NCLEX

The nurse is offering safety instructions to a parent with a 4 month-old infant and a 4 year-old child. Which statement by the parent indicates a correct understanding of the appropriate precautions to take with the children?

"I have the 4 year-old hold and help feed the 4 month-old a bottle with me."

The outpatient sleep clinic nurse is reinforcing information about sleep for a client diagnosed with insomnia. Which of the following client statements indicate that the client understands the information? (Select all that apply.)

"I will avoid drinking alcoholic beverages too close to bedtime." "I will keep a sleep log and to track my sleep and awake hours daily." "I will decrease my caffeine intake during the day and avoid coffee in the evening." "I will start a set of bedtime rituals that I will consistently use to help me fall asleep."

A client has been hospitalized for pneumonia. Which statement indicates that she has a good understanding of the discharge instructions given by the nurse?

"I will continue to do the deep breathing and coughing exercises at home."

A nurse has contacted a client to discuss his upcoming surgery. The client reports that he takes ibuprofen regularly for arthritis. Which of the following responses from the client shows he understands the nurse's instructions?

"I will discontinue taking ibuprofen prior to my surgery."

The nurse is providing information to a 28-year-old female, who is a type 1 diabetic and planning a pregnancy. The nurse is assessing the client's understanding of insulin therapy during pregnancy. Which statement, made by the client, indicates a need for more teaching?

"I will need to increase my insulin dosage during the first three months of pregnancy."

The nurse is providing education to a client in her first trimester of pregnancy. Which statement indicates the client needs further education?

"I will schedule visits with my health care provider only as needed."

A nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client makes which statement?

"I will trim corns and calluses regularly."

The nurse is assessing a 28-year-old female for risk factors contributing to osteoporosis. Which statement reported by the client should alert the nurse that additional teaching about this disease is indicated? (Select all that apply.)

"I'm a professional dancer and train 8-10 hours a day." "I take 1000 mg OsCal (calcium carbonate) every morning with breakfast."

A nurse is doing preconception counseling with a woman who is planning a pregnancy. Which statement suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?

"If I drink, my baby may be harmed before I know I am pregnant."

The nurse is teaching a client which side effects to report to the provider while she is taking an anticoagulant. Which of the following responses tell the nurse that the client understands what to report?

"If I notice dark colored stool, I should contact my provider immediately."

A client with pernicious anemia is being discharged and requires medication instruction. Which statement by the client demonstrates they understood your instructions about their at-home treatment regime?

"Initially, I will need weekly injections of Vitamin B12 and then monthly injections for maintenance, which will be a lifelong regime."

A nurse prepares for a Denver Screening II of a 3 year-old child in the clinic when the mother asks the nurse to explain the purpose of the test. What is the nurse's best response about the purpose of the Denver Screening II?

"It assesses a child's development."

A client with DM is being discharged home and the nurse is teaching them about preventing DKA. What statement by the client demonstrates they understood the nurse's teaching?

"It is important I check my blood glucose every 3-4 hours when I'm sick."

The nurse is performing an initial assessment for sports physicals at a college clinic. An 18-year old male client reveals he has legally obtained medical marijuana for his migraine headaches. Which of the following is the priority teaching point?

"It is important to avoid driving while under the influence of marijuana."

A client is evaluated in the emergency department for an ankle injury that occurred during a baseball game. What discharge teaching will the nurse provide for the client? (Select all that apply.)

"It is important to avoid standing or walking without crutches until after your follow-up visit." "To help with decrease swelling, it is important to keep your ankle elevated when you are resting." "You should apply an ice pack to your ankle for 20-30 minutes at a time, 3-4 times a day."

The nurse is teaching a client about their new ostomy. Which statement by the client suggests the client understands the nurses teaching?

"It is normal for my stoma to remain red in color."

The registered nurse (RN) is making a presentation about Lyme disease to a group of volunteers who host hiking tours through grassy areas. Which statement made by one of the volunteers indicates more teaching is needed?

"Lyme disease is caused by a virus because the symptoms are similar to the flu."

The preoperative nurse completes a health history on a client scheduled for a general anesthetic. Which of the following statements made by the client may indicate a risk for serious complications? (Select all that apply.)

"My uncle got a fever and died unexpectedly during surgery." "My lips have been itching ever since I blew up balloons for my daughter this morning." "I am kind of sore all over; I get muscle cramps a lot."

The nurse has given discharge instructions to parents of a child who will be taking liquid phenytoin. Which statement made by the parents suggests that the teaching was effective?

"Our child should brush after every meal and floss daily."

A client comes into the community health center upset and crying, stating: "I will die of cancer now that I have this disease." The client hands the nurse a piece of paper with the word "pheochromocytoma" written on it. What would be the best initial response by the nurse?

"Pheochromocytomas are usually noncancerous, but they do need to be treated to avoid complications

Order: Acetaminophen elixir 100 mg by mouth every four hours as needed for pain. Available concentration of acetaminophen is 80 mg/0.8 mL.How much acetaminophen elixir will the nurse administer?

1 mL

The nurse has received a physician's order that reads: Administer fentanyl 50 mcg IV every 1 to 2 hours, as needed, for pain. Fentanyl is packaged as 100 mcg/2 mL ampules. How many milliliters of fentanyl will the nurse draw up to administer to the client?

1 mL

A nurse from the mental health unit is reassigned to the pediatrics unit and will be caring for a child with asthma. Which of these findings would the charge nurse emphasize as the first thing to indicate a worsening condition in the child?

A downward trend in peak flow rates as measured by a peak flow meter

A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief system, the nurse would explain that illness is attributed to which focus?

A failure to keep the physiological processes of life in balance with nature and others

A Bosnian Muslim woman who does not speak English seeks care at a community clinic. Through physical gestures, the woman indicates that she has pain originating in either the pelvic or genital region. Assuming several people are available to interpret, who would be the most appropriate choice?

A female interpreter who does not know the client

The charge nurse on the evening shift is asked to determine which client is a candidate for discharge. Which of these clients should the nurse select as a potential candidate for discharge?

A middle-aged adult with a history of type 1 diabetes and one day post diabetic ketoacidosis

The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the discharge list in order to make room for a new admission?

A middle-aged client with a seven-year history of being ventilator dependent and who was admitted with bacterial pneumonia eight days ago

The 83 year-old client, who lives in a retirement community, is admitted to the hospital. The daughter reports the client no longer calls her every day, has not been participating in previously enjoyed activities, such as weekly card games, and has allowed the garden to become overgrown with weeds. The nurse should assign this client to a room with which of the following clients?

A middle-aged person who has been on the unit for 72 hours with a diagnosis of persistent depressive disorder

A client who is unconscious is brought to the emergency department by an ambulance. What document should the nurse give priority to when preparing the care for this client?

A notarized original of the advance directive brought in by the partner

A client with a primary TB infection can expect to develop which of the following:

A positive skin test

A nurse is performing a nutritional assessment on a 2 year-old child. Which of these principles should the nurse apply?

A serving size at this age is about two tablespoons

A postpartum Hispanic client refuses hospital food because it is "cold." What action should the nurse take initially?

Ask the client what foods are acceptable or are unacceptable

During an interview of a new admission, the nurse notices that the client is shifting positions, wringing the hands, and avoiding eye contact. It is important for the nurse to take which of these approaches?

Ask the client what the client is feeling at this moment

The nurse takes a medication to a client, and the client tells the nurse to take it away because she is not going to take it. The nurse's first action should be to:

Ask the client why she refuses to take the medication

The nurse is providing care for a client with subluxation of the finger joints and deformity of the hands due to rheumatoid arthritis. The client's partner states that it is increasingly difficult for the client to perform activities of daily living. Which assistive devices will the nurse teach the client about and include in the plan of care? (Select all that apply.)

Button hooks Hand splints Built-up eating utensils

The nurse is setting up a client's dinner tray. When the nurse turns her back to the client, the client grabs the nurse's buttocks and states he is hungry for much more than dinner. Which of the following responses by the nurse is indicated?

Complete an incident report

A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law?

Complete and accurate documentation of assessments and interventions

A client who was admitted with suspected acute pancreatitis reports having extreme mid-epigastric pain that radiates to the back. He states that his pain started last night. As the nurse, you know the two most common causes of acute pancreatitis are:

Gallstones and alcohol abuse

A 70-year-old woman is evaluated in the emergency department for a wrist fracture of unknown cause. During the admission process, which of the following findings should the nurse identify as being the client's greatest risk factor for developing osteoporosis?

History of oral corticosteroid use for 20 years to treat chronic lung problems (being postmenopausal and not physically active may also contribute but are less significant

A client is in the post anesthesia care unit (PACU). The vital signs are now much lower than when the client arrived in the PACU: T = 98 F (36.6 C), apical pulse = 115, respirations = 14, blood pressure = 82/46 mm Hg. The client's skin is cold and clammy. Rank the interventions the nurse should perform from first to last.

Increase the intravenous (IV) rate Elevate the lower extremities Assess the surgical dressing Assess the area dependent to the surgical incision Reassess vital signs

A client is diagnosed with severe pneumonia. Which intervention by the nurse promotes the client's comfort?

Keep conversations short

The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning the care of this client?

Keep the tissue intact

A nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." The client's remarks most likely indicate which finding?

Loose associations

A school nurse is advising a class of unwed pregnant high school students. What is the most important action the teenagers can perform to deliver a healthy child?

Maintain good nutrition

Which of the following is a priority action for a client having a seizure?

Maintain the patient's airway

The most important action of the nurse caring for a client with bronchiolitis is:

Maintaining a patent airway

A client is admitted with a diagnosis of renal calculi. The client reports moderate-to-severe flank pain and nausea. The client's oral temperature is 100.8 F (38.2 C). Which of these goals is the priority nursing focus for this client?

Manage pain

A nurse is caring for a patient with a personality disorder. He comments to the nurse that she "doesn't know what she is doing because all the other nurses let him take his coffee into his room. Most of them will even bring me coffee in my room!" The nurse recognizes that this is what type of behavior?

