Extra Alternate-Format Practice

A nurse is caring for a client with anorexia nervosa. Which interventions would be appropriate for this client? Select all that apply.

-Provide small, frequent meals. -Monitor weight gain. -Encourage the client to keep a journal.

The nurse is prioritizing care of a client in the immediate postpartum period. What is the nurse's priority assessment? Select all that apply.

-height of fundus -blood pressure -urinary output

A 12-year-old client is 2 days postoperative from an open reduction, internal fixation procedure for a fractured femur. The client's chart reads:Breakfast:1 - 4 oz cup of hot chocolate (4 oz × 30 ml = 120 ml)1 - 4 oz carton of milk (4 oz × 30 ml = 120 ml)1 bowl of oatmeal (n/a)1 - 6 oz glass of orange juice (6 oz × 30 ml = 180ml)Additional information for 8-hour shift:I.V. of lactated Ringers is running at 125 ml/hr.A 1 g cefazolin injection was administered q8h.The pharmacy sent the cefazolin injection 1 g in 100 ml 50% dextrose.Calculate this client's intake for the 7 am to 3 pm shift. Record your answer using a whole number.

1520

The nurse is calculating intake and output for a client. Intake included 1750 ml of D5W, 500 ml of ceftriaxone, 8 oz of coffee, 4 oz of juice, and 800 ml of water. The client's output included 1560 ml of urine, and 45 ml of vomitus. What is the total output for this client? Record your answer using a whole number

1605

A client is receiving 1 L of 0.9% sodium chloride IV to be infused for 12 hours. The IV infusion set has a drop factor of 15 gtt/ml. At how many drops per minute should the nurse set the IV to infuse? Record your answer using a whole number.

21

The nurse on the pediatric medical unit is admitting a school-age child from the emergency department. The child's chart entry reads:Progress NotesJuly 25, 20191445Parent reports client has had no urine output for 18 hours. Bladder scan reveals 0 ml residual urine. Pulse 98/bpm and irregular; blood pressure 78/38 mmHg. Client reports abdominal pain described as 'cramps.' Bilateral muscle weakness noted.After reviewing the client's potassium level of 5.8 mEq/L (5.8 mmol/L), the nurse should anticipate an order for what intervention?

Administer sodium polystyrene as prescribed.

The note on the chart of a client with post traumatic stress disorder reads: "During the group therapy session, the client spoke about facts related to the train accident, but did not express their feelings related to the trauma experienced."Based on this chart entry, what is the best strategy for the nurse to use to prompt further discussion during the next group therapy session?

Encourage the client to explore feelings of survivor guilt and self-blame.

The nurse is caring for a child with tricuspid atresia who develops polycythemia. Which statement most accurately describes this manifestation?

There is an increased risk of developing a thrombus.

After repeated office visits and diagnostic tests, the healthcare provider is unable to find a physical cause for the client's symptoms and recommends a psychiatric referral. The client states, "I can't imagine why I should see a psychiatrist." What statements by the nurse will help the client? Select all that apply.

-"All the diagnostic tests are negative, so we have to explore other explanations for your symptoms." -"There is a known correlation between physical symptoms and stress, and we should explore this." -"A psychiatrist is part of the medical team and can offer input into your overall plan of care."

A nurse is providing teaching to an adolescent who has been prescribed phenytoin for seizures. What information should the nurse include in this teaching? Select all that apply.

-"Brush your teeth using a soft toothbrush." -"You will need to have bloodwork done frequently." -"You should wear an ID bracelet indicating you are taking this drug."

A male client reports little or no sexual desire, causing marital discord over the past year. What priority questions will the nurse ask the client to explore lack of sexual desire? Select all that apply.

-"Did you experience this decreased desire before?" -"What are the current medications you are taking?" -"Do you have any medical conditions?"

The nurse is assessing a client for narcissistic personality disorder. What questions should the nurse ask the client? Select all that apply.

-"Do you find that most people aren't quite up to your standards?" -"If people give you a hard time, do you tend to put them in their place quickly?" -"Are you a very special person?"

The nurse is explaining discharge instructions to a client with a fractured right femur who lives alone. Which statements by the client lead the nurse to determine that this client understands the instructions? Select all that apply.

-"I will move the joints above and below the cast regularly." -"I will report any foul odor under the cast to my provider." -"I can use a hair dryer on the cool setting for any itching."

The nurse is teaching a caregiver how to effectively interact with an older adult parent who suffers from impaired memory and judgment. What is the most important information for the nurse to provide? Select all that apply.

-"Speak slowly and use understandable words and phrases." -"Allow ample time for your parent to respond to a question." -"Orient and re-orient your parent as needed throughout the day." -"Approach your parent from the front when beginning a conversation."

