Comp B
A nurse on an impatient unit is caring for a client with schizophrenia and recently started taking risperidone. Which action should the nurse take? A) Implement fall precautions for the client. B) Monitor the client's thyroid function. C) Place the client on a fluid restriction. D) Discontinue the medication if hallucinations occur.
A) Implement fall precautions for the client.
A home health nurse is assessing a 2 wk old newborn who had a birth wt of 3.64 kg (8 lb) and is being breastfed. Which of the following findings indicates effective breastfeeding? A. The newborn nurses every 4 hr during the day and sleeps through the night. B. The newborn has six to eight wet diapers per day. C. The newborn's current weight is 3.18 kg (7 lb). D. The newborn has sticky greenish stools
B. The newborn has six to eight wet diapers per day.
A nurse is caring for a post-op patient after receiving moderate (conscious) sedation. The patient suddenly becomes restless and reports feeling lightheaded. Which action should the nurse take? A) Check the client's temperature. B) Prepare to administer acetylcysteine to the client. C) Place the client in the Trendelenburg position. D) Check the client's oxygen saturation level.
D) Check the client's oxygen saturation level.
A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 DM. Which activity is the nurse's priority? A) Instruct the client about the importance of regular medical appointments. B) Encourage the client to participate in daily exercise. C) Explain proper foot care techniques to the client. D) Ensure that the client understands the medication regimen.
D) Ensure that the client understands the medication regimen.
A nurse is preparing to teach about dietary management to a patient with Crohn's disease and an enteroenteric fistula. Which nutrient should the nurse instruct the client to decrease in his diet? A) Calories B) Protein C) Potassium D) Fiber
D) Fiber
A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take. Auscultation Inspection Palpation Percussion
1) Inspection 2) Auscultation 3) Percussion 4) Palpation
A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 minutes. The patient weighs 198 lb. What is the amount in grams the nurse should administer? (Whole number)
18 g
A nurse is caring for a client who has COPD and becomes extremely short of breath. Which of the following interventions by the nurse requires completion of an incident report? A. Elevating the client's head of bed to 45° B. Administering a prescribed anxiolytic IV C. Administering a PRN bronchodilator via nebulizer D. Increasing oxygen via nasal cannula to 6 L/min
D. Increasing oxygen via nasal cannula to 6 L/min
A nurse is caring for a child who has sickle cell anemia and is having a vaso-occulsive crisis. Which of the following interventions should the nurse implement first? A. Collect a blood sample for laboratory tests. B. Administer medication for pain. C. Apply warm packs to affected areas. D. Infuse IV fluids.
D. Infuse IV fluids.
A nurse has just received change of shift report on four clients. Which of the following pts should the nurse assess first? A. A client who is postoperative with abdominal distention and no bowel sounds B. A client who has diabetes mellitus and a blood glucose level of 105 mg/dL C. A client who has heart failure and 2+ pitting edema D. A client who is receiving maintenance IV fluids and needs a new IV catheter
A. A client who is postoperative with abdominal distention and no bowel sounds
A nurse is admitting a pt who has pneumonia. The nurse should initiate which of the following isolation precautions for the pt? A. Droplet B. Airborne C. Contact D. Protective environment
A. Droplet The nurse should initiate airborne precautions for clients who have varicella zoster or measles.
A nurse is providing pt teaching about the basal body temp method of birth control. Which of the following info should the nurse include in the teaching? A. "Your body temperature will drop approximately 1 degree 1 week after ovulation." B. "You should take your body temperature each evening prior to going to sleep." C. "Your body temperature might decrease slightly just prior to ovulation." D. "Your body temperature is at its highest during menstruation."
C. "Your body temperature might decrease slightly just prior to ovulation."
A nurse is caring for a pt who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool? A. Place the client in the lithotomy position. B. Elicit a vagal response by performing gentle rectal stimulation. C. Administer oral bisacodyl 30 min prior to the procedure. D. Insert a lubricated gloved finger and advance along the rectal wall.
D. Insert a lubricated gloved finger and advance along the rectal wall.
A nurse is preparing a sterile filed to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique? A. Hold hands folded below the waist after donning sterile gloves. B. Pick up and pour solutions with the palm of the hand covering bottle labels. C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape. D. Maintain sterile objects within the line of vision
D. Maintain sterile objects within the line of vision
During a change of shift report, a night shift nurse informs the day shift nurse that a newly admitted pt was disoriented and combative during the night. Which of the following actions should the day shift nurse take? A. Keep the client's television on with the volume low. B. Insert an indwelling urinary catheter to minimize interaction with the client. C. Consult the provider regarding administering a mild sedative on a schedule. D. Move the client to a room near the nurses' station.
