Missed
The nurse determines an adolescent is showing progress toward completing Erikson's psychosocial developmental stages if the adolescent makes which statement?
"I've met people who like that kind of music and we're going to a concert next week."
The nurse is providing instructions to a parent of a child with patent ductus arteriosus (PDA). Which statement by the parent would indicate a need for further teaching?
1. "I know that my child will outgrow this problem, just give him time."
The nurse reinforces home care instructions to a client diagnosed with systemic lupus erythematosus and instructs the client about methods to manage fatigue. Which statement by the client indicates a need for further teaching?
1. "I should take hot baths because they are relaxing."
The nurse has instructed a client diagnosed with tuberculosis (TB) about how to prevent the spread of infection after discharge. The nurse determines that the client needs further teaching if the client makes which statement?
1. "I should use disposable plates, forks, and knives."
A client with tuberculosis (TB) asks the nurse about precautions to take after discharge from the hospital to prevent transmitting infection to others. Which statements indicate prevention of transmission of tuberculosis? Select all that apply.
1. "I will bleach my clothes and bedding after use." 2. "My family and I will practice good hand hygiene." 3. "I will discard disposable tissues into a plastic bag." 4. "I will cover my mouth when I cough, sneeze, or laugh." 5. "All the deep pile carpeting will be removed from my home." Correct Answer: 2, 3, 4
The nurse is assisting in performing Leopold's maneuvers. The client asks the purpose of the procedure. How should the nurse respond to the client? Select all that apply.
1. "Leopold's maneuvers are used to determine fetal position." 2. "Leopold's maneuvers are used to determine actual fetal heart rate." 3. "Leopold's maneuvers are used to determine duration of contractions." 4. "Leopold's maneuvers are used to determine frequency of contractions." 5. "Leopold's maneuvers assist in determining the degree of descent into the pelvis of the presenting part." 6. "Leopold's maneuvers assist in determining the point of maximal intensity of the fetal heart rate on the maternal abdomen." Correct Answer: 1, 5, 6
Which statements made by the nursing student accurately reflect correct information about the hormone oxytocin? Select all that apply.
1. "Production of oxytocin occurs in the ovaries." 2. "It is produced by the anterior pituitary gland." 3. "It can cause contractions of the uterus during and after birth." 4. "Release of oxytocin stimulates the pancreas to produce insulin." 5. "Oxytocin is used primarily for labor induction and augmentation." Correct Answer: 3, 5
The nurse is teaching an adolescent female about menstruation. Which statements if made by the adolescent female demonstrate a need for further teaching? Select all that apply.
1. "The average duration of menstruation is 3 days." 2. "Menstruation typically begins 14 days after ovulation." 3. "The menstrual cycle prepares the uterus for pregnancy." 4. "I will lose about 40 mL of blood during my menstrual period." 5. "The day of ovulation is counted as the first day of the menstrual cycle." Correct Answer: 1, 5
The nursing student is asked to describe the correct steps for performing adult cardiopulmonary resuscitation (CPR). Arrange the steps of adult CPR in the order of priority. All options must be used.
1. Determine unconsciousness by shaking the client and asking, "Are you OK?" Perform chest compressions. 2. Perform chest compressions. 3. Open the client's airway. 4. Initiate breathing.
The nurse is assessing a client who takes antipsychotic medication for which signs/symptoms that might indicate the development of neuroleptic malignant syndrome? Select all that apply.
1. Diaphoretic 2. Lack of muscle tone 3. Temperature of 104.8° F 4. Pulse of 56 beats per minute 5. Blood pressure of 210/130 mm Hg Correct Answer: 1, 3, 5
The client is receiving external radiation to the neck for cancer of the larynx. The nurse monitors the client knowing that which are side/adverse effects of the external radiation? Select all that apply.
1. Dyspnea 2. Diarrhea 3. Sore throat 4. Constipation 5. Red and dry skin over neck Correct Answer: 3, 5
The primary health care provider will perform a caloric test. Which is the priority order of the actions to perform this test? Arrange the actions in the order that they should be performed. All options must be used.
1. Explain the purpose and procedure to the client 2. Note if the client has had central nervous system depressants, alcohol, or barbiturates 3. Check for the presence of nystagmus, postural deviation (Romberg sign), and past-pointing 4. Examine and clean the ear canal. 5. Place emesis basin under ear to be tested then irrigate the suspected ear with hot or cold water 6. Irrigate until the client complains of nausea and dizziness or nystagmus is observed
The nursing instructor has taught a lecture on the reproductive cycle of the female and asks a nursing student to identify the functions of the vagina. The student correctly responds by identifying which functions? Select all that apply.
1. Female organ of coitus 2. Discharge of menstrual flow 3. Allows for fetal passage during the process of birth 4. Assists in propelling the ovum through the fallopian tube 5. Produces sex hormones that assist in maintaining the pregnancy Correct Answer: 1, 2, 3
The nurse is monitoring a client at risk for placental abruption. Which findings are indicative of this complication? Select all that apply.
1. Fetal distress 2. A soft abdomen 3. Painless bleeding 4. Normal blood pressure 5. Dark red vaginal bleeding Correct Answer: 1, 5
The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which observation is indicative of the signs/symptoms associated with withdrawal from opioids?
1. Fever, yawning, irritability, diaphoresis, and diarrhea
The nurse is checking a client who is taking theophylline for possible toxicity. Which signs and symptoms indicate theophylline toxicity? Select all that apply.
1. Flushing 2. Insomnia 3. Headache 4. Decreased wheezing 5. Nausea and vomiting 6. Serum theophylline level of 19 mcg/mL Correct Answer: 1, 2, 3, 5
The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL through an indwelling urinary catheter for the last 2 hours. Based on this finding, which should be the nurse's actions at this time? Select all that apply.
1. Increase the rate of the IV fluid. 2. Call the primary health care provider. 3. Administer a 250-mL bolus of normal saline (0.9%). 4. Check the client's overall intake and output record. 5. Gather data about the urinary catheter and check for patency. Correct Answer: 4, 5
A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply.
1. Notify the registered nurse immediately. 2. Document the client's complaint with the exact times. 3. Place a sterile saline dressing and ice packs over the wound. 4. Prepare the client for wound closure by notifying surgery department. 5. Place the client in a supine position without a pillow under the head. 6. Instruct the client to remain quiet and reassure the situation is being taken care of. Correct Answer: 1, 2, 4, 6
A client has returned to the nursing unit following abdominal hysterectomy. To gather data on the client's postoperative bleeding, the nurse should implement which interventions? Select all that apply.
1. Observing perineal pad drainage 2. Observing the abdominal dressing 3. Rolling the client to one side to view bedding 4. Monitoring output from the Jackson-Pratt drain 5. Auscultation of bowel sounds, especially lower quadrants 6. Observing for abdominal distention and presence of ecchymosis Correct Answer: 1, 2, 3, 4
The nurse is assessing a client with a diagnosis of bipolar affective disorder-mania. Which characteristics appropriately describe this client's diagnosis? Select all that apply.
1. Outlandish behaviors 2. Takes a shower every other day 3. Purposeless arousal and movement 4. Occasional episodes of mild depression 5. Grandiose delusions of being King Arthur 6. Incessant talking that includes sexual innuendos Correct Answer: 1, 3, 5, 6
A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply.
1. Pad the bed's side rails. 2. Place an airway at the bedside. 3. Place oxygen equipment at the bedside. 4. Place suction equipment at the bedside. 5. Tape a padded tongue blade to the wall at the head of the bed. Correct Answer: 1, 2, 3, 4
A child has been diagnosed with bacterial conjunctivitis. Which clinical manifestations of bacterial conjunctivitis should the nurse expect to note? Select all that apply.
1. Pain 2. Itching 3. Swollen lids 4. Inflamed conjunctiva 5. Serous (watery) drainage 6. Crusting on eyelids, especially in the morning Correct Answer: 3, 4, 6
A client has been diagnosed with cataracts. Which signs and symptoms should the nurse expect to note? Select all that apply.
1. Pain 2. Photophobia 3. Blurred vision 4. Decreased color perception 5. Progressive loss of peripheral vision 6. Flashes of colored light accompanied by showers of floaters Correct Answer: 2, 3, 4
Irrigate until the client complains of nausea and dizziness or nystagmus is observed
1. Reinforce the dressing. 2. Place the client flat in bed. 3. Notify the registered nurse of the drainage. 4. Check the Jackson-Pratt drain for patency. 5. Check the strength and sensation in all four extremities. Correct Answer: 2, 3
A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply
1. Remove the IV catheter at that site. 2. Apply warm moist packs to the site. 3. Notify the primary health care provider (PHCP). 4. Start a new IV line in a proximal portion of the same vein. 5. Document the occurrence, actions taken, and the client's response. Correct Answer: 1, 2, 3, 5
The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions by the nurse would be contraindicated? Select all that apply.
1. Restrain the client's limbs. 2. Loosen restrictive clothing. 3. Consider insertion of a padded tongue blade. 4. Remove the pillow and raise the padded side rails. 5. Position the client to the side, if possible, with head flexed forward. Correct Answer: 1, 3
The nurse in the prenatal clinic is collecting data regarding the client's nutritional knowledge. The nurse determines that the client understands the food items that are high in folic acid when the client states that she will be sure to eat which food items? Select all that apply.
