

B

To treat cystitis, a 14-day course of treatment with cephalexin is prescribed for a client residing in a long-term care facility. Which action is most important for the nurse to take prior to administering the first dose of this medication? A. review the client's fasting blood glucose levels for hyperglycemic trend B. determine if the client has ever had a hypersensitivity reaction to penicillins C. restrict the use of dairy products in the client's diet for the next 3 weeks D. take the client's vital signs prior to the first dose and once daily for 14 days

B

Yesterday a female client who is delusional told the nurse that her health care provider needs to be released from her case because they are going to get married on her birthday. Which statement made by the client today indicates that the client is less delusional? A. I really wish that my birthday wasn't so soon B. I don't talk about things like that anymore C. The doctor won't talk with me about this D. I think I should talk about this in group

B

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply. a. Polyuria b. Shakiness c. Palpitations d. Blurred vision e. Lightheadedness f. Fruity breath odor

B,C,E

The nurse is providing education to parents of a child diagnosed with Tay-Sachs disease. Which signs and symptoms indicate the disease is progressing? Select all that apply. A. Hyperactivity in lower limbs B. Loss of motor skills C. Chronic constipation D. Vision loss E. Skin rashes

B,D

The nurse teaches the client who is newly diagnosed with diabetes insipidus about the prescribed intranasal desmopressin. Which statements by the client indicate understanding? Select all that apply. a. "This medication will turn my urine orange." b. "I should decrease my oral fluids when I start this medication." c. "The amount of urine I make should increase if this medication is working." d. "I need to follow a low-fat diet to avoid pancreatitis when taking this medication." e. "I should report headache and drowsiness to my doctor since these symptoms could be related to my desmopressin."

B,E

A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted? a. The child has no tears b. Urine specific gravity is 1.035 c. Capillary refill is less than 2 seconds d. Urine output is less than 1 mL/kg/hr

C

A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem? a. Diarrhea b. Metabolic acidosis c. Metabolic alkalosis d. Hyperactive bowel sounds

C

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis. The initial blood glucose level is 950 mg/dL. A continuous IV infusion of short acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL. The nurse should next prepare to administer which medication? a. An ampule of 50% dextrose b. NPH insulin subcutaneously c. IV fluids containing dextrose d. Phenytoin for the prevention of seizures

C

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse should immediately prepare to initiate which anticipated health care provider's prescription? a. Endotracheal intubation b. 100 units of NPH insulin c. Intravenous infusion of normal saline d. Intravenous infusion of sodium bicarbonate

C

A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen? a. "My ulcer will heal because these medications will kill the bacteria." b. "These medications are only taken when I have pain from my ulcer." c. "The medications will kill the bacteria and stop the acid production." d. "These medications will coat the ulcer and decrease the acid production in my stomach."

C

A client with severe preeclampsia is receiving magnesium sulfate 2 grams IV hourly. The nurse assesses the client and finds: blood pressure 140/90, pulse 100, respirations 10, deep tendon reflexes 1+, and urinary output 130 mL in 4 hours. The nurse will discontinue the magnesium infusion based on which assessment finding? A. deep tendon reflexes 1+ B. blood pressure 140/90 C. respirations 10 D. urinary output 130 mL in 4 hours

C

A group of public health nurses develop a program aimed at the prevention, identification, and treatment of diabetes within a rural community. Which program intervention would be classified as secondary prevention? A. Regularly scheduled wound dressing changes for clients who have foot ulcers secondary to peripheral neuropathy and impaired wound healing B. Teaching school children how a nutritious, traditional diet can less their chances of developing adult-onset diabetes C. Staffing a booth where community residents who are attending a baseball tournament can have their blood glucose levels checked D. Administering oral antihyperglycemic medications to clients who have a diagnosis of diabetes

C

A hospitalized 5-year-old boy recovering from surgery refuses to drink fluids. Which intervention is best for the nurse to implement? A. ask the parents to participate in encouraging the child's fluid intake B. tell the child he can go outside after he drinks a full glass of water C. offer the child a popsicle and allow him to pick the flavor he prefers D. make a game of seeing who can finish a glass of water first--the nurse or the child

C

A nurse in the neurologic department is assessing a client who appears very drowsy but is able to follow simple commands and responds to painful stimuli appropriately. How should the nurse document this client's level of consciousness? A. Confusion B. Lethargy C. Obtundation D. Stupor

C

A nurse is providing education to a group of middle-aged adults regarding coronary artery disease. Which statement indicates the individuals understood the pathogenesis of coronary artery disease? A. "I have to stop smoking and then I won't have any more heart attacks." B. "My artery was clogged by fat so I will need to stop eating fatty foods every day." C. "Sounds like this comes from inflammation inside my artery that made it easy to form fatty streaks which led to my clogged artery." D. "If you do not exercise regularly to get your heart rate up, blood pools in the veins causing a clot which stops blood flow to the muscle and you have a heart attack."