Manipulative behavior

A registered nurse from the float pool is assigned to the critical care unit on the evening shift. Which of these clients should be assigned to the float pool nurse?

Pacemaker insertion on the day shift

The nurse receives an order for a medication from the hospitalist. Knowing the drug is contraindicated for the client, the nurse twice verbalizes concerns about the contraindication to the hospitalist, who does not change the order. What action should the nurse take next?

Page the attending physician to express the same concerns

A nurse is caring for a client who has reported pain at his surgical site. Which statement(s) suggests the nurse understands the pain phenomena? (Select all that apply.)

Pain can be treated using pharmacologic or complimentary therapies. Pain exists when and where the client says it exists

The RN is working in a clinic where a client presents with a painful, blistering rash on the hip. The health care provider diagnoses shingles (herpes zoster). What is the priority nursing diagnosis?

Pain related to nerve root inflammation and skin lesions

A nurse is caring for a 69 year-old client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?

Palpate for a thrill over the fistula

After an explosion at a factory, one of the employees approaches the nurse and says, "I am a certified nursing assistant (CNA) at the local hospital." Which of these tasks would be appropriate for the nurse to assign to this worker who is assisting in the care of the injured?

Palpate pulses

The nurse is assessing a client after a traumatic femur fracture. Which of the following assessment findings of the affected area require the nurse's immediate action? (Select all that apply.)

Paresthesia. Weak pulse. Pallor. Pain.

The 55-year-old female arrives in the emergency department and states she is having a panic attack. The client is breathing rapidly and deeply, and reports feeling dizzy, cold and "tingly." Protocol is begun to rule out a heart attack; the findings support a panic attack. What oxygen delivery system does the nurse expect to be ordered for this client?

Partial rebreather mask

A client with a fractured femur has been in Russell's traction for 24 hours. Which nursing action is the priority?

Perform a bilateral neurovascular check of lower extremities

A client who is HIV-positive is diagnosed with a herpes simplex type 1 (HSV-1) infection. The nurse understands that which issue is the most likely reason for the HSV-1 infection in this client?

The client is immunosuppressed

The nurse is caring for a client whose pain is not well controlled. Which statement about pain management is a priority ethical consideration that can help guide the nurse?

The client's self-report of pain is the most important consideration

A client takes 20 mg of furosemide by mouth at 10 am. What information would be essential for the nurse to include at the change of shift report at 3 pm?

The client's urine output was 1500 mL in five hours

A nurse is preparing to enter a disaster scene. What assessment priorities must the nurse adhere to? (Select all that apply.)

The nurse will allocate resources to those with the strongest probability of survival. The nurse will assess clients by considering their airway, breathing, circulation and neurological function.

A client has just received a muscle relaxant for a muscle strain prior to discharge from an urgent care facility. What is a priority assessment the nurse should make to keep the client safe?

The nurse will assess the client's transportation needs

The nurse is preparing to take a sputum sample from a client. Which of the following should be part of the nurse's preparation? (Select all that apply.)

The nurse will collect the sample in the morning Clients should not eat or drink prior to the nurse obtaining the sample

A client falls while in the nurse's care. What is the appropriate action the nurse should take first once the client is safe?

The nurse will report the incident and fill out an incident report

A nurse has unintentionally given an incorrect dose of medication to their client. No harm was done to the client. What is the next action, if any, required by the nurse?

The nurse will report the incident to their nurse manager and follow their organizational procedures for reporting

Mass casualty survivors are brought to the emergency department (ED) after a disaster. The nurse is assigned to four clients who were triaged in the field and have just arrived in the ED. Which client will the nurse care for first?

The person with hypotension and a sucking chest wound

A client who is a victim of domestic violence tells the batterer: "I need a little time away." How would the nurse expect that the batterer might respond?

With fear of rejection, resulting in increased rage toward the client

A toddler is diagnosed with atopic dermatitis. What information is important for the nurse to share with the parents about caring for their child?

Wrap the child's hand in mittens or socks to prevent scratching

Your client patient has an endotracheal tube. You are assessing placement by listening to breath sounds and you notice that they are absent on the client's left side. What does this usually indicate to the nurse?

The tube may be displaced

The nurse is performing the initial assessment of a client in the emergency department. Which statement by the client most strongly suggests domestic violence?

"I have tried leaving home, but have always gone back."

A male client admitted with a diagnosis of a spinal cord injury (SCI) at level C-5 asks the nurse how the injury will affect his sexual function. Which statement is the best response?

"Sexual functioning may be possible."

The client, who is four days post-op for a transverse colostomy and is scheduled for discharge tomorrow, asks the nurse to empty the colostomy pouch. What is the best response by the nurse?

"Show me what you have learned about emptying your pouch."

A newly graduated nurse, who has recently completed orientation, voices concern about her assignment: "I have never taken care of anyone with a lumbar drain before." Which action would be most appropriate for the charge nurse?

Change the assignment; reassign the client with the lumbar drain to a different nurse

The triage nurse identifies that a 16-year-old client is legally married and has signed the consent form for treatment. What would be an appropriate action by the nurse?

Proceed with the triage process in the same manner as any adult client

A nurse has been assigned to four clients in the emergency department, with each client experiencing one of these conditions. Which client should the nurse check first?

Tension pneumothorax with slight tracheal deviation to the right

The client is newly diagnosed with gastroesophageal reflux disease (GERD). Which statement(s) made by the client indicates a need for further education about this disease? (Select all that apply.)

"A bedtime snack may help me sleep better." "I will take my omeprazole (Prilosec) as needed when I have heartburn." "When I have a headache I'll be sure to take aspirin instead of acetaminophen."

A 90 year-old is readmitted to the hospital, less than 2 weeks after being discharged, for the same health concern. What factors contribute to hospital readmissions among older adults? (Select all that apply.)

Family preference Poor communication among providers Client health status

A 70-year-old male is recently diagnosed with osteoporosis. The nurse is teaching the client about this disease. Which of the following client responses requires further education by the nurse? (Select all that apply.)

"I don't believe the doctor because I heard that only women can get osteoporosis." "Exercising in an aquatics class will make my bones much stronger." (aqua aerobics will not make bones stronger)

A nurse is assessing a client to verify pregnancy. What information from the client will provide presumptive findings? (Select all that apply.)

Fatigue Breast sensitivity Amenorrhea Nausea

A client with a diagnosis of depression has recently been acting suicidal and is now more social and energetic than usual. Smiling, the client tells a nurse, "I've made some decisions about my life." What should be the nurse's initial response?

"Are you thinking about killing yourself?"

A female client is admitted for a breast biopsy. She says, tearfully, to a nurse, "if this turns out to be cancer and I have to have my breast removed, my partner will never come near me." Which of these statements would be the best response by the nurse?

"Are you worried that the surgery will lead to changes?"

Which assessment data would make the nurse suspect that the client has ALS?

Fatigue, progressive muscle weakness and twitching (progressive muscle weakness is often the first sx of ALS)

A parent calls the hospital hotline and is connected to the triage nurse. The caller states: "I found my child with odd stuff coming from the mouth and an unmarked bottle nearby." Which of these comments would provide the best information to help the nurse to determine if the child has swallowed a corrosive substance?

"Ask the child if their mouth is burning or throat pain is present."

A client tells the nurse, "I have something very important to tell you if you promise not to tell." The nurse should respond with which statement?

"I can't make such a promise."

A client newly diagnosed with type 1 diabetes mellitus asks: "What is the purpose of the test that measures that funny glucose value over time?" Which response best answers the client's question?

"Called glycolsolated hemoglobin, it is the average blood glucose for the past two to three months."

For a client with osteoporosis, the nurse should provide which dietary instruction to help slow the progression down?

"Eat more dairy products to increase your calcium intake."

A newly diagnosed schizophrenic client reports to the nurse that he thinks that the employees at the fitness center are conspiring to have his membership revoked. Which of the following responses by the nurse is the most therapeutic?

"Feeling this way must be frustrating and scary."

A client does not understand why she has been diagnosed with high blood pressure. What should the nurse say to her?

"Hypertension is diagnosed by taking the average of three or more blood pressure readings, two minutes apart, at each of three or more visits after an initial screening visit."

A severely injured client is moved into an examination area of the emergency department. The family member who accompanied the client to the ED is screaming at the nurse, saying that someone better start doing something right away. What is the best response by the nurse?

"I know you are upset. But please control yourself and sit down. Otherwise I will have to call security."

The nurse provides information to a client who is scheduled for a radiofrequency catheter ablation to control atrial fibrillation (AF). Which statement indicates the client correctly understands information about the procedure?

"I may need another ablation if this one doesn't work."

A 54-year-old female explains to the health care provider that she experiences approximately 10 vasomotor symptoms of menopause ("hot flashes") throughout the day and night. Different treatment options are discussed. Which statement by the client indicates she needs further instruction from the nurse?

"I may need to take estrogen and progesterone for many years." (this is a short-term tx option only)

The nurse is providing discharge education about how to avoid joint stress for a client hospitalized with an acute exacerbation of rheumatoid arthritis. Which statement by the client demonstrates the teaching has been effective? (Select all that apply.)

"I need to start carrying heavy items with my arms, instead of my hands." "I will sit on a tall kitchen stool instead of standing when I am preparing meals."

The nurse is providing discharge teaching to a client who has just undergone total hip replacement surgery. Which statement by the client would indicate to the nurse the need for further teaching?

"I should not sit in one position for more than four hours." (should not sit in one position for more than ONE hour)

A client asks the nurse for information about a living will. Which statement made by the client demonstrates an understanding of a living will? (Select all that apply.)

"I should sit down and discuss my wishes for end-of-life care with my loved ones." "A living will is a legal document that becomes a permanent part of my health care record." "My wishes for end-of-life treatment are stated in writing." "I will need to identify someone to be my health care proxy."

The nurse is reviewing information about using a plastic thoracolumbosacral orthotic (TLSO) with a teen who was recently diagnosed with scoliosis. Which statement made by the client indicates the need for further education?