D. Move the client to a room near the nurses' station.
A nurse in an ED is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the pt's family to obtain consent. Which of the following actions should the nurse take? A. Contact the facility's ethics committee. B. Obtain consent from the client's employer. C. Limit care to comfort measures. D. Proceed with provision of medical care.
D. Proceed with provision of medical care.
A nurse is developing a pt education program about osteoporosis for older adult pts. The nurse should include which of the following variables as a risk factor for osteoporosis? A. Obesity B. Acromegaly C. Estrogen replacement therapy D. Sedentary lifestyle
D. Sedentary lifestyle The nurse should encourage older adult clients to engage in weight-bearing exercises to promote bone health because they will increase calcium and phosphorus levels.
A nurse is assessing a newborn following a vaginal delivery. Which finding should the nurse report to the provider? A) Heart rate 136/min B) Nasal flaring C) Tongue not protruding D) Overlapping of sutures
B) Nasal flaring
A nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which action by the nurse manager demonstrates a democratic leadership style? A) Avoids initiating change B) Seeks input from the other nurses C) Makes decisions quickly D) Limits the amount of feedback to the staff
B) Seeks input from the other nurses
A nurse is providing teaching to a client who is to undergo ECT. The nurse should inform the client that which finding is an adverse effect of ECT? A) Agitation B) Short-term memory loss C) Post-treatment seizures D) Incontinence of the bowel and bladder
B) Short-term memory loss
A nurse is providing teaching about lithium to a pt who has bipolar disorder. Which of the following statements should the nurse include in the teaching? A. "Expect to have blurred vision while taking this medication." B. "Notify your provider if you experience increased thirst." C. "You might be unable to have an orgasm while taking this medication." D. "You should take this medication on an empty stomach."
B. "Notify your provider if you experience increased thirst."
A nurse is caring for a client who has cancer and is deciding between two treatment plans. The pt asks the nurse for assistance in making a decision. Which of the following responses should the nurse make? A. "It's been difficult for everyone who has ever had to make this decision." B. "Tell me more about your understanding of the options." C. "I'm sure you will make the right choice." D. "I will contact your provider to have him talk with you further."
B. "Tell me more about your understanding of the options."
A nurse is providing teaching to a pt who is at 24 wks of gestation and is scheduled for a 3 hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching? A. "Limit your fat intake for 72 hours before the test." B. "You will need to fast the night before the test." C. "We will collect a urine sample on the morning of the test." D. "A blood sample will be collected every 30 minutes during the test."
B. "You will need to fast the night before the test." Blood test q hr
A nurse at a mental health clinic is caring for four pts. The nurse should recognize that which of the following pts is using dissociation of a defense mechanism? A. A client forgets to buy her partner a birthday gift after a disagreement. B. A client who was abused as a child describes the abuse as if it happened to someone else. C. A client who is shorter than average is verbally assertive with his co-workers. D. A client states that she did not get a job promotion because the boss does not like her
B. A client who was abused as a child describes the abuse as if it happened to someone else.
A nurse is preparing to replace a pt's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the pt declines to accept it. Which of the following actions should the nurse take? A. Withhold pain medications for 24 hr after the old patch is removed. B. Ask another nurse to witness the disposal of the new patch. C. Seal the patches in a plastic bag and place in the client's trash basket. D. Stick the two patches to each other and place them in the sharps bin.
B. Ask another nurse to witness the disposal of the new patch.
A nurse is caring for a pt who is receiving hemodialysis with an AV fistula in the right arm. Which of the following interventions should the nurse include in the pt's plan of care? A. Avoid elevating the affected extremity. B. Auscultate the affected extremity for a bruit. C. Discourage range-of-motion exercises in the affected extremity. D. Perform venipuncture in the affected extremity
B. Auscultate the affected extremity for a bruit. q 4 hr Keep elevated to promote circulation
A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the pt that which of the following findings is an adverse effect of this med? A. Diarrhea B. Dry mouth C. Photophobia D. Bruising
B. Dry mouth
A nurse is caring for a client who has DVT. Which of the following actions should the nurse take? A. Teach the client to massage the affected extremity. B. Instruct the client to elevate the affected extremity when sitting. C. Assess pulses proximal to the affected area. D. Apply a cold compress to the affected extremity.