A mother tells the nurse she understands breastfeeding is the best, but will change to formula feedings when she returns to work in a few weeks. What should the nurse tell this mother about formula feedings? Select all that apply.

-"When mixing the powdered formula, be sure to follow the manufacturer's directions on the container to ensure proper nutrition." -"All babies on formula should have an iron-fortified formula to ensure healthy brain growth." -"Speak to your baby's health care provider about the best formula to use when you plan to change from breast to formula feeding."

A parent reports that the 6-year-old daughter recently began wetting the bed and running a low-grade fever. A diagnosis of urinary tract infection (UTI) was made following a urinalysis that came back positive for bacteria and protein. Antibiotics have been prescribed for the child. What are appropriate nursing interventions? Select all that apply.

-Assess the parent's understanding of UTI and its causes. -Instruct the parent to administer all the antibiotic as prescribed until the prescription is finished. -Discourage the taking of bubble baths.

When reviewing the chart of a client recently diagnosed with AIDS, the nurse should expect to find which assessment data? Select all that apply.

-CD4+ count below 200 cells per microliter -infection with HIV -opportunistic infection

A nurse is caring for a client whose cultural background is different from the nurse's. Which actions are appropriate? Select all that apply.

-Consider that nonverbal cues, such as eye contact, may have different meanings in different cultures. -Respect the client's cultural beliefs. -Ask if there are cultural or religious requirements that should be considered in the client's care.

A parent is planning to enroll the 9-month-old infant in a day care. The parent asks the nurse what indicators would ensure that the daycare facility is adhering to good infection control measures. How should the nurse reply? Select all that apply.

-Diapers are discarded into covered receptacles. -Disposable papers are used on the diaper-changing surfaces. -Facilities for hand hygiene are located in every classroom.

A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions for avoiding future crises should the nurse provide to the client and his family? Select all that apply.

-Drink plenty of fluids -Report a sore throat to an adult -Wash hands before meals and after playing

A nurse receives an order to start an infusion of blood for a client who is hemorrhaging due to a placenta previa. What priority action(s) will the nurse take to initiate the infusion? Select all that apply.

-Inserting a 18-gauge catheter -Confirming consent -Obtaining baseline vital signs

A client with gestational diabetes delivers an infant weighing 9 lb, 11 oz (4.4 kg) after 8 hours of labor and membranes that ruptured 3 hours ago. Which interventions would be appropriate for this neonate? Select all that apply.

-Obtain a heel stick for glucose level. -Maintain a thermo-neutral environment. -Monitor the neonate for respiratory distress.

A nurse is teaching a client about withdrawal from the excessive use of caffeine. What will the nurse include in the teaching? Select all that apply.

-One of the first symptoms of withdrawal will be a headache. -Drink fluids to help with the withdrawal. -Nausea and muscle pain may occur with withdrawal.

The nurse is caring for a client on the rehabilitation unit who has hearing loss. In planning care, the nurse documents ways to minimize the obstacles to successful communication with this client. Select all that may apply.

-Stand or sit in the client's line of vision. -Close the door to the client's room. -Minimize the distraction from television and visitors. -Be certain hearing aids are functioning properly. -Get the client's attention before communicating.

A client is admitted with hemophilia A. Which sports should the nurse recommend as safe for the client to participate? Select all that apply.

-Swimming -Golf

The nurse is assessing a client who sustained blunt chest trauma from a motor vehicle collision. There are no obvious signs of bleeding. The provider diagnoses the client with cardiac tamponade. What assessment data would the nurse anticipate? Select all that apply.

-apical pulse of 156 -blood pressure of 62/48 -muffled heart sounds -jugular vein distention

A nurse is developing a teaching plan for sleep hygiene. Which interventions should the nurse include? Select all that apply.

-avoid caffeine, alcohol, and nicotine before bedtime -prepare the room for sleep and turn off distracting noise -participate in a bedtime routine

Which factors contribute to a difficulty creating a therapeutic alliance among clients with personality disorders? Select all that apply.

-clients' suspiciousness -clients' detachment -clients' secretive style and hostility

The nurse has just admitted a client to the telemetry floor with reports of acute chest pain radiating down the left arm. Which laboratory studies should the nurse order to evaluate myocardial damage? Select all that apply.

-creatinine phosphokinase (CK-MB) -troponin T and troponin I -myoglobin

A nurse is talking to a client who delivered her baby 5 days ago, and suspects that the client is having the postpartum blues. Which client behavior is suggestive of this problem? Select all that apply.