1. Rice 2. Liver 3. Beans 4. Cheese 5. Chicken Correct Answer: 2, 3
The nurse is reviewing the medication profile of a client taking theophylline. Which medications can increase the risk of theophylline toxicity? Select all that apply.
1. Rifampin 2. Phenytoin 3. Cimetidine 4. Corticosteroids 5. Fluoroquinolones Correct Answer: 3, 4, 5
The nurse is admitting a client who has a history of bipolar disorder to the hospital, and the primary health care provider has indicated that the client is currently in the manic phase. Which actions should the nurse include in the plan of care? Select all that apply.
1. Set limits on behavior. 2. Encourage group activities. 3. Distract or redirect the client. 4. Decrease environmental stimulation. 5. Provide information on medications. 6. Provide high caloric nutritional intake. Correct Answer: 1, 3, 4, 6
A comatose client with an admitting diagnosis of diabetic ketoacidosis (DKA) has a blood glucose value of 368 mg/dL, arterial pH of 7.2, arterial bicarbonate of 14 mEq/L, and is positive for serum ketones. The diagnosis is supported by which noted data? Select all that apply.
1. Shakiness 2. Hypertension 3. Fruity breath odor 4. Rapid, deep breathing 5. Dry mucous membranes Correct Answer: 3, 4, 5
The nurse is reviewing the health care record of a newborn admitted to the nursery; the newborn is suspected of having an imperforate anus. The nurse understands that which documented findings are associated with this disorder? Select all that apply.
1. Stenosis of the anorectal canal 2. Failure to pass meconium stool 3. The presence of stool in the vagina 4. The presence of an anal membrane 5. The passage of bloody mucous stool Correct Answer: 1, 2, 3, 4
The nurse teaches a child with cystic fibrosis how to perform the "huff" maneuver. Which instructions should the nurse tell the child?
1. Take a deep breath and then exhale rapidly, whispering the word huff.
The nurse is caring for a 4-month-old infant with respiratory syncytial virus (RSV). Several clients are being admitted to the unit and assignments are being made. The nurse should question being assigned which newly admitted clients? Select all that apply.
1. The 6-month old with bronchopulmonary dysplasia 2. The 11-month-old client with diarrhea 3. The 16-year-old client taking antibiotics 4. The 1-year-old client taking corticosteroids 5. The 15-year-old with bone marrow suppression Correct Answer: 1, 4
The nurse is employed in a newborn nursery. The nurse is reviewing all medications prescribed for newborns to prevent toxicity due to which causes? Select all that apply.
1. The liver is immature. 2. The lungs are not developed. 3. Cerebral function is not fully developed. 4. The kidneys are smaller than those of adults. 5. The kidneys are less able to excrete medications 6. The neonate has more difficulty retaining body heat. Correct Answer: 1, 5
A client has experienced several episodes of sickle cell crisis. Which reinforced instructions should be included in the client's teaching plan to prevent recurrence? Select all that apply.
1. Vigorous exercise is encouraged to maintain cardiovascular function. 2. Iced liquids will combat dehydration and should be consumed regularly. 3. Wear shoes and socks when walking outside to prevent damage to the feet. 4. To prevent opioid tolerance, avoid taking pain medication at the beginning of the crisis 5. To recognize early symptoms of infection and contact primary health care provider (PHCP). Correct Answer: 3, 5
A client with liver cancer who is receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter, especially meats. The nurse should instruct the client to eat which foods instead of meat? Select all that apply.
1. Yogurt 2. Custard 3. Potatoes 4. Cantaloupe 5. Plain potato chips Correct Answer: 1, 2
The nurse is reading a client's urinalysis report. The nurse interprets which item found on the report to be considered abnormal? Select all that apply.
1. pH 6 2. Positive protein 3. Negative glucose 4. Specific gravity 1.018 5. Leukocyte esterase positive 6. White blood cells, 10 per high power screen Correct Answer: 2, 5, 6
The nurse is teaching a client who is newly diagnosed with a hiatal hernia about measures to prevent recurrence of symptoms. Which statement should the nurse make to the client for consideration?
2. "Be sure to sleep with your head elevated in bed."
The client who received a kidney transplant is taking azathioprine, and the nurse reinforces instructions about the medication. Which statement by the client indicates a need for further teaching?
2. "I need to discontinue the medication after 14 days of use."
A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The nurse should take which action first?
2. Assist the client to sit or lie down.
The licensed practical nurse (LPN) is assisting a school nurse in conducting a session with female adolescents regarding the menstrual cycle. The LPN tells the adolescents that the most likely day for ovulation in a 30-day menstrual cycle is which day?
2. Day 16
During a prenatal visit of a client diagnosed with placenta previa, the primary health care provider defers doing a vaginal examination. The nurse understands that this examination is avoided in this situation because of what potential risk?
2. Initiating severe hemorrhage
An adult client has increased fluid in the middle ear that is causing vertigo. The nurse checks this client for which associated signs and symptoms of this condition?
2. Nausea and vomiting
The nurse is caring for a client who received electroconvulsive therapy (ECT) for a major depressive disorder. On data collection, the nurse notes that the client's blood pressure is elevated at 160/100 mm Hg. Based on this finding, which nursing action would be appropriate?
2. Notify the registered nurse.
A male child who had surgery to correct hypospadias is seen in a primary health care provider's office for a well-baby checkup. The nurse provides instructions to the mother, knowing that which long-term complication is associated with hypospadias?
2. Renal anomalies
A mother arrives at the clinic with her child. The mother tells the nurse that the child has had a fever and a cough for the past 2 days, and this morning the child began to wheeze. Viral pneumonia is diagnosed. Which component of the treatment plan should the nurse anticipate?
2. Supportive treatment
In preparation for cataract surgery, the nurse is to administer cyclopentolate eye drops. The nurse administers the eye drops knowing that which is the purpose of this medication?
2. To dilate the pupil of the operative eye
The client diagnosed with tuberculosis (TB) is prescribed rifampin. The nurse should reinforce which instruction regarding this medication?
2. Wear glasses instead of soft contact lenses.
An adult female client has a hemoglobin level of 10.8 g/dL (108 g/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?
3. Iron deficiency anemia
A client with right pleural effusion by chest x-ray is being prepared for a thoracentesis. The client experiences dizziness when sitting upright. The nurse assists the client to which position for the procedure?
3. Left side-lying with the head of the bed elevated at 45 degrees
The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. Neutropenic precautions have been implemented. Which activity should the nurse question if observed while caring for this client?
3. The client orders lunch of soup, salad with tomatoes and cucumbers, and an apple.
A blood glucose screening measurement is going to be performed on a pregnant client. Which instructions should the nurse give to the client before this test?
3. There is no restriction for caffeine before the test.
The nurse is performing a safety assessment in the home of a mother with two children. The ages of the children are 1 and 3 years. Which observation noted during the assessment would present the greatest hazard to the children?
3. Toys with small loose parts in the playroom
The nurse reinforces home care instructions to the parents of a child with a brace for scoliosis. Which statement by a parent indicates a need for further teaching?
3."I understand that my child needs to wear th is brace for 12 hours a day."
The nurse is giving discharge instructions to the client concerning theophylline. Which client statement indicates a need for further teaching?
4. "I need to drink plenty of fluids, so I will drink more coffee and tea."
The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement?
4. "I will tell the nurse at the hospital that I had an Rh shot during pregnancy."
The nurse is evaluating the parent's understanding of discharge care regarding the functioning of the infant's ventricular peritoneal shunt. Which statement by a parent indicates an understanding of the shunt complications?
4. "If my baby has a high-pitched cry, I should call the primary health care provider."
The nurse is assigned to a hospitalized client with chronic pancreatitis. The nurse reviews the client's record and expects to note a serum amylase level that is most like which value?
4. 300
The nurse in a postpartum unit identifies which client as being at risk for developing endometritis following delivery?
4. An adolescent experiencing an emergency cesarean delivery for fetal distress
A client who has received sodium bicarbonate in large amounts is at risk for developing metabolic alkalosis. The nurse checks this client for which signs and symptoms characteristic of this disorder?
4. Decreased respiratory depth and rate and dysrhythmias
A client being seen in the clinic is taking phenytoin. The client's phenytoin blood level is within therapeutic range, and the client's seizures are controlled. Which data collected by the nurse would require primary health care provider notification and possible discontinuation of the medication?
4. Diffuse body rash
The nurse is teaching a pregnant client about the physiological effects and hormone changes that occur in pregnancy. The client asks the nurse about the purpose of estrogen. Which description explains the purpose of estrogen?
4. Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.
The nurse is assisting in preparing a plan of care for a client who just delivered a dead fetus. Which initial intervention in meeting the emotional needs of the client and her spouse is appropriate?
4. Gather data from the client and spouse about the perception of the event.
The nurse is reviewing the serum electrolyte laboratory results of a client and finds that the client has an elevated magnesium level. Which part of the client's history is likely associated with this problem?
4. History of chronic laxative use
The nurse is reinforcing information regarding chemotherapy with a client who has been diagnosed with cancer. The nurse tells the client that which is an advantage of continuous intravenous (IV) chemotherapy?
