COMP B

A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. What is the amount in grams the nurse should administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

18 g.

A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding 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 understand that my family can alter my advance directives if I become incapacitated."

A. "I can designate my partner as my health care surrogate."

A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching? A. "I will not allow anyone to smoke near my baby." B. "I will place bumper pads in my baby's crib." C. "My baby's head should be placed on a pillow for sleeping." D. "My baby should sleep in a side-lying position."

A. "I will not allow anyone to smoke near my baby."

A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements 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 client and her family about receiving home services. Which of the following statements 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 on a pediatric unit has received change-of-shift report for four children. Which of the following children 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

A. A 6-month-old infant who has croup and an O2 saturation of 92% on room air

A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients 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 their 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

An antepartum nurse is caring for four clients. For which of the following clients 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 36 weeks of gestation and has a positive group B streptococcal culture

A. A client who is at 33 weeks of gestation and has severe gestational hypertension

A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should include which of the following information in the teaching? A. Advocacy is a leadership role that helps others to self-actualize B. Subordinates are advocates for the nurse manager C. Advocacy encourages clients to rely on health care staff for decision-making D. Nurse managers should distrust people who expose inappropriate professional practices

A. Advocacy is a leadership role that helps others to self-actualize

A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first? A. An older adult client who is anxious and attempting to pull out an IV line B. A middle adult client who is reporting nausea after receiving pain medication C. An older adult client who has kidney failure and returned from dialysis 4 hr ago D. A middle adult client who has a terminal illness and is requesting a visit from the chaplain

A. An older adult client who is anxious and attempting to pull out an IV line

A nurse is caring for a client during a follow up visit at a gastrointestinal clinic. Nurses' Notes 0600: Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management. 0615: Client still rates pain as a 9 on a scale of 0 to 10. Hydromorphone 4 mg IV administered. Which of the following interventions should the nurse implement? Select all that apply. A. Assess peripheral circulation hourly. B. Assess the client's mouth every 8 hr. C. Use humidification with oxygen therapy. Administer IV fluids. D. Raise the knee position on the client's bed. E. Use an

A. Assess peripheral circulation hourly. B. Assess the client's mouth every 8 hr. C. Use humidification with oxygen therapy. Administer IV fluids.

A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles? A. Autonomy B. Nonmaleficence C. Justice D. Fidelity

A. Autonomy

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan? A. Avoid including raw fruits in the client's diet. B. Restrict visits from young children to 2 hr per day. C. Measure the client's temperature once per shift. D. Use disposable gloves from a box outside the client's room.

A. Avoid including raw fruits in the client's diet.

A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial selfinflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders? A. Borderline B. Antisocial C. Histrionic D. Paranoid

A. Borderline

A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? (Select all that apply.) A. Broccoli B. Yogurt C. Pepperoni pizza D. Cream cheese E. Bologna sandwich

A. Broccoli B. Yogurt

A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching? A. Delegate non-nursing tasks to ancillary staff. B. Stock client rooms with extra supplies. C. Assign dedicated equipment to each client's room. D. Change continuous IV infusion tubing every 24 hr.

A. Delegate non-nursing tasks to ancillary staff.

A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy? A. Difficulty performing ADLs B. Inability to swallow clear liquids C. Elevated blood glucose levels D. Unsteady gait when ambulating

A. Difficulty performing ADLs

A nurse in an emergency department is assessing a school-age child who was brought in by their 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 the suspicion of physical abuse with the provider. B. Confront the parents with the suspicion of physical abuse. C. Ask the hospital security to detain and question the parents. D. Contact Child Protective Services

A. Discuss the suspicion of physical abuse with the provider.

A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client? A. Droplet B. Airborne C. Contact D. Protective environment

A. Droplet

A nurse is caring for a client who is 1 hr postpartum. Nurses' Notes 1200: Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion. 1215: Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified. Select the 6 actions the nurse should take. A. Firmly massage the uterine fundus. B. Provide emotional support. C. Administer oxygen and Weigh the perineal pads. D. Insert indwelling urinary catheter and Administer methylergonovine. E. Administer terbutaline.

A. Firmly massage the uterine fundus. B. Provide emotional support. C. Administer oxygen and Weigh the perineal pads. D. Insert indwelling urinary catheter and Administer methylergonovine.

