NCLEX***
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung In a closed- chest drainage system, the purpose of the water seal is to: A. Prevent air from entering the pleural space B. Prevent fluid from entering the pleural space C. Provide a means to measure chest drainage D. Provide an indicator of respiratory effort
A
A client has chronic obstructive pulmonary disease She is slowly losing weight, and her daughter is very concerned about increasing her nutrition The nurse helps the daughter devise a plan of care for her mother The plan of care should include which of the following interventions to promote nutrition? A. Offer her oral hygiene before and after meals B. Encourage her to consume milk products C. Encourage her to engage in an activity before a meal to stimulate her appetite D. Restrict her fluid intake to three glasses of water a day
A
A client has returned to the unit from the recovery room after having a thyroidectomy The nurse knows that a major complication after a thyroidectomy is: A Respiratory obstruction B. Hypercalcemia C. Fistula formation D. Myxedema
A
A 24-year-old client presents to the emergency department protesting "I am God" The nurse identifies this as a: A. Delusion B. Illusion C. Hallucination D Conversion
A
A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days In caring for a young child with symptoms of influenza, the mother must be cautioned about: A. Giving aspirin and bismuth subsalicylate (Pepto-Bismol) to treat the symptoms B. Giving clear liquids too soon C. Allowing the child to come in contact with other children for 3 days D. The possibility of pneumonia as a complication
A
A physician's order reads: 025 normal saline at 50 mL/hr until discontinued The nurse is using a microdrip tubing set How many drops per minute should the nurse administer? A 1 gtt/min B. 5 gtt/min C. 50 gtt/min D. 100 gtt/min
C
A male client is scheduled to have angiography of his left leg The nurse needs to include which of the following when preparing the client for this procedure? A Validate that he is not allergic to iodine or shellfish B. Instruct him to start active range of motion of his left leg immediately following the procedure C. Inform him that he will not be able to eat or drink anything for 4 hours after the procedure D. Inform him that vital signs will be taken every hour for 4 hours after the procedure
A
The nurse notes scattered crackles in both lungs and 1+ pitting edema when assessing a cardiac client The physician is notified and orders furosemide (Lasix) 80 mg IV push stat Which of the following diagnostic studies is monitored to assess for a major complication of this therapy? A. Serum electrolytes B. Arterial blood gases C. Complete blood count D. 12-Lead ECG
A
The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward: A. Maintaining an adequate level of hydration B. Providing pain relief C. Preventing infection D O2 therapy
A
Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to 25% of her body? A Urine output B. Edema C. Hypertension D. Bulging fontanelle
A
A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered After 1 hour, his behavior is more subdued, but he tells the nurse, "The devil followed me into this room, I see him standing in the corner with a big knife When you leave the room, he's going to cut out my heart" The nurse's best response is: A. "I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner" B."You'll probably see strange things for a while until the PCP wears off" C. "Try to sleep When you wake up, the devil will be gone" D. "You're probably feeling guilty because you used illegal drugs tonight"
A
A 52-year-old client is scheduled for a small-bowel resection in the morning In conjunction with other preoperative preparation, the nurse is teaching her diaphragmatic breathing exercises She will teach the client to: A. Inhale slowly and deeply through the nose until the lungs are fully expanded, hold the breath a couple of seconds, and then exhale slowly through the mouth Repeat 2-3 more times to complete the series every 1-2 hours while awake B. Purse the lips and take quick, short breaths approximately 18-20 times/min C. Take a large gulp of air into the mouth, hold it for 10-15 seconds, and then expel it through the nose Repeat 4-5 times to complete the series D. Inhale as deeply as possible and then immediately exhale as deeply as possible at a rate of approximately 20-24 times/min
A
A child becomes neutropenic and is placed on protective isolation The purpose of protective isolation is to: A. Protect the child from infection B. Provide the child with privacy C. Protect the family from curious visitors D. Isolate the child from other clients and the nursing staff
A
A male client is considering having laser abdominal surgery and asks the nurse if there is any advantage in having this type of surgery? The nurse will respond based on the knowledge that laser surgery: A. Has a smaller postoperative infection rate than routine surgery B. Will eliminate the need for preoperative sedation C. Will result in less operating time D. Generally eliminates problems with complications
A