"I should wear a sweatshirt under the orthotic to help protect my skin."

The nurse is working in a community health clinic answering telephone calls. Which client would the nurse recommend to be seen immediately by a health care provider?

"I went to the bathroom and my urine looked very red but it didn't hurt when I went."

The nurse is caring for a client who has expressed some anxiety about their upcoming surgery. The most appropriate therapeutic response would be:

"Tell me more about how you are feeling."

A client referred for mammography questions the nurse about the cancer risks from radiation exposure. What is an appropriate response by the nurse?

"The radiation from a mammography is equivalent to one hour of sun exposure."

A client who has just given birth asks the nurse what an APGAR score means. The correct response by the nurse would be:

"The score is a general overview of how well your newborn is doing."

The nurse is caring for a client with urinary incontinence. The client asks the nurse about the use of Kegal exercises to treat this condition. What is the most appropriate response by the nurse?

"This type of treatment has been used successfully to manage urinary incontinence."

A client calls the evening health clinic to state, "I know I have a severely low sugar since the Lantus insulin was given three hours ago and it peaks in two hours." What should be the nurse's initial response to the client?

"What are you feeling at this moment?"

The nurse is assisting a client with substance use disorder (SUD) to deal with issues of guilt. Which response by the nurse would be best for this client?

"What have you done that you feel most guilty about? What steps can you begin to take to help you lessen this guilt?"

A pregnant client calls the nurse and reports that she is experiencing contractions regularly and they are increasing in intensity. What is an additional assessment to determine if the client is in labor?

"Where are you experiencing discomfort?"

The registered nurse (RN) has just accepted a position as a public health nurse. Which question might be the most relevant as the nurse begins employment?

"Which groups are at the greatest risk for problems?"

A nurse receives an illegible hand-written medication order. Which statement to the health care provider reflects appropriate assertive communication?

"Would you please clarify what you have written so I am sure I am reading it correctly?"

The nurse is assessing a client who had a stroke and underwent a carotid endarterectomy. The client is now experiencing motor deficits and communication problems. Which of the following findings requires immediate follow-up?

Increased pulse and decreased blood pressure (may indicate hemorrhage)

A client who has been experiencing influenza-like symptoms for the past 24 hours calls the health clinic and asks about the antiviral medication zanamivir (Relenza). How should the triage nurse respond?

"Your chart states that you have asthma, so this product would not be recommended."

The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in an automobile. What is the nurse's best response to the parents?

"Your child must use a car seat until he weighs at least 40 pounds."

A client requires rapid infusion of packed red cells. What is the benefit of using a blood warmer when rapidly infusing multiple units of packed red cells?

Increases peripheral dilatation and comfort

An elderly client is admitted to a home care agency following hospitalization for exacerbation of heart failure. The client lives alone, has difficulty completing activities of daily living (ADLs) and is unable to drive. Reorder the steps in the case management process by dragging and dropping the options below.

1. Assessment of biophysical and sociocultural considerations 2. Identification of nursing diagnosis 3. Referral to personal care attendant and transportation services 4. Reassessment of health status and ADL abilities 5. Evaluation of progress towards client's goals

A nurse is providing care to a 17 year-old client in the post anesthesia care unit (PACU) after an emergency appendectomy. Which finding is an early indication that there is diminished oxygenation?

Increasing pulse rate

The nurse is assessing a pregnant client in her third trimester. The client is informed that the ultrasound suggests the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely associated with what factor?

Maternal hypertension

An X-ray initially confirms the placement of a nasogastric (NG) feeding tube in the stomach. The nurse is now preparing to administer a medication through the tube. What action will the nurse take to verify tube placement?

Measure the pH of aspirated gastric contents

A nurse is caring for a client who is experiencing alcohol withdrawal symptoms. Which nursing considerations are most appropriate? (Select all that apply.)

Monitor vital signs Take seizure precautions Orientate the client frequently Provide prescribed medication as needed

The charge nurse in the emergency department (ED) receives a call from the ambulance crew stating that there has been a two car accident with multiple casualties. What action would the nurse take first, before the victims arrive in the ED?

Notify the nursing supervisor and request additional staff

A client is being prepped for a surgical procedure and the nurse is reviewing the informed consent with the client. The client asks, "Is there any other way to take care of this without having surgery?" The nurse has a duty to first:

Notify the surgeon that the client has additional questions about alternatives to surgery

During a 12-hour shift, a client who underwent a transurethral resection of the prostate (TURP) had an IV fluid intake of 1200 mL, an oral intake of 400 mL, continuous bladder irrigation of 2400 mL, two antibiotic piggybacks of 50 mL each and an indwelling urinary catheter output of 3000 mL. What is the end-of-shift intake/output (I/O) balance?

1100 mL

The client receives 300 mg phenytoin by mouth daily for seizures and the pharmacy sent phenytoin 125 mg/5 mL suspension.How many mL of suspension will the nurse administer?

12 mL/day

The order is for vancomycin 2 grams every 12 hours IV. The pharmacy sends the medication mixed in a 200 milliliter (mL) bag with directions to infuse it over 1.5 hours. The nurse will use an infusion pump to deliver the medication. What is the infusion rate for the vancomycin (Vancocin)?

133 mL/hr 200 mL/1.5 hours = X mL/hourX = 133 mL/hour

A nurse can delegate a task to a team member by determining their responsibility through which of the following documents? (Select all that apply.)

Nurse practice act ​​​​​​​Organization's standard of care Organization's job description

The child weighs 68.2 pounds. The nurse must administer amoxicillin by mouth at 30 mg/kg/day in divided doses every six hours.How many milligrams of amoxicillin does the nurse administer for each dose?

233 mg/dose Step one: convert the weight in pound to kilograms (1 kg = 2.2 lbs) Set up equation: Cross multiply, divide and solve: Step two: how much amoxicillin does the nurse administer each day? (Insert weight in kilograms into the dosage equation.) Step three: how much amoxicillin does the nurse administer for each dose? Calculate doses/day: Civide total daily dose by the number of doses: Dimensional Analysis Method Set up equation: The left side of the equation is the unit of measure you are solving for: The right side of the equation is where you set up information so that all factors cancel out except for the unit of measure you are solving for: Cancel out the matching information Complete the calculation: Solution: the nurse administers 233 mg of amoxicillin for each dose

The prescription is linezolid 600 mg IV in 300 mL of D5W to infuse over two hours. The IV tubing drip rate is 10 gtts/mL.What drip rate should the nurse use?

25 gtts/min Determine the hourly rate: Convert 1 hour to 60 minutes and determine mL/minute: Determine drops/minute (drip rate of IV tubing = 10 gtts/mL): Dimensional Analysis Method Set up the equation The left side of the equation is what you want:The right side of the equation is what you have - be sure to set it up so you can cancel out matching units of measure: Perform the calculations Cancel out the matching units of measure:And complete the calculation: Solution:The drip rate is 25 gtts/minute

The order reads: start nitroglycerin intravenously for chest pain; titrate to keep client pain free and keep the systolic blood pressure greater than or equal to 90 mm Hg. The pharmacy sends a 250 mL bottle of D5W with 25 mg nitroglycerin added. The client weighs 215 pounds and the nurse has titrated the nitroglycerin drip to 47 micrograms per minute (mcg/min). What is the infusion rate for the nitroglycerin?

28 mL/hr (mg on hand/mL on hand) (convert mg to mcg)(25 mg/250 mL) = 0.1 mg/mL = 100 mcg/mLmL/hr = [(desired dose in mcg/min)/ (concentration in mcg/mL)]x(60)X= (47/100) (60)X= 28.2 or 28 mL/hr

The order is for 900 mg of nafcillin and the nurse has a powder in a vial labeled "Nafcillin 1 gram, dilute with 3.4 mL of sterile water to produce 1 gram in 4 mL." How many milliliters will the nurse administer? Report the answer to the nearest tenth

3.6 mL 1000 mg/4 mL = 900 mg/x mL

The client receives epinephrine 0.25 mcg/min IV via infusion pump. The pharmacy sends epinephrine 0.1 mg in 250 mL of normal saline. What rate in mL/hr will the nurse use to program the infusion pump?

37.5 mL/hr

The charge nurse is making client room assignments. In order to minimize the risk of a hospital acquired infection, which of these children would be the most appropriate roommate for a 3 year-old child diagnosed with minimal change disease?

4 year-old with bilateral inguinal hernia repair

All of the following clients are using morphine patient controlled analgesia (PCA) pumps and are two days post-op. Which client should the nurse check first?

62 year-old following knee replacement surgery, BP 120/68, pulse 68, respirations 8

The interdisciplinary team is reviewing charts for potential candidates for hospice care. Which of the following clients meet the criteria for hospice care? (Select all that apply.)

91-year-old with Alzheimer's disease, who is no longer able to eat or drink oral fluids 8-year-old client with acute myelogenous leukemia, for whom all treatment options have failed 72-year-old with prostate cancer metastasized to the bone, who is receiving palliative radiation therapy

A nurse is conducting a community-wide seminar on childhood safety issues. Which of these children is at the highest risk for poisoning?

A 20 month-old who has just learned to climb stairs

The paramedics are transporting a poisoning victim to the local hospital. In which of these cases does the nurse anticipate that hyperbaric oxygen therapy will be used?

A 35 year-old found unconscious with suspected carbon monoxide poisoning

The nurse is reviewing the contraindications for oral anticoagulant medications. Which client should not receive an oral anticoagulant medication?

A client who is pregnant

A client has started clozapine therapy. What information should the nurse emphasize to the client about this medication during discharge teaching?

A common side effect is extreme salivation

A client of Hispanic heritage refuses emergency unit treatment until a curandero is called. What should the nurse understand about the practices of a curandero?

A curandero uses holistic healing practices

Which is the most effective way to screen for BPH?

A digital rectal exam

Which of these clients should the nurse assess and monitor for Clostridium difficile (C. difficile) diarrhea?