A nurse is assessing a client who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective? A. Hemoglobin 14.9 g/dL B. WBC count 12.000/mm C. Potassium 48 mEq D. BUN 18 mg/dL

A. Hemoglobin 14.9 g/dL

A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions 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 nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take? A. Instruct the client to void. B. Position the client on their left side. C. Insert an IV catheter. D. Prepare the client for moderate (conscious) sedation.

A. Instruct the client to void.

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? A. Irritability B. Increased urination C. Vomiting D. Facial flushing

A. Irritability

A nurse is assessing a client 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 is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client? A. Radial vein of the inner arm B. Great saphenous vein of the leg C. Dorsal plexus vein of the foot D. Basilic vein of the hand

A. Radial vein of the inner arm

A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse? A. The child exhibits discomfort while walking B. The child has thin extremities C. The child has bruises on the upper back D. The child is wearing a stained shirt

A. The child exhibits discomfort while walking

A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings 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 caring for a client who has a prescription for a continuous passive motion (CPM) 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. C. Instruct the client how to adjust the 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 client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin? A. aPTT B. PT C. INR D. WBC count

A. aPTT

A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication? A. "Have you experienced muscle stiffness?" B. "Have you had any stomach pain or bloody stools?" C. "Have you experienced a dry cough?" D. "Have you noticed an increase in urine output?"

B. "Have you had any stomach pain or bloody stools?"

A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make? A. "Perhaps you think the ECT is dangerous, but I've seen it have good results." B. "You have the right to change your mind about this procedure at any time." C. "Everyone gets a little nervous about this procedure as the time for it approaches." D. "Your doctor wouldn't have suggested ECT if they didn't think it would help you."

B. "You have the right to change your mind about this procedure at any time."

A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism? A. A client forgets to buy their 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 coworkers. D. A client states that they did not get a job promotion because the boss did not like them

B. A client who was abused as a child describes the abuse as if it happened to someone else.

A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take? A. Perform ADLs for the client to promote rest B. Allow for frequent rest periods throughout the day C. Use heat to reduce joint inflammation D. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain

B. Allow for frequent rest periods throughout the day

A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client 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 teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider? A. Tinnitus B. Cough C. Polyuria D. Blurred vision

B. Cough

A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective? A. Decreased blood pressure B. Decreased hallucinations C. Decreased cholesterol D. Decreased esophageal reflux

B. Decreased hallucinations

A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP? A. Perform gastrostomy feedings through a client's established gastrostomy tube B. Determine if the PRN pain medication administered 30 min ago has helped C. Provide instructions about client care to a family member over the telephone D. Teach a client how to measure their own blood pressure

B. Determine if the PRN pain medication administered 30 min ago has helped

A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication? A. Diarrhea B. Dry mouth C. Photophobia D. Bruising

B. Dry mouth

A nurse is caring for a client 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 assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider? A. Heart rate 136/min B. Nasal flaring C. Transient strabismus D. Overlapping of sutures

B. Nasal flaring

A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer? A. Measuring the group's work against the assigned objectives B. Noting the progress of the group toward assigned goals C. Sharing experiences as an authority figure D. Offering new and fresh ideas on an issue

B. Noting the progress of the group toward assigned goals

A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following actions by the newly licensed nurse requires intervention by the preceptor? A. Documents client tasks upon completion B. Starts a task then determines what supplies are needed C. Completes a client assessment while infusing an IV antibiotic over 30 min D. Returns to the nurses' station after completing several tasks in the same location

B. Starts a task then determines what supplies are needed

A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan? A. Massage bony prominences on the client's left side. B. Support the client's left arm on a pillow while sitting. C. Position the bedside table on the client's left side. D. Place the client's cane on their left side while ambulating.

B. Support the client's left arm on a pillow while sitting.

A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client 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 preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift 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

B. The client's most recent ventilator settings

A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record? A. Completion of the incident report B. Time the medication was given C. Reason for the medication error D. Notification of the pharmacist

B. Time the medication was given

A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include? A. Maintain a flexible daily schedule for the child B. Use a reward system to modify the child's behavior C. Provide a variety of family members to care for the child D. Administer alprazolam as needed to reduce the child's anxiety

B. Use a reward system to modify the child's behavior

A nurse is providing teaching for a client who has a fracture of the right fibula with a shortleg cast in place and a new prescription for crutches. The client is nonweight-bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching? A. Adjust the crutches for comfort as needed. B. Use a three-point gait. . Wear leather-soled shoes. D. Advance the affected leg first when walking upstairs.