-crying -difficulty sleeping -mood swings

Which characteristics would the nurse anticipate in a child diagnosed with tricuspid atresia? Select all that apply.

-cyanosis -capillary refill more than two seconds -clubbed fingers

The nurse is assessing a client with a hematoma and compartment syndrome in the same extremity. Which symptoms would the nurse anticipate? Select all that apply.

-edema -increased venous pressure -decreased venous circulation

The nurse is caring for a child who has been diagnosed with a brain tumor. Which assessment findings are recognized as early signs of increased intracranial pressure? Select all that apply.

-headache -irritability -dizziness

A nurse is assisting in monitoring a client who's receiving oxytocin to induce labor. Which maternal adverse reactions should the nurse should be alert to? Select all that apply.

-hypertension -fluid overload -uterine tetany

A two-year-old child is being monitored after cardiac surgery. Which assessment findings would represent a decrease in cardiac output? Select all that apply.

-hypotension -decreased urine output -weak peripheral pulses

The nurse is teaching a client about the risk factors for developing osteoporosis. What is the most important information for the nurse to include? Select all that apply.

-inadequate dietary intake of calcium -family history -smoking

Which manifestation of varicose veins would the nurse anticipate while assessing a woman in the third trimester of pregnancy? Select all that apply.

-leg fullness -leg fatigue

The nurse is performing an assessment on a child diagnosed with impetigo. How should the nurse document these assessment findings? Select all that apply.

-lesions filled with pus -reddened patches with sharply marginated, irregular outlines -pustules with a yellowish-brown crust -reddish macule

Which conditions or situations are most likely to result in difficulty sleeping? Select all that apply.

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

The nurse is caring for a 19-year-old client recently diagnosed with multiple sclerosis (MS). What interventions would be important for the nurse to include when teaching this client ways to prevent the exacerbation of symptoms? Select all that apply.

-suggesting a support group or meditation to decrease stress -planning activities to avoid fatigue -promoting regular physical activity

The nurse is assessing an infant with neonatal bronchopulmonary dysplasia (chronic lung disease). Which symptoms would the nurse expect to find? Select all that apply.

-tachypnea -hyperexpansion on chest X-ray -wheezing

A client is started on steroid therapy after an adrenalectomy. Which information is most important to share with this client? Select all that apply.

-take the prescribed dose daily, and do not miss a dose -notify your healthcare provider if you experience increased urination -take this medication for the rest of your life

A client asks the nurse what factors affect how long it will take for a hip to heal following hip replacement surgery. What are the best responses by the nurse? Select all that apply.

-the age of the client -the client's comorbidities

A middle-age adult has been identified as being in the stagnation stage of developmental conflict. What evidence would support this assessment? Select all that apply.

-withdrawn from family obligations -increased nap and sleeping hours

A healthcare provider prescribes an I.V. solution to infuse at a rate of 125 ml/hr. How many liters of solution will the client receive during an eight hour shift? Record your answer using a whole number.

1

The nurse reads the chart entry for a client who attends group therapy and uses cannabis daily:2/101700The client is congested, with a dry hacking cough. The client could not verbalize treatment goals when asked in the group session. The client laughed when the therapist gave each participant a worksheet to fill out and bring back to the next group, and stated, "I'm not doing that."What health problem is this client experiencing because of extended cannabis use?

amotivational syndrome

The nurse is assessing breath sounds of a child admitted to the unit. Based on the following progress notes, which respiratory illness would the nurse suspect?Progress notes10/152030Seven-year-old child admitted from ER. Oxygen via mask at 4 L/min. Frequent, tight cough. A/Ox3. Shortness of breath noted while talking to mom. HEENT normal. Lungs with wheezing in bases. Heart RRR, no murmur. Abdomen soft, flat. Active bowel sounds. Moving all extremities well.

asthma

A nurse is admitting a child to the unit. Based on the history, what illness would the nurse suspect?History and physical10/151030Nine-year-old child admitted with frequent cough and fever of > 100.5° F (38.1° C) for the past month. Child lives with parents and with grandparents who recently emigrated from SE Asia. Weight = 20 kg. Parent reports significant weight loss in child. Child reporting fatigue and poor appetite. Denies vomiting/diarrhea. Does have some nausea. No problems with voiding or stooling. Child does well in school.

tuberculosis

The nurse is evaluating the external fetal monitoring strip of a client in labor. What condition is the nurse concerned about?

uteroplacental insufficiency

The chart documentation of a client with paranoid personality disorder is listed below:10/151830The client stays by oneself as much as possible during the afternoon. The client paced the hallway at times and was irritated if approached by staff or other clients. The client questioned another male client and accused that client of lying. At the beginning of the shift the nurse spoke to the client accused of lying.Which statement, from the client accused of lying, would require further intervention?