4. It uses smaller doses to kill cancer cells, so it is less toxic to normal tissues.
The nurse reviews the nursing care plan developed by a nursing student caring for a client who is receiving continuous tube feedings via a nasogastric (NG) tube. The nurse intervenes if the student documents which intervention in the plan?
4. Keep the feeding bag filled with at least 100 mL of feeding continuously so that it does not run dry.
A cervical radiation implant is placed in the client for treatment of cervical cancer. Which intervention would the nurse most likely expect to note in the primary health care provider's prescriptions?
4. Place an indwelling urinary catheter
A client receives meperidine by the intramuscular route. Thirty minutes after receiving the medication, the client's temperature is 101° F, and the skin is warm and flushed with a notable rash on the chest and back. The nurse further assesses the client and contacts the registered nurse, who then contacts the primary health care provider. The nurse completes an incident report and accurately documents which?
4. Thirty minutes after receiving meperidine, the temperature is 101° F, skin is warm and flushed, and a rash is noted on the chest and back; the primary health care provider was notified.
The nurse is reviewing the complete blood count (CBC) laboratory results of a female adult client suspected of having iron deficiency anemia. The nurse reviews the results and determines that which results are consistent with this diagnosis? Select all that apply.
*1. Hemoglobin (Hgb) 8.8 g/dL *2. Hematocrit (Hct) 30% 3. Platelet count 300,000 mm3 4. White blood count (WBC) 7500 mm3 *5. Decreased mean corpuscular volume (MCV) 66 fL
The nurse is monitoring the status of the postoperative client after abdominal surgery earlier in the day. Which signs or symptoms noted by the nurse would indicate an evolving complication associated with hypovolemia? Select all that apply.
1. Increasing restlessness 2. Capillary refill of 3 seconds in all extremities 3. Hypoactive bowel sounds in all four quadrants 4. White blood cell (WBC) count 9,500 mm3 (9.5 × 109/L) 5. Blood pressure of 104/66 mm Hg with a pulse of 106 beats per minute Correct Answer: 1, 5 ✓
The nurse is preparing a client for the administration of a tuberculin skin test. The nurse determines that which body areas are appropriate for intradermal injections? Select all that apply.
1. Inner aspect of the forearm 2. Outer aspect of the forearm 3. Dorsal aspect of the upper arm 4. Away from heavy pigmentation 5. Near a visible peripheral venous vessel Correct Answer: 1, 3, 4
A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse trying to enhance the client's respiratory status should avoid performing which actions? Select all that apply.
1. Keeping the head of the bed elevated 2. Monitoring the client's oxygen saturation level *3. Increase the liter flow to 5 L per nasal cannula 4. Assisting the client to turn, cough, and deep breathe *5. Encouraging the client to breathe slowly and shallowly
The nurse is preparing a client for surgery. Which should be components of the plan of care? Select all that apply.
1. Verify the preoperative laboratory studies were drawn. 2. Report any increases in blood pressure (BP) on the day of surgery. 3. Verify that the client has received nothing by mouth (NPO) for 24 hours before surgery. 4. Instruct the client not to swallow water with oral hygiene on the morning of surgery. 5. Document that any medications the client was instructed to take before surgery are given. Answer: 4, 5
A client has a serum sodium level of 129 mEq/L (129 mmol/L) because of hypervolemia. The nurse anticipates the primary health care provider to prescribe which measures? Select all that apply.
2. Restrict fluid intake. 4. Monitor electrolytes every 24 hours
The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which finding should the nurse expect to note documented in the infant's record regarding this condition?
2. Symmetric thigh and gluteal folds
A client is being advanced to a full liquid diet on the second postoperative day. Which foods are allowed for this client? Select all that apply.
*1. Tea 2. Crackers *3. Ice cream 4. Scrambled eggs *5. Cream of tomato soup *6. Cream of wheat cereal
The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned clients are at risk for excess fluid volume? Select all that apply.
*1. The client with renal failure 2. The client with an ileostomy *3. The client with chronic cirrhosis 4. The client with a draining abdominal wound 5. The client with a nasogastric tube to low suction
The insulin drip (continuous insulin infusion) is infusing at 1.5 mL per hour. There are 100 units of regular insulin in 100 mL of 0.9% NaCl. How many units of insulin will the client receive per hour? Fill in the blank. Record the answer to one decimal place.
1.5 units/hr
The nurse is providing care to a client diagnosed with multiple sclerosis. The nurse knows that which populations are affected by this disease? Select all that apply.
1.Multiple sclerosis affects women twice as often as men. 2. Native-Americans are always immune from this disease. 3. Adults who live in colder climates never acquire this condition. 4. People who had a traumatic back injury are more likely to be affected. 5. Multiple sclerosis occurs in adults between the ages of 20 and 50 years. 6. Multiple sclerosis most often affects Caucasians of Northern European ancestry. Correct Answer: 1, 5, 6
The nurse is assigned to care for a client with a diagnosis of Ménière's disease. After reinforcing discharge instructions, which client statement indicates a need for further teaching?
2. "I will become totally deaf if I don't follow instructions."
A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to which value?
2. 15 mg/dL (5.25 mmol/L)
A nursing instructor asks a student nurse assigned to care for an infant with a diagnosis of tricuspid atresia to describe the infant's disorder. Which statement by the student indicates the need to further research this disorder?
3. "The disorder means there is no communication from the right atrium to the right ventricle of the heart."
Warfarin sodium has been prescribed for a client, and the nurse teaches the client and family about the medication. Which statement by the client indicates a need for further teaching?
3. "I will not take any over-the-counter medications except aspirin."
The nurse documents the following assessment findings at 1 minute following birth: heart rate, 122 beats/minute; good, lusty cry; well flexed; cries appropriately; and the body is pink with blue extremities. What should the nurse document as this newborn's 1-minute Apgar score?
9
The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL (2.0 mmol/L). The nurse understands that which condition would cause this serum calcium level?
Prolonged bed rest
A client diagnosed with hyperthyroidism will be taking propylthiouracil. The nurse reinforces medication instructions and determines that the client understands the information if the client states that it is most important to report which symptoms to the primary health care provider?
Sore Throat
Abdominal ultrasonography is prescribed for a client who is pregnant. The nurse provides information to the client regarding the procedure and makes which statement?
"You will be positioned on your back and turned slightly to one side with your head elevated."
A client is admitted to the hospital with a diagnosis of malnutrition. The nurse is told that blood will be drawn to determine whether the client has a protein deficiency. Which laboratory data indicate that the client is experiencing a protein deficiency? Select all that apply.
*1. Albumin 2.2 g/dL 2. Calcium, 10 mg/dL 3. Sodium, 138 mEq/L *4. Transferrin, 90 mg/dL *5. Prealbumin 10 mg/dL
The nurse is reinforcing instructions to a client about complete/high quality protein foods. Which food choices would indicate the client understood the teaching? Select all that apply
*1. Eggs 2. Beans 3. Cereal 4. Oranges *5. Chicken 6. Broccoli
A hospitalized client is prescribed phenelzine sulfate for the treatment of depression. The nurse reinforces instructions to the client and tells the client to avoid consuming which foods while taking this medication? Select all that apply.
1. Figs 2. Yogurt 3. Crackers 4. Aged cheese 5. Tossed salad 6. Oatmeal cookies Correct Answer: 1, 2, 4
The nurse instructs a client at risk for hypokalemia from thiazide diuretic therapy about foods that are high in potassium. The nurse determines that there is a need for further teaching if the client states that which foods are high in potassium and should be included in the diet plan? Select all that apply.
*1. Eggs 2. Beef 3. Pork 4. Raisins *5. White bread with butter
A client has been placed on neutropenic precautions. Which information is appropriate when explaining what this means? Select all that apply.
*1. Get plenty of sleep and rest. *2. Take all medications as prescribed. 3. Eat plenty of fresh fruits, salads, and vegetables. *4. Wash your hands frequently with antibacterial soap. 5. Having indoor plants is permissible, but no outdoor gardening. *6. Contact the primary health care provider (PHCP) if even a low-grade fever develops.
A client with a diagnosis of tonic-clonic seizures is being admitted to the hospital, and the nurse needs to institute seizure precautions. During a seizure, which items are inappropriate to use and could cause harm to the client? Select all that apply.
*1. Restraints 2. Nasal cannula 3. Suction catheter 4. Padded side rails *5. Padded tongue blade
The nurse is reinforcing instructions to a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the client indicates an understanding of the daily fluid requirement?
1. "I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement."
The nurse is instructing a client with osteomalacia about appropriate food items to include in the diet. Which food items should be included in the client's diet? Select all that apply.
1. Milk 2. Citrus fruits 3. Bread products 4. Wild caught salmon 5. Green, leafy vegetables Correct Answer: 1, 4
A client is receiving lithium carbonate. The client's lithium carbonate level is 1.5 mEq/L, which indicates an early sign of toxicity. Which are some early signs/symptoms of toxicity? Select all that apply.