A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2- week period Her husband asks, "Isn't that a lot?" The nurse's best response is: A. "Yes, that does seem like a lot" B. "You'll have to talk to the doctor about that The physician knows what's best for the client" C. "Six to 10 treatments are common Are you concerned about permanent effects?" D. "Don't worry Some clients have lots more than that"
C
To facilitate maximum air exchange, the nurse should position the client in: A. High Fowler B. Orthopneic C. Prone D Flatsupine
B
The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury Normal fluid intake for a child of 2 years is: A 900 mL/24 hr B. 1300 mL/24 hr C. 1600 mL/24 hr D. 2000 mL/24 hr
C
To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following? A. Positive inotropic therapy B. Negative chronotropic therapy C. Increase in balance of myocardial O2 supply and demand D. Afterload reduction therapy
A
The nurse is caring for a client who has had a tracheostomy for 7 years The client is started on a fullstrength tube feeding at 75 mL/hr Prior to starting the tube feeding, the nurse confirms placement of the tube in the stomach The hospital policy states that all tube feeding must be dyed blue On suctioning, the nurse notices the sputum to be a blue color This is indicative of which of the following? A. The client aspirated tube feeding B. The nurse has placed the suction catheter in the esophagus C. This is a normal finding D. The feeding is infusing into the trachea
A
A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs She denies any pain previously or currently The client is very concerned about whether her baby will be all right Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 982_F, and fetal heart rate 146 bpm Laboratory findings revealed hemoglobin 90 g/dL, hematocrit 26%, and coagulation studies within normal range On admission, the peripad she wore was noted to be half saturated with bright red blood A medical diagnosis of placenta previa is made The priority nursing diagnosis for this client would be: A. Decreased cardiac output related to excessive bleeding B. Potential for fluid volume excess related to fluid resuscitation C. Anxiety related to threat to self D. Alteration in parenting related to potential fetal injury
A
A 42-year-old male client has been treated at an alcoholic rehabilitation center for physiological alcohol dependence The nurse will be able to determine that he is preparing for discharge and is effectively coping with his problem when he shares with her the following information: A. "I know that I will not ever be able to socially drink alcohol again and will need the support of the AA group" B. "I know that I can only drink one or two drinks at social gatherings in the future, but at least I don't have to continue AA" C. "I really wasn't addicted to alcohol when I came here, I just needed some help dealing with mydivorce" D. "It really wasn't my fault that I had to come here If my wife hadn't left, I wouldn't have needed those drinks"
A
A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice He has a 20- year history of alcohol abuse The client is diagnosed with cirrhosis His serum ammonia level is high, indicating hepatic encephalopathy He has esophageal varices Which of the following may cause the varices to rupture? A. Lifting heavy objects B. Walking briskly C. Ingestion of barbiturates D. Ingestion of antacids
A
A male client received a heart-lung transplant 1 month ago at a local transplant center While visiting the nursing center to have his blood pressure taken, he complains of recent weakness and fatigue He also tells the nurse that he is considering stopping his cyclosporine because it is expensive and is causing his face to become round He fears he will catch viruses and be more susceptible to infections The nurse responds to this last statement by explaining that cyclosporine: A. Is given to prevent rejection and makes him less susceptible to infection than other oral corticosteroids B. Is available at discount pharmacies for a reduced price C. Is usually not necessary after the first year following transplantation D. May initially cause weakness, dizziness, and fatigue, but these side effects will gradually resolve themselves
A
A psychiatric client has been stabilized and is to be discharged The nurse will recognize client insight and behavioral change by which of the following client statements? A. "When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices" B. "If I have any side effects from my medicines, I will take an extra dose of Cogentin" C. "When I get home, I should be able to taper myself off the Haldol because the voices are gone now" D. "As soon as I leave here, I'm throwing away my medicines I never thought I needed them anyway
A
After instructing a female client on circumcision care, the nursery nurse asks her to restate some of the key points covered Which statement shows that the client will properly care for her son's circumcision? A. "I'll make sure I soak the gauze with warm water first, before I take it off each time" B. "I'll make sure that I report any drainage around where they operated" C. "I'll apply alcohol to the area daily to clean it and prevent any infection" D "I'll keep a close watch on it for a day or two"