"If I have an opportunity, I will not let him get away with this."

A young adult client who uses cannabis multiple times a day, has just participated in a family meeting at a community mental health center. The chart entry reads:2/100900The family meeting began by the client's family demanding that the client "stop using marijuana at once, or there will be severe consequences, including no support to attend college." The drug, and the problems associated with its use, were explained to the family.What educational topic should the nurse address with this family during the next teaching session?

Address how the substance use has affected each member of the family.

A 7-year-old has just been admitted to the unit for excessive vomiting. Based on the available chart data, what is the nurse's most appropriate action?10/150730Vital Signs RecordT: 104.9° F (40.5° C)P: 98RR: 30Lab ValuesSerum Potassium: 3.1 mmol/LSerum Sodium: 128 mmol/LNurse's NoteSkin flushed and warm to touch; good turgor; petechiae noted over entire trunk

Assess the child's neurological status.

An IV of 1000 ml 5% dextrose in water is ordered to infuse over eight hours for a client who is dehydrated after receiving chemotherapy. The drop factor for the IV set is 10 gtt/ml. At what rate (in gtt/min) should the nurse start the infusion? Record your answer using a whole number.

21

The nurse is calculating intake and output for a client. Intake included 1750 ml of D5W, 500 ml of ceftriaxone, 8 oz of coffee, 4 oz of juice, and 800 ml of water. The client's output included 1560 ml of urine, and 45 ml of vomitus. What is the total intake for this client? Record your answer using a whole number.

3410

A client has given birth to an 8 lb 2.5 oz (3,700 g) infant. A newborn infant requires 110 to 120 cal/kg/day. What is the minimum number of calories per day this neonate requires? Record your answer using a whole number.

407

The pediatric nurse is caring for a 10-month-old infant. The health care provider orders an I.V. infusion of dextrose 5% in 0.45% NaCl solution to be infused at 7 ml/kg/hr. The infant weighs 22 lb (10 kg). How many ml/hr of the ordered solution should the nurse infuse? Record your answer using a whole number.

70

The health care provider orders documentation of a client's intake and output. Using the following information, calculate this client's intake in milliliters. Record your answer to the nearest tenth. 250 ml decaffeinated coffee 125 ml green gelatin 62.5 ml apple juice 125 ml lemon-lime soda 250 ml beef broth 300 ml of urine output

812.5

A nurse explains the process of cane usage to a hospitalized client with left-sided weakness. Place the steps of teaching proper cane usage in the correct order. All options must be used.

Perform hand hygiene. Secure a gait belt around client's waist. Place the cane in the right hand. Have client advance the cane and the left leg. Have client advance the right leg.

The nurse is reviewing the chart of a client with type 2 diabetes prior to a scheduled appointment. The chart states:Progress notes10/15/160245Client states that he has not been following his prescribed diabetes management program for the past 2 to 3 months. Client is aware of his blood glucose monitoring regimen and diet but has difficulty integrating each into his routines. Client denies recent changes in urinary function, sensation or vision.How can the nurse best determine this client's glycemic control since the last assessment?

Review the results of the client's HbA1c.

A nurse is caring for a client with the visual field deficit depicted above. What is the most important information for the nurse to teach this client?

Scan the environment on the affected side.

The nurse prepares the client for a lumbar puncture (LP) (see client chart below) to rule out a subarachnoid hemorrhage. Which assessment finding would require intervention before the procedure?2/10/2017190056-year-old, right-handed client presents with severe onset of headache and projectile vomiting that started 45 minutes prior to admission. Physical examination findings include nuchal rigidity.

Suspected increased intracranial pressure (ICP)

When reviewing a client's chart, the nurse reads the progress note below. 10/151130Client, age 28, admitted to unit with diagnosis of antisocial personality disorder and suicide attempt after cutting his right wrist. Right wrist dressing appears dry and intact. Client states, "I don't want to be here and I'm not following your treatment plan or any of your rules. I'm going to tell everyone here not to follow your rules."—Barbara Jones, RNWhich statement, about the client's condition, is most accurate?

The client is not motivated to change his behavior or his lifestyle.