B. Use a three-point gait.

A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching? A. Check the functioning of oxygen equipment once each week. B. Wear clothing made with cotton fabrics while oxygen is in use. C. Apply petroleum-based lubricant to the nares as needed. D. Store full oxygen tanks on their side.

B. Wear clothing made with cotton fabrics while oxygen is in use.

A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make? A. "I'm sure your family does not want you to die." B. "Why would you believe such things?" C. "How does this make you feel?" D. "You should talk to your family about your feelings."

C. "How does this make you feel?"

A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism? . "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 home health nurse is evaluating a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements? A. "My child doesn't like to sit still for nebulizer treatments." B. "I think that my child has been running a fever over the last couple of days." C. "My child has only a small amount of mucus after percussion therapy." D. "I am concerned about my child's future participation in team sports."

C. "My child has only a small amount of mucus after percussion therapy."

A nurse is providing client teaching about the basal body temperature method of birth control. Which of the following information 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 client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider? A. Obtain capillary blood glucose level every 2 hr B. Check the neurovascular status of the client's lower extremities every hour C. Apply a cold pack to the client's ankle for 30 min every hour D. Maintain the affected ankle elevated and immobilized

C. Apply a cold pack to the client's ankle for 30 min every hour

A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Evaluate dietary intake for a client who has anorexia. B. Measure the vital signs of a client who just returned from the PACU C. Arrange the lunch tray for a client who has a hip fracture. D. Assess I&O for a client who is receiving dialysis.

C. Arrange the lunch tray for a client who has a hip fracture.

A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority? A. Assess fluid intake every 24 hr. B. Ambulate three times a day. C. Assist with deep breathing and coughing. D. Monitor the incision site for findings of infection.

C. Assist with deep breathing and coughing.

A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth? A. Constipation B. Urinary urgency C. Cervical laceration D. Retained placenta

C. Cervical laceration

A rural community health nurse is developing a plan to improve healthcare delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources? A. Agency for Healthcare Research and Quality B. National Institutes of Health C. Department of Agriculture D. World Health Organization

C. Department of Agriculture

A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload? A. Oliguria B. Bradycardia C. Dyspnea D. Poor skin turgor

C. Dyspnea

A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first? A. Document the client's refusal in the medical record B. Honor the client's decision to refuse the blood transfusion C. Explore the client's reasons for refusing the treatment D. Discuss the client's refusal with the provider

C. Explore the client's reasons for refusing the treatment

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)? A. February 1 B. February 8 C. February 15 D. February 22

C. February 15

A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions 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 of the following steps of the time management process should the nurse manager include as the 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 of the following tasks should the nurse delegate to an assistive personnel (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 caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? A. Assess the client's IV site every 8 hr. B. Check the client's WBC count every 48 hr. C. Monitor the client's mouth every 8 hr. D. Change the client's IV tubing every 48 hr.

C. Monitor the client's mouth every 8 hr.

A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication? A. Hypotension B. Report of tinnitus C. Report of chest pain D. Ecchymosis

C. Report of chest pain

A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg, and HCO3 of 25 mEq/L. The nurse should identify that the client 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 manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions 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

C. Schedule a staff meeting to present the different options to staff members

An RN is observing a licensed practical nurse (LPN) and an assistive personnel (AP) move a client up in bed. For which of the following situations should the nurse intervene? A. The LPN and AP lower the side rails before lifting the client up in bed. B. Prior to lifting the client, the LPN and AP raise the bed to waist level. 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.

C. The LPN and the AP grasp the client under his arms to lift him up in bed.

A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take? A. Select a 1-inch needle B. Use a 45° 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 providing information to a client 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 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 immunization."

D. "I will make sure my child receives a yearly influenza immunization."

A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching? A. "I will change your IV tubing once every 48 hours." B. "Abdominal distention is an expected effect of this therapy." C. "I will need to check your gastric residual before administering feedings." D. "I will need to measure your weight daily."