A
An 80-year-old widow is living with her son and daughter- in-law The home health nurse has been making weekly visits to draw blood for a prothrombin time test The client is taking 5 mg of coumadin per day She appears more debilitated, and bruises are noted on her face Elder abuse is suspected Which of the following are signs of persons who are at risk for abusing an elderly person? A. A family member who is having marital problems and is regularly abusing alcohol B. A person with adequate communication and coping skills who is employed by the family C. A friend of the family who wants to help but is minimally competent D A lifelong friend of the client who is often confused
A
In client teaching, the nurse should emphasize that fetal damage occurs more frequently with ingestion of drugs during: A. First trimester B. Second trimester C. Third trimester D Every trimester
A
On admission, the client has signs and symptoms of pulmonary edema The nurse places the client in the most appropriate position for a client in pulmonary edema, which is: A High Fowler B. Lying on the left side C. Sitting in a chair D. Supine with feet elevated
A
One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid A lithium level is ordered The client's level is 13 mEq/L The nurse recognizes that this level is considered to be: A. Within therapeutic range B. Below therapeutic range C. Above therapeutic range D At a level of toxic poisoning
A
Parents should be taught not to prop the bottle when feeding their infants In addition to the risk of choking, it puts the infant at risk for: A Otitis media B. Asthma C. Conjunctivitis D. Tonsillitis
A
Priapism may be a sign of: A. Altered neurological function B. Imminent death C. Urinary incontinence D Reproductive dysfunction
A
The healthcare team determines that an elderly client has had progressive changes in memory over the last 2 years that have interfered with her personal, social, or occupational functioning Her memory, learning, attention, and judgment have all been affected in some way These symptoms describe which of the following conditions? A Dementia B. Parkinsonism C. Delirium D. Mania
A
The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have: A A low birth weight B A birth defect C Anemia D Nicotine withdrawal
A
The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her meals for tomorrow's menu Which vitamin is the most essential in promoting tissue healing? A Vitamin C B. Vitamin B1 C.Vitamin D D Vitamin A
A
Which nursing implication is appropriate for a client undergoing a paracentesis? A Have the client void before the procedure B. Keep the client NPO C. Observe the client for hypertension following the procedure D. Place the client on the right side following the procedure
A
When discussing the relationship between exercise and insulin requirements, a 26year-old client with IDDM should be instructed that: A When exercise is increased, insulin needs are increased B. When exercise is increased, insulin needs are decreased C. When exercise is increased, there is no change in insulin needs D. When exercise is decreased, insulin needs are decreased
B
A client had a transurethral resection of the prostate yesterday He is concerned about the small amount of blood that is still in his urine The nurse explains that the blood in his urine: A. Should not be there on the second day B. Will stop when the Foley catheter is removed C. Is normal and he need not be concerned about it D. Can be removed by irrigating the bladder
C
A 10-year-old client with a pin in the right femur is immobilized in traction He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony Which of the following nursing implementations would be most effective in helping him cope with immobility? A. Providing him with books, challenging puzzles, and games as diversionary activities B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision C. Having a volunteer come in to sit with the client and to read him stories D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's
B
A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder She is obsessed with her appearance She will not leave her room until her hair, clothes, and makeup are perfect She always dresses immaculately Recently, she expressed disgust over her appearance after she gained 5 lb After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia She eats everything on her plate, then runs to the bathroom In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings What defense mechanism is she using? A. Dissociation B. Intellectualization C. Rationalization D Displacement
B
A 55-year-old man has recently been diagnosed with hypertension His physician orders a low- sodium diet for him When he asks, "What does salt have to do with high blood pressure?'' the nurse's initial response would be: A. "The reason is not known why hypertension is associated with a high-salt diet" B. "Large amounts of salt in your diet can cause you to retain fluid, which increases your blood pressure" C. "Salt affects your blood vessels and causes your blood pressure to be high" D. "Salt is needed to maintain blood pressure, but too much causes hypertension"