1. Slurred speech 2. Muscle weakness 3. Lethargy 0.7 mEq/L 4. Diarrhea 1.0 mEq/L 5. Weight gain 1.1 mEq/L 6. Blurred vision 1.7 mEq/L Correct Answer: 1, 2, 3, 4
A client receiving total parenteral nutrition (TPN) asks the nurse if he has developed diabetes when the capillary blood glucose level is monitored and he is given insulin. The nurse explains that which is the reason for monitoring glucose levels and administering insulin?
1. TPN impairs pancreatic function and insulin production. 2. TPN increases the cortisol levels, which causes hyperglycemia. 3. TPN increases the risk for infection, which raises the blood glucose. *4. TPN contains concentrated carbohydrates and raises blood glucose.
The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is nonreddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 mm3 (7.5 × 109/L). Which interpretation does the nurse make of these findings?
1. The incision line is slightly edematous but shows no active signs of infection.
The nurse who is assisting in a weight loss program prepares to monitor a client's weight. The client receives education about caloric intake and weight reduction. In order to lose 2 pounds per week the caloric intake should be decreased by how many calories per day?
1000 calories
The nurse is preparing to administer 30 mEq of liquid potassium chloride (KCl) to an adult client. The label on the medication bottle reads 40 mEq/15 mL. The nurse prepares how many milliliters of KCl to administer the correct dose of medication? Fill in the blank. Round your answer to the nearest whole number.
11.25
The nurse is monitoring the vital signs of a client after delivery of a healthy newborn one day ago and notes that the mother's apical pulse is 56 beats/min. Which nursing action is appropriate related to this finding?
2. Document the finding.
A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which should the nurse wear to perform these tasks?
2. Gown and gloves
An anxious client is experiencing respiratory alkalosis from hyperventilation as a result of anxiety. The nurse should do which action to help the client experiencing this acid-base disorder?
2. Provide emotional support and reassurance.
Which is the most appropriate catheter for a male client with severe urinary retention, a history of urinary tract infections, and a stage 4 pressure injury on the coccyx? Refer to chart.
3
The nurse is reinforcing discharge instructions to a client with cancer of the prostate after a suprapubic prostatectomy. The nurse should reinforce which discharge instruction? Select all that apply.
3. Take the prescribed stool softener every day. 4. Avoid lifting objects heavier than 20 pounds for 6 weeks.
A client with acute pyelonephritis is scheduled for a voiding cystourethrogram. After the nurse provides information about this procedure, the client states, "I can't urinate in front of other people. I have a 'bashful' kidney." What is the nurse's best response?
3. "You will be screened and given as much privacy as possible."
The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?
3. Advance the catheter to the bifurcation and inflate the balloon.
A male client has a tentative diagnosis of urethritis. The nurse collects data from the client knowing that which are signs/symptoms of this disorder?
3. Dysuria and penile discharge
A client is receiving standard oral anticoagulant therapy with warfarin. The result of a newly drawn international normalized ratio is 3.8 seconds. The client needs to have an invasive procedure done on the next day. Which medication will likely be ordered to reverse the anticoagulant effect?
3. Phytonadione
The nurse is assessing a newly admitted client recently diagnosed with depression. Which data best supports that the client is at risk for self-harm?
3. Reported hopelessness
A client receiving total parenteral nutrition (PN) has a history of heart failure. The health care provider has prescribed furosemide 40 mg orally daily to prevent fluid overload. The nurse is giving instructions about taking furosemide in relation to the client's health plan. Which statement by the client indicates a need for further teaching?
4. "I need to talk to my doctor about increasing my digoxin."
A pilocarpine ocular system is prescribed for the client with glaucoma. The nurse reinforces instructions to the client regarding the medication. Which statement by the client indicates an understanding of the use of this medication?
4. "I should check my eye each morning to make sure that the medication system is in place.
Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply.
*1. Platelets 35,000 mm3 (35 × 109/L) *2. Sodium 150 mEq/L (150 mmol/L) 3. Potassium 5.0 mEq/L (5.0 mmol/L) *4. Segmented neutrophils 40% (0.40) 5. Serum creatinine, 1 mg/dL (88.3 mcmol/L) *6. White blood cells, 3000 mm3 (3.0 × 109/L)
A caregiver of a client with an advanced case of acquired immune deficiency syndrome (AIDS) asks the nurse to review instructions in order to take care of the client. Which instructions would be appropriate for the nurse to reinforce? Select all that apply
*1. Wash soiled clothes in hot water. 2. Disinfect surfaces with 100% bleach. *3. Use gloves when handling body fluids. 4. Encourage a minimum of 12 hours sleep per day. 5. Other members of the household should not share a bathroom. *6. Soak cleaning rags, sponges and mops in a 1:10 bleach solution for 5 minutes.
The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply.
*1. Wearing gloves when emptying the client's bedpan *2. Keeping all linens in the room until the implant is removed *3. Wearing a film (dosimeter) badge when in the client's room *4. Wearing a lead apron when providing direct care to the client 5. Placing the client in a semiprivate room at the end of the hallway
The medication prescribed is hydromorphone hydrochloride 3 mg intramuscularly, every 4 hours as needed. The medication label reads hydromorphone hydrochloride 4 mg/1 mL. The nurse should prepare to administer how many mL to the client? Fill in the blank.
0.75 mL
The nurse has given medication instructions to the client receiving phenytoin. The nurse determines that the client understands the instructions if the client makes which comments? Select all that apply.
1. "I should not suddenly stop taking this medication." 3. "Good oral hygiene is needed, including brushing and flossing."
A client has been diagnosed with open-angle glaucoma. Which signs and symptoms are found in open-angle glaucoma? Select all that apply.
1. Blurred or hazy vision 3. Tonometry reading 30 mm Hg
The nurse working in a human immunodeficiency virus (HIV)/acquired immunodeficiency (AIDs) clinic is reviewing modes of transmission for HIV for a new nurse to the clinic. Which potential modes of HIV transmission should the nurse review? Select all that apply.
1. Needle-stick injuries 3. Transmission by breast milk 5. Inconsistent use of protective equipment
The nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which findings would indicate a sign of a potential complication? Select all that apply.
1. Absent bowel signs *2. Increasing restlessness *3. A pulse rate of 108 beats per minute *4. A blood pressure (BP) of 88/58 mm Hg *5. Increasing pain unrelieved by analgesics
The nurse is assisting with conducting a health-promotion program to community members regarding testicular cancer. The nurse determines that further teaching is needed if a community member states that which is a sign/symptom of testicular cancer? Select all that apply.
1. Alopecia 2. Back pain 3. Painless testicular swelling 4. A heavy sensation in the scrotum 5. Elevation in prostate specific antigen (PSA) levels Correct Answer: 1, 5
A client is scheduled to receive chemotherapy with a group of medications, one of which is asparaginase. The nurse anticipates that this medication should be removed from the regimen after noting which findings in the client's medical record? Select all that apply.
1. History of pancreatitis 2. History of heart failure 3. History of thyroidectomy 4. Chronic obstructive lung disease 5. Significantly elevated serum amylase Correct Answer: 1, 5
The nurse is collecting data on a client who is pregnant with twins. Which signs should alert the nurse to potential problems specifically related to the twin pregnancy? Select all that apply.
1. Hypertension 2. Elevated blood glucose levels 3. Uterine size is large for gestational age 4. Six or more uterine contractions per hour 5. Mother is confirmed as blood type Rh negative Correct Answer: 1, 4
The nurse reviews the laboratory values on a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,000 mm3 (19 × 109/L).Based on this laboratory result, which actions should the nurse include in the plan of care? Select all that apply.
1. Neutropenic precautions *2. Testing stools and urine for blood *3. Using a soft toothbrush for mouth care 4. Monitoring closely for signs of infection 5. Monitoring the temperature every 4 hours
The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions should the nurse use to move this client? Select all that apply.
1. Use a friction-reducing slide sheet. 2. Use a mechanical lift to move the client. 3. Place the client in Trendelenburg's position. 4. Keep elbows close and work close to the body. 5. Administer oral pain medication 5 minutes before moving the client. 6. Obtain assistance of a second caregiver to assist with mechanical aids. Correct Answer: 1, 2, 4, 6
A client with acute kidney injury secondary to heart failure develops fluid volume excess. Which signs and symptoms should the nurse expect to see? Select all that apply.
1. Weak pulse 2. Weight gain 3. Decreased hematocrit 4. Distended jugular veins 5. Decreased breath sounds on auscultation 6. Decreased specific gravity with high volume Correct Answer: 2, 3, 4, 6
The nurse is caring for a hospitalized older client who has pulled out his IV for the second time. The nurse inserts a new IV. Which intervention should the nurse institute next for the client?
1. Wrap a light roll of gauze to cover the IV site.
The metabolic panel of a client reveals a calcium level of 6.5 mg/dL (1.6 mmol/L). Based on this laboratory finding, which additional data specific to this calcium level should the nurse collect? Select all that apply.
1. Presence of Chvostek's sign 2. Presence of muscle weakness 4. Presence of electrocardiogram abnormalities 5. Presence of tingling in the fingertips and around the mouth 6. Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes
The nurse is planning to administer an oral glucose tolerance test (OGTT) to a client to rule out or confirm diabetes mellitus. The nurse knows that the client needs more information when the client makes which statements? Select all that apply
1. "I may not eat anything during the test." *2. "I can at least drink fluids during the test." *3. "I have 30 minutes to drink the glucose load." 4. "I may not smoke for the duration of the test." 5. "I will have blood drawn every 30 minutes for the next 2 hours." *6. "I will have blood drawn every 5 minutes for the next 3 hours."
