Nclex pn
118. The medication prescribed is heparin 5000 units subcutaneously, every 12 hours. The medication vial reads heparin 10,000 units/ml. The nurse prepares how many milliliters to administer one dose? FILL IN THE BLANKS Desired x ml/ available
0.5 ml
121. The medication prescribed is prochlorperazine 5 mg intramuscularly, every 4 hours as needed. The medication label states prochlorperazine 10 mg/ ml. The nurse prepares how much medication to administer the dose? FILL IN THE BLANKS Desired x ml/ available
0.5 ml
120. The medication prescribed is morphine sulfate 6mg subcutaneously. The medication label states morphine sulfate 10 mg/ 1 ml. The nurse plans to prepare how much medication to administer the dose? FILL IN THE BLANKS Desired x ml/ available
0.6 ml
765. The nurse is preparing to administer 35 mg of a prescribed intramuscular dose of medication to a client. The medication label reads 50mg/ml to the client. Fill in the blank
0.7 ml
116. The medication prescribed is hydromorphone hydrochloride 3 mg intramuscular every 4 hours as needed. The medication label reads hydromorphone hydrochloride 4 mg/1 ml. The nurse should prepare to administer how many ml to the client? FILL IN THE BLANK Desired x ml/ available
0.75ml
122. The medication prescribed is haloperidol, 4 mg intramuscularly, immediately. The medication label states 5 mg/1 ml. The nurse prepares how much medication to administer the dose ? FILL IN THE BLANKS Desired x ml/ available
0.8 ml
129. The medication is an intramuscular dose of 400,000 units of penicillin G benzathine. The medication label reads penicillin G benzathine 300,000 units/ml. The nurse prepares how much medication to administer the correct dose? FILL IN THE BLANKS AND RECORD THE ANSWER USING ONE DECIMAL PLACE Desired x ml/ available
1.3 ml
125. The medication prescribed is methylprednisolone acetate 60 mg intramuscularly. The medication label states methylprednisolone acetate 40 mg/1ml. How many milliliters will the nurse prepare to administer to the client? FILL IN THE BLANKS Desired x ml/ available
1.5 ml
184. The nurse is caring for a 5y/o child who has been placed in traction after a fracture of the femur. Which is the MOST APPROPRIATE activity for this child?
10 piece puzzle
3. The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions with regard to avoiding the use of herbal medications?
10 y/o female client with a urinary tract infection
400. The client arrives at the ED after a burn injury that occurred in their home basement and an inhalation injury is suspected. Which should the ruse anticipates as being prescribed for the client?
100% oxygen via a tight fitting nonrebreather face mask
771. A PHCP prescribes potassium chloride (KCI) elixir, 20 mEq orally daily. The medication label states KCI, 30 mEq/15ml. How many ml should the nurse prepare to administer the dose? Fill in the blank D/A x volume = ml per dose
10ml
611. The client is taking phenytoin for seizure control, and a blood sample for serum drug level is drawn. Which lab result are therapeutic?
15 mcg/ml
202. During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted?
150 BPM
207. A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation?
16 and 20 weeks gestation
768. The nurse is asked to regulate the flow rate of an IV solution being administered to a client. The IV bag contains 50ml of solution and the solution is to be administered over 30 minutes. The administration set ha a drop factor of 10 drops (gtts) ml. The nurse should regulate the roller clamp on the infusion set to deliver how many drops per minute? Fill in the blank and round to the nearest whole number Total volume x drop factor/time in minutes=
17 gtts/min
390. The PHCP has prescribed an antibiotic for a child. The average adult dose is 500 mg. The child has a body surface are (BSA) of 0.63m2. What is the dose for the child? BSA child/BSA adult x adult dose = child dose
182.0 mg
505. The nurse is caring for a client with emphysema receiving oxygen. The nurse should consult with a RN if the oxygen flow rate exceeded how many L/min of oxygen?