A hospitalized middle-aged client receiving IV cephalexin (Keflex)

A client tells the nurse, "I'm in a lot of pain." As the nurse collects more information about the client's pain, what should be the first step in pain assessment?

Accept the client's report of pain

The client is in her first trimester of pregnancy. What major developmental task should the client accomplish during this stage of pregnancy?

Accepting physical changes related to pregnancy.

The nurse manager is discussing the goals of total quality management (TQM) with the health care team. Which statement correctly identifies a key element of TQM?

All employees participate in systematically working toward common goals

The nurse is caring for a young adult client with an acute attack of inflammatory bowel disease. Which of the following findings by the nurse indicates a potential complication? (Select all that apply.)

Abdominal distention Chills and fever

A nurse is providing home care for a client with chronic bilateral heart failure. Which nursing diagnosis should have the priority when planning care for this client?

Activity intolerance related to an imbalance in oxygen supply and demand

The nurse is making a home visit to a client diagnosed with chronic obstructive pulmonary disease (COPD). The client tells the nurse that he used to be able to walk from the house to the mailbox without difficulty. Now, he has to pause to catch his breath halfway through the trip. Which nursing diagnosis is appropriate for this client based on this assessment?

Activity intolerance related to chronic tissue hypoxia as evidenced by fatigue

The nurse's assessment data reveals dehydration, fatigue, muscle weakness, skin hyperpigmentation and unintentional weight loss.

Addison's disease

The nurse is preparing a client for an intravenous pyelogram (IVP). The nurse should take which action to adequately prepare the client?

Administer a laxative to the client the evening before and an enema the morning of the test

An antibiotic is ordered to be administered to a 2 year-old child intramuscularly. The total volume of the injection equals 2 mL. What is the correct nursing action?

Administer the medication in two separate injections (1 mL in each)

A nurse is assessing a newborn infant and observes low-set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum. What priority focus in the maternal history should the nurse ask about?

Alcohol use during pregnancy

The nurse is working the triage area of the emergency room department. The nurse will determine in which order the clients will be seen. (Drag and drop the items into the correct order.)

An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be delayed 24-48 hours if necessary.

The new graduate nurse interviews for a position in a nursing department of a large health care agency that uses the approach of shared governance. Which of these statements best illustrate the shared governance model?

Nursing departments share responsibility for client outcomes

A client has a sucking puncture wound to the chest. Which action should the nurse take first?

Apply a dressing over the wound and tape it on three sides

The nurse is assessing a client with a stage II skin ulcer. Which of these approaches should be most effective to promote healing?

Apply a hydrocolloid or foam dressing

A client with late-stage cirrhosis develops portal hypertension. Which of the following options below are complications that can develop from this condition? (Select all that apply.)

Ascites Splenomegaly Esophageal overload

The client is admitted to the hospital with a diagnosis of right -sided heart failure. Which of the following findings would the nurse expect? (Select all that apply.)

Ascites Anorexia and nausea Dependent edema

A 65-year-old Hispanic-Latino client diagnosed with prostate cancer rates his pain as a six on a 0-10 scale. Other than Ibuprofen (Motrin), the client refuses all pain medication even though Motrin does not relieve his pain. What should be the next action for the nurse to take?

Ask the client about the refusal of certain pain medications

There is an order to remove the client's nasogastric tube (NGT). What action is the safest when the tube is being removed?

Ask the client to hold a breath until the tube is completely out

The nurse is assessing the mental status of a client admitted with possible dementia. Which of these options would best assess the functioning of the client's short-term memory?

Ask the client to recall three words the nurse had previously asked the client to remember

A 30-year-old client at 39-weeks gestation has just delivered and experienced a fetal demise. The client's partner is at the bedside. Which of the following nursing actions are appropriate at this time? (Select all that apply.)

Ask the parents if there are any special religious or cultural rituals for neonatal death Clean and wrap the baby and offer it to the parents to view or hold when desired Stay with the parents and offer supportive care to both of them

A nurse is performing well-child assessments at a day care center when a staff member interrupts the examinations for assistance with another child. The nurse finds a crying 3 year-old child on the floor with bleeding gums and two unlabeled open bottles nearby. What should be the nurse's first action?

Ask the staff member about the contents of the bottle

The nurse is providing discharge teaching to a client with asthma. The nurse should warn against the concurrent use of which over-the-counter medications?

Aspirin products for pain relief

While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say "no" to almost everything is an indication of what psychosocial skill?

Assertion of control

The nurse is caring for a patient who has just experienced a spontaneous abortion (miscarriage). What is a priority nursing action the nurse must implement first?

Assess and monitor bleeding and pain

A 5-month-old is hospitalized with a diagnosis of bronchiolitis related to respiratory syncytial virus (RSV). The parent reports the baby has been sneezing and wheezing, has had a runny nose for two days, and has not eaten for more than nine hours. Vital signs are: temperature 100.2° F (38° C), pulse 102, respiratory rate 32. Place the nurse's actions in order of priority by dragging and dropping the options below.

Assess for respiratory distress Promote adequate tissue oxygenation Initiate droplet isolation precautions Administer prescribed medications Promote desired fluid intake Perform family teaching

An 80-year-old client with tuberculosis has difficulty coughing up secretions for a sputum specimen. Which nursing action is appropriate?

Assist the client to an upright sitting position on the edge of the bed

A community health clinic nurse is interviewing a client who is experiencing lightheadedness. The client reports a history of arthritis and is taking naproxen sodium for the pain. The client is pale, the blood pressure is 88/40, pulse is 114, respiratory rate is 22 and temperature is 98.2° F (36.7 C°). What additional information should the nurse solicit from the client? (Select all that apply.)

Color of bowel movements Bruising Frequency and amount of naproxen used

The nurse is talking with a client who suddenly becomes tearful and stares out the window after seeing a rose on the lunch table. The client has a history of sexual abuse. Which of the following should the nurse include in the plan of care for this client?

Assess if the client is having a flashback

The nurse is performing the following actions immediately following the delivery of a healthy, normal newborn. Indicate the correct sequence of actions by dragging and dropping the options below into the correct order.

Assess infant's airway and breathing Perform bulb suctioning if excess mucus is present Assess infant's HR Place identification bracelets on mom and baby Administer Vitamin K shot to infant

A client diagnosed with renal calculi is admitted to the unit. Which intervention should the nurse implement first?

Assess the client's pain and rule out complications

The nurse is about to administer a unit of blood. The nurse has checked the blood/crossmatch and client identification with another nurse. Which is the most important action for the nurse to take prior to administering the blood?

Assess the client's vital signs

The nurse is providing care to a client in labor. The client has chosen natural childbirth with assistance from a doula, her mother and boyfriend. Which of the following nursing actions can help the client achieve her goal of an unmedicated labor and birth?

Assess the effectiveness of the labor support team and offer suggestions as needed

A 28-year-old is transferred to the emergency department (ED) via ambulance with a traumatic head injury. The client is awake and reports having a headache and some amnesia. What are the priority nursing interventions for this client? (Select all that apply.)

Assess the wound for presence of drainage or bruising on the head Assess vital signs and neurological function Assess the airway Prepare for CT imaging of the head

The nurse has called a physician to obtain orders about their mutual client. Below is the transcript of the call:Hello Dr. B this is Nurse A calling about our client Mr. F. The client is a 63-year-old male 24 hours post-surgical appendectomy who is having pain. He has a history of hearing loss and urinary tract infections. I would like to increase Mr. F's morphine from 0.5 mg per hour as needed to 1 mg per hour as needed.​​​​​​​ What communication step did the nurse forget to include?

Assessment

A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?

Assist with oral hygiene without the use of mouthwash

The nurse is working with a client who is diagnosed with MS. The nurse is teaching the client about how to reduce muscle spasticity. Which of the following statements by the client indicate the need for further teaching?

At the end of a day, taking a nice hot bath may relieve the muscle spasms

The client, who is diagnosed with dementia, wanders throughout the long-term care facility. How can the nurse best ensure the safety of a client who wanders?

Attach a monitoring band to the client's wrist

The nurse enters the client's room and finds the client, who was previously alert, lethargic and slow to respond. Prioritize the nursing actions by dragging and dropping the options below.

Attempt to elicit a response by physically shaking the client and loudly stating "open your eyes and talk to me." Complete a quick neurological assessment: orientation, pupil response, ability to follow commands Call the rapid response team and report the client's situation; request immediate assistance Remain with the client; send another staff member to get the list of medications and the chart

The client is diagnosed with gastroesophageal reflux disease (GERD). Which recommendation made by the nurse would be most helpful?

Avoid eating two hours before going to sleep Maintain an upright posture for at least 2 hours after eating

A client is receiving radiation therapy to the left axilla. The nurse should emphasize:

Avoid tight clothing around the area

A client with a fractured lower right leg is medicated for pain with meperidine (Demerol) 100 mg and hydroxyzine hydrochloride (Vistaril) 50 mg IM. One hour later the client reports the pain is getting worse. What should the nurse recognize as a potential reason for the unrelieved pain?

Compartment syndrome

A nurse is caring for a client after a tonsillectomy. The nurse observes the client swallowing frequently in between sips of water. The nurse understands that this could be a sign of:

Bleeding

The nurse is administering the initial total parenteral nutrition (TPN) solution to a client. Which finding requires the nurse's immediate attention?

Blood glucose of 350 mg/dL (19.4 mmol/L)

A nurse is monitoring a client that is in labor and has received an epidural. Which of these assessments is the nurse's first priority to be done immediately? (Select all that apply.)

Blood pressure Fetal heart rate

The nursing is caring for a client who is suffering from spinal shock. What finding might the nurse expect?

Bradycardia (also have hypotn and flaccid paralysis)

A client with the diagnoses of anorexia nervosa, electrolyte imbalance and cardiac dysrhythmias is hospitalized on a medical unit. Which findings would the nurse expect during the admission process?

Brittle hair, lanugo, amenorrhea

The nurse discusses nutrition with a pregnant woman who is iron-deficient and follows a vegetarian diet. The selection of which foods indicates the woman has learned food sources of iron?