B
A client undergoes a transurethral resection, prostate (TURP) He returns from surgery with a three- way continuous Foley irrigation of normal saline in progress The purpose of this bladder irrigation is to prevent: A. Bladder spasms B. Clot formation C Scrotal edema D Prostatic infection
B
A common complication of cirrhosis of the liver is prolonged bleeding The nurse should be prepared to administer? A. Vitamin C B. Vitamin K C. Vitamin E D Vitamin A
B
A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago She has taken phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor, for 7 straight days She states that she is not feeling any better The nurse explains that the drug must accumulate to an effective level before symptoms are totally relieved Symptom relief is expected to occur within: A. 10 days B. 2-4 weeks C. 2 months D 3 months
B
A female client decides on hemodialysis She has an internal vascular access device placed To ensure patency of the device, the nurse must: A. Assess the site for leakage of blood or fluids B. Auscultate the site for a bruit C. Assess the site for bruising or hematoma D. Inspect the site for color, warmth, and sensation
B
A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening Which of these plans by the nurse would be most successful? A. Examine the 4 year old first B. Provide time for play and becoming acquainted C. Have the mother leave the room with one child, and examine the other child privately D. Examine painful areas first to get them "over with"
B
In acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms In addition to the lithium, which one of the following medications might the physician prescribe? A. Diazepam (Valium) B. Haloperidol (Haldol) C. Sertraline (Zoloft) D. Alprazolam (Xanax)
B
In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit A client with antisocial personality disorder makes the following remark, "Forget all those rules I always get along well with the nurses" Which nursing response to him would be most effective? A. "OK, don't listen to the rules See where you end up" B. "I'm pleased that you get along so well with the staff You must still know and abide by the rules" C. "It is irrelevant whether you get along with the nurses" D. "I'm not the other nurses You better read the rules yourself"
B
One of the most reliable assessment tools for adequacy of fluid resuscitation in burned children is: A. Blood pressure B. Level of consciousness C. Skin turgor D Fluid intake
B
The nurse should facilitate bonding during the postpartum period What should the nurse expect to observe in the taking-hold phase? A Mother is concerned about her recovery B. Mother calls infant by name C. Mother lightly touches infant D. Mother is concerned about her weight gain
B
A 16-month-old infant is being prepared for tetralogy of Fallot repair In the nursing assessment, which lab value should elicit further assessment and requires notification of physician? A. pH 739 B. White blood cell (WBC) count 10,000 WBCs/mm3 C. Hematocrit 60% D. Bleeding time of 4 minutes
C
A 25-year-old client believes she may be pregnant with her first child She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy Her last menstrual period began May 20, and her estimated date of confinement using Nagele's rule is: A. March 27 B. February 1 C. February 27 D. January
C
A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband at 32 weeks' gestation She experienced a sudden onset of painless vaginal bleeding Following an ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made Expected assessment findings concerning the abdomen would include: A. A rigid, boardlike abdomen B. Uterine atony C. A soft relaxed abdomen D.Hypertonicity of the uterus
C
A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus What is the first symptom that indicates increased intracranial pressure? A Bulging fontanelles B. Seizure C. Headache D. Ataxia
C
A 32-year-old female client is being treated for Guillain- Barre syndrome She complains of gradually increasing muscle weakness over the past several days She has noticed an increased difficulty in ambulating and fell yesterday When conducting a nursing assessment, which finding would indicate a need for immediate further evaluation? A. Complaints of a headache B. Loss of superficial and deep tendon reflexes C. Complaints of shortness of breath D Facial paralysis
C
A 6-year-old child is attending a pediatric clinic for a routine examination What should the nurse assess for while conducting a vision screening? A. Hearing test B. Gait C. Strabismus D Papilledem
C
A client has been in labor 10 hours and is becoming very tired She has dilated to 7 cm and is at 0 station with the fetus in a right occipitoposterior position She is complaining of severe backache with each contraction One comfort measure the nurse can employ is to: A. Place her in knee-chest position during the contraction B. Use effleurage during the contraction C. Apply strong sacral pressure during the contraction D. Have her push with each contraction
C