2 L/min
127. The medication prescription reads phenytoin 0.2 g orally, twice daily. The medication label states 100mg capsules. The nurse prepares how many capsules to administer one dose? FILL IN THE BLANKS Desired x capsules/ available
2 capsules
119. The medication prescribed is metoclopramide hydrochloride 10 mg intramuscularly times one dose. The medication label reads metoclopramide hydrochloride 5 mg/ml. The nurse prepares how much medication to administer the dose? FILL IN THE BLANKS Desired x ml/ available
2 ml
117. The medication prescribed is Digoxin 0.25 mg orally, daily. The medication label reads digoxin 0.125 mg/tablet. The nurse should prepare how many tablets to administer the dose? FILL IN THE BLANKS Desired x tablet/ available
2 tablets
123. The medication prescribed is levodopa 1 g orally daily. The medication label states levodopa 500 mg tablets. The nurse prepares to administer how many tablets at the evening dose? FILL IN THE BLANKS Desired x tablets/ available
2 tablets
124. The medication prescribed is zidovudine, 0.2 g orally, three times a daily. The medication label states zidovudine, 100 mg tablets. The nurse prepares to administer how many tablets for one dose? FILL IN THE BLANKS Desired x tablets/ available
2 tablets
65. The nurse is caring for a client with a DX of cancer who is immunosuppressed. The nurse would suggest to the RN the need for implementing neutropenic precautions if the clients WBC is which value?
2000 mm3
128. The IV prescription is 1000ml of 0.9% NS to run over 12 hours. The drop factor is 15 gtt/1ml. The nurse plans to adjust the flow rate to how many gtts/minute? FILL IN THE BLANKS Total volume x drop factor/ time in minutes
21 gtts/minute
130. The IV prescription is 3000ml of 5% dextrose in water (D5W) to run over a 24 hr period. The drop factor is 10 gtts/1ml. The nurse plans to adjust the flow rate to how many gtts/minute? FILL IN THE BLANKS AND RECORD THE ANSWER TO THE NEAREST WHOLE NUMBER Total volume x drop factor / time in minutes
21 gtts/minute
70. A client with DM has blood sample drawn for the determination of a fasting blood glucose level. When reviewing the clients results, the nurse determines that which requires a call to the PHCP for intervention?
240 mg/dl
812. A postoperative client has a prescription to receive an IV infusion of 1000ml NS solution over a period of 10 hrs. The drop (gtts) factor for the IV infusion set at 15 gtts/ml. The nurse sets the flow rate at how many drops per minute? Fill in the blank Total volume x gtts/minutes =
25 gtts/minute
766. The nurse is calculating a client's 24 hr fluid intake. Coffee 8oz Water 8oz OJ 6 oz Soup 4oz Ice tea 8oz Milk 10oz Tea 8oz Water 8oz Water 24oz X 3 = + =
2520 ml
212. The nurse is collecting data from a pregnant client who is currently at 28 weeks gestation. At her prior prenatal visits, her fundal height measured 22 cm. The nurse measures the fundal height at this visit in cm and should expect which finding?
26 cm
391. An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The clients clothes caught on fire and the client ran, which caused subsequent burn injuries of the posterior torso. According to the rule of nines, what is the extent of this clients burn injury? Fill in the blank
36%
389. Sulfisoxazole 1 g orally four times daily, is prescribed for an adolescent with UTI. The medication label reads 250mg tablets. The nurse determines that the prescribed dose is safe. How many tablets per dose should the nurse administer to the adolescent? Desire/ available x tablets = Or 1000/250=
4 tablets
155. The nurse is assisting with monitoring the functioning of a chest tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings should the nurse expect to note? Select all that apply
50 ml of drainage in the drainage collection chamber The drainage system is maintained below the clients chest An occlusive dressing is in place over the chest tube insertion site Fluctuation of water in the tube of the water seal chamber during inhalation and exhalation
816. The nurse is monitoring the lab results of a client preparing to receive chemotherapy. The nurse determines that the WBC count is normal if which results are present?