D. "I will need to measure your weight daily."

A nurse has received change-of-shift report on four assigned clients. For which of the following clients 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 home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of AllInclusive Care for the Elderly (PACE) for which of the following clients? A. A client whose family requests hospitalbased hospice care B. A client who requires transfer to a skilled care facility C. A client who qualifies for telehealth for pacemaker diagnostics D. A client whose caregiver requests adult day care services

D. A client whose caregiver requests adult day care services

A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? A. An older adult client who reports constipation of 4 days 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 charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation? A. Evaluate the changes the partner requests B. Review the client's plan of care C. Analyze other reports of poor care to look for trends D. Ask the partner to list specific concerns

D. Ask the partner to list specific concerns

A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take? A. Wear a surgical mask when providing client care B. Have visitors maintain a distance of 1.8 m (6 feet) from the client C. Restrict fresh flowers from the client's room D. Assign the client to a private room with negative air pressure

D. Assign the client to a private room with negative air pressure

A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication? A. Diarrhea B. Frequent urination C. Excessive salivation D. Blurred vision

D. Blurred vision

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities 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 providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities 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 client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet? A. Calories B. Protein C. Potassium D. Fiber

D. Fiber

A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease? A. Initiate contact precautions for the client upon admission B. Restrict visitors from entering the client's room during hospitalization C. Wear a surgical mask while providing care for 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 planning to reinforce teaching with a preschooler who is about to undergo an incision and drainage for cellulitis on the left arm. Which of the following techniques should the nurse use? A. Plan for a 30-min instructional session. B. Schedule the instructional session for 24 to 36 hr before the procedure C. Take the child on a tour of the surgery and recovery areas. D. Help the child put a dressing on a doll

D. Help the child put a dressing on a doll

A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority? A. Encourage oral fluids. B. Apply topical calamine lotion. C. Administer acetaminophen as an antipyretic D. Initiate transmission-based precautions

D. Initiate transmission-based precautions

A nurse is caring for a client 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 field 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 client 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 is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure (ICP)? A. Flex the client's neck forward B. Group several nursing activities to be completed at one time C. Limit suctioning the client's airway to 30 seconds at a time D. Place the client in a quiet environment

D. Place the client in a quiet environment

A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client'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 client education program about osteoporosis for older adult clients. 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

A nurse is providing teaching to a schoolage child who has asthma about using an albuterol metered-dose inhaler. Which of the following 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 on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client'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 their partner that "the staff here is so controlling C. The client is sitting with their head in their hands and appears to be crying D. The client is pacing around the chair in which their partner is sitting

D. The client is pacing around the chair in which their partner is sitting

A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse not include in the change-ofshift 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

D. The frequency in which the client presses the call button

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures 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 their 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 who has COPD. Which of the following findings 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 nurse is caring for a client who is 1 day postoperative following a total thyroidectomy. Laboratory Results 0700: Sodium 143 mEq/L (136 to 145 mEq/L) Potassium 3.5 mEq/L (3.5 to 5.0 mEq/L) Chloride 104 mEq/L (98 to 106 mEq/L) BUN 15 mg/dl (10 to 20 mg/dl) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Total calcium 8.0 mg/dL (9.0 to 10.5 mg/dL) Phosphate 4.6 mg/dL (3.0 to 4.5 mg/dL) Glucose 95mL (74 to 106 mg/dL) WBC 9,500/mm3 (5,000 to 10,000/mm3) Complete the following sentence by using the lists of options. The client is at the highest risk for developing hypocalcemia evidenced by the ____

Total calcium 8.0 mg/dL (9.0 to 10.5 mg/dL)

A nurse is providing phone advice for a client who is pregnant. Complete the following sentence by using the lists of options. Nurses' Notes We e k 6 o f ge s tatio n: Spoke with client ove r t h e ph o n e. Clie n t r epo r t s nau s ea and v o miting wit h a w eig h t loss of 0.9 kg (2 lb) from their prepregnancy weight. Client reports no noted change in vomiting pattern and denies dr y m u c u s m e mbran e s. Advis ed clie n t t o eat s mall f r equ e n t m eal s o f n o n-g r e a s y , dr y , s w e e t o r sal t y f o ods , s u c h as d r y t o a s t , c rac k e r s , and pr e t z els. E n c o u raged clie n t t o call bac k if nau s ea and v o mitin g w o r s e n s. We e k 1 0 o f ge s tatio n: Spoke with client ove r t h e ph o n e. Clie n t r epo r t s a 6.8 kg ( 1 5 lb) w eigh t lo s s o v e r t h e pas t m o n t h. Clie n t s tat e s nau s e a c o n tin u e s , making it di f fic ult t o eat. T h e y de s c

Vomiting