B. Instruct the client to elevate the affected extremity when sitting.
A nurse is assessing an infant who has hydrocephalus and is 6 hr postop following placement of a VP shunt. Which of the following findings should the nurse report to the provider? A. Heart rate 122/min B. Irritability when being held C. Hypoactive bowel sounds D. Urine specific gravity 1.018
B. Irritability when being held
A nurse is caring for a pt who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report? A. Weight loss B. Jaundice C. Bradycardia D. Polyuria
B. Jaundice
A nurse is reviewing the urinalysis report of a client who has acute glomerulonephritis. Which of the following findings should the nurse expect in the client's urine? A. Uric acid crystals B. Protein C. WBCs D. Nitrates
B. Protein Uric acid crystals are an expected finding for a client who has urolithiasis.
A nurse is caring for a pt who is receiving positive end expiratory pressure (PEEP) via mechanical ventilator. The nurse should monitor the pt for which of the following adverse effects of PEEP? A. Hypoxemia B. Tension pneumothorax C. Malignant hypertension D. Atelectasis
B. Tension pneumothorax
A nurse is assessing a newborn's HR. Which of the following actions should the nurse take? A. Assess the apical pulse while the newborn is crying to detect cardiac problems. B. Palpate the radial pulse and determine the rate based on number of beats per minute. C. Listen to the apical pulse while palpating the radial pulse to detect variance. D. Auscultate the apical pulse and count beats for at least 1 min.
D. Auscultate the apical pulse and count beats for at least 1 min.
A nurse is developing a discharge plan for a school-age child who has thrombocytopenia. The nurse should instruct the child to avoid which of the following? A. Large groups of people B. Quickly changing positions C. Eating fresh fruits D. Blowing the nose
D. Blowing the nose
A nurse is assessing a pt who has depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of this med? A. Diarrhea B. Frequent urination C. Excessive salivation D. Blurred vision
D. Blurred vision
A nurse in an ED is assessing a school-age child who was brought in by her parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take? A. Discuss his suspicion of physical abuse with the provider. B. Confront the parents with his suspicion of physical abuse. C. Ask the hospital security to detain and question the parents. D. Contact child protective services.
D. Contact child protective services.
A nurse on an inpt mental health unit is monitoring a visit between a pt who has a history of aggressive behavior and the pt's partner. Which of the following observations should the nurse identify as an indication for potential violence? A. The client is taking numerous deep, measured breaths. B. The client is calmly telling his partner that "the staff here is so controlling." C. The client is sitting with his head in his hands and appears to be crying. D. The client is pacing around the chair in which his partner is sitting
D. The client is pacing around the chair in which his partner is sitting
A charge nurse notices that one of the nurses on her shift frequently violates unit policies by taking an extended amount of time for her break. Which statement should the charge nurse make to address this conflict? A) "I would like to talk to you about the unit policies regarding break time." B) "If you continue to take a long lunch break, I will have to report this to the nurse manager." C) "Have you thought about how your extended lunch breaks affect the other members of our team?" D) "Did you inform the other members of your team about when you left and returned from break?"
A) "I would like to talk to you about the unit policies regarding break time."
A hospice nurse is consulting with a patient and her family about receiving home services. Which statement should the nurse identify as an indication that the family understands home hospice care? A) "We can expect the hospice nurse to provide support for us after our mother's death." B) "A hospice nurse will come to the house each time our mother needs pain medication." C) "Now that my mother is receiving hospice services, we will not be able to get respite care." D) "Hospice care focuses on arranging treatment that will prolong our mother's life."
A) "We can expect the hospice nurse to provide support for us after our mother's death."
A nurse must recommend clients for discharge to make room for several critically injured clients from a local disaster. Which client should the nurse recommend for discharge? A) A client who has cellulitis and is receiving oral antibiotics every 8 hr B) A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex C) A mother and her newborn 12 hr postdelivery D) A client who has lower extremity weakness and is newly admitted for observation
A) A client who has cellulitis and is receiving oral antibiotics every 8 hr
A nurse manager is preparing an education session about advocacy to a group of nurses. The nurse manager should include what information in the teaching? A) Advocacy is a leadership role that helps others to self-actualize. B) Subordinates are an advocate for the nurse manager. C) Advocacy is to encourage client dependence in decision making. D) Nurse managers should distrust people who speak out about harmful or inappropriate professional practices.
