NCLEX Passpoint (120/200)

The nurse instructs parents about the physical signs to look for in their child suspected of using cocaine. What finding should the nurse tell the parents is consistent with cocaine use? "His eyes would be red and bloodshot." "His pupils would be constricted to pinpoints." "His pupils would be large." "His eyes would look tired."

"His pupils would be large." Amphetamines, including cocaine, cause pupils to dilate.

A client is on several medications to control hypertension. As the nurse reviews the mechanism of action for each medication, what statement does the nurse use to describe how furosemide treats hypertension? "It decreases sympathetic cardioacceleration." "It dilates peripheral blood vessels." "It inhibits the angiotensin-converting enzyme." "It inhibits reabsorption of sodium and water in the loop of Henle."

"It inhibits reabsorption of sodium and water in the loop of Henle."

A client admitted for treatment of a colon tumor, asks, "Do I have cancer?" Which response by the nurse would be most therapeutic? "Tumors are not always cancerous." "You sound concerned about what's happening." "You'll have to have some tests to rule out cancer." "Your healthcare provider can discuss this in more detail."

"You sound concerned about what's happening."

Which suggestions should the nurse include when teaching the parents of a child who has viral tonsillitis? Select all that apply. Give acetaminophen for sore throat. Supply a regular diet. Offer cough medicine every 4 hours. Gargle with warm salt water. Offer lots of fluids. Administer aspirin for fever control.

Gargle with warm salt water. Give acetaminophen for sore throat. Offer lots of fluids.

A home care nurse is assessing a new client whose albumin level is 1.5 g/dL (15 g/L) and whose body weight is 25% below the ideal weight. What action should the nurse take? Perform capillary refill time assessment. Perform 3-day diet recall with client. Obtain order for enteral feedings. Obtain order for total protein level.

Perform 3-day diet recall with client.

A nurse is providing home care to a client with a foot ulcer related to diabetes. The client needs daily insulin injections. Family caregivers do not possess the technical skills to inject insulin. Which should the nurse keep in mind? Family caregivers are always perceived to be supportive of good care. The current reimbursement system recognizes the family's nontechnical value priorities. The nurse needs to be creative in integrating the technical and relational aspects of care. Nurses should avoid asking the family caregivers to conduct the skilled task.

The nurse needs to be creative in integrating the technical and relational aspects of care.

The nurse is caring for a group of clients. Which client should the nurse see first? a client with new onset of atrial fibrillation who has a heart rate of 95 a client with stable angina who took one sublingual nitroglycerine 30 minutes ago a client with a placement of a coronary artery stent 30 minutes ago a client with a history of sinus tachycardia who is to receive a beta-blocker

a client with stable angina who took one sublingual nitroglycerine 30 minutes ago

A nurse is conducting a group session for children and adolescents who have been diagnosed with depression. Which behaviors would a nurse anticipate in this group? Select all that apply. mania anxiety irritability suicidal thoughts delusions somatic symptoms

anxiety irritability somatic symptoms suicidal thoughts

A client diagnosed with rheumatoid arthritis reports that pain and stiffness are worse when arising in the morning. What interventions can the nurse suggest to assist the client in decreasing the pain? Select all that apply. splint the joints in the same position adaptive equipment around the clock opioids for pain hot bath to alleviate stiffness energy conservation techniques

energy conservation techniques adaptive equipment hot bath to alleviate stiffness

The parent of an autistic child visits the clinic and tells the nurse that her child has been acting out in school, particularly in the cafeteria and during gym class. Understanding that the child may be having difficulty with sensory processing, the nurse should suggest that the health care provider refer the child to which professional? physical therapist mental health provider occupational therapist speech language pathologist

occupational therapist Occupational therapists can help evaluate sensory processing issues and fine motor difficulties. Many occupational therapists are also trained in coping strategies to help individuals feel more comfortable in their surroundings.

A nurse is caring for a client in restraints on a psychiatric unit. Which nursing action would cause the charge nurse to intervene? placing two fingers between the restraint and the client's skin before securing to the bed frame removing the restraints and performing range-of-motion activities every 4 hours obtaining restraint orders every 24 hours from the healthcare provider tying a quick-release knot when securing the restraints

removing the restraints and performing range-of-motion activities every 4 hours

After a cholecystectomy, the client is to follow a low-fat diet. Which food would be most appropriate to include in a low-fat diet? roast beef sandwich with lettuce and tomato cheese omelet with onions peanut butter on wheat toast ham salad sandwich made with mayonnaise

roast beef sandwich with lettuce and tomato

When providing discharge instructions to a client being discharged from the hospital, the nurse knows that specific interventions can promote cost-effective care. Which intervention(s) is appropriate during discharge teaching? Select all that apply. Discuss the importance of filling new prescriptions and taking them as prescribed. Confirm that the client has the means (financial, transportation) to get new prescriptions and to attend appointments. Ensure that the client has a follow-up appointment scheduled with the primary care provider prior to discharge. Tell the client to return to the hospital for all follow-up concerns. Educate the client on signs and symptoms that may be experienced and which level of care is appropriate for those situations.

Discuss the importance of filling new prescriptions and taking them as prescribed. Ensure that the client has a follow-up appointment scheduled with the primary care provider prior to discharge. Confirm that the client has the means (financial, transportation) to get new prescriptions and to attend appointments. Educate the client on signs and symptoms that may be experienced and which level of care is appropriate for those situations.

A client with congestive heart failure is admitted to the hospital. Which interventions should the nurse include in the plan of care to prevent skin breakdown? Select all that apply. Apply 2 liters of oxygen per nasal cannula if SaO2 < 93%. Encourage the client to ambulate three times a day. Apply heel protectors when lying in bed. Monitor vital signs every 4 hours. Weigh the client daily at the same time in the morning.

Encourage the client to ambulate three times a day. Apply heel protectors when lying in bed.

A client is admitted with a tentative diagnosis of acquired immunodeficiency syndrome (AIDS). The client undergoes biopsies of facial lesions. The preliminary report indicates Kaposi's sarcoma. Which action by the nurse is most appropriate? Inform the client of the biopsy results and support them emotionally. Tell the client that Kaposi's sarcoma is common in people with AIDS. Explore the client's feelings about the facial disfigurement. Pretend not to notice the lesions on the client's face.

Explore the client's feelings about the facial disfigurement.

During rounds, a nurse finds that a client with hemiplegia has fallen from the bed because the nursing assistant failed to raise the side rails after giving a back massage. The nurse assists the client to the bed and assesses for injury. As per agency policies, the nurse fills out an incident report. Which activity should the nurse perform related to documentation? Include the time and date of the incident in the report. Highlight the mistake in the client record. Include the name of the nursing assistant in the report. Attach a copy of the finished report to the client record.

Include the time and date of the incident in the report.

The nurse is assessing a client with Buerger's disease. The nurse should determine if the client is experiencing: Inflammation and fibrosis of arteries, veins, and nerves. Vasospasm lasting several minutes. Pain, pallor, and pulselessness. Thickening of the intima and media of the artery.

Inflammation and fibrosis of arteries, veins, and nerves. White blood cells infiltrate the area and become fibrotic, which results in occlusion of the vessels. Signs and symptoms include slowly developing claudication, cyanosis, coldness, and pain at rest.

The nurse is performing wound care on a client with an open fracture. What is the nurse's priority action to clean the wound? Apply antibiotic ointment to the site. Irrigate the wound with normal saline. Administer ordered pain medication.

Irrigate the wound with normal saline.

A client has radiation seeds implanted into the prostate gland. Which action should the nurse take to safely provide care to this client? Select all that apply. Identify the safest amount of time to be at the bedside. Explain that the implanted seeds will be expelled through the urine. Place a permanent divider to shield the client in a semi-private room. Learn the safe distance from the client. Obtain the necessary shielding when providing care.

Learn the safe distance from the client. Identify the safest amount of time to be at the bedside. Obtain the necessary shielding when providing care.

A nurse writes a note in a client's chart that says: "The physician is incompetent because the physician ordered the incorrect drug dosage." This statement may lead to a charge of libel. slander. battery. assault.

Libel refers to written communication that harms a person's reputation.

An assessment of a client on the first day after a thoracotomy shows a temperature of 100° F (37.8° C); heart rate, 96 bpm; blood pressure, 136/86 mm Hg; and shallow respirations at 30 breaths/min, with rhonchi at the bases. The client is diaphoretic, anxious, and reports of incisional pain. Which nursing action is priority? Give ibuprofen as ordered to reduce the fever. Encourage the client to cough and breathe deeply. Help the client get out of bed. Medicate the client for pain as ordered.

Medicate the client for pain as ordered.

The emergency-room nurse is caring for a trauma client with the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How should the nurse interpret these results? Metabolic acidosis with a compensatory respiratory alkalosis Metabolic alkalosis with a compensatory alkalosis Metabolic acidosis with no compensation Respiratory acidosis with no compensation

Metabolic acidosis with a compensatory respiratory alkalosis

The therapeutic team has identified the need to formulate strategies to maintain a safe environment for a client with schizophrenia displaying inappropriate behavior. Which strategy must be initiated immediately? Monitor the client's behavior. Teach appropriate ways to communicate and interact with others. Identify the client's thought process that leads to the client's behavior. Explore with the client's reasons for demonstrating this behavior.

Monitor the client's behavior. The unit must be maintained as a safe environment for the client and the other clients; therefore, the client should never have unsupervised time on the unit.

A nurse is caring for a client on life support in the cardiac care unit. The client's family, which is strongly religious, is unable to unanimously decide to remove life support. What should the nurse do? Select all that apply. Notify the hospital's ethics committee of the ethical dilemma. Supply the family with information and pamphlets on funeral services. Request pastoral services to assist the family in this decision. Ask the family to leave the unit to pray for a unified decision. Initiate family discussions around what the client would have wanted.