The nurse is assisting in preparing a client for discharge to home. Daily cold therapy has been prescribed for the client, and the nurse reinforces instructions about this treatment. Which client statements indicate adequate understanding of cold therapy treatment? Select all that apply.
1. "I need to apply the cold pack for at least 60 minutes." *2. "I will remove the ice pack if I start to feel numbness." 3. "I should check my pulse before using the ice on my joints." 4. "I can lie on the ice by placing it between the bed and my body." *5. "I should wrap the frozen ice pack in a towel to help adjust to the cold."
The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy. The woman asks the nurse about the purposes of estrogen. Which responses should the nurse make to the client? Select all that apply.
1. "It maintains the uterine lining for implantation." 2. "It prevents the involution of the corpus luteum." 3. "It stimulates the breasts to prepare for lactation." 4. It stimulates metabolism of glucose and converts the glucose to fat." 5. "It maintains the production of progesterone until the placenta is formed." 6. "It stimulates uterine development to provide an environment for the fetus." Correct Answer: 3, 6
Which diagnostic tests indicate active tuberculosis? Select all that apply.
1. Chest x-ray 3. Gastric analysis washings 4. Sputum smear and culture
The nurse is caring for a client recently diagnosed with secondary gout. Secondary gout involves hyperuricemia (excessive uric acid in the blood) caused by another disease or factor. Which diseases or factors make clients more at risk for acquiring this condition? Select all that apply
1. Older clients 2. Obese people 3. Client with liver disease 4. Postmenopausal women 5. Clients from poor economic communities 6. Clients with cardiovascular health problems Correct Answer: 1, 2, 4, 6
The nurse has inserted a nasogastric (NG) tube in a client and is checking for the correct placement of an NG tube. Which is the most reliable data to ensure that the end of the tube is in the stomach?
1. Placement is verified on x-ray.
The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions should be included to accurately administer the medication? Select all that apply.
1. Position the client supine to assist with medication absorption. 2. Clamp the NG tube for 30 minutes after medication administration. 3. Before medication administration, verify correct placement of tube. 4. Flush the NG tube with saline before and after medication administration. 5. Discontinue the suction from the tube during administration of medication. Correct Answer: 2, 3, 4, 5
A primary health care provider (PHCP) has written a prescription for calcium carbonate for the client with hypocalcemia. The nurse is reinforcing teaching with the client and should include which instructions? Select all that apply.
1. Take the calcium carbonate with or just after meals. 2. Avoid foods such as beets, spinach, and bran in the diet. 3. Take the medication with a full glass of water (8 oz/240 mL). 4. It is permissible to swallow whole and not chew the chewable tablets. 5. It is permissible to take an extra calcium pill if the client develops tremors. Correct Answer: 1, 2, 3
The nurse is assisting in the admission of a woman for induction of labor. The nurse should contact the primary health care provider before proceeding with the induction if which conditions are noted during the assessment? Select all that apply.
1. The membranes are ruptured. 2. The fetus is in the breech position. 3. Lesions are present on the perineum. 4. The fetus is not settled into the pelvis. 5. The pregnancy is at 41 weeks' gestation. Correct Answer: 2, 3, 4
The primary health care provider has prescribed butenafine for a client. The nurse recognizes that this has been prescribed to treat which disorder?
1. Tinea pedis
A pregnant client tests positive for hepatitis B virus (HBV). The nurse determines that the client understands this infection when the client makes which statement?
3. "I am so glad that I can breastfeed my baby after she has been vaccinated."
The nurse is trying to communicate with a stroke (brain attack) client with aphasia. Which action by the nurse would be least helpful to the client?
3. Completing the sentences that the client cannot finish
The nurse assists the primary health care provider in performing a lumbar puncture on a 3-year-old child with leukemia suspected of central nervous system (CNS) disease. In which position should the nurse place the child during this procedure?
4. Lateral recumbent with the knees flexed to the abdomen and head bent with the chin resting on the chest
The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which questions should the nurse ask the client? Select all that apply. Refer to video. Click on the Question Video button to view a video showing preparation procedures.
1. "What does the pain feel like?" 2."Where is the pain located?" 3. "Does pain medication help?" 4. "How does the pain affect you?" 5. "Do you have the pain when you sleep?" 6. "What makes your pain better or worse?" Correct Answer: 1, 2, 4, 6
The child is diagnosed with tinea capitis of the scalp. Oral griseofulvin has been prescribed for the child, and the nurse provides instructions regarding the administration of the medication. Which instructions should the nurse include to the mother?
1. Administer the medication with milk.
The client with peptic ulcer disease has been prescribed to take cimetidine. The nurse determines that which is the primary action of this medication?
4. Protects the gastric mucosa
Oxytocin is utilized in multiple ways in the labor and delivery unit. The nurse correctly identifies which purposes for administering this medication? Select all that apply.
1. Aids milk let down 2. Controls uterine atony 3. Minimizes uterine infection 4. Augments labor contractions 5. Stimulates uterine contractions Correct Answer: 1, 2, 4, 5
The nurse on a telemetry unit checks a client's chart and notes that the potassium level is 6.3 mEq/L. Based on this laboratory result, which signs/symptoms should the nurse anticipate? Select all that apply.
1. Anxiety 2. Bradycardia 3. Hypertension 4. Hyperglycemia 5. Electrocardiogram (ECG) changes Correct Answer: 1, 5
A client is receiving phenytoin. Which findings would indicate that the client is experiencing side/adverse effects related to this medication? Select all that apply.
1. Ataxia 2. Constipation 3. Bleeding gums 4. Decreased white blood cells 5. Decreased platelet count Correct Answer: 2, 3, 4, 5
A client suffered smoke inhalation and burns to the anterior trunk during a house fire. The nurse reviews the plan of care and notes that the client has an airway problem. Which findings support an airway problem? Select all that apply.
1. Bradypnea 2. Hoarse voice 3. Flushing of the skin 4. Nonproductive cough 5. Guttural respiratory sounds Correct Answer: 2, 5
A mother of a 6-year-old child calls the nurse who lives in the neighborhood and tells the nurse that her child accidentally rubbed waterproof sunscreen in his eyes. Which action should the nurse tell the mother to immediately perform?
1. Call the poison control center.
A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data as a baseline and then checks the client's skin turgor by doing which action? Refer to video. Click on the Question Video button to view a video showing preparation procedures.
4. Pulling up and releasing the skin on the sternal area
A primary health care provider prescribes an intramuscular (IM) dose of 250,000 units of penicillin G benzathine. The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine 300,000 units/mL. How much medication will the nurse prepare to administer the correct dose? Fill in the blank. Record your answer to one decimal place.
0.8 mL
The nurse-midwife is conducting a session on the process of conception with a group of nursing students. Which statements reflect that the nursing students understand the process of conception? Select all that apply.
1. "Fertilization occurs in the outer third of the fallopian tube." 2. "Only 1 sperm will penetrate the ovum to produce fertilization." 3. "The pre-embryonic period is defined as the first 8 weeks of gestation." 4. "Implantation occurs in the anterior or posterior fundal region of the uterus." 5. "The ovary produces hormones to maintain the pregnancy before placental development." Correct Answer: 1, 2, 4, 5
The student nurse is being taught by the registered nurse (RN) how to collect data from a client and is attempting to obtain subjective data regarding the client's sexual reproductive status. The client states, "I don't want to discuss this; it's private and personal." Which response by the student nurse indicates a need for further teaching?
1. "I am the nurse and, as such, I'll have you know that all information is kept confidential."
The nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse should take which actions? Select all that apply.
1. Check the client's temperature. 2. Check the placement of the tube. 3. Administer prescribed medications. 4. Warm the feeding to body temperature. 5. Aspirate the contents from the nasogastric tube. 6. Observe the characteristics and pH of the aspirate from the nasogastric tube. Correct Answer: 2, 5, 6
The nurse is caring for a postoperative client who has a Jackson-Pratt drain inserted into the surgical wound. Which actions should the nurse take in the care of the drain? Select all that apply.
1. Check the drain for patency. 2. Check that the drain is decompressed. 3. Observe for bright red, bloody drainage. 4. Maintain aseptic technique when emptying. 5. Empty the drain when it is half full and every 8 to 12 hours. 6. Secure the drain by curling or folding it and taping it firmly to the body. Correct Answer: 1, 2, 3, 4, 5
A client is brought to the labor unit. As the nurse is attaching the fetal heart monitor, the client's membranes rupture spontaneously. What should be the nurse's immediate action?
1. Check the fetal heart rate.
The nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.
1. Client with asthma 2. Client with pancreatitis 3. Malnourished client 4. Client with diabetes mellitus 5. Client with status epilepticus 6. Client with severe prolonged diarrhea Correct Answer: 2, 3, 4, 5, 6
A 4-year-old child sustains a fall at home injuring the right arm and is brought to the emergency department by the mother. The nurse should perform which emergency actions in the care of the child? Select all that apply.