A) Advocacy is a leadership role that helps others to self-actualize.
A nurse manager in a long-term care facility is having difficulty with staffing weekend shifts and is planning to implement changes to the scheduling procedure. Which action should the nurse manager take first? A) Form a committee of staff members to investigate current staffing issues. B) Provide support to staff members who are resistant to staffing changes. C) Schedule a staff meeting to present the different options to staff members. D) Give the staff members advance written notice of staffing changes.
A) Form a committee of staff members to investigate current staffing issues.
A nurse is assessing a client at 11 weeks gestation and reports drinking ginger tea. Which finding indicates the client's use of ginger tea is effective? A) The client reports a decrease in episodes of nausea. B) The client reports a decrease in breast tenderness. C) The client reports a decrease in headaches. D) The client reports a decrease in urinary frequency.
A) The client reports a decrease in episodes of nausea.
A nurse is providing teaching about advance directives to a middle adult pt. Which of the following pt responses indicates an understand of the teaching? A. "I can designate my partner as my health care surrogate." B. "I am only 40 years old, so I don't need to worry about this yet." C. "I will need a lawyer's help to draw up the documents." D. "I have no family, so I don't need to worry about having advance directives."
A. "I can designate my partner as my health care surrogate."
A nurse is providing teaching for a pt about his right to confidentiality. Which of the following statements should the nurse take? A. "You can provide a list of family members who can receive information about your diagnosis." B. "Your provider can legally discuss your test results with your partner without your permission." C. "Your provider will need to approve your advance directives before we can implement them." D. "You can give your friend who is an RN in another department permission to access your medical
A. "You can provide a list of family members who can receive information about your diagnosis."
An antepartum nurse is caring for 4 pts. For which of the following pts should the nurse initiate seizure precautions? A. A client who is at 33 weeks of gestation and has severe gestational hypertension B. A client who is at 16 weeks of gestation and has a hydatidiform mole C. A client who is at 28 weeks of gestation and is experiencing vaginal bleeding D. A client who is at 12 weeks of gestation and has group B streptococcus
A. A client who is at 33 weeks of gestation and has severe gestational hypertension The nurse should initiate seizure precautions for a client who has severe gestational hypertension because an extremely elevated blood pressure in an antepartum client can trigger seizure activity. The nurse should provide the client with a quiet, darkened environment; place suction equipment and oxygen at the bedside; and place the call button within the client's reach.
A nurse is preparing to transfer a pt who has had a stroke to a rehab facility. The pt's fam tells the nurse they are concerned about the level of care the pt will receive. Which of the following actions should the nurse take? A. Facilitate an interdisciplinary conference at the new facility for the family. B. Refer the client and family to a social worker for assistance and a follow-up meeting. C. Reassure the client's family that the same provider will provide care at the new facility. D. Tell the family that the rehabilitation facility has an excellent client care record.
A. Facilitate an interdisciplinary conference at the new facility for the family.
A nurse is assessing a pt who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy is effective? A. Hemoglobin 14.9 g/dL B. WBC 12,000/mm3 C. Potassium 4.8 mEq/L D. BUN 18 mg/dL
A. Hemoglobin 14.9 g/dL The nurse should identify that the hemoglobin and hematocrit levels indicate the effectiveness of RBC transfusion therapy. This hemoglobin level is within the expected reference range, indicating the therapy is effective.
A nurse is preparing for a pt for a paracentesis. Which of the following actions should the nurse take? A. Instruct the client to void. B. Position the client on his left side. C. Insert an IV catheter. D. Prepare the client for conscious sedation.
A. Instruct the client to void.
A nurse is providing teaching to a pt who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the pt to monitor for which of following findings as a manifestation of hypoglycemia? A. Irritability B. Increased urination C. Vomiting D. Facial flushing
A. Irritability
A nurse is assessing a pt who has pulmonary edema. Which of the following findings should the nurse expect? A. Pink, frothy sputum B. Bradycardia C. Flushed, dry skin D. Wheezing
A. Pink, frothy sputum
A nurse enters a pt's room and sees smoke coming from a small fire in the trash can. Which of the following actions should the nurse take first? A. Remove the client from the room. B. Activate the fire alarm. C. Close the door to the client's room. D. Extinguish the fire with a fire extinguisher
A. Remove the client from the room.
A nurse in the ED is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of sexual abuse? A. The child exhibits discomfort while sitting. B. The child lacks personal hygiene. C. The child has a laceration on the torso. D. The child does not cry during wound care.