A client has been taking lithium 300 mg po bid for the past two weeks This morning her lithium level was 1 mEq/L The nurse should: A. Notify the physician immediately B. Hold the morning lithium dose and continue to observe the client C. Administer the morning lithium dose as scheduled D. Obtain an order for benztropine (Cogentin)
C
A client returned to the unit following a pneumonectomy As the nurse is assessing her incision, she notices fresh blood on the dressing The nurse should first: A Reinforce the dressing B. Continue to monitor the dressing C. Notify the physician D. Note the time and amount of blood
C
A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge Because this client is at risk for autonomic dysreflexia, he and his family should be instructed to assess for and report: A. Dizziness and tachypnea B. Circumoral pallor and lightheadedness C. Headache and facial flushing D. Pallor and itching of the face and neck
C
A client with cirrhosis of the liver becomes comatose and is started on neomycin 300 mg q6h via nasogastric tube The rationale for this therapy is to: A. Prevent systemic infection B. Promote diuresis C. Decrease ammonia formation D. Acidify the small bowel
C
A client with cystic fibrosis exhibits activity intolerance related to the pulmonary problems associated with his disease However, he needs to be encouraged to participate in daily physical exercise The ultimate aim of exercise is to: A. Create a sense of well-being and self-worth B. Help him overcome respiratory infections C. Establish an effective, habitual breathing pattern D. Promote normal growth and development
C
A male client is experiencing extreme distress He begins to pace up and down the corridor What nursing intervention is appropriate when communicating with the pacing client? A. Ask him to sit down Speak slowly and use short, simple sentences B. Help him to recognize his anxiety C. Walk with him as he paces D. Increase the level of his supervision
C
An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago When performing the admission assessment, the nurse would expect to observe which of the following: A Both lower extremities warm to touch with 2_pedal pulses B. Both lower extremities cyanotic when placed in a dependent position C. Decreased or absent pedal pulse in the left leg D. The left leg warmer to touch than the right leg
C
Plans for the care of a client with an ulcer caused by emotional problems need to take into consideration that: A. His priority needs are limited to medical management B. There is no real psychological basis for his illness C. The disorder is a threat to his physical well-being D. He is unable to participate in planning his care
C
Prior to an amniocentesis, a fetal ultrasound is done in order to: A. Evaluate fetal lung maturity B. Evaluate the amount of amniotic fluid C. Locate the position of the placenta and fetus D. Ensure that the fetus is mature enough to perform the amniocentesis
C
Respiratory function is altered in a 16-year-old asthmatic Which of the following is the cause of this alteration? A. Altered surfactant production B. Paradoxical movements of the chest wall C. Increased airway resistance D. Continuous changes in respiratory rate and depth
C
The FHR pattern in a laboring client begins to show early decelerations The nurse would best respond by: A. Notifying the physician B. Changing the client to the left lateral position C. Continuing to monitor the FHR closely D. Administering O2 at 8 L/min via face mask
C
The nurse in the mental health center is instructing a depressed client about the dietary restrictions necessary in taking her medication, which is a monoamine oxidase (MAO) inhibitor Which of the following is she restricting from the client's diet? A. Cream cheese B. Fresh fruits C. Aged cheese D Yeast bread
C
The nurse is admitting an infant with bacterial meningitis and is prepared to manage the following possible effects of meningitis: A Constipation B Hypothermia C Seizure D Sunken fontanelles
C
The nurse is collecting a nutritional history on a 28- year-old female client with irondeficiency anemia and learns that the client likes to eat white chalk When implementing a teaching plan, the nurse should explain that this practice: A. Will bind calcium and therefore interfere with its metabolism B. Will cause more premenstrual cramping C. Interferes with iron absorption because the iron precipitates as an insoluble substance D. Causes competition at iron-receptor sites between iron and vitamin B1
C
Which of the following ECG changes would be seen as a positive myocardial stress test response? A. Hyperacute T wave B. Prolongation of the PR interval C.ST-segment depression D Pathological Q wave
C
Which of the following should be included in discharge teaching for a client with hepatitis C? A He should take aspirin as needed for muscle and joint pain B. He may become a blood donor when his liver enzymes return to normal C. He should avoid alcoholic beverages during his recovery period D. He should use disposable dishes for eating and drinking
C
A woman diagnosed with multiple sclerosis is disturbed with diplopia The nurse will teach her to: A. Limit activities which require focusing (close vision) B. Take more frequent naps C. Use artificial tears D. Wear a patch over one eye