Notify the hospital's ethics committee of the ethical dilemma. Request pastoral services to assist the family in this decision. Initiate family discussions around what the client would have wanted.

After the administration of t-PA, the assessment priority is to: Monitor breath sounds. Monitor the 12-lead electrocardiogram (ECG) every 4 hours. Monitor for fever. Observe the client for chest pain.

Observe the client for chest pain. observing the client for chest pain is the nursing assessment priority because closure of the previously obstructed coronary artery may recur.

A nurse is caring for a full-term neonate who is 24 hours old. Assessment findings include axillary temperature of 96.8° F (36° C), apical heart rate of 188 beats/minute, and respiratory rate of 48 breaths/minute. The mother reports that the neonate is lethargic when she tries to breast-feed and looks "like a rag doll." The mother also has a low-grade fever. Pulse oximetry reveals saturation of 89% on room air, and the neonate has dusky mucous membranes. What are the most appropriate nursing interventions? Select all that apply. Observe the neonate carefully, contact the physician, and explain her suspicions of early neonatal sepsis. Encourage the mother to breast-feed because the neonate is becoming dehydrated. Provide blow-by oxygen and monitor the neonate's respiratory status. Keep the neonate in the nursery, monitor vital signs every 2 hours, and inform the physician of the neonate's status when the physician makes routine rounds in the nursery. Inform the parents that she wants to monitor the neonate closely.

Observe the neonate carefully, contact the physician, and explain her suspicions of early neonatal sepsis. Provide blow-by oxygen and monitor the neonate's respiratory status. Inform the parents that she wants to monitor the neonate closely.

A client has undergone total gastrectomy due to stomach cancer. Which nursing interventions are necessary for this client immediately after surgery? Select all that apply. Irrigate and reposition the nasogastric (NG) tube if drainage is minimal. Maintain the client in a supine position. Encourage incentive spirometry use every hour during the client's waking hours. Administer opioid analgesics as prescribed. Observe the wound for redness, swelling, and warmth.

Observe the wound for redness, swelling, and warmth. Encourage incentive spirometry use every hour during the client's waking hours. Administer opioid analgesics as prescribed.

A multipara who gave birth to a viable male neonate 12 hours ago plans to breastfeed her baby, although she bottle-fed her first two children. The client tells the nurse that she has cramps every time she breastfeeds. What should the nurse do? Suggest more frequent ambulation during the day. Offer the client a prescribed stool softener. Advise the client to breastfeed more often. Offer the client a prescribed analgesic.

Offer the client a prescribed analgesic. Multiparas tend to experience cramps while breastfeeding more frequently than do primiparas because breastfeeding releases oxytocin, causing uterine muscles to contract. The uterine muscles tend to be more tonically contracted after childbirth in primiparas.

The nurse is preparing to help a client move up in bed with a goal of prevention of skin breakdown. Place the following steps in order for the procedure. All options must be used. 2Place a friction-reducing sheet under the client's midsection. 1Place the bed in the Trendelenburg position to prepare for the move. 3Have the client lift the head during the move. 4Have the client place the feet flat on the bed during the move.

Place a friction-reducing sheet under the client's midsection. Place the bed in the Trendelenburg position to prepare for the move. Have the client place the feet flat on the bed during the move. Have the client lift the head during the move.

A client has a plaster cast applied to the lower extremity that is still wet to touch. In which way should the nurse move the casted limb to elevate it on a pillow? Lift the limb from the knee. Place the palms on both sides of the cast. Place the fingers around the cast. Lift the limb from the ankle.

Place the palms on both sides of the cast.

A client with a T2-to-T3 spinal cord injury suddenly has a throbbing headache and blurred vision. The client is flushed and sweating on the upper trunk and face, and the hairs on the arms are raised. What should the nurse do first? Assess for hypotension. Logroll the client to see if he is lying on a foreign object. Raise the head of the bed. Check the client for a distended bladder.

Raise the head of the bed. When the client demonstrates clinical manifestations of autonomic dysreflexia, the nurse should first elevate the head of the bed immediately to decrease the intracerebral pressure caused by the hypertension that developed from autonomic stimulation

The nurse is caring for a client with a nasogastric tube who is receiving intermittent tube feedings by gravity every 4 hours. The nurse aspirates 75 mL of residual prior to the next feeding. What action should the nurse take next? Return the residual and begin the feeding. Hold the feeding and recheck the residual in 4 hours. Discard the residual and subtract the residual amount from the feeding. Administer an amount of water equivalent to the feeding.

Return the residual and begin the feeding.

A client with heart failure has been receiving an I.V. infusion at 125 ml/hour. Now the client is short of breath and the nurse notes bilateral crackles, jugular vein distention, and tachycardia. What should the nurse do first? Discontinue the I.V. catheter. Administer a ordered diuretic. Notify the physician. Slow the I.V. infusion.

Slow the I.V. infusion.

The nurse in an inpatient psychiatric adult unit is assigned care for a group of clients. Which client would the nurse see first during morning rounds? client with depression who refused medications last evening and will not get out of bed client with schizophrenia scheduled to be discharged today client admitted to the hospital for agitation and paranoia client with advanced dementia who has not communicated in the 2 days since arriving on the unit

client admitted to the hospital for agitation and paranoia

When developing a nutritional plan for a child who needs to increase protein intake, the nurse should suggest which foods? Select all that apply. potatoes apples cooked dry beans peanut butter yogurt

cooked dry beans peanut butter yogurt

To treat cervical cancer, a client has had an applicator of radioactive material placed in the vagina. Which observation by the nurse indicates a radiation hazard? The nurse checks the applicator's position every 4 hours. The head of the bed is at a 30-degree angle. The client receives a complete bed bath each morning. The client is maintained on strict bed rest.

The client receives a complete bed bath each morning. The client shouldn't receive a complete bed bath while the applicator is in place. In fact, she shouldn't be bathed below the waist because doing so puts the nurse at risk for radiation exposure.

In setting goals for a client with advanced liver cancer who has poor nutrition, which is a desired outcome for the client? The client will have normalized albumin levels. The client will gain 1 lb (0.5 kg) every 2 weeks. The client will return to ideal body weight. The client will maintain current weight.

The client will maintain current weight.

After the nurse instructs a client who is scheduled for in vitro fertilization (IVF) about the procedure, which statement by the client indicates to the nurse that the instructions have been successful? "I will need to receive a series of estrogen injections after I have the procedure." "After fertilization, three or four embryos will be transferred through the cervix." "My risk for multiple births is lower with this procedure than with the gamete intra-fallopian transfer procedure." "I know that the chances of getting pregnant with this procedure are about 50%."

"After fertilization, three or four embryos will be transferred through the cervix."

The nurse is evaluating the client's learning about combination chemotherapy. Which statement by the client about reasons for using combination chemotherapy indicates the need for further explanation? "Combination chemotherapy is used to decrease resistance." "Combination chemotherapy is used to minimize the toxicity from using high doses of a single agent." "Combination chemotherapy is used to destroy cancer cells and treat side effects simultaneously." "Combination chemotherapy is used to interrupt cell growth cycle at different points."

"Combination chemotherapy is used to destroy cancer cells and treat side effects simultaneously."

A client with a forceful, pounding heartbeat is diagnosed with mitral valve prolapse. Which client statement indicates to the nurse a need for additional teaching? "I should eat foods rich in protein." "I can still drink coffee and tea in moderation." "I should increase my fluid intake." "I'll enroll in an aerobic exercise program."

"I can still drink coffee and tea in moderation."

The nurse is caring for a senior citizen who lives alone. When evaluating the effectiveness of adding fluticasone propionate and salmeterol to the chronic obstructive airway disease (COPD) client's medication regimen, which client statements would support symptom improvement? Select all that apply. "I seem to feel nervous and shaky, making me more productive." "I have begun walking upstairs to use the bathroom." "The nurse aide no longer comes to the house to help me bathe." "I can rely on the medication when I have an exacerbation of symptoms." "I can now push my granddaughter on the swings when she visits." "I have noted an increase in sputum production."

"I have begun walking upstairs to use the bathroom." "I can now push my granddaughter on the swings when she visits." "The nurse aide no longer comes to the house to help me bathe."

After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching? "I'll have to catheterize my pouch every 2 hours." "I'll have to wear an external collection pouch for the rest of my life." "I'll need to drink at least eight glasses of water a day." "I should eat foods from all the food groups."

"I'll have to wear an external collection pouch for the rest of my life."

A nurse is caring for a newly admitted client who appears anxious and fearful. The client states, "I do not trust any of you. Stay away from me!" Which nursing actions would be beneficial? Select all that apply. The nurse would sit quietly near the client and respond to questions. The nurse would calmly state, "I am here to help you. What can I do?" The nurse would mirror the client's mannerisms and anxiety level. The nurse would notify the health care provider and ask for a sedative. The nurse would state, "Tell me why you do not trust me." The nurse would agree saying that it is hard to trust people these days

The nurse would calmly state, "I am here to help you. What can I do?" The nurse would state, "Tell me why you do not trust me." The nurse would sit quietly near the client and respond to questions.

A client is taking an antacid for treatment of a peptic ulcer. Which statement best indicates that the client understands how to correctly take the antacid? "It is best for me to take my antacid 1 to 3 hours after meals." "I should take my antacid before I take my other medications." "I need to decrease my intake of fluids so that I do not dilute the effects of my antacid." "My antacid will be most effective if I take it whenever I experience stomach pains."

"It is best for me to take my antacid 1 to 3 hours after meals."

Metabolic screening of an infant revealed a high phenylketonuria (PKU) level. Which statement the infant's mother indicates understanding of the disease and its management? Select all that apply. "A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby grow." "My baby will grow out of this by the age of 2." "My baby will eventually become intellectually disabled because of this disease." "My baby cannot have milk-based formulas." "We have to follow a strict low-phenylalanine diet." "This is a hereditary disease, so any future children will have it, too."