5000 mm3
743. A client received 20 units of NPH insulin SUBCUT at 8am. The nurse should check the client for a potential hypoglycemic reaction at which time?
5pm
461. A client is taking Humulin NPH insulin daily every morning. The nurse reinforces instructions to the cleint and should tell the client that which is the MOST LIKELY time for hypoglycemia reaction to occur?
6-14 hours after administration
388. The PHCP has prescribed phenobarbital sodium, 25 mg orally twice daily, for a child with febrile seizures. The medication label reads phenobarbital sodium, 20 mg/5ml. The nurse has determined that the dose prescribed is safe dose for the child. How many ml per dose should the nurse administer to the child? Desired/available x ml =
6.25 ml
387. The PHCP prescription reads acetaminophen 240 mg orally every 6 hrs for relief of pain, for a 5 y/o child. The medication label reads "acetaminophen 160 mg per 5 ml" how many ml per dose should the nurse administer to the child? Desired/available x ml =
7.5 ml
759. An adult client with hepatic encephalopathy has a serum ammonia level of 120 mcg/dl and receives treatment with lactulose syrup. The nurse determines that the client has the BEST response in the level changes to which after medication administration ?
70 mcg/dl
627. The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position?
8 inches to the front and side of the client's toes
332. isoniazid is prescribed for a2y/o child with a positive TB test. The mother of the child asks the nurse how long the child will need to take the medication. Which time frame is the appropriate response to the mother?
9 months
195. Which client is MOST LIKEY at risk to become a victim of elder abuse
A 90y/o woman with advanced Alzheimer's disease
396. The client arrives at the ED and has experienced frostbite to the right hand. What should the nurse expect to find when inspecting the clients hand?
A White color of the skin which is insensitive to touch
746. A 4 y/o child is admitted to the hospital with suspected acute lymphocytic leukemia. (ALL). The nurse should prepare for which diagnostic study that can confirm this DX?
A bone marrow biopsy
245. The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated?
A change in the uterine contour
361. The parents of a child recently DX with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition?
A chronic disability characterized by impaired muscle movements and posture
703. A client with a DX of anorexia nervosa, who is in state of starvation, is in a two bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate?
A client receiving diagnostic test
30. The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from FIRST?
A client receiving oxygen who is having difficulty breathing
24. The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first?
A client who is dependent on a ventilator
23. The nurse employed in a long term care facility is planning the client assignment for the shift. Which client should the nurse assign to the UAP?
A client who requires a 24 hour urine collection
22. The nurse is planning the client assignments for the day. Which is the MOST APPROPRIATE assignment for the UAP?
A client who requires frequent ambulation
25. The nurse employed in the ED is assigned to assist with the triage of clients arriving to the ED. The nurse should assign PRIORITY to which client?
A client with chest pain who states that they just ate pizza that was made with a very spicy sauce.
722. The nurse is assisting with creating a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which about a crisis response?
A clients response to a crisis is individualized and what constitutes a crisis for one person may not for another
557. A sulfonamide is prescribed for a client with a UTI. During review of the clients record, the nurse notes that the client is taking warfarin sodium daily. Which prescription should the nurse anticipate for this client?
A decrease in the warfarin sodium dosage
288. The nurse caring for a child who substained a burn injury plans care based on which pediatric considerations associated with the injury? Select all that apply
A delay in growth may occur after a burn injury An immature immune system presents an increased risk of infection for infants and young children Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults
221. The perinatal client is admitted to the OB unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse should consult with the dietitian to ensure which dietary measures?
A diet high in fluids and fiber to decrease constipation
752. During data collection, which behavior should the nurse expect a client DX with agoraphobia to describe?
A fear of leaving the house
738. The nurse is monitoring a client receiving glipizide. Which outcome indicates an ineffective response from this medication?
A glycosylated hemoglobin level of 12%
785. The nurse is assigned to care for a child with a compound fracture of the arm that occurred as a result of a fall. The nurse plans care knowing that this type of fracture involves which specific characteristics?