Cereal and dried fruits

The nurse is caring for a client who has just been diagnosed with HIV. The client asks what would determine the actual development of AIDS. Which of the following is a diagnostic criterion for AIDS?

CD4 T-cell count below 200/µL

A client is seen in the emergency department with a left hemiplegia. To determine if the stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request which diagnostic procedure?

CT scan

The nurse assesses a cardiac client and observes that he has the classic triad of symptoms. Which of the following nursing actions should take priority?

Call a rapid response and anticipate a pericardiocentesis

A 62-year-old client is admitted to the emergency department. The client has a history of anemia and peptic ulcer disease and is now experiencing chest pain, nausea and dizziness. The nurse anticipates which laboratory tests to be ordered right away? (Select all that apply.)

Cardiac enzymes Complete blood count (CBC)

There is an order to administer a vesicant chemotherapy medication intravenously (IV). Which nursing action is the priority before starting the flow of the medication?

Check for blood return in the intravenous line

A nurse is caring for a client who is receiving enteral tube feeding. What is the first action the nurse should take before administering the feeding?

Check for tube placement prior to administration

A client presents with COPD. The client has a chronic, productive cough with dyspnea on excretion. Arterial blood gases show a low oxygen level and high carbon dioxide level in the blood. On assessment, the client has cyanosis in his lips and edema in his abdomen and legs. Based on your nursing knowledge and these symptoms, you suspect the client suffers from what type of COPD?

Chronic bronchitis

A nurse is assessing a 3-week-old infant for possible development dysplasia of the right hip. Which finding should the nurse expect with this condition?

Clicking sound from affected hip

A nurse is caring for a newly admitted client with a concussion due to a helmet to helmet hit to the head during the client's football game. The nurse performs an assessment. Which assessment data would call for an immediate nursing intervention?

Client exhibits signs of confusion

The nurse is preparing a speech to a local service organization about clinical trials in cancer care. Which of the following statements would be correct to include? (Select all that apply.)

Clinical trials require approval of a human subjects review board Clinical trials have led to improved cancer prevention and treatment

The client is 48 hours post-insertion of an abdominal catheter for peritoneal dialysis and is currently undergoing a fluid exchange. The nurse understands that which of these findings needs to be reported to the health care provider immediately?

Cloudy drainage

A nurse manager suspects a staff nurse of substance use disorder (SUD). Which approach would be the best initial action by the nurse manager?

Consult with human resources personnel about the issue and needed actions

A client's uncle calls for an update on the condition of his nephew. What should the nurse do first before providing the information to the caller?

Consult with the client and obtain permission to update the client's uncle of his condition

The nurse is providing burn prevention education to parents of a toddler and a school-age child. What safety measures should the nurse include in the teaching? (Select all that apply.)

Cook with pot handles turned towards the center of the stove Create an escape plan and practice it with the children Checks for hot straps or buckles before placing a child in a car seat

A client is in the third month of her first pregnancy. During the interview, she tells a nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of these nursing interventions is best at this time?

Counsel the woman to consent to HIV testing

The nurse's assessment data reveals acne, buffalo hump, hirsutism, moon shaped face and upper body obesity.

Cushing's disease

The postpartum nurse is caring for a couplet four hours after a vaginal delivery with a partial abruption of the placenta prior to delivery. The nurse would immediately notify the health care provider (HCP) based on which of the following data?

D-dimer test result is increased

A client is brought to the emergency department after falling 10 feet off a roof. The client is drowsy and reports back pain and difficulty moving the lower extremities. Which additional nursing assessment is an indication the client may be experiencing neurogenic shock?

Decrease in blood pressure

A nurse is performing a neurological assessment on a client following a right cerebrovascular accident (CVA). Which finding, if observed by the nurse, would warrant immediate attention?

Decrease in level of consciousness

A client is diagnosed with gastroesophageal reflux disease (GERD). The nurse's instruction to the client about approaches to dietary changes should include which topic?

Decrease intake of fatty foods

The nurse assesses the use of coping mechanisms by an adolescent one week after the client had a motor vehicle accident resulting in multiple serious injuries. Which of these characteristics are most likely to be observed by the nurse?

Denial, projection, regression

The client is transported to the emergency department with minor injuries suffered during a home fire. The client experiences intense anxiety after learning his home was completely destroyed. What is the most important initial intervention for this client?

Determine available community and personal support resources

A nurse is admitting a client that is newly bedbound. During the nurse's initial assessment, the nurse must ask a client about any other medical diagnosis that affects their mobility status. Which would be most concerning?

Diabetes mellitus

The nurse collects data on a client with type 1 diabetes mellitus. Which finding requires an immediate nursing action?

Diaphoresis and shakiness (sx of hypoglycemia)

A client becomes short of breath and complains of chest pain during his hemodialysis. The nurse suspects an air embolism. What is the priority nursing action?

Discontinue dialysis and notify the health care provider.

The nurse is caring for a pregnant woman who is diagnosed with pregnancy induced hypertension (PIH) and is receiving magnesium sulfate intravenously. During assessment of the client, the nurse notes that respirations are 12, pulse and blood pressure have dropped significantly, and the eight-hour urine output is 200 mL. What should the nurse do first?

Discontinue the magnesium sulfate

The client with newly diagnosed irritable bowel syndrome (IBS) states: "All this fiber I have to eat now is making me full of gas! It makes me want to stop taking it." What instruction by the nurse will help the client manage this side effect and increase compliance with the diet? (Select all that apply.)

Discuss a work-up for lactose intolerance with the health care provider Reduce intake of gas-forming foods Cut back on fiber and then add it again slowly to the diet

Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of these approaches should be the best initial action?

Discuss the consequences of an unbalanced diet with the child

A client is admitted to the medical-surgical unit following a motor vehicle accident. Twelve hours after admission the client becomes diaphoretic, tremulous and irritable, and the client's pulse and blood pressure are elevated. The client states to the nurse, "I have to get out of here." What is the most likely cause for the client's symptoms and behavior?

Early stage of alcohol withdrawal

A nurse is providing discharge teaching to a client who has a new diagnosis of renal calculi. Which point should the nurse include as a dietary recommendation to prevent recurrence of this condition?

Eat calcium-rich foods several times per day

A nurse is caring for a client with chronic renal failure who is treated with hemodialysis three times a week. The client becomes confused and irritable six hours before the next treatment. Which of these physiologic changes might explain the reason for the client's behavior?

Elevated blood urea nitrogen (BUN)

A new nursing assistant is instructed to weigh clients diagnosed with anorexia nervosa only if the clients wear a gown with underwear but no street clothing. What is the rationale for this intervention?

Eliminates the risk of hiding objects in clothing or shoes

A male client with benign prostatic hypertrophy is admitted with a distended bladder due to acute urinary retention. There is an order to insert an indwelling urinary catheter (IUC). What should the nurse understand about catheter insertion and care for this client?

Empty the bladder quickly and completely

An adolescent client arrives at a clinic three weeks after the birth of her first baby. She tells the nurse she is very worried about not returning to her pre-pregnancy weight. Which approach should the nurse take first?

Encourage her to talk about her self-image

The nurse is caring for the neonate immediately following a vaginal delivery. Which of the following interventions will promote temperature regulation in the neonate? (Select all that apply.)

Encourage skin-to-skin contact with the mother Wrap the neonate in blankets Place the neonate under a radiant warmer Dry the neonate off with warm towels

A postoperative client has a prescription for acetaminophen with codeine. What should a nurse recognize as a primary effect of this combination?

Enhanced pain relief

A client arrives in the emergency department after a radiolgical accident at a local factory. After placing the client in a decontamination room, the nurse gives priority to which intervention?

Ensure physiological stability of the client

A client diagnosed with a terminal condition is admitted to the nursing unit. What should be the initial action taken by the nurse?

Ensure the client is free from pain, nausea or dyspnea

The nurse is reviewing the medication administration record for a newly admitted client. The client is prescribed the beta blocker propranolol, but is not diagnosed with hypertension and does not have a history of heart disease. Which health issue might best explain the reason for prescribing propranolol?

Essential tremors

The nurse is assessing a client in the labor and delivery unit. Which of the following actions is correct when using palpation to assess the characteristics and pattern of uterine contractions?

Evaluate intensity by pressing fingertips into the uterine fundus

The nurse is providing discharge information to a client with glaucoma. Which of the following instructions would the nurse include?

Eye medications will need to be administered lifelong

Which of the following are complications associated with Crohn's disease? (Select all that apply.)

Fistulas Strictures Anal fistulas

A client is admitted with the diagnosis of meningitis. Which finding should the nurse expect when assessing this client?

Flexion of the hips and knees with passive flexion of the neck (Brudzinski's sign)

A client receiving TPN exhibits symptoms of congestive heart failure (CHF) and pulmonary edema. Which complication of TPN is the client most likely experiencing?

Fluid overload

The lab results for a 70 year-old postoperative client indicate that the serum blood urea nitrogen (BUN), creatinine ratio, and hematocrit (HCT) levels are all elevated. Sodium, chloride and potassium lab results are slightly elevated. Based on these findings, which of the following issues may be the actual problem?

Fluid volume deficit

The nurse administers an intermittent intravenous medication through a client's peripherally inserted central catheter (PICC) and disconnects the infusion from the PICC site. To best maintain patency of the PICC site, which action does the nurse take next?

Flush the catheter using a rapid push-pause technique

A nurse is caring for a 74-year-old client with benign prostatic hypertrophy (BPH). Which finding would the nurse anticipate when assessing this client?

Frequent urination

A 15 year-old is admitted with a fracture of the arm and is told that surgery is required. A nurse finds the child crying and unwilling to talk. What is the most appropriate approach by the nurse?

Give the child some privacy

A client is admitted with severe pain in the knees. Which form of arthritis is characterized by urate deposits and joint pain, usually in the feet and legs, and occurs primarily in men?

Gouty arthritis

The nurse's assessment data reveals anxiety, exophthalmos, heat intolerance, restlessness and weakness.