"My baby cannot have milk-based formulas." "We have to follow a strict low-phenylalanine diet." "A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby

The nurse is working on a labor and delivery unit, and is precepting a new graduate nurse. The graduate asks the preceptor, "Is oxytocin used for pain in labor and delivery?" What is the best response by the preceptor? Select all that apply. "Oxytocin is used to control postpartum bleeding." "Oxytocin is used for labor induction." "Oxytocin is used to stimulate breast milk ejection." "Oxytocin is used to prevent pregnancy." "Oxytocin is used for amenorrhea."

"Oxytocin is used to control postpartum bleeding." "Oxytocin is used to stimulate breast milk ejection." "Oxytocin is used for labor induction."

A primigravid client is seen for her first visit in the antenatal clinic and tells the nurse that her brother was born with cystic fibrosis (CF). When teaching the client about this disorder, the nurse should include which information? Select all that apply. Persons of Asian descent have the highest inheritance rates. Chorionic villi sampling (CVS) can identify prenatally if their child carries the trait or has the disease. Fetal testing can occur by checking the shape of the red blood cells. To inherit CF, each parent must carry a recessive trait for the disease. If both parents carry the trait, each offspring has a 25% chance of inheriting the disease.

To inherit CF, each parent must carry a recessive trait for the disease. If both parents carry the trait, each offspring has a 25% chance of inheriting the disease. Chorionic villi sampling (CVS) can identify prenatally if their child carries the trait or has the disease.

A nurse is caring for a client with pulmonary edema. The physician writes the accompanying orders. Which order should the nurse clarify? furosemide I.V. 40 mg every 6 hours 0.9% normal saline solution I.V. at 150 ml/hour dobutamine 5 mcg/kg/minute I.V. morphine I.V. 2 mg every 2 hours P.R.N. for shortness of breath

0.9% normal saline solution I.V. at 150 ml/hour

The partner of a 22-year-old client dies in a drunk-driving accident. The client complains of difficulty eating, sleeping, and working. The reaction is considered: a pathologic response to grief. a crisis of anticipated life transitions. a non-crisis situation. a crisis caused by traumatic stress.

a crisis caused by traumatic stress. This client is in crisis as a result of the traumatic stress of losing the partner. A traumatic event can create symptoms, such as difficulty eating, sleeping, and working.

A registered nurse (RN) is assigning tasks to a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) on the client care team. Which task is restricted in terms of which care team member it could be delegated to? Select all that apply. administering oral pain medication to a postoperative client assisting a client to the bathroom who uses a walker for mobility assessing a client who just returned from cardiac catheterization providing oral care to a client who had nothing by mouth before surgery taking the health history of a newly admitted client

administering oral pain medication to a postoperative client assessing a client who just returned from cardiac catheterization taking the health history of a newly admitted client

A client in a catatonic state is admitted to the inpatient unit. The client is emaciated, stares blankly into space, and doesn't respond to verbal or tactile stimuli. In formulating nursing care interventions, the nurse should give priority to:

assessing the client's nutritional and hydration status

Which drug delivery system most effectively reduces the likelihood of medication errors? floor stock unit-dose individual prescription automated

automated

A client who's a member of Jehovah's Witnesses refuses a blood transfusion based on religious beliefs and practices. The client's decision must be followed based on which ethical principle? the right to die autonomy of the client substituted judgment advance directive

autonomy of the client

A client is taking finasteride. The nurse is most concerned when this client manifests azotemia. breast enlargement. decreased prostate size. flushing.

azotemia. a buildup of nitrogenous waste products in the blood, indicates impaired renal function. Finasteride, an antiandrogenic agent, is prescribed for chronic urinary retention secondary to benign prostatic hypertrophy (BPH).

The nurse manager is preparing to meet with several registered nurses (RNs) in the department to address practice issues. Which behavior by an RN will the nurse manager address as a violation of the RN's "duty to care"? fabricated assessment results in the medical record for an admitted client declined assignment to care for a client with dementia who was incontinent of stool shared confidential information about a hospitalized client on social media administered medications to a client in error that were intended for the client's roommate

declined assignment to care for a client with dementia who was incontinent of stool

A child with heart failure is taking captopril. What are the desired effects of this medication? Select all that apply. increased urine output decreased urine output decreased preload decreased blood pressure increased blood pressure increased preload

decreased blood pressure decreased preload increased urine output

The nurse has administered meperidine to a client in labor. Which change in the fetal heart rate tracing would the nurse expect to occur as a result of the meperidine administration? early decelerations decreased fetal heart rate variability fetal bradycardia repetitive late decelerations

decreased fetal heart rate variability

A client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs? increased urinary frequency impaired color discrimination increased appetite decreased hearing acuity

decreased hearing acuity

A nurse strives daily to provide competent care and make moral choices in the practice of nursing. Which behaviors demonstrated by the nurse exemplify the moral choices in practice? Select all that apply. receiving baked goods from a client's family for care rendered providing in-service education for staff to advance up the clinical ladder spending time caring for a client and receiving no acknowledgement for the effort coming in to work an extra shift to receive an incentive bonus delivering the same quality care while working overtime due to a staffing shortage

delivering the same quality care while working overtime due to a staffing shortage spending time caring for a client and receiving no acknowledgement for the effort

Which intervention will the nurse expect for a client with a positive tuberculin skin test? a) Obtain a sputum specimen for AFB b) Administer the first dose of rifampin c) Prepare the client for a chest X-ray d) Place to client in airborne precautions

c) Prepare the client for a chest X-ray

A client is to receive total parental nutrition (TPN) solution. The nurse is aware it will be given via a central line and contains which main nutrient? electrolytes and 10 units of heparin amino acids, including vitamin K 50% dextrose 10% fat emulsions

50% dextrose TPN is a hypertonic solution that consists of dextrose, proteins, and electrolytes. High-glucose solutions are better tolerated in a central line based on viscosity. Other answers can be given peripherally and do not require a central line.

Every morning, a client with type 1 diabetes receives 15 units of Humulin 70/30. What does this type of insulin contain? 70% NPH insulin and 30% regular insulin 70% regular insulin and 30% NPH insulin 70 units of neutral protamine Hagedorn (NPH) insulin and 30 units of regular insulin 70 units of regular insulin and 30 units of NPH insulin

70% NPH insulin and 30% regular insulin

A nurse is caring for a client with a pulmonary infection secondary to acquired immunodeficiency syndrome (AIDS). Which intervention would be most effective to manage night sweats? Administer an antipyretic medication prophylactically as needed before the client goes to sleep. Encourage fluids to maintain hydration; keep fluids at the bedside at night. Administer tepid sponge baths in the early evening to prevent the night fever. Change the bed linens as needed to prevent skin breakdown.

Administer an antipyretic medication prophylactically as needed before the client goes to sleep.

The nurse reviews the nurse's note of an older adult client and implements which intervention to help with the maintenance of skin integrity? Turn the client to the left side using assistive devices. Apply a warm blanket after checking the client's temperature. Change the surgical dressing. Administer the ordered pain medication.

Administer the ordered pain medication.

Before the neonate's discharge, the mother tells the nurse that she is worried that her 5-year-old daughter will be jealous of the new baby when they get home. After explaining ways to deal with sibling rivalry, the nurse determines that the mother understands the instructions when she says she will do which action? Allow the 5-year-old undivided attention several times a day. Tell the daughter that the baby is just like one of her dolls. Divide her time equally between the baby and the daughter. Let the 5-year-old feed the baby at least once every day.

Allow the 5-year-old undivided attention several times a day.

A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What should the nurse anticipate in this client's plan of care? Alternation of hot and cold compresses An increased need for insulin and blood glucose monitoring Prepare the client for transillumination of the sinuses Bilateral nasal and tympanic membrane cultures

An increased need for insulin and blood glucose monitoring

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. The client is incontinent and has a tarry stool. Their blood pressure is 90/50 mm Hg, and hemoglobin is 10 g. Which nursing intervention is a priority for this client? performing range-of-motion (ROM) exercises on the left side elevating the head of the bed to 30 degrees checking stools for occult blood keeping skin clean and dry

elevating the head of the bed to 30 degrees Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client's risk of aspiration.

A client with a long history of ulcerative colitis takes sulfasalazine to control the condition. The nurse should evaluate the client for which nutritional deficit that can occur as a result of taking this drug? cobalamin deficit iron deficit niacin deficit folic acid deficit

folic acid deficit Clients who take sulfasalazine are susceptible to developing impaired folic acid absorption.

A client is receiving a blood transfusion, and 1 hour after starting the transfusion the client reports dyspnea and has crackles on lung auscultation. Which medication would be most important for the nurse to give? acetaminophen 600 mg PO diphenhydramine 50 mg PO furosemide 40 mg I.V. methylprednisolone 250 mg I.V. bolus

furosemide 40 mg I.V.

While assessing a neonate 30 minutes after birth, the nurse observes that the child has a short neck covered with webbing. The nurse should further assess the client for which problem? cleft palate neural tube defects genetic deviations Potter's syndrome

genetic deviations

A homeless client comes to the clinic coughing up blood and is diagnosed with active tuberculosis (TB). Which intervention by the nurse will be most effective in ensuring adherence with the pharmacological treatment regimen? Provide the client with written instructions about the importance of adherence to the treatment plan. Arrange for the client to pick up the medication in unit dose packaging at a local pharmacy. Arrange for the client to come to a community center each day to receive a meal and medication. Recommend having the client admitted to the hospital until the medication regimen is completed.

Arrange for the client to come to a community center each day to receive a meal and medication. Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen for tuberculosis. Providing the client with a daily meal will help ensure the client will come to receive the medication.

The nurse enters a client's hospital room and has difficulty identifying the hospitalized client among the six people in the room. The nurse is administering new medication. What are the nurse's best actions? Select all that apply Return to the room after the visitors leave. Ask the visitors to step out of the room. Ask the client to show his/her hospital name band. Ask the client to identify his/her name and date of birth. Assume the client is sitting on the bed.