1. Elevate the right arm. 2. Apply warm packs to the right arm. 3. Check the neurovascular status of the right extremity. 4. Check the range of motion of the right arm and shoulder. 5. Determine the level of pain using a pediatric pain assessment tool. Correct Answer: 1, 3, 5
The nurse on the mental health unit is caring for a client with a history of alcoholism. Aversion conditioning has been chosen as the treatment for this client because other less drastic measures have failed to produce the desired effects. Which are some paradigms or clear examples of aversion conditioning? Select all that apply.
1. Emphasis on group and social interaction and that rules and expectations are mediated by peer pressure. 2. Increased exposure to an object or situation that causes anxiety increases until the anxiety about the object ceases. 3. Punishment (e.g., punishment applied after the client has had an alcoholic drink) 4. Cognitions (verbal or pictorial events) based on attitudes or assumptions developed from previous experiences. These cognitions may be fairly accurate, or they may be distorted. 5. Avoidance training (e.g., client avoids punishment by pushing a glass of alcohol away within a certain time limit) 6. Pairing of a maladaptive behavior with a noxious stimulus (e.g., pairing the sight and smell of alcohol with electric shock), so that anxiety or fear becomes associated with the once-pleasurable stimulus Correct Answer: 3, 5, 6
The nurse is reinforcing the teaching to parents of a diabetic child about the signs/symptoms of hypoglycemia. Which signs/symptoms should the nurse include when reinforcing the teaching? Select all that apply.
1. Fatigue 2. Sweating 3. Headache 4. Dizziness 5. Trembling Correct Answer: 2, 4, 5
The nurse is participating in a care plan session for a client with a terminal illness. Which nursing actions should be included? Select all that apply.
1. Follow standard care plans for end-of-life care. 2. Respond to requests from the client and family promptly. 3. Support the client's decision-making in order to promote client control. 4. Discuss sensitive topics quickly and efficiently to avoid upsetting the client and family. 5. Provide information about what to expect during the dying process to the client and family. Correct Answer: 2, 3, 5
A newborn infant is diagnosed with gastroesophageal reflux (GER). The mother of the infant asks the nurse to explain the diagnosis. The nurse plans to base the response on which description of this disorder?
1. Gastric contents regurgitate back into the esophagus
A 39-year-old man learned today that his 36-year-old wife has an incurable cancer and is expected to live not more than a few weeks. The nurse identifies which responses by the husband as indicative of effective individual coping? Select all that apply.
1. He states that he will not allow his wife to come home to die. 2. He refuses to visit his wife in the hospital or to discuss her illness. 3. He immediately arranges for their three teenage children to live with relatives in another state. 4. He expresses his anger at God and the primary health care providers for allowing this to happen. 5. He tells the nurse he has prayed that God will allow his wife to live long enough to watch their children's high school graduation. 6. He has asked his wife and children to assist him in making funeral arrangements, such as casket selection and cemetery burial sites. Correct Answer: 4, 5, 6
Which medications cause ototoxicity? Select all that apply.
1. Ibuprofen 2. Metoprolol 3. Furosemide 4. Vancomycin 5. Acetaminophen Correct Answer: 1, 3, 4
The client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. Besides treatment of the lung cancer, the nurse anticipates that which interventions may be prescribed to treat the SIADH? Select all that apply.
1. Increase fluid intake. 2. Decrease sodium intake. 3. Institute safety measures. 4. Frequently monitor sodium blood levels. 5. Gather data about the neurological status frequently. 6. Administer medication that is antagonistic to antidiuretic hormone (ADH). Correct Answer: 3, 4, 5, 6
Which are the major roles the nurse can play in advocating for psychiatric evaluation and intervention for clients with a history of depression, schizophrenia, obsessive-compulsive disorder, generalized anxiety disorder, or bipolar disorder? Select all that apply.
1. Medication management 2. Administering antidepressants 3. Monitoring and documenting behavioral changes 4. Notifying the health care provider of behavioral changes 5. Keeping the family involved in the client's plan of care 6. Planning care for the needs of those clients with mental illness Correct Answer: 1, 3, 4, 6
A client has had a set of arterial blood gases drawn. The results are pH, 7.34; Paco2, 37 mm Hg; Pao2, 79 mm Hg; and HCO3,- 19 mEq/L. The nurse interprets that the client is experiencing which acid-base imbalance?
1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis Correct Answer: 1
The nurse is assisting in caring for a victim of a burn injury during the emergent/resuscitative phase. On data collection of the client, the nurse notes that the urine output has decreased and the blood pressure is dropping. The nurse should perform which immediate action?
1. Notify the registered nurse.
The nurse is preparing to suction a client through a tracheostomy tube. The nurse should perform which actions when performing this procedure? Select all that apply.
1. Preoxygenating the client before suctioning 2. Applying suction for a period of no more than 15 seconds 3. Moistening the catheter tip in sterile saline solution before suctioning 4. Introducing the catheter into the tracheostomy tube using a sterile gloved hand 5. Placing suction on the catheter while introducing the catheter into the tracheostomy tube Correct Answer: 1, 3, 4
The nurse receives a report at the beginning of the shift regarding a client with an intrauterine fetal demise. Which signs/symptoms should the nurse expect to note when collecting data on the client? Select all that apply.
1. Proteinuria 2. Absence of fetal movement 3. Fetal heart tones not audible 4. Fundal height greater than expected for gestational age 5. Prenatal record indicating no change in fundal height for several weeks Correct Answer: 2, 3, 5
The nurse is caring for a client who was recently admitted to the inpatient unit of a psychiatric hospital with a diagnosis of delusions. Which are some therapeutic communication interventions the nurse needs to use when communicating with this client? Select all that apply.
1. Refer to hallucinations as if they are real. 2. Ask the client directly about the hallucinations. 3. Don't focus on reality-based, "here-and-now" activities such as conversations or simple projects. 4. Discourage the use of competing auditory stimuli such as listening to music through headphones. 5. Watch the client for cues that he or she is hallucinating, such as eyes tracking an unheard speaker, muttering, or talking to self. 6. Address any underlying emotion, need, or theme that seems to be indicated by the hallucination, such as fear with menacing voices or guilt with accusing voices. Correct Answer: 1, 2, 5, 6
The critical care nurse is caring for a client with a subclavian central line catheter. The nurse knows that a specific central-line bundle was developed to reduce the client's risk for developing a catheter-related bloodstream infection (CLABSI). The interventions include which essential actions? Select all that apply.
1. Strict hand washing 2. Daily dressing change 3. Betadine skin antisepsis 4. Optimal catheter site selection 5. Strict sterile technique with maximal barrier precautions during placement 6. Infection control primary health care provider as a member of the client's health care team Correct Answer: 1, 4, 5
Bethanechol is prescribed for the client with urinary retention, and an injectable form of bethanechol is available for use as prescribed. The nurse informs the client of the primary health care provider's prescription, knowing that the medication will be administered by which injectable route?
4. Subcutaneously
A client with a diagnosis of heart failure (HF) is preparing for discharge to home from the hospital. Which condition indicates the client is ready for discharge to home?
4. The client can verbally describe the daily medications, doses, and times to be administered.
A child is brought to a clinic after developing a rash on the trunk and on the scalp. The parents report that the child has had a low-grade fever, has not felt like eating, and has been generally tired. The child is diagnosed with chickenpox. Which statement by the nurse is accurate regarding chickenpox?
4. The communicable period is 1 to 2 days before the onset of the rash to 6 days after the onset and crusting of lesions.
The nurse reviews the nursing care plan of an older client with diabetic neuropathy of the lower extremities as a result of type 2 diabetes mellitus. The nurse plans care knowing that which problem has the highest priority for this client?
4. The possibility of injury as a result of decreased sensation in the legs and feet
The primary health care provider's prescription reads "phenytoin 0.2 g orally, twice daily." The medication label states 100-mg capsules. How many capsule(s) should the nurse plan to administer over a 24-hour period? Fill in the blank.
Correct Answer: 4 capsule(s)
The nurse is administering a medication intramuscularly to an assigned client. The nurse should include which actions in administering the medication? Select all that apply.
1. Massage the site after injection. 2. Use a Z-track method for administration. 3. Wear sterile gloves to administer the medication. 4. Hold the syringe as if it is a dart to insert the needle. 5. Select an appropriate injection site such as the ventral gluteus. 6. Cleanse the injection site using a back-and-forth motion with an antiseptic pad. Correct Answer: 2, 4, 5
The nurse is caring for a client following a total hip replacement. The client has been diagnosed with iron deficiency anemia. The nurse instructs the client to increase intake of which foods? Select all that apply.
1. Milk and yogurt *2. Clams and mussels 3. Apples and mangos 4. Potatoes and carrots *5. Lean beef and chicken liver
The nurse is reinforcing instructions to a client and family regarding home care following cataract removal with lens implantation in the left eye. The nurse should provide the client with instructions to contact the surgeon promptly for which signs or symptoms? Select all that apply
1. New floaters 2. Improvement in vision clarity 3. Increasing redness in the eye 4. Sensation of mild grittiness in the eye 5. Pain relieved by acetaminophen 500 Correct Answer: 1, 3
The nurse is administering mouth care to an unconscious client. The nurse should avoid doing which actions? Select all that apply.