A greater risk of infection than a simple fracture
500. The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a TB infection?
A man who is an inspector for the USPS
238. The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assist with the examination of the client, knowing that which routine labor procedure is contraindicated?
A manual pelvic examination
16. The nurse finds the client lying on the floor. The nurse calls the RN who checks the client and then calls the nursing supervisor and the PHCP to inform them of the occurrence. The nurse completes the incident report for which purpose?
A method of promoting quality care and risk management
171. The nurse is caring for an older client who is reminding about past life experiences in a positive manner. The nurse plans care with the understanding that this behavior indicates which?
A normal psychosocial response
560. Phenazopyridine hydrochloride is prescribed for a client for sympathomimetic relief of pain resulting from lower UTI. Which should the nurse reinforce to the client?
A reddish orange discoloration of the urine may occur
662. The client with DX AIDS and pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temp of 101F. The nurse continues to monitor the client, knowing that this sign would MOST LIKELY indicate which condition?
A result of another infection caused by the leukopenic effects of the medication
637. The nurse is reviewing the record of a client who has been prescribed baclofen. Which disorder should alert the nurse to contact the PHCP?
A seizure disorder
568. The nurse assigned to care for a client with a detached retina. Which findings should the nurses expect to be documented in the client's record?
A sense of curtain across the field of vision
577. The nurse notes that the PHCP has documented a DX of prebycusis on the client's chart. Which explanation should the nurse give to the client to explain this condition?
A sensorineural hearing loss that occurs with aging
318. The nurse is caring for an 18m/o child who has been vomiting. Which is the appropriate position to place the child during naps and sleep time?
A side lying position
210. The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the HCP has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which change that occurs with pregnancy?
A softening of the cervix
608. The client with myasthenia gravis becomes increasingly weak. The PHCP prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or increasing severity of the disease (myasthenia gravis). An injection of edrophonium is administered. Which change in condition indicates that the client is in cholinergic crisis?
A temporary worsening of the condition
136. The nurse is monitoring an adult client for postoperative complications. Which is MOST indicative of a potential postoperative complication that requires further observation?
A urinary output of 20 ml/hr
182. When caring for a 3y/o child, the nurse should provide which toy for the child?
A wagon
702. A client who has been drinking alcohol on a regular basis admits to having a problem and is asking for assistance with the problem. The nurse should encourage the client to attend which community group?
AA
533. Heparin sodium is prescribed for the client. Which lab results indicates that the heparin is prescribed at a therapeutic level?
APTT of 55 seconds
427. When reinforcing teaching about S/S of ovarian cancer with a community group of women, the nurse emphasizes which S/S as being a typical manifestation of the disease recognized by persons DX with the condition?
Abdominal distention or fullness
272. The nurse notes hypotonia, irritability, and poor sucking reflex in a full term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS?
Abnormal palmar creases
778. A client is taking lansoprazole for the chronic management of Zollinger-Ellison Syndrome. If prescribed, which medication would be appropriate for a client if needed for a headache?
Acetaminophen
588. A client was just admitted to the hospital to rule out gastrointestinal bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment , the client states lately, i have been hearing some roaring sounds in my ears. Especially when I am alone. Which medication should the nurse determine to be the cause of the clients complaints?
Acetylsalicylic acid
648. The nurse is assisting with the administration of immunizations at a health care clinic. The nurse should understand that immunization provides which protection?
Acquired immunity from disease
107. The ED nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the ED.
Activate the agency emergency response plan
110. The nurse enters a clients room and finds that the wastebasket is on fire. The nurse quickly assist the client out of the room. Which is the NEXT nursing action?
Activate the fire alarm
494. The nurse is preparing a list of homecare instructions for the client who has been hospitalized and treated for TB. Which instructions should the nurse reinforce? Select all that apply
Activities should be resumed gradually A sputum culture is needed q2-4 weeks once medication therapy is initiated Respiratory isolation is not necessary because family members have already been exposed Cover the mouth and nose when coughing or sneezing and confine used tissue to plastic bags
639. Dantrolene sodium is prescribed for a client experiencing flexor spasms, and the client asks the nurse about action of the medication. The nurse responds knowing that which is the therapeutic action of this medication?