C

A parent whose 12-year-old child has been inhaling paint fumes asks the nurse, "Can he become addicted to paint fumes?" What is the best response for the nurse to provide? A. Only hard drugs like cocaine and heroin can cause problems with addiction B. Tell me what you think may have caused him to start inhaling pain fumes C. Abuse of any of the inhalants can eventually lead to addiction D. Any time you use an illegal substance, you are abusing drugs

C

A young adult female is brought to the emergency department by family members who report that she ingested a large quantity of acetaminophen. The nurse should prepare for which treatment to be implemented? A. IV administration of Narcan B. syrup of ipecac per nasogastric tube C. acetylcysteine 140 mg/kg D. gastric lavage with normal saline

C

During surgery, the nurse anesthetist assesses the client for malignant hyperthermia. The initial assessment for this disorder includes: A. Hypotension B. Acute renal failure C. Skeletal muscle rigidity D. Sudden cardiac arrest

C

The RN charge nurse is making shift assignments to the surgical staff, which consists of two RNs, two LPNs, and two UAPs. Which assignment would be most appropriate for the RN charge nurse to make? a. Instruct the RN staff nurse to administer all PRN medications b. Instruct the UAP to clean the recently vacated room c. Assign the LPN to change the client's ileal conduit bag d. Request the LPN to complete the admission for a new client

C

The RN primary nurse and UAP are caring for a client diagnosed with right-sided paralysis. Which action by the UAP requires the RN to intervene? a. The UAP places the gait belt around the client's waist before ambulating b. The UAP places the client on the abdomen with the client's head to the side c. The UAP places her hand under the client's right axilla to help the client move up in bed d. The UAP praises the client for performing activities of daily living independently

C

The UAP reports to the RN primary nurse that the client's urine output has bright red blood. Which intervention should the RN implement first? a. Instruct the UAP to take a urine specimen to the lab b. Document the findings in the client's nursing notes c. Assess the client's urine specimen and complete a renal assessment d. Ask the UAP to take the client's vital signs

C

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? a. Hold the next dose of insulin b. Come to the clinic immediately c. Encourage the child to drink liquids d. Administer an additional dose of regular insulin

C

The nurse is administering a normal saline solution intravenously. What effect will the solution have within the client's body? A. Shrink B. Swell C. Neither shrink nor swell D. Rupture

C

The nurse is administering medications for clients on a neurological unit. Which medication should the nurse administer first? a. A pain medication to a client report a headache rated at 8 b. A steroid to the client experiencing an acute exacerbation of multiple sclerosis c. An anticholinesterase medication to a client diagnosed with myasthenia gravis d. An antacid to a client diagnosed with pyrosis who has called several times over the intercom

C

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? a. Clamp the T-tube b. Irrigate the T-tube c. Document the findings d. Notify the health care provider

C

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? a. Urinary output of 50 mL/hr b. A coagulation time of 5 minutes c. A heart rate that is 90 beats per minute and irregular d. A blood urea nitrogen level of 20 mg/dL

C

The nurse is providing discharge teaching for a client newly diagnosed with type 2 diabetes mellitus who has been prescribed metformin. Which client statement indicates the need for further teaching? a. "It is okay if I skip meals once in a while." b. "I need to let my doctor know if I get unusually tired." c. "I need to constantly watch for signs of low blood sugar." d. "I will be sure not to drink alcohol excessively while on this medication."