Graves' disease

A primigravida in the third trimester is hospitalized with a diagnosis of preeclampsia. The nurse determines that the client's blood pressure has a trend of increased readings. Which action should the nurse take first?

Have the client turn to the left side

The 78 year-old reports having difficulty moving his bowels. What information is most important for the nurse to obtain during the assessment process?

Health history and client's diet

The nurse notices body outgrowths on the distal interphalangeal joints. The nurse documents these findings as:

Heberden's Nodes

A client with a brain tumor is scheduled for a CT scan with contrast. Which of the options listed below would be a concern for the nurse when preparing the client for this test? (Select all that apply.)

History of asthma Positive pregnancy test BUN is 40 mg/dL (14.28 mmol/L) (client has poor renal function)

A nurse is caring for a client who was successfully resuscitated from a pulseless arrhythmia. Which assessment is critical for the nurse to include in the plan of care?

Hourly urine output

The client is a 16-year-old with full-thickness burns involving 20% total body surface area. After the initial 24 hours of treatment to replace fluids, which factor is used to determine if the client's fluid needs are being met?

Hourly urine output

A client diagnosed with diabetes mellitus has a blood glucose of 175 this morning. After the nurse reports this lab result along with the client's findings of being hungry and thirsty, what type of insulin should the nurse expect the health care provider to order?

Humulin-R insulin (short-acting; works in about 30 min)

The nurse's assessment data reveals dry/scaly skin, muscle cramps and tingling of the lips, fingers and toes.

Hypoparathyroidism

The nurse's assessment data reveals abdominal pain, amenorrhea, decreased libido, osteoporosis and sensitivity to cold.

Hypopituitarism

The nurse has administered furosemide 40 mg orally to a client with heart failure. For which side effect should the nurse monitor the client?

Hypotension

The client needs assistance to insert bilateral in-the-ear hearing aids. What action should the nurse take before inserting the hearing aids?

Identify which hearing aid goes in the right and left ears

A client is receiving an antibiotic infusion for acute osteomyelitis of the left femur. Which nursing intervention will be included in the plan of care?

Immobilization of the left leg

A 85-year-old client fell while going to the bathroom. It appears he may have a bone fracture in his right leg. The nurse observes a deformity in the affected leg and the client is unable to move it. He is alert and oriented but in pain. Which is the FIRST nursing action to take after confirming the patient is safe and stable?

Immobilize the fracture with a splint

A client with hepatitis A (HAV) is newly admitted to the unit. Which action(s) would be the priority to include immediately in the plan of care? (Select all that apply)

Implement standard and contact precautions

A 4-year-old child is admitted with burns on the legs and lower abdomen. During the assessment of the child's hydration status, which finding indicates a less-than-adequate fluid replacement therapy?

Increased hematocrit and decrease in the urine volume

A client is being seen in the emergency department for a myocardial infarction (MI). The client mentions that she stopped taking the metoprolol (Lopressor) five days ago because she was feeling better. Which of the following nursing diagnoses takes priority for this client?

Ineffective tissue perfusion; cardiopulmonary

The client is two days post-op following a hip replacement and is not transferring well from bed to chair. The nurse checks and then confirms that the client is not progressing on any part of the mobility training program. What action is the nurse's priority?

Inform the case manager of the variance in the critical pathway

The client is admitted with anemia, suspected to be caused by slowly bleeding esophageal varices. Which physician order should the nurse question?

Insert nasogastric (NG) tube to gravity

The nurse observes a nursing assistant using antiseptic hand sanitizer and rubbing their hands vigorously after leaving the room of a client diagnosed with Clostridium difficile (C-Diff). Which action by the nurse is appropriate?

Instruct the nursing assistant to wash their hands again with soap and water.

A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What action should the nurse take first?

Interview the client privately

The home health nurse is seeing a client diagnosed with type 2 diabetes. The client has a small foot ulcer that was debrided and requires daily dressing changes. Which intervention is most important for the nurse to implement to meet the goal of uncomplicated wound closure?

Involve the client in the decision making process

A nurse is assessing an 8-month-old infant with a malfunctioning ventriculoperitoneal shunt. Which of these findings should the nurse anticipate the infant might exhibit?

Irritability

Following a diagnosis of acute glomerulonephritis (AGN) in their 6-year-old child, the parents remark: "We just don't know how he caught the disease!" The nurse's response should be based on an understanding of which of these points?

It is not "caught" but is usually an immune response to a previous strep infection or an autoimmune condition

The health care provider has ordered the anti-infective tetracycline for a young woman. When teaching the client about the medication, what information would be necessary for the nurse to reinforce?

It may decrease the effectiveness of some oral contraceptives

Why is it important for the nurses to handle antineoplastic medications with caution?

It may increase their risk for leukemia

The nurse is admitting a 72-year-old with a diagnosis of right-sided heart failure. What finding should the nurse anticipate when assessing the client?

Jugular vein distention

A newly admitted client has a skin ulcer that tested positive for MRSA (methicillin-resistant Staphylococcus aureus). What precautions should the nurse take when caring for this client? (Select all that apply.)

Keep all equipment in the client's room for their sole use. Place the client in a private room. Perform hand hygiene after contact with the client and before leaving the room. Place personal protective equipment (PPE) at the door to the room.

The nurse is caring for a client in labor. Which non-pharmacologic measures can the nurse implement to provide the laboring client with a sense of control and comfort? (Select all that apply.)

Lamaze breathing techniques Aromatherapy Childbirth education Counterpressure

A nurse enters a 2-year-old child's hospital room in order to administer an oral medication. When the nurse asks the child, "Are you ready to take your medicine?" the response is an immediate, "No!" What would be an appropriate next action by the nurse?

Leave the room and return five minutes later and give the medicine

The nurse cares for a client who was admitted in status epilepticus and whose last seizure was four hours ago. What is the most important nursing assessment for this client?

Level of consciousness

A nurse is caring for a client with a confirmed diagnosis of myocardial infarction. Which finding requires the nurse's immediate action?

Lightheadedness (inadequate CO)

The partner of a client with Alzheimer's disease expresses concern about the burden of caregiving. Which of these actions by the nurse should be a priority?

Link the caregiver with a support group

The nurse receives an order for several medications for a client. Which combination of medications would require the nurse to contact the provider to discuss the orders? (Select all that apply.)

Lithium and furosemide (Lithium should not be given with diuretics)

A client who is thought to be homeless is brought to the emergency department (ED) by the police. The client is unkempt, has difficulty concentrating, is unable to sit still, and speaks in a loud tone of voice. Which of these actions is the appropriate nursing intervention for the client at this time?

Locate a room that features minimal stimulation during the admission process

The nurse is providing care to a 14-year-old adolescent with scoliosis. Which issue would be most difficult for this client?

Looking different from their peers

A client has moles with irregular edges that vary in color located on her hands. The nurse knows that this could be associated with what type of skin cancer?

Melanoma

The medication benztropine mesylate (Cogentin) is ordered, but the nurse incorrectly administers carvedilol (Coreg). What are the most important actions the nurse should take after making this medication error? (Select all that apply.)

Monitor and document the client's BP Document the administration of carvedilol (Coreg) Notify the nurse manager Notify the healthcare provider

The oncology nurse is preparing to administer the initial dose of vincristine to a child diagnosed with acute lymphocytic leukemia (ALL). Which intervention is most appropriate to add to the plan of care? (Select all that apply.)

Monitor liver enzyme tests Monitor for numbness or tingling in the fingers and toes Verify blood return before, during and after intravenous administration

The nurse is providing care to a client who has just received an epidural for anesthesia during labor. The nurse recognizes which of the following as the most important nursing intervention following this procedure?

Monitor maternal blood pressure for possible hypotension

The 54 year old client is scheduled for a coronary angiography. The client's medical history includes angina, type 2 diabetes mellitus and mild renal insufficiency. Which of the following orders does the nurse anticipate?

Monitor serum creatinine levels pre- and post-procedure

A neonate is having difficulty maintaining a temperature above 98 F (36.6 C) and is placed in an infant warming system (IWS). Which of the following actions will ensure the safety of the neonate?

Monitor the neonate's temperature continuously

A nurse is anticipating providing guidance to parents of a toddler about readiness for toilet training. Which statements describe what the nurse should know in order to provide such guidance? (Select all that apply.)

Myelination of the spinal cord is completed by this age The child learns voluntary sphincter control through repetition

The nurse's assessment data reveals facial puffiness, macroglossia, ptosis, course/sparse hair, confusion, hypothermia and bradycardia.

Myxedema coma

A family arrives at the emergency department. A parent believes the child ingested an undetermined number of acetaminophen tablets approximately 1 hour ago. The serum acetaminophen level confirms acute poisoning. Which of these orders should be implemented first?

N-acetylcysteine (NAC) (Mucomyst)

A client is recovering from hip replacement and is taking acetaminophen with codeine (Tylenol No. 3) every three hours for pain. Which finding associated with opioid analgesics does the nurse anticipate when assessing the client?

No bowel movement for three days

The 86 year-old client is being treated for a urinary tract infection. During the client handoff, the nurse learns the client is experiencing new-onset confusion, new-onset incontinence and refuses to eat. The client's most recent vital signs are recorded in the table below. What action by the nurse is indicated? temperature 98.4 F (36.9 C) pulse 82 respirations 16 blood pressure 126/70

Notify the health care provider of the changes

The client is observed falling out of bed when reaching for something on the overbed table. The client then states: "Don't just stand there. I feel fine - help me up." What is the correct order of actions the nurse should take?

Obtain a complete set of vital signs Assist the client back to bed with the help of other staff Call the healthcare provider Complete an incident report

A client, who is receiving a blood transfusion, reports having a headache and low back pain. What are the nurse's actions? (Select all that apply.)

Obtain first voided urine (within one hour of reaction) Stop the blood transfusion Establish a saline lock or patent IV Send the tubing and bag to the blood bank

The nurse is assisting clients diagnosed with trigeminal neuralgia (tic douloureux) to meet their nutritional needs. Which approach should the nurse recommend?