Acts directly on the skeletal muscle to relieve spasticity
516. A post cardiac surgery client with a blood urea nitrogen (BUN) level of 4.5 mg/dl and a serum creatinine level of 2.2 mg/dl has a total 2 hr urine output of 25ml. The nurse understands that the client is at risk for which condition?
Acute kidney injury
100. The nurse notes documentation that a client has conductive hearing loss. The nurse plans care knowing that this kind of hearing loss can be caused by which circumstances? Select all that apply
Acute otitis media with effusion A physical obstruction to the transmission of sound waves
519. The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea,tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the RN and expects which interventions to be prescribed? Select all that apply
Admin oxygen Inserting a Foley catheter Admin furosemide Admin morphine sulfate IV
126. The medication prescription states to administer acetaminophen 650 mg orally for a temperature of more than 38C. The medication bottle states acetaminophen 325mg tablets. The nurse takes the clients temperature and notes that it is 101F. The nurse plans to take what action?
Administer 2 tablets
475. The nurse is reviewing the prescriptions of a client admitted to the hospital with a DX of acute pancreatitis. Which interventions should the nurse expect to be prescribed? Select all that apply
Administer antacids, as prescribed Encourage coughing and deep breathing Administer anticholinergics, as prescribed
250. The nurse suspects that the client has a pulmonary embolism. Which is the MOST IMPORTANT nursing action?
Administer oxygen by face mask, as prescribed
585. The client is receiving an eyedrops and an eye ointment to the right eye. Which action should the nurse take?
Administer the eyedrops first followed by the eye ointment
176. The parents of a 16y/o child tell the nurse that they're concerned because the child sleeps until noon every weekend. Which is the MOST APPROPRIATE nursing response?
Adolescents love to sleep late in the mornings
157. The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?
Advance the catheter to the bifurcation and inflate the balloon
690. A client is unwilling to get out of the house for fear of doing something crazy in public. Because of this fear, the client remains home bound except when accompanied outside by the spouse. The spouse asks the nurse, what is the name of my wife's disorder? Which answer should the nurse give to the spouse?
Agoraphobia
115. The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which I'd the next action the nurse should perform?
Aim at the base of the fire
465. Glimepiride is prescribed for a client with DM. The nurse reinforces instruction for the client and tells the client to avoid which while taking this medication?
Alcohol
177. A 16y/o child is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which interventions is MOST APPROPRIATE to facilitate normal growth and development?
Allow the child to participate in activities with other individuals in the same age group when the conditions permits
169. The nurse is providing instructions regarding the psychological development of the infant. Using Erikson's psychosocial development theory, which instruction should the nurse reinforce to the parents?
Allow the infant to signal a need
187. The nurse should plan which to encourage autonomy in the client who is a resident in a long term care facility?
Allowing the client to choose social activites
2. A nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with their meal?
Allowing the client to unwrap the utensils and prepare his own meal for eating
417.the nursing is assisting with conducting a health promotion program to community members regarding testicular cancer. The nurse determines that FURTHER TEACHING IS NEEDED if a community member status that which is a S/S of testicular cancer? Select all that apply
Alopecia Elevation in prostate specific antigen (PSA) levels
545. A client with chronic Kidney disease has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now has mental cloudiness, dementia, and complaints of bone pain. Which does this data indicate?
Aluminum intoxication
260. The nurse is assigned to care for the client after a C section. To prevent thrombophlebitis, the nurse should encourage the women to take which PRIORITY action?
Ambulate frequency
392. The nurse, employed in a long term facility, is planning the clinical assignment for the day. The nurse knows not to assign which staff member to the client with a DX of herpes zoster?
An UAP who has never had chicken pox
644. The client DX with pemphigus is being seen in the clinic regularly. The nurse should plan care based on which description of this condition?