Ask the client to identify his/her name and date of birth. Ask the client to show his/her hospital name band. Ask the visitors to step out of the room.

The nurse is instructing a client who will have a total hip replacement tomorrow. Which information is most important to include in the teaching plan at this time? Show the client what an actual hip prosthesis looks like. Teach how to prevent hip flexion. Demonstrate coughing and deep-breathing techniques. Assess the client's fears about the procedure.

Assess the client's fears about the procedure.

A client with right lower quadrant pain is admitted to the emergency department with a white blood cell (WBC) count of 17.8/mm3. What should the nurse do next? Notify the healthcare provider. Perform a complete abdominal assessment. Prepare the client for surgery. Assess vital signs.

Assess vital signs.

A nurse is delegating activities to unlicensed assistive personnel (UAP). Which activities can be appropriately delegated? Select all that apply. Assist client with oral care prior to breakfast. Determine if client is oriented to person, place and time and report to nurse. Observe and document effect of medication after given by the nurse. Ask about location, quality, and radiation of pain. Change a simple dry dressing on a client's coccyx while bathing. Measure and record intake and output throughout the shift.

Assist client with oral care prior to breakfast. Measure and record intake and output throughout the shift.

While caring for the neonate of a human immunodeficiency virus-positive mother, the nurse prepares to administer a prescribed vitamin K intramuscular injection at 1 hour after birth. Which action should the nurse do first? Place the neonate under a radiant warmer. Bathe the neonate. Wash the injection site with povidone-iodine solution. Wait until the first dose of antiretroviral medication is given.

Bathe the neonate. Newborns are typically bathed 2 to 4 hours after birth when their temperatures have had time to stabilize, but early/immediate bathing is recommended for the infants of HIV-positive mothers to decrease blood exposure.

A physician orders terbutaline 2.5 mg by mouth four times a day, for a child with bronchitis. If the child receives an I.V. infusion of terbutaline, which serious adverse reaction is possible? hypokalemia hyperkalemia hypocalcemia hypercalcemia

hypokalemia The nurse should monitor the client receiving an I.V. infusion of terbutaline for hypokalemia, lactic acidosis, chest pain, arrhythmias, dyspnea, bloating, chills, or anaphylactic shock

According to hospital protocol, after a client is restrained, the staff meet and discuss the restraint situation. In addition to sharing feelings and offering support, what should the nurse identify as the long-term goal for the debriefing? improving the staff's use of restraint procedures deciding when to release the client from restraints providing feedback to each other on how procedures were handled comparing the perceptions of the various staff members

improving the staff's use of restraint procedures

When creating an educational program about safety, what information should the nurse include about sexual predators? Select all that apply. Child molesters maintain the secrecy of their actions by making threats if offering attention and favors fail or if the child is close to revealing the secret. Child molesters pick children or teens over which they have some authority, making it easier for them to manipulate the child with special favors or attention. Child molesters gain the child's trust before making sexual advances so the child feels obligated to comply with sex. Child molesters resort to molestation because they have bad childhoods, so understanding that can help them decrease their molesting. Child molesters often choose children whose parents must work long hours, making the extra attention initially welcomed by the child.

Child molesters pick children or teens over which they have some authority, making it easier for them to manipulate the child with special favors or attention. Child molesters gain the child's trust before making sexual advances so the child feels obligated to comply with sex. Child molesters often choose children whose parents must work long hours, making the extra attention initially welcomed by the child. Child molesters maintain the secrecy of their actions by making threats if offering attention and favors fail or if the child is close to revealing the secret.

The nurse instructs the unlicensed assistive personnel on how to collect a 24-hour urine specimen. Which of the following instructions is correct for a collection that is scheduled to start at 7 a.m. (0700) Monday and end at 7 a.m. (0700) Tuesday? Send the first voided urine specimen on Monday to the laboratory for culture. Keep each day's urine collection in separate containers. Collect and save the urine voided at 7 a.m. (0700) on Tuesday. Collect and save the urine voided at 7 a.m. (0700) on Monday.

Collect and save the urine voided at 7 a.m. (0700) on Tuesday. When finishing a 24-hour urine collection, the final voided urine is saved and added to the collection container. The first urine specimen, voided at 7 a.m. (0700) Monday, is discarded. The urine is not sent for a urine culture. It is not necessary to separate each day's collection of urine.

What is the most cost-effective suggestion for bereavement support for the hospice nurse to give a woman whose husband died 3 months ago and her three young children? Remind her gently that bereavement care before death minimizes grieving. Request individual counseling and medication to manage depression. Continue her bereavement support through hospice. Seek group counseling support for the three children.

Continue her bereavement support through hospice.

Which vaccine should a nurse encourage a client with chronic obstructive pulmonary disease (COPD) to receive? Select all that apply. pneumonia pertussis varicella influenza hepatitis B

influenza pneumonia pertussis

A nurse caring for a client who has just received chemotherapy infusion is wearing a disposable gown, gloves, and goggles for protection. The nurse knows that accidental exposure to chemotherapy agents can occur through absorption through the gloves. absorption through the gown. inhalation of aerosols. absorption through the goggles.

inhalation of aerosols. Aerosol inhalation or absorption through the skin can cause accidental chemotherapy exposure

A nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to wear protective devices when exercising. wear worn, comfortable shoes. install safety devices in the home. get help when lifting objects.

install safety devices in the home.

A client is experiencing dryness in the nares while receiving oxygen via nasal cannula at 4 L/minute. Which medication should the nurse apply to help alleviate the dryness? lubricant jelly petroleum jelly antibiotic ointment sterile water

lubricant jelly

When formulating a plan of care for the postterm neonate at discharge, which outcome would be most appropriate? maintenance of a normal bilirubin level gain of 4 oz (120 g) by the time of discharge maintenance of normal body temperature establishment of a deep respiratory pattern

maintenance of normal body temperature

When administering an intravenous medication, the nurse should explain which teaching points to the client? Select all that apply. . possible adverse effects incompatibilities with other medications purpose of the medication manufacturer of the medication name of the medication date the medication will expire

name of the medication purpose of the medication . possible adverse effects

A client is undergoing a diagnostic workup for suspected thyroid cancer. What is the most common form of thyroid cancer in adults? follicular carcinoma medullary carcinoma papillary carcinoma anaplastic carcinoma

papillary carcinoma Papillary carcinoma accounts for about 70% of thyroid cancer cases in adults. Follicular carcinoma accounts for roughly 15%; anaplastic carcinoma, about 5%; and medullary carcinoma, about 5%.

A home health care nurse is making an initial visit to a 68-year-old client who was recently discharged from a rehabilitation facility after experiencing a stroke. The client has significant left-sided weakness and needs assistance with dressing and hygiene. The client lives alone with a 68-year-old partner. The partner has chronic obstructive pulmonary disease (COPD) and uses oxygen intermittently. Assessment findings include vital signs within normal parameters and intact pink, moist skin. The client denies any problems with urinary and bowel elimination. Based on the client's assessment, the nurse would most likely initiate referrals to which discipline? Select all that apply. occupational therapy skilled nursing service home health aide speech therapy physical therapy

physical therapy occupational therapy home health aide

Which foods should the nurse encourage the mother to offer to her child with iron-deficiency anemia? macaroni, cheese, and ham cereal, milk, and yellow vegetables pudding, green vegetables, and rice potato, peas, and chicken

potato, peas, and chicken

Which is an advantage of using biologic burn grafts such as porcine (pigskin) grafts? Porcine grafts: provide for permanent wound closure. promote the growth of epithelial tissue. encourage formation of tough skin. facilitate development of subcutaneous tissue.

promote the growth of epithelial tissue. They enhance the growth of epithelial tissues, minimize the overgrowth of granulation tissue, prevent loss of water and protein, decrease pain, increase mobility, and help prevent infection.

A registered nurse is mentoring a new graduate nurse. Which action by the new graduate demonstrates a need for further teaching? administers adenosine as a rapid I.V. push over 2 seconds to a client with supraventricular tachycardia turns the defibrillator to synchronize before defibrillating a client with ventricular fibrillation administers diltiazem to a client with atrial fibrillation administers lidocaine to a client experiencing frequent premature ventricular contractions (PVCs)

turns the defibrillator to synchronize before defibrillating a client with ventricular fibrillation

An unemployed client cannot afford prescription medications and has not taken the prescribed levothyroxine for some time. The client reports, "I've been getting sicker by the day." Which symptom is most likely related to not taking this medication? warm, dry, flushed skin diarrhea and vomiting tympanic temperature of 94° F (34.4° C) rapid heart rate

tympanic temperature of 94° F (34.4° C) Hypothyroidism leads to a hypodynamic state, so a low body temperature is expected after the levothyroxine has been metabolized

A neonate born at 30 weeks' gestation and weighing 2,000 g is admitted to the neonatal intensive care unit. What nursing measure will decrease insensible water loss in a neonate? use of eye patches with phototherapy use of a radiant warmer use of humidity in the incubator bathing the baby as soon after birth as possible

use of humidity in the incubator

A client with Alzheimer's disease is being treated for malnutrition and dehydration. The nurse decides to place them closer to the nurses' station because of their tendency to wander. exhibit acquiescent behavior. not change their position often. forget to eat.

wander.

A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should wash their hands after touching the client. place the client in a private room. wear a mask when handling the client's bedpan. wear a gown when providing personal care for the client.

wash their hands after touching the client. To maintain enteric precautions, the nurse must wash their hands after touching the client or potentially contaminated articles and before caring for another client.