D
A 27-year-old primigravida at 32 weeks' gestation has been diagnosed with complete placenta previa Conservative management including bed rest is the proper medical management The goal for fetal survival is based on fetal lung maturity The test used to determine fetal lung maturity is: A. Dinitrophenylhydrazine B.Metachromatic stain C. Blood serum phenylalanine test D. Lecithin-sphingomyelin ratio
D
A 44-year-old female client is receiving external radiation to her scapula for metastasis of breast cancer. Teaching related to skin care for the client would include which of the following? A. Teach her to completely clean the skin to remove all ointments and markings after each treatment B. Teach her to cover broken skin in the treated area with a medicated ointment C. Encourage her to wear a tight-fitting vest to support her scapula D. Encourage her to avoid direct sunlight on the area being treated
D
A 48-year-old client is in the surgical intensive care unit after having had three-vessel coronary artery bypass surgery yesterday She is extubated, awake, alert and talking She is receiving digitalis for atrial arrhythmias This morning serum electrolytes were drawn Which abnormality would require immediate intervention by the nurse after contacting the physician? A. Serum osmolality is elevated indicating hemoconcentration The nurse should increase IV fluid rate B. Serum sodium is low The nurse should change IV fluids to normal saline C. Blood urea nitrogen is subnormal The nurse should increase the protein in the client's diet as soon as possible D. Serum potassium is low The nurse should administer KCl as ordered
D
A 48-year-old female client is going to have a cholecystectomy in the morning In planning for her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be high risk for: A. Knowledge deficit B. Urinary retention C. Impaired physical mobility D. Ineffective breathing pattern
D
A 5-year-old has just had a tonsillectomy and adenoidectomy Which of these nursing measures should be included in the postoperative care? A Encourage the child to cough up blood if present B. Give warm clear liquids when fully alert C. Have child gargle and do toothbrushing to remove old blood D. Observe for evidence of bleeding
D
A 67-year-old client will be undergoing a coronary arteriography in the morning Client teaching about postprocedure nursing care should include that: A. Bed rest with bathroom privileges will be ordered B. He will be kept NPO for 8-12 hours C. Some oozing of blood at the arterial puncture site is normal D. The leg used for arterial puncture should be kept straight for 8-12 hours
D
A client had a hemicolectomy performed 2 days ago Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision This complication of wound healing is known as: A. Excoriation B. Dehiscence C. Decortication D Evisceration
D
A client is now pregnant for the second time Her first child weighed 4536 g at delivery The client's glucose tolerance test shows elevated blood sugar levels Because she only shows signs of diabetes when she is pregnant, she is classified as having: A. Insulin-dependent diabetes B. Type II diabetes mellitus C. Type I diabetes mellitus D. Gestational diabetes mellitus
D
A client states to his nurse that "I was told by the doctor not to take one of my drugs because it seems to have caused decreasing blood cells" Based on this information, which drug might the nurse expect to be discontinued? A. Prednisone B. Timolol maleate (Blocadren) C. Garamycin (Gentamicin) D. Phenytoin
D
A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL Life-threatening complications may occur initially, so the nurse will monitor him closely for serum: A. Chloride level of 99 mEq/L B. Sodium level of 136 mEq/L C. Potassium level of 31 mEq/L D. Potassium level of 63 mEq/L
D
A female client has just died Her family is requesting that all nursing staff leave the room The family's religious leader has arrived and is ready to conduct a ceremony for the deceased in the room, requesting that only family members be present The nurse assigned to the client should perform the appropriate nursing action, which might include: A. Inform the family that it is the hospital's policy not to conduct religious ceremonies in client rooms B. Refuse to leave the room because the client's body is entrusted in the nurse's care until it can be brought to the morgue C. Tell the family that they may conduct their ceremony in the client's room; however, the nurse must attend D. Respect the client's family's wishes
D
A gravida 2 para 1 client is hospitalized with severe preeclampsia While she receives magnesium sulfate (MgSO4) therapy, the nurse knows it is safe to repeat the dosage if: A. Deep tendon reflexes are absent B. Urine output is 20 mL/hr C. MgSO4serum levels are>15 mg/dL D. Respirations are>16 breaths/min
D
A violent client remains in restraints for several hours Which of the following interventions is most appropriate while he is in restraints? A Give fluids if the client requests them B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed C. Measure vital signs at least every 4 hours D.Release restraints every 2 hours for client to exercise