An autoimmune disease that causes blistering in the epidermis
482. The client has an as needed prescription for loperamide hydrochloride. For which condition should the nurse administer this medication?
An episode of diarrhea
31. The nurse who is caring for a client with kidney failure notes that the client is dyspneic and crackles are heard listening to breath sounds in the lungs. Which additional S/S should the nurse expect to note in this client?
An increase in B/P
641. Which individual is least at risk for development of Kaposi's sarcoma?
An individual working in an environment where exposure to asbestos exists
111. A LVN attends a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the NEED FOR FURTHER TEACHING about anthrax?
Anthrax bacteria produces a neurotoxin leading to serious, possible fatal paralysis
140. The nurse is checking a clients surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which actions should the nurse take to deal with the event? Select all that apply
Apply a sterile dressing soaked in NS to the wound Notified the RN and PHCP at once
289. A topical corticosteroid is prescribed by the HCP for a child with atopic dermatitis (exzema) which instruction should the nurse give the parent about applying the cream?
Apply a thin layer of cream and rub it into the area throughly
378. A 6m/o infant receives a DTaP immunization at the well baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which intervention by the nurse is appropriate?
Apply an ice pack to the injection site
793. The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? Select all that apply
Apply disposable gloves Lubrications the enema tube and insert it approximately 4 inches Clamp the tubing if the client expresses discomfort during the procedure Ensure that the temp of the solution is between 100F and 105F
571. A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which IMMEDIATE action?
Apply ice to the effected eye
444. The nurse is assisting with preparing a teaching plan for the client with DM regarding proper foot care. Which instruction should be included in the plan of care?
Apply moisturizing lotion to dry feet but not between the toes
420. The nurse is reinforcing instructions to a client receiving external radiation therapy. The nurse determines that the client NEEDS FURTHER TEACHING if the client states an intention to take which action? Select all that apply
Apply pressure on the radiated area prevent bleeding Avoid standing within 6 feet of a person under the age of 18 y/o
749. The nurse is preparing to suction an adult client through the clients tracheostomy tube. Which interventions should the nurse perform for this procedure? Select all that apply
Apply suction for up to 10 seconds Hyperoxgenate the client before suction Apply intermittent suction while rotating and withdrawing the catheter Advance the catheter until resistance is met and the pull the catheter back 1 cm
781. The nurse is caring for a client with a DX of pemphigus. The nurse should include which interventions in the plan of care for this client? Select all that apply
Applying prescribed topical antibiotic Administering prescribed corticosteroids Applying Domeboro solution to the effected skin
522. To use an external cardiac defibrillator on a client, which action should be performed to check the cardiac rhythm?
Applying the adhesive patch electrodes to the skin and moving away from the client
669. Lab work is prescribed for a client who has been experiencing delusions. When the lab tech approaches the client to obtain a specimen of the client's blood, the client begins to shout " you're all vampires" let me out of here!" The nurse presents at the time should respond with which question or statement?
Are you fearful and think that others may want to hurt you
428. The nurse is caring for a client after a mastectomy. Which findings would indicate that the client is experiencing a complication that may become a chronic problem related to the surgery?
Arm edema on the operative side
730. A client receiving a tricyclics antidepressant arrives at the mental health clinic. Which observation indicates that the client is correctly following the medication plan?
Arrives at the clinic neat and appropriate in appearance
21. The nurse is recording a nursing hands off (end of shift) report for a client. Which information needs to be included?
As needed medications given that shift
348. A child is admitted to the hospital with a probable DX of nephrotic syndrome. Which findings should the nurse expect to observe? Select all that apply
Ascites Anorexia Protenuria Periorbital and facial edema
134. The nurse obtains the vital signs on a postoperative active client who just returned to the nursing unit. The clients B/P 100/60 mmHg, P 90bpm, and R 20bpm. On the basis of these findings, which actions should the nurse take? Select all that apply
Ask how the client feels and inquire about any feelings of dizziness Review the client record to determine time and type of analgesia last recorded Review the client record to note the vital signs taken in the post anesthesia care unit (PACU)
647. The client calls the office of the PHCP and states to the nurse that they were just stung by a bumblebee while gardening. The client is afraid of a severe reaction because their neighbor experienced such a reaction just 1 week ago. Which should be the appropriate nursing action?