Emergency restraints or seclusion may be implemented without a physician's order under which condition? if a voluntary client wants to leave against medical advice never when a licensed practitioner will do a face-to-face assessment within 1 hour when a child is acting out

when a licensed practitioner will do a face-to-face assessment within 1 hour In an emergency, a client who is a threat to self or others may be restrained without an order. If restraints are initiated without an order the client must be assessed within 1 hour of application by a licensed, independent practitioner.

The nurse is performing a medication reconciliation, and the client requests a green coffee bean supplement to lose weight. What is the nurse's best response? "The hospital does not offer any of the green coffee bean items, but I can get you some tomorrow from my home." "I will call your healthcare provider and tell them you are interested in adding the supplement to your medication regime." "The hospital does not have green coffee bean supplements in the formulary, but you can bring them from home." "There is limited scientific information on the connection between green coffee beans and weight loss."

"I will call your healthcare provider and tell them you are interested in adding the supplement to your medication regime." The nurse needs to contact the healthcare provider (HCP) to complete the medication reconciliation process. The supplement should be added to the regimen only after the HCP has assessed potential contraindications and given approval.

The nurse is developing a plan of care for a 10-year-old child who is hospitalized with acute osteomyelitis. The leg is immobilized in a splint and there is swelling and tenderness of the proximal tibia. What is an appropriate expected outcome for this child? "The child will bear weight on the affected limb." "The child will ambulate with crutches." "The child will change position with minimal discomfort." "The child will participate in age-appropriate activities."

"The child will change position with minimal discomfort."

A nurse is preparing to help a client with weakness in the right leg move from the bed to a wheelchair. Where should the nurse place the chair? Perpendicular to the bed on the right side 45 degrees to the bed on the left side 45 degrees to the bed on the right side

45 degrees to the bed on the left side The nurse should place the wheelchair at a 45 degree angle or parallel to the bed on the client's strong side to help prevent a fall.

A client with alcohol withdrawal syndrome is pulling at the central venous catheter, saying, "I'm swatting the spiders crawling all over me." What is the nurse's priority action? Encourage the client to rest. Tell the client there are no spiders. Explain that the client is pulling the I.V. tubing. Assign a nursing assistant to stay with the client.

Assign a nursing assistant to stay with the client.

A client loses control and throws two chairs toward another client. What should the nurse do next? Administer an oral PRN tranquilizer, and prepare for a show of determination. Call for assistance to restrain the client, and administer a PRN intramuscular tranquilizer. Process the incident with the client and discuss alternative behaviors. Ask the client to go to the quiet area and talk about the behavior.

Call for assistance to restrain the client, and administer a PRN intramuscular tranquilizer.

A 19-year-old primigravid client has decided to breastfeed. Her 22-year-old husband supports her decision. The client tells the nurse, "My mother breastfed all of her children, but I'm going to need lots of help with breastfeeding. I'm worried that I won't be able to do this." What additional information should the nurse obtain prior to teaching the client about breastfeeding? Ask the client if she has read any literature about breastfeeding. Perform a complete physical examination to determine her need for help. Assess her body-to-fat ratio and nutritional status before beginning breastfeeding. Determine the client's level of motivation to breastfeed.

Determine the client's level of motivation to breastfeed.

A nurse observes a hospitalized 10-month-old infant chewing on the security alarm attached to his identification bracelet. What intervention is most appropriate for the nurse to perform? Distract the infant with a more appropriate toy. Instruct the infant's parents regarding the safety hazard. Cover the device with gauze wrap so that it isn't visible. Remove the security device because it's a choking hazard.

Distract the infant with a more appropriate toy.

When caring for an oncology client receiving cisplatin and experiencing nausea and mouth sores, which nursing interventions are best to improve the client's diet? Select all that apply. Offer small, frequent, light meals 5-6 times daily. Offer cool drinks and foods as tolerated. Administer oral anesthetic 15 minutes prior to meals. Schedule a large lunch with a nutritious snack for dinner. Encourage a favorite meal of pizza and wings. Schedule high-nutrient shakes between meals.

Schedule high-nutrient shakes between meals. Offer small, frequent, light meals 5-6 times daily. Administer oral anesthetic 15 minutes prior to meals. Offer cool drinks and foods as tolerated.

A nurse is teaching a client to use a metered-dose inhaler (MDI) to administer bronchodilator medication. Indicate the correct order of the steps from first to last the client should take to use the MDI appropriately. All options must be used.

Shake the inhaler immediately before use. Breathe out through the mouth. Activate the MDI on inhalation. Hold the breath for 5 to 10 seconds and then exhale.

A girl in second grade with no remarkable medical history experiences a generalized tonic-clonic seizure in the classroom. Immediately after the seizure, the nurse arrives and notices that the child has been incontinent of urine and is difficult to arouse. Which action would be most appropriate at this time? Ask the teacher if the child has had any urinary problems. Stay with the child, and allow her to sleep in a side-lying position. Awaken the child every 3 to 5 minutes to assess mentation. Perform a complete neurologic check every 3 to 5 minutes.

Stay with the child, and allow her to sleep in a side-lying position During this time, the nurse should stay with the child, allowing sleep until she awakens. The side-lying position is best to prevent possible aspiration.

A 6-month-old infant is being admitted with a diagnosis of bacterial meningitis. What considerations should be made by the nurse regarding the infant's room assignment? Select all that apply. A private room is required. The child will need to be on droplet precautions. There must be a window in the door to view the child. The room should be near the nurses' station. The infant's parents will not be allowed in the room.

The child will need to be on droplet precautions. A private room is required. The room should be near the nurses' station.

A nurse recognizes improvement in a client with the nursing diagnosis of Ineffective role performance related to the need to perform rituals. Which behaviors indicate improvement? Select all that apply. The client refrains from performing rituals during stress. The client performs ritualistic behaviors in private. The client rationalizes ritualistic behavior. The client verbalizes the relationship between stress and ritualistic behaviors. The client avoids stressful situations. The client verbalizes that he uses "thought stopping" when obsessive thoughts occur.

The client refrains from performing rituals during stress. The client verbalizes that he uses "thought stopping" when obsessive thoughts occur. The client verbalizes the relationship between stress and ritualistic behaviors.

Which client does the nurse evaluate as having the highest risk of developing a postoperative wound infection? The client who had a perineal prostatectomy A postsurgical client following a radical prostatectomy The client who had a transurethral resection of the prostate A postsurgical client following a suprapubic prostatectomy

The client who had a perineal prostatectomy The incision in a perineal prostatectomy is close to the rectum, which normally contains gram-negative organisms that can cause infection if introduced into other areas of the body. Therefore, a perineal incision can become contaminated more easily than those of the other procedures.

In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open-heart surgery, what should the nurse tell the family? The client will remain in the ICU for 5 days. Noise and activity within the ICU are minimal. The client will receive medication to relieve pain. The client will sleep most of the time while in the ICU.

The client will receive medication to relieve pain.

A client comes to the clinic for an ophthalmologic screening, which will include measurement of intraocular pressure (IOP) with a tonometer. Which statement about this procedure is true? The tonometer will register the force required to indent or flatten the corneal apex. The client should wear dark glasses for several hours after the procedure. The client will direct the gaze forward while the physician rests the tonometer on the scleral surface. A topical anesthetic will be administered after the examination.

The tonometer will register the force required to indent or flatten the corneal apex. The tonometer will register the force required to indent (using Schiotz's tonometer) or flatten (using an applanation tonometer) the corneal apex.

Which of the following situations does the nurse recognize as having the greatest risk for the fetus? a fetal heart rate of 170 bpm with fetal movements a gestational age of 37 weeks a breech lie a fundal height of 27 cm at 32 weeks gestation

a fundal height of 27 cm at 32 weeks gestation Fundal height, measured in centimeters, should equal gestational weeks throughout the pregnancy (e.g., fundal height of 27 cm should occur at 27 weeks gestation). A fundal height of 27 cm at 32 weeks gestation is a very ominous finding that requires immediate attention and investigation.

A nurse is assessing a child who recently received an antibiotic for an ear infection. The parent states that the child seems to have a harder time hearing than before and that the child reported ringing in the ears. The nurse suspects the child is taking an antibiotic from which class? aminoglycosides carbapenems penicillins cephalosporins

aminoglycosides

A client with metastatic ovarian cancer is ordered cisplatin. Before administering the first dose, the nurse reviews the client's medication history for drugs that may interact with cisplatin. Which drug may cause significant interactions when given concomitantly with cisplatin? erythromycin an aminoglycoside a cephalosporin a tetracycline

an aminoglycoside An aminoglycoside may cause nephrotoxicity and ototoxicity when given concomitantly with cisplatin.

A client with pulmonary fibrosis is prescribed home oxygen therapy. Which health team member is responsible for evaluating the client's knowledge of home oxygen use? hospital staff nurse respiratory rehabilitation assistant home health nurse social worker

home health nurse

Before undergoing a subtotal thyroidectomy, a client receives potassium iodide (Lugol's solution) and propylthiouracil (PTU). The nurse should expect the client's symptoms to subside in 3 to 4 months. in a few days. immediately. in 1 to 2 weeks.

in 1 to 2 weeks.

What occurs during the working phase of the nurse-client relationship? A nurse and a client discuss their feelings about terminating the relationship. A nurse and a client explore each others' expectations of the relationship. A nurse assesses a client's needs and develops a care plan. A nurse and a client evaluate and modify the goals of the relationship.

A nurse and a client evaluate and modify the goals of the relationship.

The nurse is administering digoxin .125mg IVP to the client via healthcare provider's order. Which interventions should the nurse implement? Select all that apply. Call the nursing supervisor to clarify the order. Give the medication. Call the healthcare provider and clarify the order. Call the pharmacy to clarify the order. Hold the order.

Call the healthcare provider and clarify the order. Hold the order.

A neonate is admitted to the nursery following a long and difficult labor. Admission vital signs are temperature 96.5° F (35.8° C), heart rate 168 beats/minute, and respiratory rate 64 breaths/minute. After placing the neonate under the radiant heater, the nurse should take which action? Review the pregnancy and delivery history. Perform a full neonatal assessment. Check the neonate's blood glucose level. Call the pediatrician to report findings.