C

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 70 mg/dL, temperature of 101 F, pulse of 82 beats per minute, respirations of 20 breaths per minute, and blood pressure of 118/68 mm Hg. Which finding would be the priority concern to the nurse? a. Pulse b. Respiration c. Temperature d. Blood pressure

C

When culturing a wound, the nurse should obtain the sample from which part of the wound? A. the outer edges of the wound B. all necrotic sections of the wound C. areas containing purulent or pooled exudates D. any particularly painful area of the wound

C

Which action should the nurse take first when performing tracheostomy care? A. cleanse around the stoma B. suction the tracheostomy C. oxygenate with 100% oxygen D. secure the new neck strap

C

Which cells are primarily programmed to remove invading organisms and remember the antigen to respond rapidly during the next exposure? A. CD4 and CD8 cells B. Natural killer cells and macrophages C. T-lymphocytes and B-lymphocytes D. White blood cells and platelets

C

Which client is most likely to experience an impairment to the wound healing process? A. An older adult male with chronic obstructive pulmonary disease B. A middle-aged female with multiple sclerosis and impaired mobility C. A middle-aged male with poorly controlled blood sugars and small blood vessel disease D. A young adult female with congenital heart defects and anemia

C

Which motor disorder of sleep can be life threatening? A. Narcolepsy B. Periodic limb movement disorder C. Obstructive sleep apnea D. Restless leg syndrome

C

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply. a. Administer regular insulin b. Encourage the child to ambulate c. Give the child a teaspoon of honey d. Provide electrolyte replacement therapy intravenously e. Wait 30 minutes and confirm the blood glucose reading f. Prepare to administer glucagon subcutaneously if unconsciousness occurs

C, F

The RN staff nurse is caring for a client diagnosed with Alzheimer's disease. Which nursing tasks can the RN staff nurse delegate to the UAP? Select all that apply. a. Check the client's skin under the restraints b. Administer the client's antipsychotic medication c. Perform the client's morning hygiene care d. Ambulate the client to the bathroom e. Obtain the client's routine vital signs

C,D,E

A client in the intensive care unit with a brain tumor has experienced a sharp decline. The care team suspects that water and protein have crossed the blood-brain barrier and been transferred from the vascular space into the interstitial space. What diagnosis best explains this pathophysiology? A. Focal hypoxia B. Cytotoxic edema C. Hydrocephalus D. Vasogenic edema

D

A client who had a cesarean section two weeks ago is admitted to the hospital for an infected surgical abdominal wound. Which room is best for the nurse to assign this client? A. a negative pressure room B. a semi-private room on a surgical unit C. a postpartum room in the birthing center D. a private room on a medical unit

D

A client with acute pancreatitis is admitted to the medical unit. During the nurse's admission interview, which assessment has the highest priority? A. history of alcohol intake B. time of last meal C. frequency of vomiting D. intensity of pain

D

A health care provider tells the nurse that a certain medication will be prescribed for a client. After the prescription is written, the nurse notes that the provider has prescribed another medication that sounds similar to the medication that the provider and nurse originally discussed. What action should the nurse implement? A. write the correct prescription as a verbal order received from the health care provider B. correct the misspelled medication in the written prescription and initial the change C. consult with the pharmacist to determine the best medication for the client D. contact the health care provider to clarify the prescription intended for the client

D

A school-age child with type 1 diabetes mellitus has soccer practice and the school nurse provides instructions regarding how to prevent hypoglycemia during practice. What should the school nurse instruct the child to do? a. Eat twice the amount normally eaten at lunchtime b. Take half the amount of prescribed insulin on practice days c. Take the prescribed insulin at noon rather than in the morning d. Eat a small box of raisins or drink a cup of orange juice before practice

D

A staff member tells the charge nurse that a float nurse assigned to work on the unit has made several medication errors in the past, but is currently working with the education department to improve this skill. What action is best for the charge nurse to take? A. dismiss the staff nurse's report about the float nurse because it may be just gossip B. call the nursing supervisor and request a different employee be sent to the unit C. assign the float nurse to function as a UAP for the day D. arrange for someone to be available to assess and assist the float nurse

D

An 8-year-old male client with nephrotic syndrome is in remission following treatment with prednisone. The nurse should teach the child to check his urine for which finding? A. white blood cells B. glucose C. ketones D. protein

D

Several clients in the medical department require diagnostic blood work. Which client would most likely have an erythrocyte sedimentation rate (ESR) screening test ordered? An adult with: A. Alzheimer disease and depression B. Orthostatic hypotension and syncopal episodes C. Congestive heart failure D. Systemic lupus erythematosus

D

The charge nurse has received laboratory data for clients on the medical unit. Which client would require intervention by the charge nurse? a. The client diagnosed with a stroke who has a platelet level of 250 x10/microL b. The client diagnosed with a seizure disorder who has a valproic acid level of 75 mcg/mL c. The client diagnosed with multiple sclerosis on prednisone who has a glucose level of 208 mg/dL d. The client receiving phenytoin who has serum levels of 24 mcg/dL