A. The child exhibits discomfort while sitting.
A nurse is caring for a pt who has a prescription for continuous passive motion machine following a total knee arthroplasty. Which of the following actions should the nurse take? A. Turn off the CPM machine during mealtime. B. Maintain the client's affected hip in an externally rotated position. Instruct the client how to adjust the C. CPM settings for comfort. D. Store the CPM machine under the client's bed when not in use.
A. Turn off the CPM machine during mealtime.
A nurse is caring for a pt who is receiving a continuous heparin infusion. Which of the following lab tests should the nurse review prior to adjusting the pt's heparin? A. aPTT B. PT C. INR D. WBC count
A. aPTT
A nurse is caring for a newborn who has herpes simplex virus (HSV). Which of the following isolation precautions should the nurse initiate? A. contact B. droplet C. airborne D. protective environment
A. contact
A nurse is assessing a client whose partner recently died. The client states "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make? A) "It's natural for you to feel this way now, but things will get better with time." B) "You seem to be having a difficult time right now." C) "Why do you feel like your life isn't worth living?" D) "You'd be surprised how many people experience these feelings."
B) "You seem to be having a difficult time right now."
A nurse is assessing a client taking propranolol. Which finding should indicate to the nurse the client is experiencing an adverse reaction to propranolol? A) Weight loss B) Coughing at night C) Blood pressure 146/92 mm Hg D) Heart rate 110/min
B) Coughing at night
A nurse is caring for a client who is taking chlorpromazine. Which finding should the nurse identify as an indication that the med is effective? A) Decreased blood pressure B) Decreased hallucinations C) Decreased cholesterol D) Decreased esophageal reflux
B) Decreased hallucinations
A nurse is assessing a client with bipolar disorder. Which alterations in speech is the client using? (Listen to the clip) A) Tangentiality B) Flight of ideas C) Word salad D) Perseveration
B) Flight of ideas
A nurse is providing discharge teaching for the parents of a preschoo;-age child taking amoxicillin/clavulanate suspension. Which instructions should the nurse include in the teaching? (Select all) A) "You will give the medication every 4 hours." B) "Shake the medication bottle well before each dose is given." C) "Store the medication in the refrigerator." D) "Report diarrhea to the provider immediately." E) "Discard the unused portion of medication after 21 days."
B) "Shake the medication bottle well before each dose is given." C) "Store the medication in the refrigerator." D) "Report diarrhea to the provider immediately."
A nurse is caring for a patient with major depressive disorder and has signed an informed consent to receive ECT. The patient states "I'm not sure about this now. I'm afraid it's too risky." What response should the nurse make? A) "Perhaps you think the ECT is dangerous, but I can guarantee it's quite safe." B) "You have the right to refuse to have the ECT, even after you have agreed to it." C) "Everyone gets a little nervous about this procedure as the time for it approaches." D) "Your doctor wouldn't have suggested this procedure if he didn't think it would help you."
B) "You have the right to refuse to have the ECT, even after you have agreed to it."
A nurse is providing teaching to a pt who speaks a different language than the nurse about an upcoming diagnostic procedure. Which of the following actions should the nurse take? A. Speak in a loud voice when explaining the procedure to the client. B. Use pictures to illustrate the procedure to the client. C. Use medical terminology to explain the procedure to the client. D. Validate the client's understanding of the procedure by watching for the client to smile and nod
B. Use pictures to illustrate the procedure to the client.
A nurse is talking with a patient who has stage 4 breast cancer. The nurse should recognize which statement by the client as a constructive use of a defense mechanism? A) "I have experienced physical discomfort when intimate with my partner since my diagnosis." B) "I wish other women would stop socializing with my partner." C) "I told my doctor that I would like to start a support group for other women who are sick in my community." D) "I used to mistrust my doctor, but now I know that she is the best one to care for me during my illness."
C) "I told my doctor that I would like to start a support group for other women who are sick in my community."