Check the neonate's blood glucose level.

A mother brings her 2-year-old adopted child from an Asian background to the clinic for an initial checkup. The child has been living with the adopted family for several weeks. The nurse notes an irregular area of deep blue pigment on the child's buttocks extending into the sacral area. What should the nurse do? Ask the mother in private how the bruise occurred. Notify social services of a case of possible child abuse. Question the mother about the family's discipline style. Do nothing concerning this finding.

Do nothing concerning this finding.

Upon assessment of third-degree heart block on the monitor, what should the nurse do first? Place transcutaneous pads on the client. Call a code. Begin cardiopulmonary resuscitation (CPR). Prepare for defibrillation.

Place transcutaneous pads on the client.

A nurse is caring for a client diagnosed with hepatic encephalopathy. Which sign or symptom would indicate that the disease is improving? Select all that apply. Serum ammonia levels are increased. The client is able to circle choices on the menu. The client is able to eat previously restricted food items. The electroencephalogram shows generalized slowing of brain waves. Deep tendon reflexes are flaccid.

The client is able to circle choices on the menu. The client is able to eat previously restricted food items.

The nurse is instructing an unlicensed assistive personnel (UAP) on how to correctly position a client who has had a recent total hip replacement. In which position should the nurse tell the UAP to place the affected leg when the client is lying on the nonoperative side? abduction and extension adduction and extension adduction and flexion abduction and flexion

abduction and extension

A school-age child presents to the office for a routine examination. Given the child's developmental level, a nurse should give highest priority to: encouraging the child to hold a stuffed animal during the examination. allowing the child to change into a gown while the nurse isn't in the room. asking the parents to leave the room during the child's examination. allowing the child to play with medical equipment before the examination begins.

allowing the child to change into a gown while the nurse isn't in the room.

A hospital is changing the format for documentation in an attempt to decrease the time the nurses are spending on charting. The new type of charting will require that nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which best defines this type of charting? variance charting charting by exception focus charting problem, Intervention, Evaluation (PIE) charting

charting by exception Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in the narrative notes.

For the client with a substance abuse problem, which intervention would be most helpful to aid the client in dealing with feelings and concerns related to alcohol and drugs? recreation individual therapy solitary activities group sessions

group sessions

A nurse is caring for a client admitted with arching of the back, extension and rotation of the neck, and slow involuntary contractions of the arms and neck. After review of the client's medication list, the nurse would be correct in associating these symptoms with which medication? benztropine pantoprazole haloperidol propranolol

haloperidol

A client's medication order reads, "Thioridazine 200 mg P.O. q.i.d. and 100 mg P.O. PRN" A nurse should: question the physician about the order. administer the order for 200 mg P.O. q.i.d. but not for 100 mg P.O. PRN. administer the medication as ordered. administer the medication as ordered but observe the client closely for adverse effects.

question the physician about the order.

When caring for a client with nonresectable colon cancer, which nursing diagnosis requires the nurse to function collaboratively to achieve the best outcome related to client comfort? Activity intolerance Imbalanced nutrition: Less than body requirements Acute pain Risk for deficient fluid volume

Acute pain

A young adult client who uses cannabis multiple times a day, has just participated in a family meeting at a community mental health center. The chart entry reads:2/100900The family meeting began by the client's family demanding that the client "stop using marijuana at once, or there will be severe consequences, including no support to attend college." The drug, and the problems associated with its use, were explained to the family.What educational topic should the nurse address with this family during the next teaching session? Discuss the possibility of the client developing violent tendencies. Talk about how things were prior to the client's substance use. Encourage the family to be more flexible with their thoughts and feelings. Address how the substance use has affected each member of the family.

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

A client has a chest tube attached to suction. Which interventions would the nurse perform? Select all that apply. Change the dressing as ordered using aseptic technique. Mark the amount of drainage in the chamber at the end of the shift. Clamp the chest tube when suctioning the client. Position the client on the side to apply pressure to the chest tube site. Palpate the surrounding area of the chest tube for crepitus.

Change the dressing as ordered using aseptic technique. Palpate the surrounding area of the chest tube for crepitus. Mark the amount of drainage in the chamber at the end of the shift.

The nurse is teaching the parents of a child with sickle cell disease. What information should the nurse give the family on how to prevent sickle cell crisis? Exercise in cool temperatures. Take anti-inflammatory medications before exercising. Drink at least 2 quarts (1.9 liters) of fluids per day. Avoid contact sports.

Drink at least 2 quarts (1.9 liters) of fluids per day.

Which would be most important to teach a client older than 65 years to prevent a recurrence of bacterial pneumonia? Decrease the amount of protein in the diet. Receive prophylactic antibiotic therapy. Obtain influenza and pneumococcal vaccines. Seek prompt antibiotic therapy for viral infections.

Obtain influenza and pneumococcal vaccines.

The most effective health-promotion measure related to glaucoma that the nurse could teach clients is: prompt treatment of all eye infections. avoidance of extended-wear contact lenses by older people. appropriate blood pressure control. annual intraocular pressure measurements for people older than 40 years.

annual intraocular pressure measurements for people older than 40 years. People who are at risk for developing glaucoma, such as those with diabetes or hypertension, African ancestry, and a family history of glaucoma, should have their intraocular pressure checked annually after 35 years of age.

During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, a nurse should instruct the client to push the control button at which time? at the beginning of each contraction at the beginning of each fetal movement at the end of fetal movement after every three fetal movements

at the beginning of each fetal movement

To decrease the likelihood of bradyarrhythmias in children during endotracheal intubation, succinylcholine is used with which agent? atropine isoproterenol epinephrine lidocaine

atropine

A nurse is developing a teaching plan for sleep hygiene. Which interventions should the nurse include? Select all that apply. eat a large meal and drink fluids before bedtime keep the room very warm avoid caffeine, alcohol, and nicotine before bedtime schedule bedtime when you feel tired participate in a bedtime routine prepare the room for sleep and turn off distracting noise

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

A client isn't progressing with dilation during labor. Her physician recommends a cesarean birth to minimize the potential for fetal distress. After surgery, what should the nurse assess for in this client? Select all that apply. hemorrhage hematuria endometritis infection mastitis

infection hemorrhage hematuria

Which clinical characteristic affects client compliance? disease duration and severity psychosocial factors the nurse-client relationship drug knowledge

the nurse-client relationship

The health care provider (HCP) has performed an amniotomy on a laboring client. Which details must be included in the documentation of this procedure? Select all that apply. time of rupture size of amnio-hook used during the procedure color and clarity of fluid fetal heart rate (FHR) and pattern before and after the procedure odor and amount of fluid

time of rupture color and clarity of fluid fetal heart rate (FHR) and pattern before and after the procedure odor and amount of fluid

A nurse is teaching a client with a left fractured tibia how to walk with crutches. Which instruction is appropriate? "Use the axillae to help carry the weight." "Keep feet 12 inches (30 cm) apart to provide stability and a wide base of support." "All weight should be on the hands." "Take long strides to maintain maximum mobility."

"All weight should be on the hands."

A pregnant client, who is originally from another country, is admitted to the hospital in labor. During the admission process, the spouse tells the nurse that the client will not receive any pain medication during the process. The spouse then waits in the waiting room. As the birthing process continues, the nurse asks the client if she needs pain medication. She declines the offer and reminds the nurse by saying, "My spouse told you I cannot have any pain medicine." What is the nurse's best response to the client? "I want to advocate for you and assist with the pain during this process." "I think that this is extreme. Pain medication will not affect the child." "I am sorry. I do not want to offend your husband." "I am going to talk to the provider about this."

"I want to advocate for you and assist with the pain during this process."

To treat a child's atopic dermatitis, a physician orders a topical application of hydrocortisone cream twice daily. After medication instruction by the nurse, which statement by the parent indicates effective teaching? "I will avoid using soap and water on the affected area and will apply an emollient cream on this area frequently." "I will gently scrape the skin before applying the cream to promote absorption." "I will apply a moisturizing cream sparingly and will wash the affected area frequently." "I will spread a thick coat of hydrocortisone cream on the affected area and will wash this area once a week."

"I will avoid using soap and water on the affected area and will apply an emollient cream on this area frequently."

When teaching about prevention of infection to a client with a long-term venous catheter, the nurse determines that the client has understood discharge instructions when the client makes which statement? "My husband will change the dressing three times per week, using sterile technique. "I know it's very important to wash my hands after irrigating the catheter." "I won't remove the dressing until I return to the clinic next week." "I will monitor my temperature once every other day."

"My husband will change the dressing three times per week, using sterile technique.

A nurse is teaching the proper use of crutches to a school-age child with a femur fracture with no weight bearing. What will the nurse include with teaching about walking with crutches? "After advancing both crutches the length of one step, move your 'good' leg forward." "Advance the one crutch forward on your good side, then advance your 'bad' leg." "After advancing both crutches the length of one step, move your 'bad' leg forward." "Advance one crutch forward on the affected side, then advance your 'good' leg."

"After advancing both crutches the length of one step, move your 'good' leg forward." When walking with crutches, a child should be instructed to advance both crutches, then advance the unaffected leg. The unaffected leg then supports much of the weight associated with ambulation.

Which client statement indicates to the nurse that the client needs further teaching about disulfiram? "I'll read the labels on cough syrup and mouthwash for possible alcohol content." "A metallic or garlic taste in my mouth is normal when starting on disulfiram." "I can take disulfiram at bedtime if it makes me sleepy." "I can drink one or two beers and not get sick while on disulfiram."

"I can drink one or two beers and not get sick while on disulfiram."