A nurse is teaching a client, who has Parkinson's disease, and their family about dietary practices. Which signs and symptoms are most important for the nurse to address? Select all that apply.

drooling aspiration choking dysphagia

A chart entry reads:2/10/20171700The client presents with a sad affect, stooped posture, limited eye contact, and slow, but clear speech. The client is oriented and stays away from peers. During a one-to-one interaction the client stated," I'm not worth it. It won't do me any good to talk about it."Based on the progress note shown here, which is the best intervention for the nurse to initiate?

gently question the negative self-statements made by the client

The emergency department healthcare provider diagnoses a 35-year old client with a small peri-tonsillar abscess. The client's chart entry readsDischarge notes10/15/161400The client is being discharged following a needle aspiration of the peri-tonsillar abscess. Clindamycin 600 mg/bid is order, and the client is to take ibuprofen 400 mg/qid as needed for pain. Instructions were given to keep the follow-up appointment.Based on this discharge note, what is the nurse's priority intervention?

instruct the client to report frequent swallowing or coughing up blood

The chart entry for a client with a fungal infection in the maxillary sinus readsProgress notes10/15/161530Client reports increased nasal discharge, a productive cough with green discharge, and increasing facial pain 60 minutes after pain medication was given. Recent vital signs: Temperature 98.2° F (37° C), Pulse 120, and Respirations 26.What is the priority nursing action?

obtain a sputum sample

2/10/2017210018-year-old college student presents to the emergency department with a severe headache and onset of bizarre behavior that started approximately five hours ago. Client is oriented to person, but not place or time. Physical assessment includes petechiae. Oral temperature is 104° F (40° C). HR: 128/bpm. RR: 24/min, O2: 95% on room air. Lumbar puncture ordered. Client is being evaluated for bacterial meningitis.What is the most important action by the nurse?

obtaining I.V. access in preparation of antibiotic administration

A 5-year-old client was admitted to a pediatric unit 4 hours ago with reports of pain in the right ankle. Upon assessment, the nurse documents the following findings: VS: 102.8° F (39.3° C), P 112, R 16 BP 96/55, O2 99% on RA, moderate amount of erythema and +2 edema over the lateral aspect of the right ankle, warm to touch, limited range of motion noted. The nurse also reviews the laboratory values. Based on the assessment findings and laboratory data in the chart below, for what is this client at risk?CBC:WBC: 17.8 x 103/µlRBC: 4.8 million/mm3Hgb: 13.5 gm/dlHCT: 38%Bands: 13 PMN%CRP: 2.8 ng/dlBlood Culture: Gram positive: Staphylococcus aureus

osteomyelitis

The chart entry for a client with chronic pharyngitis readsProgress notes10/150945A 37-year-old client, who works in a textile factory, has returned to the clinic with symptoms of a persistent sore throat which makes swallowing uncomfortable and congestion that causes frequent episodes of coughing to expel mucous.Based on this chart entry, how should the nurse teach this client how to manage these symptoms?

recommend decreasing exposure to environmental irritants by wearing a mask

A nurse begins their shift by reading the following shift report. The nurse interprets these results as indicating which of these?H.B. age 78Hyperventilating, RR 36Bpm. C/O dizziness, shortness of breath, tingling in hands and feet, weakness. Anxious.ABG: pH 7.48PaCO2: 33 mmHg

respiratory alkalosis

A college student visited the health center almost daily during the second half of the semester, before course examinations. Physical causes for these visits have been eliminated. Based on the following progress note entry in the client's chart, the nurse should suspect2/10/20171600Throughout the semester, this student presented at the walk-in clinic an average of twice per week reporting a variety of symptoms. A full work-up was done to rule out mononucleosis, influenza, colitis, pregnancy, kidney infection, and chronic fatigue. The student presented in a dramatic and worried manner with each new complaint. She did not question any of the findings, seeming to simply suffer a repeat of a previous malady or present with a new set of symptoms. It is recommended that the client have a consult to mental health services.

somatic symptom disorder

Prioritize the steps needed to perform an electrocardiogram (ECG). Use all options.

wash hands explain the importance of lying still, breathing normally, and refraining from talking during the test apply conductive gel to the client's skin attach electrodes to the client's skin and obtain a reading disconnect the electrodes from the client clean the gel from the client's skin

A male with an antisocial personality disorder is court-mandated to receive counseling after being detained by law enforcement officials. The chart entry reads:10/151130The client came to the group therapy session and was verbally aggressive to other clients. The group leader set limits on his behavior, reinforced the group rules and guidelines. At two different times the client made excuses for his behavior, stating, "I really don't have to be here," and minimized the comments of other group members.Which priority action must the nurse group leader initiate?

Formulate an individual contract for appropriate behavior during the group.

The nurse is obtaining a specimen of wound drainage from a client with osteomyelitis. Prioritize the nurse's steps necessary to collect this specimen. All options must be used.

Identify client using two identifiers. Complete hand hygiene. Apply clean gloves. Open sterile culture tube. Insert tip of swab into the wound in the area of the drainage and rotate. Return swab to culture tube.