1. Positioning the client supine 2. Using products with lemon or alcohol 3. Brushing the teeth with a small soft toothbrush 4. Cleansing the mucous membranes with tooth sponges 5. Having oral suction equipment at the bedside and turned on Correct Answer: 1, 2
The nurse is collecting data from a client who is pregnant with twins. The nurse understands that which complications are more likely to occur with a twin pregnancy? Select all that apply.
1. Preterm labor 2. Postterm labor 3. Maternal anemia 4. Oligohydramnios 5. Gestational diabetes Correct Answer: 1, 3
The nurse is teaching a client with osteoporosis who is being discharged with a prescription for a bisphosphonate. What comment by the client shows a need for further teaching?
4. "I'll take it before supper with 8 ounces of water and stay in an upright position for 30 to 60 minutes."
The nurse is preparing to provide mouth care to an unconscious client. The nurse collects which items to perform this procedure? Select all that apply.
1. A soft toothbrush 2. Irrigation syringe 3. Bite stick or a padded tongue blade 4. Mouthwash of full strength peroxide 5. Suction with oral suction catheter attached Correct Answer: 1, 2, 3, 5
The nurse is caring for a client with Paget's disease. The nurse knows that when serum calcium levels are lowered, what hormone secretion increases to release calcium to the blood?
1. Antidiuretic hormone (ADH)
The student nurse is learning about leadership and management. The student knows that which are the main styles of group leadership? Select all that apply.
1. Autocratic leader 2. Democratic leader 3. Independent leader 4. Conservative leader 5. Laissez-faire leader 6. Problem-solving leader Correct Answer: 1, 2, 5
The nurse is monitoring a client following a thyroidectomy for signs/symptoms of hypocalcemia. Which signs/symptoms noted in the client indicates the presence of hypocalcemia? Select all that apply.
1. Bradycardia 2. Muscle spasms 3. Positive Trousseau's sign 4. Negative Chvostek's sign 5. Tingling around the mouth Correct Answer: 2, 3, 5
The nurse is caring for a cardiac client who has recently displayed this monitored rhythm. Which actions by the nurse are most appropriate? Refer to figure. Select all that apply.
1. Check all telemetry leads. 2. Check blood pressure (BP). 3. Review cardiac laboratory markers. 4. Obtain stat electrocardiogram (ECG). 5. Review client's history and physical data. 6. Assess client's level of consciousness (LOC). Correct Answer: 1, 2, 4, 6
The nurse is assigned to care for a client being admitted to the mental health unit following a suicide attempt. The client attempted the suicide by lacerating both wrists. Which is the initial nursing action upon admission of the client?
1. Check the wound sites.
Which clients would the nurse determine is at risk for development of metabolic alkalosis? Select all that apply.
1. Client with emphysema 2. Client who is hyperventilating 3. Client with chronic kidney disease 4. Client who has been vomiting for 2 days 5. Client receiving oral furosemide 40 mg daily 6. Client admitted with acetylsalicylic acid overdose Correct Answer: 4, 5
The nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which information is accurate regarding depression and the older client? Select all that apply.
1. Depression in an older person is rarely treatable. 2. Depression in an older person is considered a normal finding. 3. Suicide is a frequent cause of death among the older population. 4. Some indications of dementia may actually originate as depression. 5. Depression in an older person is likely to have physical manifestations. Correct Answer: 3, 4, 5
The nurse is assisting in the care of a client who has a serum sodium level of 128 mEq/L (128 mmol/L). The nurse relates which of the client's signs and symptoms to this electrolyte imbalance? Select all that apply.
1. Dry flaky skin 2. Bleeding from the gums 3. Weakness in all extremities 4. Confusion with garbled speech 5. Diarrhea with abdominal cramping Correct Answer: 3, 4, 5
The nurse is reinforcing instructions to a client receiving external radiation therapy. The nurse determines that the client needs further teaching if the client states an intention to take which action? Select all that apply.
1. Eat a high-protein diet. 2. Avoid exposure to sunlight. 3. Wash the skin with a mild soap and pat it dry. 4. Apply pressure on the radiated area to prevent bleeding. 5. Avoid standing within 6 feet of persons under the age of 18 years. Correct Answer: 4, 5
The nurse who is reinforcing instructions to a client who has had a gastric resection should include which considerations? Select all that apply.
1. Eat small frequent meals. 2. Avoid iron supplementation. 3. Take action to prevent dumping syndrome. 4. Self-monitor for signs of lower gastrointestinal (GI) bleeding. 5. Consume a diet that is relatively high in vitamin B12 content. Correct Answer: 1, 3
The nurse is caring for a client who had a total knee replacement and was put on a continuous passive motion (CPM) machine in the postanesthesia care unit (PACU). What are some of the actions the nurse needs to monitor to operate this machine? Select all that apply.
1. Ensure that the machine is well padded. 2. Assess the client's response to the machine. 3. When the machine is not in use, store it on the floor. 4. Check the cycle and range-of-motion settings once a day. 5. Turn off the machine while the client is having a meal in bed. 6. Make sure that the joint being moved is properly positioned on the machine. Correct Answer: 1, 2, 5, 6
The client is admitted to the hospital with a diagnosis of suspected Hodgkin's disease. Which signs and symptoms of the client are associated with Hodgkin's disease? Select all that apply
1. Fatigue 2. Weakness 3. Joint pain 4. Weight gain 5. Night sweats 6. Enlarged lymph nodes Correct Answer: 1, 2, 5, 6
The nurse is aware that the Americans with Disabilities Act provides which rights? Select all that apply.
1. Labels asymptomatic HIV as a disability 2. Protects the privacy of individuals with HIV 3. Provides employment to persons with disabilities 4. Prohibits discrimination in employment and public services 5. Allows health care workers to refuse to care for a client with schizophrenia Correct Answer: 1, 2, 4
A client with a burn injury is scheduled for an autograft. The nurse is planning care for the client for immediately after the graft procedure. Which should the nurse include in the plan of care? Select all that apply.
1. Leaving the donor site open to air 2. Immobilizing the graft area for 24 hours 3. Administering pain medications as prescribed 4. Applying a pressure dressing on the grafted site 5. Monitoring the donor site and the graft site for signs of infection Correct Answer: 3, 5
The nurse is collecting data on a client with chronic sinusitis. Which are signs and symptoms of chronic sinusitis? Select all that apply.
1. Loss of smell 2. Chronic cough 3. Nasal stuffiness 4. Clear nasal discharge 5. Severe evening headache Correct Answer: 1, 2, 3
The nurse has assisted with the insertion of a Levin tube for gastrointestinal (GI) decompression. Which settings should the nurse anticipate to be prescribed by the primary health care provider? Select all that apply.
1. Low 2. High 3. Medium 4. Continuous 5. Intermittent Correct Answer: 1, 5
A client with left-sided heart failure has been admitted to the hospital. The nurse is reviewing the medical record and notes which signs and symptoms? Select all that apply.
1. Orthopnea 2. Weight gain 3. Sleep apnea 4. Pitting edema 5. Pink frothy sputum Correct Answer: 1, 3, 5
The nurse observes a student nurse using a bladder scanner to determine a postoperative hysterectomy client's post-void residual (PVR). Which actions observed demonstrate the need for further teaching? Select all that apply.
1. Placing the scan head on the symphysis pubis and aiming toward the bladder 2. Pressing and holding the done button to display the volume measurement and print results 3. Applying a generous amount of transmission/conductivity gel across the client's abdomen 4. Pressing the gender button to select the male setting and wiping the scan head with an alcohol pad 5. Turning on the scanner by pressing the on/off button and then the scan button to turn on the scanning screen 6. Assisting the client to a supine position with head elevated on a pillow and exposing the client's lower abdomen Correct Answer: 1, 3
The nurse is preparing to administer furosemide to a client with a diagnosis of heart failure. Which is the most important laboratory test result for the nurse to review before administering this medication?
1. Potassium level
The nurse is explaining how sound is conducted from the middle ear to the inner ear in teaching a client who is experiencing hearing loss. What is the order of structures conducting sound waves from the middle ear to the inner ear? Arrange the structures in the order that they should occur. All options must be used.
1. Tympanic membrane 2. Malleus, incus, stapes 3. Oval window 4. Cochlea 5. Organ of Corti
The nurse is caring for a hospitalized client following cystoscopy. Which discharge instructions are given to the client? Select all that apply
1. Use antispasmodics for pain. 2. Restrict oral fluids for 1 to 2 days. 3. Expect pink-tinged urine for 1 week. 4. Take sitz baths for voiding discomfort. 5. Report severe pain to health care provider. Correct Answer: 1, 4, 5
The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. Which documented symptoms support this diagnosis? Select all that apply.
1. Vertigo 2. Confusion 3. Flat affect 4. Balance and coordination problems 5. Difficulty remembering new information Correct Answer: 1, 4
A nursing student is asked to discuss juvenile idiopathic arthritis (JIA) at a clinical conference scheduled for the end of the clinical day. Which statement by the nursing student indicates the need for further research of this disorder?