A nurse is caring for an older adult client with advanced Parkinson's disease. Which client statement about advance directives indicates a need for further instruction? "Signing an advance directive now will help ensure that my family and care team know what I want when I'm eventually unable to make decisions." "I don't really need to sign anything. I'm depending on my health care provider to tell my family what to do if something bad happens." "My family will take care of me. I've given my daughter durable power of attorney for health care." "I've signed the advance directive papers and will fight to maintain the highest quality of life until my time comes."

"I don't really need to sign anything. I'm depending on my health care provider to tell my family what to do if something bad happens."

After instructing a primiparous client who is breastfeeding on how to prevent nipple soreness during feedings, the nurse determines that the client needs further instruction when she makes which statement? "I should make sure the baby grasps the entire areola and nipple." "I should air dry my breasts and nipples for 10 to 15 minutes after the feeding." "I should position the baby the same way for each feeding." "I shouldn't use a hand breast pump if my nipples get sore."

"I should position the baby the same way for each feeding."

A nurse is caring for a client with a new prescription of digoxin. Which client statement would require further teaching about digoxin? Select all that apply. "I will notify my health care provider if experiencing increased fatigue or muscle weakness." "If I forget a dose, I will catch-up by doubling the next dose." "I will take the digoxin at 9 AM daily." "I will take my pulse before each dose of digoxin." "I will take the digoxin with my antacids at night." "I understand that I will need annual blood work to check therapeutic levels."

"I will take the digoxin with my antacids at night." "If I forget a dose, I will catch-up by doubling the next dose." "I understand that I will need annual blood work to check therapeutic levels."

2/10180019-year-old client with mild concussion after slipping in school parking lot three hours prior. No loss of consciousness. No appreciable neurological deficits. CT scan normal. Client was preparing for discharge. Now reports a 5/10 headache. Acetaminophen PO prescribed.When offered acetaminophen, the client's parents tell the nurse that they would like their child to have something stronger. What is the nurse's best response? "We avoid giving aspirin to children and young adults because of the danger of Reye syndrome." "Opioids are avoided following a head injury because they may hide a deteriorating condition." "Stronger medications may lead to vomiting, which increases the intracranial pressure." "Acetaminophen is strong enough for your child's mild concussion."

"Opioids are avoided following a head injury because they may hide a deteriorating condition."

The client diagnosed with conversion disorder has a paralyzed arm. A staff member states, "I would just tell the client her arm is paralyzed because she had an affair and neglected her baby's care to the point where the baby had to be hospitalized for dehydration." Which response by the nurse is best? "We will meet with the client and confront her with her behavior." "Pushing insight will increase the client's anxiety and the need for physical symptoms." "Ignore the client's behaviors, and treat her with respect." "Pushing awareness will be helpful and further the client's recovery."

"Pushing insight will increase the client's anxiety and the need for physical symptoms."

The nurse is caring for a 7-year-old child who has just returned from the postoperative unit after surgery. The child is playing in bed with toys. The child's parents are smiling and state, "Isn't it great that our child does not have any pain?" What is the best response by the nurse? "Children don't experience as much pain after surgery as adults." "A child who resumes usual play is not experiencing pain." "Some children distract themselves with play while in pain." "The child's activity level is the best indicator of pain."

"Some children distract themselves with play while in pain."

A client who is at 38 weeks gestation has been admitted to the hospital for meconium stained rupture of membranes. The nurse inserts an internal fetal scalp electrode (FSE). The client appears anxious and asks why she requires the FSE. What is the nurse's most appropriate response? "The baby has had a bowel movement, indicating severe fetal distress." "This is a routine assessment and your baby is fine." "The baby has had a bowel movement, indicating mild fetal distress." "The baby needs to be observed more closely."

"The baby needs to be observed more closely."

A nurse is caring for a client with schizophrenia whose symptoms are managed with medications. The client reports feeling so well that the medications are no longer needed.. Which response indicates that the nurse understands the client's diagnosis? "The medications are helping you. If you suddenly stop taking them, you could get sick again." "You should take the medication for several months after you go home." "I'll pass this information on to your physician to see if the physician feels this might be wise." "You have to take the pills the physician has ordered for you."

"The medications are helping you. If you suddenly stop taking them, you could get sick again."

The nurse is teaching the parents of a young child who had surgery to form a colostomy what to expect when the child goes home. The parents express concern about the appearance of the stoma. Which of the following is the most appropriate response by the nurse? "The stoma will change to a flesh color after three months." "The size of the new stoma should stabilize in 6-8 weeks." "Children have a difficult time accepting a stoma." "You can use a skin barrier to cover the appearance of the stoma."

"The size of the new stoma should stabilize in 6-8 weeks."

The husband of a client with cervical cancer says to the nurse, "The doctor told my wife that her cancer is curable. Is he just trying to make us feel better?" Which would be the nurse's most accurate response? "Saying a cancer is curable means that 50% of all women with the cancer survive at least 5 years." "When cervical cancer is detected early and treated aggressively, the cure rate is almost 100%." "The 5-year survival rate is about 75%, which makes the odds pretty good." "Cancers of the female reproductive tract tend to be slow-growing and respond well to treatment."

"When cervical cancer is detected early and treated aggressively, the cure rate is almost 100%."

The family member of a client diagnosed with dissociative identity disorder (DID) asks a nurse if hypnotic therapy might help the client. How should the nurse respond? "No, hypnosis is rarely used in the treatment of DID." "Yes, but only after other types of therapy have failed." "No, hypnosis is a controversial treatment." "Yes, a client is often not consciously aware of alter personalities."

"Yes, a client is often not consciously aware of alter personalities."

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He's placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than 0.5. 0.21. 0.7. 0.35.

0.5.

The nurse who cared for a client in the home environment for several months learns that the client has died. What should the nurse do to support the family at this time? Send flowers. Avoid phoning the family to permit the family to grieve. Remove the client's name from the care list. Attend the funeral.

Attend the funeral.

A client has been admitted with severe abdominal pain that has lasted for the past 4 hours. Place in chronological order the correct sequence for conducting an abdominal assessment. All options must be used. 3Ask the client to urinate. 1Auscultate the client's abdomen. 4Percuss the client's abdomen. 2Perform light palpation.

Ask the client to urinate. Auscultate the client's abdomen. Percuss the client's abdomen. Perform light palpation.

A client is undergoing tests for multiple myeloma. Diagnostic study findings in multiple myeloma include serum calcium level of 7.5 mg/dl (1.9 mmol/L) Bence Jones protein in the urine serum creatinine level 0.5 mg/dl (44.2 mcmol/L) serum protein level 5.8 g/dl (58 g/L)

Bence Jones protein in the urine The presence of Bence Jones protein in the urine almost always confirms multiple myeloma.

The home health nurse is visiting an 80-year-old client diagnosed with Alzheimer's dementia. During the visit, the nurse notes bruising on the client's face and upper arms in various shades of healing. The client is unable to communicate effectively because of the disease progression. What is the nurse's responsibility in this situation? Select all that apply. Monitor the situation during the subsequent home visits. Report the suspicion to the local Adult Protective Services Agency within 24 hours. Do nothing because the nurse has no proof of actual wrongdoing or abuse by anyone. Bring up the suspected physical abuse with a trusted authority figure. Try to convince the client to verbalize that there has been abuse.

Bring up the suspected physical abuse with a trusted authority figure. Report the suspicion to the local Adult Protective Services Agency within 24 hours. Monitor the situation during the subsequent home visits.

A nurse working in the emergency department is concerned that a client, who is in police custody, is handcuffed to the stretcher. The nurse asks the police officer to remove the cuffs, but the officer refuses. What should be the next action by the nurse? Continue to assess the client, allowing the officer to assume responsibility for the handcuffs. Ask the physician for an order to remove the handcuffs. Call the supervisor and report the officer's decision to keep the handcuffs on. Refuse to provide care while the client is handcuffed to the stretcher.

Continue to assess the client, allowing the officer to assume responsibility for the handcuffs.

The nurse is caring for a client who entered the hospital with a diagnosis of dehydration. The client's serum potassium is 5.2 mmol/L this morning and the healthcare provider orders the primary I.V. fluid as D5 1/2 NSS with 20 mEq/KCL (mmol/L). What will the nurse do? Select all that apply. Clarify the order with the healthcare provider. Review the lab results. Clarify the order with the pharmacy. Hold the I.V. fluid. Hang the I.V. fluid.

Hold the I.V. fluid. Clarify the order with the healthcare provider. Review the lab results.

On the first day after abdominal surgery, the nurse auscultates a client's abdomen for bowel sounds; there are none. What should the nurse do next? Encourage the client to take more ice chips. Notify the health care provider (HCP). Ask another nurse to validate the absence of bowel sounds. Document assessment findings in the client's medical record.

Document assessment findings in the client's medical record.

A nurse is working with a client on recognizing the relationship between alcohol use and interpersonal problems. What is the nurse's priority intervention for this client? Help the client recognize personal strengths. Have the client work with peers who can serve as role models. Have the client identify compulsive behaviors. Encourage the client's use of defense mechanisms.

Help the client recognize personal strengths. The client's outcomes are best promoted if the nurse engages the client from a strengths-based approach

A client is prescribed a bisacodyl suppository. When administering the suppository, the nurse will include what actions? Position client on the right side in Sim's position to ensure the flexure of the rectum is at the proper angle for insertion. Insert the suppository approximately 1 inch (2.5 cm) into the rectum, or just past the internal anal sphincter. Have client sit on a commode or toilet immediately after the insertion of the suppository to prevent incontinence. Ensure the suppository is in direct contact with the stool in the rectum to facilitate mechanism of action.

Insert the suppository approximately 1 inch (2.5 cm) into the rectum, or just past the internal anal sphincter.