A nurse is caring for a patient who recently signed an informed consent form to donate a kidney to her sibling who has end-stage kidney disease. The donor states "I don't want my brother to die, but what if I need this kidney one day?" Which response should the nurse make? A) "I understand your hesitation, but I'm very proud of you for making the right decision." B) "Organ donation from a first-degree relative is your brother's best chance of survival." C) "You're afraid that your other kidney will fail at some point after the organ donation." D) "I know this process won't be easy, but you should focus on saving your brother's life."
C) "You're afraid that your other kidney will fail at some point after the organ donation."
A nurse is providing teaching to a client who has a peripheral arterial disease. Which client action indicates understanding of the teaching? A) Warms her feet with a heating pad while sleeping B) Trims toenails with a rounded edge C) Applies lubricating lotion to her feet D) Elevates the feet above the level of the heart when resting
C) Applies lubricating lotion to her feet
A nurse is caring for a patient with GI bleeding and an NG tube in place. While performing gastric lavage, which action should the nurse take? A) Instill 50 mL of sterile water. B) Instill 75 mL of 0.9% sodium chloride irrigation. C) Ask the client to lie on the left side. D) Ask the client to lie supine.
C) Ask the client to lie on the left side.
A nurse is assessing a client for compartment syndrome. Which finding should the nurse expect? A) Fever B) Shortened femoral neck C) Edema D) Dark brown urine
C) Edema
A nurse on a med-surg unit is caring for a patient with a new diagnosis of terminal cancer. The patient wants to go home to be with family and loved ones. What action should the nurse take? A) Contact the facility chaplain to visit with the client. B) Explain the process of leaving the facility against medical advice. C) Make a referral for social services. D) Encourage the client to continue with inpatient care.
C) Make a referral for social services.
A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which step of the time management process should the nurse manager include as priority? A) Organizing the work environment B) Delegating assigned tasks appropriately C) Making a list of activities to complete D) Rewarding yourself for accomplishing goals
C) Making a list of activities to complete
A nurse is caring for a client who has fluid volume overload. Which task should the nurse delegate to the AP? A) Palpate the degree of edema. B) Regulate IV pump fluid rate. C) Measure the client's daily weight. D) Assess the client's vital signs.
C) Measure the client's daily weight.
A nurse is teaching self-administration of insulin to a patient with a new prescription for a short-acting and intermediate-acting insulin. Which action by the client indicates an understanding of the teaching? A) Withdraws the intermediate-acting insulin before the short-acting insulin B) Injects the insulin into the deltoid muscle C) Pinches the skin prior to injecting the insulin D) Inserts the needle at a 30° angle
C) Pinches the skin prior to injecting the insulin
A nurse in a provider's office is caring for an 19-month old toddler who has a blood lead level of 3. Which action should the nurse take? A) Schedule chelation therapy. B) Contact the poison control center. C) Recommend rescreening in 1 year. D) Refer the family to social services.
C) Recommend rescreening in 1 year.
An RN is observing an LPN and an AP move a client up in bed. Which situation should the nurse intervene? A) The side rails are lowered before lifting the client up in bed. B) Prior to lifting the client, the bed is put in high position. C) The LPN and the AP grasp the client under his arms to lift him up in bed. D) The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift him.
C) The LPN and the AP grasp the client under his arms to lift him up in bed.
A nurse is caring for a patient who is 2 days postpartum. Which behavior indicated the client is bonding with her newborn? A) The client calls the nurse for help when the newborn cries. B) The client wakes the newborn when she is sleeping. C) The client tells visitors how much the newborn looks like her sister. D) The client talks on the phone while feeding the newborn.
C) The client tells visitors how much the newborn looks like her sister.
A nurse is preparing to transfer a patient from ICU to medical floor. The patient was weaned from mechanical ventilation following a pneumonectomy. Which information should the nurse include in report? A) The last time the provider evaluated the client B) The client's most recent ventilator settings C) The time of the client's last dose of pain medication D) The frequency in which the client presses the call button
C) The time of the client's last dose of pain medication
A nurse is preparing to administer an IM injection to a client who is obese. Which action should the nurse plan to take? A) Select a 1-inch needle. B) Use a 45º angle when inserting the needle. C) Use the ventrogluteal site. D) Pinch the skin up during injection.
C) Use the ventrogluteal site.