Offer small meals consisting of high calorie, soft foods

An 8 year-old child is admitted to the children's inpatient mental health unit. After the mother's departure, the client cries and refuses to eat dinner. Which of the following nursing actions is most appropriate?

Offer to play with the child

The nurse is caring for a client in the coronary care unit who has developed acute renal failure as a consequence of cardiogenic shock. Which of the following findings are consistent with the diagnosis? (Select all that apply.)

Oliguria Pitting sacral edema Crackles on auscultation in bilateral bases JVD

The nurse is caring for a client who had a sigmoid colostomy and requests assistance with removing flatus from a one-piece drainable ostomy pouch. Which should be the the correct intervention by the nurse?

Open the bottom of the pouch to allow the flatus to be expelled

The health care provider has finished writing admission orders for a client diagnosed with pneumonia and sepsis who has a history of type 1 diabetes. Prioritize how the nurse should complete the orders listed below (with 1 being the top priority).

Oxygen 2 liters nasal cannula Blood and sputum cultures IV normal saline at 100 mL/hr Ceftriaxone (Recephin) 1 gram every 12 hours IVPB Fingerstick before each meal and at bedtime

A nurse is caring for a client who has been diagnosed with ARDS. Which lab value should the nurse report to the health care provider? pH: 7.40 PaCO2: 91 HCO3: 26 PaO2: 78

PaCO2

The 72-year-old client, admitted for exacerbation of chronic obstructive pulmonary disease (COPD), is receiving 2 liters of oxygen per nasal cannula but is reporting dyspnea. An arterial blood gas (ABG) test is ordered and the results are: PaO2 40, pH 7.38, PaCO2 50, HCO3 28. Which option best explains the finding and indicates the required treatment?

PaO2 is too low and oxygen flow rate should be increased

A unique finding from a client who has endometriosis would be?

Painful defecation

A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing intervention would provide the most comfort to the client?

Perform frequent oral care using a tooth sponge

The female client is newly diagnosed with urge incontinence. She confides that she is often incontinent of large amounts of urine and expresses a fear of falling when rushing to the bathroom. What are the most appropriate nursing interventions to review with the client? (Select all that apply.)

Perform pelvic floor muscle exercises Schedule urination Restrict foods that may irritate the bladder

The nurse recognizes that obtaining accurate post anesthesia vital signs is extremely important. Which of the following client conditions are not appropriate for electronic blood pressure measurement? (Select all that apply.)

Peripheral vascular obstruction Irregular heart rate Shivering

A 3 year-old child is brought to the health clinic. The grandmother reports that the child is always "scratching his bottom" and is "extremely irritable." Based on this information, which health issue would the nurse assess for initially?

Pinworm

A nurse is caring for a client diagnosed with an unstable spinal cord injury at the T-7 level. Which intervention should take priority during the planning of care?

Place client on a pressure-reducing support surface

The school nurse is providing information for teachers at a school where a 10 year-old child with epilepsy attends. What is the most important action a teacher can take when the child experiences a tonic-clonic seizure in the classroom?

Place something soft and flat under the child's head

A nurse enters the room as a 3-year-old child is having a generalized seizure. Which intervention should the nurse perform first?

Place the child on his or her side

A client is admitted to the rehabilitation unit after having had a cerebral vascular accident (CVA) with residual mild dysphagia. The appropriate intervention for this client is which action?

Place the client in an upright position while eating

The nurse is preparing to insert a NG tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action?

Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process.

The nurse is reviewing the lab results for a male client on a heparin infusion to treat a deep vein thrombosis (DVT) and cellulitis of the right lower leg. Which of the lab results would the nurse be most concerned about?

Platelet count 50,000 per microliter (50 x 109/L)

The clinic nurse assists the health care provider with physical examinations and the collection of laboratory specimens. Which of these findings should the nurse report to the public health department?

Positive stool culture for shigella

The nurse reviews the most recent lab results for a client on telemetry who is experiencing premature ventricular beats at 12 per minute. Which lab test would require immediate action by the nurse?

Potassium 2.5 mEq/L (2.5 mmol/L)

The nurse is caring for a client with chronic renal failure. Which of the following orders written by the health care provider would the nurse question?

Potassium chloride (Micro-K) 20 mEq daily with breakfast (hyperkalemia is the most dangerous side effect of renal failure so additional K would be contraindicated)

The nurse is providing information to a pregnant client about the risk of an amniocentesis. Identify which risk factors the nurse will discuss. (Select all that apply.)

Preterm labor Premature rupture of membranes Spontaneous abortion

The nurse is to administer a new medication to a client. Which of the following actions best demonstrates an awareness of safe and proficient nursing practice?

Prior to administration of the medication, the nurse should ask: "What is your name? What allergies do you have?" and then check the client's name band and allergy band.

The nurse understands that which situations require hand hygiene such as handwashing or hand sanitation? (Select all that apply.)

Prior to and after eating Before having direct contact with a client After cleaning a wound After contact with objects in the immediate vicinity of the client

The nurse is preparing interventions for a client with major depression who has been showing signs of impaired social interaction. Which of the following nursing interventions is initially appropriate for this client?

Provide activities that require minimal concentration

Which of these activities can be assigned to an unlicensed assistive person (UAP)?

Provide basic care to the client

The nurse has been caring for a client who was seriously injured in a bus accident. Several people were killed in the accident, including the client's son. The client's spouse has had several episodes of yelling at the staff and is now threatening legal action due to "inadequate care." What intervention should the nurse implement? (Select all that apply.)

Provide information about grief support groups Allow the spouse to express their feelings

The charge nurse is making assignment for the health care team. Which of these tasks can be safely delegated to the licensed practical nurse (LPN)?

Provide stoma care for a client with a well-functioning ostomy

The nurse is caring for a newly admitted client with a diagnosis of hyperosmolar hyperglycemic nonketotic state (HHNS). Which interventions would the nurse expect the health care provider to order? (Select all that apply.)

Rapid infusion of intravenous fluids BUN and creatinine levels

The nurse is performing the initial assessment of a client with asthma at the beginning of the shift. The client has oxygen running at 2 liters per minute per nasal cannula. Which assessment finding would the nurse be most concerned about?

Rapid shallow respirations with intermittent wheezes

Which type of insulin has an onset of 15 minutes and peaks at about one hour with a duration of three hours?

Rapid-acting

The nurse is reviewing and reinforcing information about the use of a peak flow meter with a client newly diagnosed with asthma. Which of these statements should the nurse include when explaining how to use the peak flow meter? (Select all that apply.)

Record the number achieved on the indicator; this is your peak flow rate Take a deep breath before placing your lips tightly around the mouthpiece Set the marker to the bottom of the numeric scale on the device

The health care provider orders an osmotic diuretic for a client diagnosed with a traumatic brain injury (TBI). Why is this medication ordered?

Reduce intracranial pressure

A client reports to the nurse that he must check to make sure that the iron is unplugged 10 times before leaving the house. The nurse understands that this is the client's attempt to:

Reduce personal anxiety

A client with goiter is treated preoperatively with potassium iodide. What should the nurse recognize as the purpose of this medication?

Reduce vascularity of the thyroid gland

A client is in the acute phase of RA. Which of the following should the nurse identify as highest priority in the plan of care? (Select all that apply.)

Relieving pain Preserving joint function Preventing joint deformity

The nurse performs a heel stick for a blood glucose check on a 1-hour-old, full-term newborn who weighed 9 lbs (4.1 kg) at birth. The serum glucose reading is 45 mg/dL (2.5 mmol/L). What action is needed by the nurse?

Repeat the test in 2 hours

The nurse manager overhears a health care provider loudly criticize one of the staff nurses within hearing range of other staff and visitors. Which approach by the nurse manager is indicated in this situation?

Request an immediate private meeting with the health care provider and staff nurse

A woman dressed in a business suit with no visible identification is at the nurses station looking at client charts. What nursing action is most appropriate?

Request to see identification and an explanation as to why the woman is viewing client charts

A nurse in the labor and delivery unit is caring for several clients. For which of these mother-baby pairs should the nurse review the results of the Coombs test to decide whether to administer Rho(D) immune globulin within 72 hours of birth?

Rh negative mother with Rh positive baby

A nursing care plan for a client in the diuresis stage of AKI should include what risk potential?

Risk for electrolyte imbalance

Behaviors of alcohol and drug abuse have outcomes of impaired judgment and increased risk-taking behavior. What nursing diagnosis best applies to this data?

Risk for injury

The nurse is caring for a 50-year-old client diagnosed with advanced cirrhosis of the liver. Which nursing diagnosis should take priority?

Risk of injury: hemorrhage (liver disease interferes with clotting factors)

The client is diagnosed with post-traumatic stress disorder (PTSD). What are the some of the more common treatment options for PTSD? (Select all that apply.)

Selective serotonin reuptake inhibitors (SSRIs) Eye movement desensitization and reprocessing (EMDR) Cognitive behavioral therapies

The home health nurse makes a scheduled visit to provide wound care and finds the client lethargic and confused. The client's partner states the client fell down the stairs two hours ago. What action should the nurse take next?

Send the client via ambulance to the emergency department for evaluation

An 80 year-old client, who is experiencing unintentional weight loss, is admitted with a diagnosis of malnutrition. The nurse understands that which of these lab tests is the most sensitive measure of nutritional status?

Serum albumin

The nurse assesses a 70 year-old male's laboratory results during a routine clinic visit. Which result would indicate a need for information and education?

Serum albumin 2.5 g/dL (25 g/L)

A client is admitted to an inpatient crisis unit with the diagnosis of acute mania and has been placed in seclusion. The nurse is assigned to observe the client at all times. It is now time for the client's dinner. What action should the nurse take next?

Serve the dinner in the seclusion room, maintaining observation

The nurse working in the intensive care unit (ICU) is told that a client is being newly admitted with a diagnosis of hyperglycemic hyperosmolar nonketotic state (HHNS). The nurse would expect which of the following clinical findings in this client? (Select all that apply.)