A nurse at the family clinic receives a call from the mother of a 5-week-old infant. The mother states that her child was diagnosed with colic at the last checkup. Unfortunately, the symptoms have remained the same. Which teaching instructions are appropriate? Select all that apply. Immediately bring the infant to the emergency department. Soothe the child by humming and rocking. Position the infant on the back after feedings. Burp the infant adequately after feedings. Offer a pacifier if it is not time for the infant to eat. Provide small but frequent feedings to the infant.

Soothe the child by humming and rocking. Burp the infant adequately after feedings. Provide small but frequent feedings to the infant. Offer a pacifier if it is not time for the infant to eat.

A client who was transferred from a long-term care facility is admitted with dehydration and pneumonia. Which nursing interventions can help prevent pressure ulcer formation in this client? Select all that apply. Tuck bed covers tightly into the foot of the bed. Reposition the client every 2 hours. Use commercial soaps to keep the skin dry. Perform range-of-motion exercises. Encourage the client to eat a well-balanced diet.

Reposition the client every 2 hours. Perform range-of-motion exercises. Encourage the client to eat a well-balanced diet.

The nurse is required initially to restrain all four of a client's extremities. For what reason would the nurse anticipate the need to add a full-length restraint blanket? The staff want extra protection for themselves. The client states that the restraints are tight and uncomfortable. The client is at risk for injury from fighting the restraints. Staff assessment reveals that the client will feel more secure under the blanket.

The client is at risk for injury from fighting the restraints.

A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which would the highest priority goal in planning nursing interventions? The client will be able to problem solve in situations on the psychiatric unit. The client will be oriented to person, place, and time. The client will be free from anxiety and be able to use self-calming techniques before reaching panic level. The client will show no self-harm or harm to staff.

The client will show no self-harm or harm to staff.

A nurse is caring for a pediatric client with scoliosis who has to wear a brace. The nurse should develop a teaching plan with the client to include which instruction? Use lotions to relieve skin irritations. Wear a form-fitting t-shirt under the brace. Wear the brace during waking hours. Bathe the skin under the brace once per week.

Wear a form-fitting t-shirt under the brace.

A hospitalized client asks the nurse for "something for pain." Which information is most important for the nurse to gather before administering the medication? Select all that apply. effectiveness of prior dose of medication client's most current height and weight type of medication the client has been taking client's pain level on a scale of 1 to 10 client's reaction to the previous dose administration time of the last dose

administration time of the last dose client's pain level on a scale of 1 to 10 type of medication the client has been taking client's reaction to the previous dose effectiveness of prior dose of medication

A client, who had intracavity radiation treatment for cervical cancer 1 month earlier, reports small amounts of vaginal bleeding. This finding most likely represents recurrence of the carcinoma. an expected effect of the radiation therapy. development of a rectovaginal fistula. infection secondary to a change in vaginal flora.

an expected effect of the radiation therapy. After intracavity radiation, some vaginal bleeding occurs for 1 to 3 months.

What should be the nurse's priority assessment after an epidural anesthetic has been given to a nulligravid client in active labor? level of consciousness contraction pattern blood pressure cognitive function

blood pressure

A client has sudden, severe pain in the back and chest, accompanied by shortness of breath. The client describes the pain as a "tearing" sensation. The health care provider suspects the client is experiencing a dissecting aortic aneurysm. The nurse should assess the client for which potential complication of a dissecting aneurysm? pulmonary edema stroke cardiac tamponade myocardial infarction

cardiac tamponade

A nurse is caring for a client with a history of cardiac disease and type 2 diabetes. The nurse is closely monitoring the client's blood glucose level. Which medication is the client most likely taking? carvedilol amiodarone procainamide diltiazem hydrochloride

carvedilol The nurse must monitor blood glucose levels closely in clients with type 2 diabetes who are taking beta-adrenergic blockers such as carvedilol, because beta-adrenergic blockers may mask the signs of hypoglycemia.

A client who speaks little English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions? asking an interpreter to relay the instructions to the client asking frequently whether the client understands the instructions demonstrating the procedure and having the client return the demonstration writing out the instructions and having a family member read them to the client

demonstrating the procedure and having the client return the demonstration

A client with Parkinson's disease needs assistance with eating but does not require thickened liquids to aid swallowing. For what action by the unlicensed assistive personnel should the nurse intervene? allowing time between bites for the client to rest turning off the television when the client begins eating elevating the head of the client's bed to 45 degrees instructing the client to chew food thoroughly

elevating the head of the client's bed to 45 degrees

The client presents to the clinic with severe anemia, and is a Jehovah's Witness with religious beliefs that prohibit the administration of blood products. Which concurrent medications does the nurse teach the client about when receiving blood products? Select all that apply. epoetin alfa NSAIDs ferrous sulfate aspirin levothyroxine

epoetin alfa ferrous sulfate

Interferon alfa-2b has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which common adverse effects? hypoglycemia constipation flulike symptoms retinopathy

flulike symptoms

When teaching a client with Cushing's syndrome about dietary changes, the nurse should instruct the client to increase intake of cereals and grains. dairy products. fresh fruits. processed meats.

fresh fruits.

The nurse on the oncology unit is caring for a client with a total white blood cell (WBC) count equal to 2000/µL (2.0 ×109/L). Which intervention is most important to include in the plan of care? Monitor temperature every 4 hours avoid rectal thermometers and suppositories perform proper hand hygiene restrict visitors and provide a private room

perform proper hand hygiene

On the first postpartum day, the primiparous client reports perineal pain of 5 on a scale of 1 to 10 that was unrelieved by ibuprofen 800 mg given 2 hours ago. The nurse should further assess the client for which complication? perineal hematoma. history of drug abuse. puerperal infection. vaginal lacerations.

perineal hematoma. If the client continues to have perineal pain after an analgesic medication has been given, the nurse should inspect the client's perineum for a hematoma because this is the usual cause of such discomfort. apply ice , sitz bath for 20 min 3x daily, can resolve within 6 wks

A 7-year-old child is admitted to the hospital with acute rheumatic fever. During the acute phase of the illness, which diversional activity would the nurse most discourage? playing with a doll with the nurse watching the television with a sibling reading a book with the father playing checkers with a roommate

playing checkers with a roommate School-aged children enjoy board games and are commonly intense about following rules. Their play can become emotional. Adequate rest is of utmost importance during the acute stage of rheumatic fever. Therefore, playing a game with another child probably would be too strenuous. Such diversional activities as reading a book, playing with a doll, and watching television would be more satisfactory.

When caring for the client diagnosed with delirium, the nurse should investigate which condition as the most important? impaired hearing cancer of any kind prescription drug intoxication heart failure

prescription drug intoxication

The nurse works with the health care team to establish a policy regarding sleep positions for infants with gastroesophageal reflux. What information should the nurse search for first? policies from other hospitals data from retrospective studies expert opinions published national standards

published national standards Published national standards are based on the best evidence and when available should serve as the foundation for nursing unit policies.

A nurse should expect a client with hypothyroidism to report increased appetite and weight loss. thyroid gland swelling. nervousness and tremors. puffiness of the face and hands.

puffiness of the face and hands.

Which nursing intervention is essential in caring for a client with compartment syndrome? keeping the affected extremity below the level of the heart wrapping the affected extremity with a compression dressing to help decrease the swelling starting an I.V. line in the affected extremity in anticipation of venogram studies removing all external sources of pressure, such as clothing and jewelry

removing all external sources of pressure, such as clothing and jewelry

A client claims to have a "special mission from God". The nurse incorporates this religious delusion of grandeur into the client's plan of care based on the understanding that the primary purpose of such a delusion is to provide: comfort. safety. survival. self-esteem.

self-esteem.

An adolescent with a history of surgical repair for an undescended testis comes to the clinic for a sports physical. Which anticipatory guidance for the parents and adolescent is most important? technique for monthly testicular self-examinations the adolescent's sterility the adolescent's future plans need for a lot of psychological support

technique for monthly testicular self-examinations

A client involved in a motor vehicle accident is admitted to the intensive care unit. The emergency department admission record indicates that the client hit their head on the steering wheel. The client complains of a headache, and a nursing assessment reveals that the client has difficulty comprehending language and diminished hearing. Based on these findings, the nurse suspects injury to which lobe of the brain? parietal temporal occipital frontal

temporal

The nurse is prioritizing care for several clients. Which client should the nurse assess first? the client with bilateral wheezing receiving a breathing treatment the client with chest pain improving after medication the client with stridor who just received the first dose of an antibiotic the client with a blood pressure of 150/90 mmHg

the client with stridor who just received the first dose of an antibiotic

A child's most recent diagnostic testing reveals elevated levels of T3 and T4. When assessing this child for exophthalmos, the nurse should inspect what region?

the eyes

When the client is involuntarily committed to a hospital because the client is assessed as being dangerous to himself or others, which client rights are lost? the right to send and receive uncensored mail the right to leave the hospital against medical advice the right to access healthcare freedom from seclusion and restraints

the right to leave the hospital against medical advice

A client is brought to the emergency department having been involved in a fire while putting lighter fluid on a grill. The client sustained burns to both arms. The nurse assesses the burns to be dry and pale white with some areas that are brown and leathery. Which type of burns does the nurse determine are present? third degree (full thickness) first degree (superficial) fourth degree (full thickness that includes fat, fascia, muscle, and/or bone) second degree (partial thickness)

third degree (full thickness)

A nurse is performing an assessment on an adult with hypertension who falls into the middle-old elderly population. Which findings would be reported to the health care provider? nails are thickened, brittle, and yellow urine output of 600mL/24 hours lower peripheral pulses +1 bilaterally increased sensitivity to glare

urine output of 600mL/24 hours

A client with newly diagnosed type 2 diabetes is admitted to the metabolic unit. The primary goal for this admission is education. Which goal should the nurse incorporate into their teaching plan? smoking reduction but not complete cessation weight reduction through diet and exercise maintenance of blood glucose levels between 180 and 200 mg/dl (9.9 and 11.1 mmol/L) an eye examination every 2 years until age 50

weight reduction through diet and exercise