A nurse is caring for a pt who has a pulmonary embolism. The pt is receiving heparin via a continuous IV infusion at 1,200 units and warfarin 5 mg PO. The morning lab values for the pt are aPTT 98 sec and INR 1.8. Which of the following actions should the nurse take? A. Prepare to administer vitamin K1. B. Prepare to administer alteplase. C. Withhold the heparin infusion. D. Withhold the next dose of warfarin.
C) Withhold the heparin infusion. The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by a factor of 1.5 to 2, making the aPTT 60 to 80 seconds. An aPTT level of 98 is above the expected reference range, indicating that the dosage should be reduced or the infusion withheld until the aPTT returns to the therapeutic range.
A pt is receiving IV fluids at 150 mL/hr. Which of the following findings indicated that the pt is experiencing fluid overload? A. Oliguria B. Bradycardia C. Dyspnea D. Poor skin turgor
C. Dyspnea
A nurse is performing an admission assessment on a pt who had a recent positive prego test. The first day of her last menstrual period was May 8. According to Nagele's rule, which of the following dates should the nurse document as the pt's estimated date of birth? A. February 1 B. February 8 C. February 15 D. February 22
C. February 15 Using Nägele's rule, the nurse should add 7 days to the first day of the client's LMP (8 + 7 = 15) and then subtract 3 months. Therefore, the nurse should document the client's EDB as February 15th.
A nurse is caring for a pt who is the resuscitation phase of burn injury. Which of the following findings should the nurse expect? A. Decreased hematocrit B. Hypokalemia C. Hyponatremia D. Increased albumin
C. Hyponatremia
A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client's visual loss? A. An increase in the intraocular pressure B. Deterioration of the macula C. Increased opacity of the lens D. Vitreous hemorrhage
C. Increased opacity of the lens A cataract is a cloudy or opaque area in the lens of the eye that inhibits light penetration.
A nurse is providing care for a pt who has a colostomy. Which of the following actions should the nurse take? A. Cleanse the skin at the stoma site with povidone-iodine for 15 seconds. B. Dampen the skin before applying the skin barrier and ostomy pouch. C. Place the skin barrier over the stoma and hold it for 30 seconds. D. Apply sterile gloves before cleaning the stoma site.
C. Place the skin barrier over the stoma and hold it for 30 seconds.
A nurse is reviewing the ABG values of a pt. The pt has a pH of 7.20, PaCO2 of 60 mm Hg, and HCO3 of 25 mEq/L. The nurse should identify that the pt has which of the following acid-base imbalances? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis
C. Respiratory acidosis
A nurse is caring for a child who has hypotonic dehydration and is receiving an oral rehydration solution. Which of the following lab results indicates that the treatment regimen is effective? A. Urine pH 6.0 B. Urine specific gravity 1.035 C. Serum sodium 136 mEq/L D. Serum potassium 3.9 mEq/L
C. Serum sodium 136 mEq/L A child who has hypotonic dehydration has a serum sodium level below 130 mEq/L. A serum sodium level of 136 mEq/L, which is within the expected reference range, indicates that this child is responding well to the oral rehydration solution.
A nurse is caring for a pt who has hyperthyroidism. Which of the following findings should the nurse expect? A. Dry, coarse hair B. Bradycardia C. Tremors D. Periorbital edema
C. Tremors
A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction? A. Dry the newborn immediately after birth. B. Maintain an ambient room temperature of 24° C (75.2° F). C. Use a protective cover on the scale when weighing the infant. D. Place the newborn's bassinet away from outside windows.
C. Use a protective cover on the scale when weighing the infant.
A nurse is conducting a visual acuity test using the Snellen letter chart for a school-age child with eyeglasses. Which instructions should the nurse give to the child? A) "You should remove your glasses throughout the testing." B) "You should stand 15 feet away from the chart." C) "You should get three symbols on a line correct to pass the line." D) "You should keep both eyes open during the testing."
D) "You should keep both eyes open during the testing."