Severe dehydration Blood glucose level of at least 600 mg/dL (33.33 mmol/L)

A client states, "I feel funny." The nurse uses electronic equipment to obtain vital signs and notes these findings: blood pressure 100/56 mm Hg, pulse 38, respirations 26. The client's previous reading: blood pressure 130/88 mm Hg, pulse 82, respirations 21. List the correct order of actions the nurse should now take (with 1 being the top priority).

Simultaneously check an apical and radial pulse manually Assess for chest pain, dyspnea, low oxygen saturation, restlessness or other signs of respiratory or cardiac impairment Notify the health care provider Anticipate the need for ECG, oxygen administration, and emergency pacing

During a well-baby visit, the nurse is evaluating developmental milestones for the 7-month-old child. Which of these developmental activities should the child be able to perform?

Sits without support

Following a major burn to the lower extremities, a diet high in protein and carbohydrates is ordered for a 7 year-old child. What reason would the nurse give the family that would help explain these dietary requirements?

Spare protein catabolism to meet the child's metabolic needs

The nurse is caring for a client who has hearing loss. Which of the following actions should be implemented by the nurse to improve communication? (Select all that apply.)

Speak to the client at eye level Use short sentences

A child is brought to the emergency department with suspected ingestion of a toxic substance. Place the following nursing actions in priority order by dragging and dropping the options.

Stabilize the child Start an IV infusion Obtain a history of the ingestion Reverse or eliminate the toxic substance

A client's wound has tested positive for Staphylococcus aureus (MRSA). What level of precaution should the nurse place the client on?

Standard and contact precautions

A 2 year-old child is brought to the emergency department at 2:00 pm. The mother states: "My child has not had a wet diaper all day." The child is pale, with a heart rate of 132 beats per minute. What other assessment data would the nurse obtain next to help determine an admitting diagnosis?

Status of the eyes and the tongue

The nurse is meeting a client for the first time. The client has told the nurse that he does not take his medication as prescribed. Which is the best response:

Tell me more about why you are not taking the medication as prescribed

At the geriatric day care program, a client who has been diagnosed with a neurocognitive disorder (dementia) is crying and repeatedly saying: "I want to go home. Call my daddy to come for me." The nurse should take which action?

Tell the client you will call someone to come get the client and suggest the client to join an exercise group while waiting

The registered nurse (RN) and the unlicensed assistive person (UAP) are caring for clients on a surgical unit. Which action(s) by the UAP warrant immediate intervention? (Select all that apply.)

The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate in the hall The UAP applies a fingertip pulse oximeter on a client whose fingernail is painted dark blue The UAP assists a client, who had a total knee replacement two days ago, to shave using a straight-edge razor

The parents of a child who has recently been diagnosed with asthma ask the nurse to explain the condition to them. The best response by the nurse should include the point that asthma causes what change?

The airway becomes narrowed, obstructing airflow in response to triggers

The nurse works in an ambulatory care clinic where there are four children with gastrointestinal findings waiting to be seen by the health care provider. Which child is at greatest risk for developing metabolic acidosis?

The child with severe diarrhea for 24 hours

A client is admitted with a diagnosis of schizophrenia. The client refuses to take any medication and states, "I don't think I need those medications. They make me too sleepy and drowsy. I want you to explain their use and side effects of these medications." The nurse should respond with an understanding of which statement?

The client has a right to know about the use and side effects of the prescribed medications

The nurse is assessing the functioning of a chest tube drainage system. The nurse should expect which of the following assessment findings? (Select all that apply.)

The drainage system is maintained below the client's chest Drainage in the drainage collection chamber Occlusive dressing is over the insertion site

A bone marrow transplant is being considered for treatment of a client with acute leukemia who has not responded to chemotherapy. In discussing the treatment with the client, the nurse explains that:

The transplant procedure takes place in a sterile operating room to minimize the risk for infection

A nurse is teaching a client with genital herpes. Teaching for this client should include an explanation of:

The importance of informing his partners of the disease

The nurse manager is conducting rounds on the floor. Which of these findings would require immediate corrective action and further instruction to the assigned nurse about proper care?

The legs of a client who underwent hip replacement surgery yesterday are adducted

The nurse is checking on clients in the unit. Which of these findings indicates that an infusion pump set to deliver a morphine drip basal rate of 10 mL per hour, plus PRN dosages for breakthrough pain, is not functioning correctly?

The level of the drug is 100 mL at 8 am and is 80 mL at 12 noon

The nurse, who is caring for a client with complex and unique health needs, describes the nature of the illness in an online social forum for nurses. Neither the client's real name nor any other personal identifiers are used. What, if any, consequence could result from posting this information online?

The nurse could be fired for breach of confidentiality

A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting or singing. Which of the following actions by the nurse is an example of cultural awareness?

The nurse silently reflects about how her biases regarding Native Americans can influence how she approaches the client's parent.

A client presents with a burn that is pale and waxy with large flat blisters. The client asks the nurse about the severity of the burn. How should the nurse respond to this question?

The wound is a deep partial-thickness burn

What is the action of anti-anxiety medications?

They affect the neurotransmitters

The nurse is explaining an illness to a 10 year-old child. What should the nurse keep in mind about the cognitive development of children at this age?

They are able to think logically in the organization of facts

The nurse is caring for a client who is not oriented to time, place or person and has repeatedly attempted to pull out intravenous lines and a feeding tube. The nurse receives an order from the health care provider to apply a vest and soft wrist restraints. Which of the following actions by the nurse are appropriate? (Select all that apply.)

Tie the restraints using quick-release knots Conduct a thorough assessment of the client Explain the rationale for restraints to the client Document which alternative interventions were used or attempted

A nurse is assessing a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5 g/dL. Which approach to therapy should the nurse anticipate?

Total parenteral nutrition (TPN) via central line

The nurse is caring for a 4-year-old client who is diagnosed with Kawasaki disease. Which of the following signs and symptoms will indicate to the nurse that the client is developing a complication from the disease? (Select all that apply.)

Total urine output of 100 mL in an 8-hour shift Crackles throughout the lungs Heart rate of 160 bpm

A client is admitted to the ER with chest pain. He has been in the ER for five hours and is being admitted to your unit for observation. From the options below, what is the most IMPORTANT information the nurse needs to know about this client at this time?

Troponin result and when the next troponin level is due to be collected

A client is to receive three doses of potassium chloride 10 mEq in 100 mL of 0.9% normal saline to infuse over 30 minutes each. Which action is a priority assessment to perform before the nurse gives this medication?

Urine output

A nurse needs to administer cardiopulmonary resuscitation to a 5-year-old child. In order to be effective, the nurse should take which action as a single rescuer?

Use a ratio of two breaths to 30 compressions

The nurse is teaching the mother of a child with cystic fibrosis how to do postural drainage and percussion. The nurse should tell the mother to:

Use cupped hands during percussion

The nurse is reviewing the medical record of a client on the medical surgical unit and notes a positive result of the stool for occult blood (OB) test. The nurse recognizes which risk factors for this result? (Select all that apply.)

Use of naproxen sodium for pain relief Eating a steak dinner the night before Recent teeth cleaning at the dentist office Recent use of corticosteroids

The client has undergone a dilation and curettage (D & C) following a spontaneous abortion at 8 weeks. To promote an optimal recovery, what information should the nurse include in the discharge teaching? (Select all that apply.)

Use sanitary pads until vaginal bleeding has stopped Referral for grief counseling Strenuous sport activities should be postponed until bleeding stops

Which of these are examples of primary care activities? (Select all that apply.)

Vaccination Car seat installation education Exercise class

The nurse is preparing to administer a blood transfusion for a client with anemia secondary to intraoperative blood loss. Which of the following interventions by the nurse will help reduce the risk of complications associated with the transfusion? (Select all that apply.)

Verify that a 20-gauge or larger catheter is used Prior to infusion, check client identification against unit of blood to be transfused Monitor vital signs during blood administration

The client reports seeing spiders crawling on the walls, over the bed, and on the food tray, but denies feeling spiders crawling on the skin. The nurse determines that there are no spiders in the room. Which of the following assessments should the nurse use to document these findings? (Select all that apply.)

Visual hallucinations Spiders not found in the room Spiders reported to be crawling on surfaces

The nurse observes a student nurse inserting an indwelling urinary catheter for a female client. After the student inserts the catheter, no urine appears and the student begins to remove the catheter. What should the nurse do at this time?

Walk up and whisper in the student's ear: "Stop. Leave the catheter in place. I'll get a new sterile catheter."

A nurse is teaching a client with a diagnosis of metastatic bone disease about actions to prevent hypercalcemia. It would be important for the nurse to include which of these points?

Walking as much as possible keeps the calcium in the bone

A client is diagnosed with gastroenteritis, caused by a salmonella infection. Which of these actions is the primary nursing intervention designed to limit the transmission of salmonella?

Wash hands thoroughly with soap and water before and after client contact

A client with a central line catheter is being discharged. Which of the following methods is the most accurate way for the nurse to evaluate the client's partner's ability to provide central line catheter dressing changes at home?

Watch the partner change the dressing

The school nurse is checking students for pediculosis capitis. Which manifestation observed by the nurse confirms the presence of pediculosis capitis?

Whitish oval specks sticking to the hair shaft

The mother of a 3 month-old infant tells the nurse, "I want to change from formula to whole milk and add cereal and meats to my infant's diet." What should be emphasized as the nurse teaches about infant nutrition?

Whole milk is difficult for infants to digest

The nurse is caring for a client with a chest injury that required a chest tube placement. The client is confused and pulls out the chest tube as the physician has just finished replacing it. The nurse applies soft restraints on the client's wrist. Is this an appropriate nursing action?

Yes, the nurse can apply a restraint to protect the client from injury or harm, then obtain an order.

A nurse is caring for a client in skeletal traction. Which nursing intervention is appropriate for this client?

maintain correct body alignment

A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to note that the ulcer:

​​​​​​​Is brown and leathery