D

The clinic nurse reviews the record of an infant and notes that the primary health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant? a. Diarrhea b. Projectile vomiting c. Regurgitation of feedings d. Foul-smelling ribbon-like stools

D

The nurse has just administered ibuprofen to a child with a temperature of 102 F. The nurse should also take which action? a. Withhold oral fluids for 8 hours b. Sponge the child with cold water c. Plan to administer salicylate in 4 hours d. Remove excess clothing and blankets from the child

D

The nurse is caring for clients on a renal unit and making assignments for the day. Which client should the nurse assess first? a. The client diagnosed with interstitial cystitis who has urinary urgency and pain in the bladder b. The client diagnosed with acute post-streptococcal glomerulonephritis who has hematuria with a smoky appearance c. The client diagnosed with Goodpasture syndrome who has pallor, anemia, and renal failure d. The client diagnosed with nephrolithiasis who has hematuria and is complaining of pain rating it as a 9

D

The nurse is caring for clients on a surgical unit. Which client should the nurse assess first after shift report? a. The client diagnosed with polycystic kidney disease who has a BP of 170/100 b. The client diagnosed with bladder cancer who has gross painless hematuria c. The client diagnosed with renal calculi who thinks he passed a stone d. The client diagnosed with acute pyelonephritis who has nausea/vomiting and is dehydrated

D

The nurse is preparing to administer medications. Which medication should the nurse administer first? a. Digoxin due at 0900 b. Furosemide due at 0800 c. Propoxyphene due in 2 hours d. Acetaminophen due in 5 minutes

D

The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease (GERD). Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis? a. Provide less frequent, larger feedings b. Burp the infant less frequently during feedings c. Thin the feedings by adding water to the formula d. Thicken the feedings by adding rice cereal to the formula

D

The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? a. "I will stop taking my insulin if I'm too sick to eat." b. "I will decrease my insulin dose during times of illness." c. "I will adjust my insulin dose according to the level of glucose in my urine." d. "I will notify my primary care provider if my blood glucose level is higher than 250 mg/dL."

D

When making a home visit to a family with a teething 4-month-old, what information is most important for the nurse to provide the parents? A. Though child development is characterized by individual differences, first teeth usually erupt during the seventh month B. Providing cooled teething toys can help decrease the discomfort associated with tooth eruption C. No action is required for the common symptoms associated with teething, which include drooling, irritability, and poor sleeping D. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention

D

When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next? A. place sterile drape under the client's buttocks B. instruct the client to inhale and then exhale slowly C. discard the gloves and apply new sterile gloves D. apply a sterile lubricant to the end of the catheter

D

Which client data is most important for the nurse to obtain prior to beginning a client's blood transfusion of packed red blood cells? A. skin turgor B. Weight C. oxygen saturation D. vital signs

D

Which medication is used to treat acute attacks of multiple sclerosis? A. Immunomodulators B. Anticonvulsants C. Antibiotics D. Corticosteroids

D

Which outcome is best for the nurse to include in the plan of care for a client with impaired social interaction and obsessive-compulsive disorder? A. describes success in dismissing persistent thoughts that used to be bothersome B. reports that the obsessions and compulsions experienced are silly C. avoids obsessive verbalizations while interacting with family and staff D. participates in one social or recreational activity each morning and afternoon

D

Which situation is an example of a maladaptive cellular change? A. 18-year-old body builder who has developed extremely large pectoral muscles following years of weightlifting B. 31-year-old marathon runner who has developed hypertrophied myocardial cells C. 54-year-old female who has developed ovarian atrophy following loss of estrogen stimulation during menopause D. 44-year-old with a 60 pack/year smoking history who was diagnosed with a histological grade 3 lung cancer

D

Which situation is an example of passive immunity? A. A 6-month-old infant receives his scheduled immunization against measles, mumps, and rubella B. A 9-year-old boy is immune to chickenpox after enduring the infection 1 year ago C. An 8-year-old girl recovers from a respiratory infection after intravenous antibiotic treatment D. A 6-week-old infant receives antibodies from his mother's breast milk

D

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is begin assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. a. Diarrhea b. Black, tarry stools c. Hyperactive bowel sounds d. Gray-blue color at the flank e. Abdominal guarding and tenderness f. Left upper quadrant pain with radiation to the back

D,E,F