D
After the RN is finished the initial assessment of a newborn baby and after the initial bonding between the newborn and the mother has taken place in the delivery room, the RN will bring the newborn to the well-baby nursery Before the newborn is taken from the delivery roomand brought to the well-baby nursery, the RN makes sure that which of the following interventions was completed? A. The physician verifies the exact time of birth B. The nurse counts the instruments and sponges with the scrub nurse C. The nurse instills prophylactic ointment in the conjunctival sacs of the newborn's eyes D. The nurse makes sure the mother and her newborn have been tagged with identical bands
D
An 11-year-old boy has received a partial-thickness burn to both legs He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs What is the first nursing action? A Apply ice packs to both legs B. Begin debridement by removing all charred clothing from wound C. Apply Silvadene cream (silver sulfadiazine) D. Immerse both legs in cool water
D
Based on your knowledge of genetic inheritance, which of these statements is true for autosomal recessive genetic disorders? A Heterozygotes are affected B.The disorder is always carried on the X chromosome C. Only females are affected D. Two affected parents always have affected children
D
Cystic fibrosis is transmitted as an autosomal recessive trait This means that: A. Mothers carry the gene and pass it to their sons B. Fathers carry the gene and pass it to their daughters C. Both parents must have the disease for a child to have the disease D. Both parents must be carriers for a child to have the disease
D
Diagnostic assessment findings for an infant with possible coarctation of the aorta would include: A. A third heart sound B. A diastolic murmur C. Pulse pressure difference between the upper extremities D. Diminished or absent femoral pulses
D
During a client's first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus This may be due to: A. Endometritis B. Fibroid tumor on the uterus C. Displacement due to bowel distention D. Urine retention or a distended bladder
D
Following a gastric resection, which of the following actions would the nurse reinforce with the client in order to alleviate the distress from dumping syndrome? A. Eating three large meals a day B. Drinking small amounts of liquids with meals C. Taking a long walk after meals D. Eating a low-carbohydrate diet
D
NO65 A schizophrenic client who is experiencing thoughts of having special powers states that "I am a messenger from another planet and can rule the earth" The nurse assesses this behavior as: A. Ideas of reference B. Delusions of persecution C. Thought broadcasting D.Delusions of grandeur
D
The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure Which one of the following actions should the nurse take? A Place a tongue blade in the child's mouth B. Restrain the child so he will not injure himself C. Go to the nurses station and call the physician D. Move furniture out of the way and place a blanket under his head
D
The nurse is assessing breath sounds in a bronchovesicular client She should expect that: A. Inspiration is longer than expiration B. Breath sounds are high pitched C. Breath sounds are slightly muffled D. Inspiration and expiration are equal
D
The pediatric nurse charts that the parents of a 4-yearold child are very anxious Which observation would indicate to the nurse unhealthy coping by these parents: A. Discussing their needs with the nursing staff B. Discussing their needs with other family members C. Seeking support from their minister D. Refusing to participate in the child's care
D
The pediatrician has diagnosed tinea capitis in an 8- year-old girl and has placed her on oral griseofulvin The nurse should emphasize which of these instructions to the mother and/or child? A. Administer oral griseofulvin on an empty stomach for best results B. Discontinue drug therapy if food tastes funny C. May discontinue medication when the child experiences symptomatic relief D. Observe for headaches, dizziness, and anorexia
D
The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 1-2 hours if needed The most likely rationale for this order is: A. The client will settle down more quickly if he thinks the staff is medicating him B. The medication will sedate the client until the physician arrives C. Haloperidol is a minor tranquilizer and will not oversedate the client D. Rapid neuroleptization is the most effective approach to care for the violent or potentially violent client
D
Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression His wife stated that he had threatened to kill himself with a handgun As the nurse admits him to the unit, he says, "I wish I were dead because I am worthless to everyone; I guess I am just no good" Which response by the nurse is most appropriate at this time? A. "I don't think you are worthless I'm glad to see you, and we will help you" B. "Don't you think this is a sign of your illness?" C. "I know with your wife and new baby that you do have a lot to live for" D. "You've been feeling sad and alone for some time now?"
D