Ask if the client as ever been stung in the past
132.the nurse is caring for a client who is scheduled for surgery. The client states concern about surgical procedure. How should the nurse initially address the clients concerns?
Ask the client to discuss information known about the planned surgery
135. A client arrives to the surgical nursing unit after surgery. What should be initial nursing action after surgery?
Assess patency of the airway
714. A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurses MOST IMPORTANT intervention to maintain client safety?
Assign a staff member to the client who will remain with him or her at all times
712. The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse should avoid which intervention in the plan of care?
Assigning the client to a room at the end of the hall to prevent disturbing the other clients
679. The nurse is preparing a client for the termination phase of the nurse- client relationship. Which task should the nurse appropriately plan for during this phase?
Assist with making appropriate referrals
415. The camp nurse asks the children preparing to swim in the lake if they applied sunscreen. The nurse reminds the children that chemical sunscreens are MOST EFFECTIVE when applied at which times?
At least 30 minutes before exposure to the sun
257. After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note?
At the level of the umbilicus
167. The parents of a 8 y/o child tell the nurse that they're concerned about the child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response?
At this age, the child is developing his or her own personality
586. The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question?
Atropine sulfate
589. Pilocarpine hydrochloride is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity?
Atropine sulfate
615. The client with myasthenia gravis is receiving pyridostigmine. The nurse monitors for S/S of cholinergic crisis caused by overdose of the medication. The nurse checks the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs?
Atropine sulfate
578. A client with Ménière's disease is experiencing sever vertigo. The nurse reinforces instructions to the client to do which to assist with controlling vertigo?
Avoid sudden head movements
663. Saquinavir is prescribed for the client who is DX with HIV seropositive. The nurse should reinforce medication instructions about which health care measures to the client?
Avoid sun exposure
640. The nurse is reinforcing discharge instructions to a client receiving baclofen. Which should the nurse include in the instructions?
Avoid the use of alcohol
354. An 18m/o child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measures should the nurse stress to the parents as they prepare to take this child home?
Avoid tub baths until the stent has been removed
659. The nurse is caring for a postrenal transplantation client with prescription for cyclosporine. If the nurse notes an increase in one of the clients vital signs and the client is complaining of a headache, which vital sign is MOST LIKELY increased?
B/P
799. The nurse is planning to administer amlodipine to a client. The nurse should plan to check which before administering this medication?
B/P and heart rate
558. Following kidney transplantation, cyclosporine is prescribed for a client. Which lab results would indicate an adverse effect from the use of this medication?
BUN level of 25 mg/dl
412. The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply the medication to which body area? Select all that apply
Back Soles of feet Palms of the hands
353. The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for lab results of the urine test and would MOST LIKELY expect to note which findings?
Bacteriuria
74. A low sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet?
Baked turkey
214. The nurse is checking a clients record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply
Ballottement Chadwick' s sign Uterine enlargement Braxton Hicks contractions
819. The nurse is caring for a client dying of cancer. During care, the client states, if I can just live long enough to attend my daughters graduation, I'll be ready to go. Which phase of coping is this client experiencing?
Bargaining
231. The nurse is assigned to care for a client who is in early labor. Which collecting data from the client, which should the nurse check FIRST?
Baseline FHR (fetal heart rate)
162. The nurse assisting in planning care for a client with a chest tube. The nurse should suggest to include which interventions in the plan? Select all that apply
Be sure all connections remain airtight Be sure all connections are taped and secure Monitor closely for tubing that is kinked or obstructed
541. The nurse is caring for the client with epididymitis. Which treatment modalities should be implemented? Select all that apply
Bed rest Site bath Antibiotics Scrotal elevation
267. The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught which intervention?
Begin with the eyes and face
175. The nursing student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately relates to this stage?
Beginning of toilet training
284. RhO(D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from what condition?
Being effected by Rh incompatibility
280. A client in preterm labor (31 weeks) who is dilated to 4cm has been started on magnesium sulfate and her contractions have stopped. If the client's labor can be inhibited for the next 48 hrs, the nurse anticipates a prescription for which medication?