3. "This disease is twice as likely to occur in boys as in girls."
The nurse is reviewing the health care record of a pregnant client at 24 weeks' gestation. The nurse should anticipate that the fundus should be located at which level?
3. 22 cm to 26 cm
The nurse has a prescription to give a client albuterol (two puffs) and beclomethasone dipropionate (two puffs) by metered-dose inhaler. How much time should the nurse place between administering the albuterol and then the beclomethasone dipropionate?
3. 5 minute
The nurse provides instructions to the parents of an infant with gastroesophageal reflux (GER) regarding proper positioning to manage reflux. The nurse should tell the parents that the infant should be maintained in which position?
3. A 60-degree angle when supine
The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident?
3. Document a complete entry in the client's record concerning the incident.
A client has just undergone lumbar puncture (LP). The nurse assists the client into which optimal position?
3. Flat, turning from side to side as needed
The nurse is reviewing the health record of an infant with a diagnosis of gastroesophageal reflux. Which signs/symptoms of this disorder should the nurse expect to note documented in the record?
3. Hiccupping and spitting up after a me
During the emergent phase after a major burn injury, which abnormalities should the nurse expect to note?
3. Increased hematocrit and increased potassium
The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client?
4. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce
The nurse has given dietary instructions to a client to minimize the risk of osteoporosis. The nurse determines that the client understands the recommended changes if the client verbalizes the intention to increase intake of which foods? Select all that apply.
1. Fish *2. Yogurt 3. Potatoes 4. Chicken 5. White bread *6.Cottage cheese
The nurse has admitted a client to the clinical nursing unit following a right mastectomy. Which interventions should be included in the plan of care? Select all that apply.
1. Elevate the right arm on one or two pillows. 2. Do not check the radial pulse in the right arm. 3. Use small-gauge needles if the IV is initiated in the left arm. 4. Instruct the client to avoid bending the fingers of the right hand. 5. Ensure that no venipunctures or blood pressures (BPs) are done in the right arm. Correct Answer: 1, 5
The nurse is reviewing the client's record and notes that the primary health care provider (PHCP) has documented that the client has a renal disorder. Which laboratory results would indicate a decrease in renal function? Select all that apply.
1. Elevated serum creatinine level 2. Elevated thrombocyte cell count 3. Decreased red blood cell (RBC) count 4. Decreased white blood cell (WBC) count 5. Elevated blood urea nitrogen (BUN) level Correct Answer: 1, 3, 5
The nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which activities in the care of the client? Select all that apply.
1. Ensure the client doesn't bend the hips beyond 120 degrees. 2. Ensure the client doesn't sit or stand for long periods of time. 3. Ensure the client engages in rigorous exercise to maintain strength. 4. Ensure the client doesn't cross the legs past the midline of the body. 5. Ensure the client uses assistive/adaptive devices with activities of daily living. Correct Answer: 2, 4, 5
The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating which pathophysiological processes are occurring? Select all that apply.
1. "The loss of electrolytes is greater than the loss of water." 2. "The loss of water is greater than the loss of electrolytes." 3. "Serum sodium level rises above 150 mEq/L (150 mmol/L)." 4. "The client is likely to have impaired mental status due to low sodium levels." *5. "Water and electrolytes are lost in approximately the same proportion as they exist in the body." *6. "A client who has a large blood loss due to an accident will initially have an isotonic dehydration."
The nurse is preparing to discontinue an indwelling urinary catheter. Which pieces of equipment should the nurse obtain to perform this procedure? Select all that apply.
1. Clean towel 2. Sterile gloves 3. Water-soluble lubricant 4. Sterile 5- or 6-mL syringe 5. Sterile 10- or 12-mL syringe Correct Answer: 1, 5
The nurse prepares a client for the lumbar puncture procedure by which interventions? Select all that apply.
1. Review the coagulation laboratory studies. 2. Observe the lower lumbar area for skin infections. 3. Determine whether the client is allergic to iodine or seafood. 4. Check to see the client has a signed consent for the procedure. 5.Explain to the client about assuming a prone position for the procedure. Correct Answer: 1, 2, 4
A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia (BPH), the nurse questions the client about use of which medication?
4. Decongestants
The nurse is performing a vaginal check of a pregnant client in labor. The nurse notes that the umbilical cord is protruding from the vagina. Which action should the nurse immediately perform?
4. Exert upward pressure against the presenting part with gloved fingers.
A client diagnosed with pleurisy is being started on medication therapy with ibuprofen. Which statement by the nurse accurately describes the purpose of the medication for the client?
4. Ibuprofen is a nonsteroidal anti-inflammatory medication to enhance coughing and deep breathing.
The nurse is assisting in the care of a client for whom an arterial blood gas (ABG) must be drawn. The nurse notes that the person who draws the blood sample from the radial artery performs an Allen's test first. The nurse recognizes that this is being done to determine the adequacy of which circulations? Select all that apply.
1. Ulnar circulation 2. Radial circulation
The nurse has a prescription to give a dose of Rho(D) immune globulin to a client who has delivered an infant. Which criteria need to be met in order to administer this medication? Select all that apply.
1. Rh negative mother 2. Rh negative infant 3. Rh negative father 4. Negative Coombs' test 5. Negative serum AFP test Correct Answer: 1, 4
A client receiving enteral feedings develops abdominal distention and diarrhea shortly after initiation of the feedings. Which is the appropriate intervention for the nurse to implement?
4. Notify the primary health care provider (PHCP) of the client's signs and symptoms.
The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit after abdominal surgery. The client has an indwelling urinary catheter in place. The vital signs are temperature 99.6° F (37.6° C), pulse 104 beats per minute, respirations 16 breaths per minute, and blood pressure (BP) 100/70 mm Hg. Urinary output is 20 mL for the past hour. Based on this data, which actions should the nurse take before notifying the registered nurse? Select all that apply.
1. Auscultate breath sounds. *2. Review vital signs from previous hour. *3. Observe the urinary catheter for patency and flow. *4. Observe the IV site for patency and correct flow rate. *5. Review when the client last received pain medication.
The nurse is asked to assist with preparing a client who will be receiving a continuous total parenteral nutrition (TPN) solution via a central line. The nurse plans to institute which interventions for this client related to the TPN? Select all that apply.
1. Central line dressing changes per protocol 2. Blood glucose monitoring around the clock 3. Monitoring central venous pressure every shift 4. Using an electronic infusion pump with the infusion 5. Applying sequential compression devices (SCD) to the legs 6. Reviewing prescribed blood laboratory values including electrolytes Correct Answer: 1, 2, 4, 6
The nurse determines that the client has a proper fitting of the crutches when which criteria have been fulfilled? Select all that apply.
1. Crutches were fitted for a person who is the same height. 2. Handgrips are positioned so the axillae bear the weight of the client. *3. Handgrips are positioned so the elbows are bent approximately 30 degrees. *4. The space between the axilla and the top of the crutch pad is 1½ to 2 inches. *5. The nurse can place 3 to 4 fingerbreadths between the axilla and the crutch pad.
The nurse is collecting data on a pregnant client in her twenty-second week. The nurse prepares to use a fetoscope to auscultate the fetal heart rate. The nurse hears a fetal heart rate of 115 beats per minute. Which action should the nurse take?
1. Document the assessment.
The nurse is planning to reinforce dietary teaching about following a diet that is low in potassium to a client receiving a potassium-retaining (sparing) diuretic. The nurse should be sure to include which strategies to avoid foods high in potassium in the diet? Select all that apply.
1. Dried fruits are good for snacks. 2. Use eggs as a source for protein. 3. Limit cereals and bread products. 4. Avoid eating lunch meats and bolognas. 5. Eat salads with cabbage and lettuce and avoid spinach Correct Answer: 2, 4, 5
The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and should be reported to the primary health care provider before the surgery? Select all that apply.
1. Is allergic to penicillin 2. Quit smoking 3 months earlier 3. History of tonsillectomy at the age of 7 years 4. Wonders if the surgery could cause incontinence 5. Takes daily multivitamin and calcium supplement. 6. History of deep venous thrombosis in right leg 10 years earlier Correct Answer: 1, 2, 4, 6
The nurse is assigned to care for a client who has just returned to the nursing unit following a renal biopsy. The nurse plans to do which actions to properly care for this client for the remainder of the shift? Select all that apply.
1. Limit intake of oral fluids. 2. Withhold all pain medication. 3. Test the urine for occult blood. 4. Ambulate the client twice in the hall. 5. Observing the urine and biopsy site for bleeding. Correct Answer: 3, 5
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted during assessment? Select all that apply.
1. Proteinuria of 3+ 2. Respirations of 10 breaths/minute 3. Presence of deep tendon reflexes 4. Urine output of 20 mL in an hour 5. Serum magnesium level of 6 mEq/L (3 mmol/L) Correct Answer: 2, 4
The nurse is caring for a client with diabetes mellitus who is scheduled to have a right below-knee amputation. The nurse assesses which factors that can put this client at risk for amputation? Select all that apply.
1. Psoriasis 2. Bony deformity 3. Limited joint mobility 4. Peripheral neuropathy 5. Peripheral vascular disease 6. History of skin ulcers or previous amputation