A nurse on a pediatric unit received report on 4 children. Which child should the nurse assess first? A) A 6-month-old infant who has croup and an O2 saturation of 92% on room air B) A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication C) A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel movements over the past 24 hr D) A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain
D) A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain
A nurse working in the ED is triaging 4 patients. Which patient should the nurse recommend for treatment first? A) An older adult client who has severe abdominal pain B) A preschooler who has a skin rash C) An adolescent who has a closed fracture D) A middle adult client who has unstable vital signs
D) A middle adult client who has unstable vital signs
A nurse is caring for a client who has TB. Which action should the nurse plan to take to prevent the transmission of the disease? A) Initiate contact precautions for the client. B) Restrict visitors from entering the client's room. C) Wear a surgical mask during contact with the client. D) Have the client wear a surgical mask while being transported outside the room.
D) Have the client wear a surgical mask while being transported outside the room.
A nurse is providing teaching to a school-age child with asthma about using albuterol mertered-dose inhaler. Which instructions should the nurse include? A) Clean the mouthpiece with warm water every 2 weeks. B) Wait 10 seconds between inhalations. C) Take a quick inhalation when pressing the dispenser. D) Take the medication 15 min before playing sports.
D) Take the medication 15 min before playing sports.
A nurse is preparing to administer a blood transfusion to a client. Which procedure should the nurse follow to ensure proper client identification? A) Check the client's blood type and crossmatch it against the provider's orders. B) Ask the client to state her blood type prior to beginning blood administration. C) Compare information on the blood product to the informed consent form. D) Verify the client and blood product information with another licensed nurse.
D) Verify the client and blood product information with another licensed nurse.
A nurse is assessing a client with COPD. Which finding should the nurse expect? A) Weight gain B) Decrease in anteroposterior diameter of the chest C) HCO3- 24 mEq/L D) pH 7.31
D) pH 7.31
A community health nurse is providing teaching about home safety with a group of older adult pts. Which of the following statements should the nurse make? A. "Unplug your appliances by grasping the cord and pulling it straight from the outlet." B. "Set your water heater temperature at 130 degrees Fahrenheit." C. "Use throw rugs in high-traffic areas to partially cover wood floors." D. "Have grab bars installed around your bathtub and toilet."
D. "Have grab bars installed around your bathtub and toilet."
A nurse is providing info to a pt immediately before his scheduled Romberg test. Which of the following statements should the nurse make? A. "You will be standing with your feet 1 foot apart." B. "You will place and hold your hands on your hips." C. "I will be standing across the room from you to evaluate your sense of balance." D. "I will be checking you once with your eyes open and once with them closed."
D. "I will be checking you once with your eyes open and once with them closed."
A nurse is providing discharge instructions about newborn care to a pt who is 2 days postpartum. Which of the following statements indicates to the nurse that the pt understands the teaching A. "I will breastfeed my baby on a schedule of every 4 hours." B. "I will bathe my baby daily." C. "I will be place my baby on her stomach for sleeping." D. "I will cover my baby's body when I wash her hair." E. "I will use the bulb syringe first in her mouth and then in her nose."
D. "I will cover my baby's body when I wash her hair." E. "I will use the bulb syringe first in her mouth and then in her nose." Newborns are highly susceptible to heat loss. The client should wrap the newborn in a towel when washing the hair to minimize heat loss. Daily bathing can disrupt the integrity of the newborn's skin, but the client should clean the perineum after every diaper change.
A nurse is providing education to the parent of a school age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will administer aspirin to my child to treat pain or fever." B. "I will record an average of three readings from my child's peak expiratory flow meter." C. "I will place carpet in my child's bedroom to control allergens." D. "I will make sure my child receives a yearly influenza vaccination."
D. "I will make sure my child receives a yearly influenza vaccination."
A nurse has received change of shift report on 4 assigned pts. For which of the following pts should the nurse intervene to prevent a potential food and medication interaction? A. A client who is receiving verapamil and has a continuous infusion of total parenteral nutrition (TPN) B. A client who is taking phenytoin and is requesting a milkshake C. A client who is receiving a diet high in potassium-rich foods and furosemide by mouth D. A client who is receiving an MAOI and is requesting a cheeseburger for dinner
D. A client who is receiving an MAOI and is requesting a cheeseburger for dinner
A nurse educator is teaching a group of newly licensed nurses about the need to complete an incident report. Which of the following examples should the nurse include as a reportable incident and an indication for completing a report? A. A nurse has had two unsuccessful attempts at starting a new IV line on a client. B. Two visitors are heard arguing at the nurses' station. C. A client refuses to take his prescribed antibiotic medication. D. A nurse administered a medication via the wrong route.
D. A nurse administered a medication via the wrong route.