Betamethasone
550. After a renal biopsy, the client complains of pain at the biopsy site that radiates to the front of the abdomen. Which would this indicate?
Bleeding
265. The nurse is assisting in caring for a post term neonate immediately after admission to the nursery. The PRIORITY nursing action should be to monitor which clinical parameter?
Blood glucose level
281. Methylergonovine is presided for a woman to treat postpartum hemorrhage. Before administration of methyegonovine, what is the priority nursing assessment?
Blood pressure
708. The nursing student is asked to identify the characteristics of bulimia nervosa. Which characteristic if identified by the student indicates FURTHER TEACHING?
Body weight well below ideal range
562. The nurse who is administrating bethanechol chloride is monitoring for acute toxicity associated with the medication. The nurse should check the client for for which signs of toxicity?
Bradycardia
553. A client with benign prostatic hypertrophy (BPH) undergoes a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation postoperatively. Which are the S/S of TUR syndrome?
Bradycardia and confusion
240. The nurse is collecting data from a client who has been DX with placenta pervia. Which findings should the nurse expect to note? Select all that apply
Bright red vaginal bleeding Soft, relaxed, nontender uterus
493. The nurse is caring for a client after a bronchoscope and biopsy. Which findings should be reported IMMEDIATELY to the PHCP?
Bronchospasms
44. The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium?
Butter
45. The nurse is caring for a client with hyperparathyroidism and notes that the clients serum calcium level is 13 mg/dl. Which prescribed medication should the nurse plan to assist in administering to the client?
Calcitonin
322. The nurse reinforces instructions to the mother about to dietary measures for a 5y/o child with lactose intolerance. The nurse should tell the mother that which supplement will be required as a result of the need to avoid lactose in the diet?
Calcium and vitamin D
439. The client with metastatic breast cancer is reviewing tamoxifen. The nurse specifically monitors which lab value while the client is taking this medication?
Calcium levels
520. The nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia (VT), followed by ventricular fibrillation (VF). The client suddenly loses consciousness. Which intervention should the nurse do FIRST?
Call for help start CPR
753. The nurse checks the food on a tray delivered for an orthodox Jewish client and notes that the client has received a cheeseburger and potato friends with whole milk as a beverage. Which action should the nurse take?
Call the dietary department and ask for a different meal
707. A hospitalized client with a history of alcohol abuse tells the nurse, I'm leaving right now. I have to go. I don't want anymore treatment. I have things that I have to do right away. The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hr. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. Which is the appropriate nursing action?
Call the nursing supervisor
106. A mother calls a neighborhood nurse and tells the nurse that her 3 y/o child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take FIRST?
Call the poison control center
309. A child has fluid volume deficit. The nurse collects data and determines that the child is improving and the deficit is resolving if which finding is noted?
Cap refill is less than 2 seconds
580. A client is DX with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma?
Cardiovascular disease
750. The nurse is assisting with caring for a client who has a placenta previa. The nurse understands that the cervical exam should NOT be performed on the client primarily because it could have which consequence?
Cause hemorrhage
511. A client has been started on a long term therapy with rifampin. Which information about this medication should the nurse provide to the client?
Causes red orange discoloration of sweat, tears, urine,and feces
92. The nurse is preparing an IV solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to take which action?
Change the IV tubing
815. The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which outcome?
Characteristic of a thrush infection
620. The nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action should the nurse take FIRST?
Check clients alignment in bed
537. A hospitalized client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers Nitroglycerin 0.4mg, sublingual. After 5 minutes the client states, My chest still hurts. Which appropriate actions should the nurse take? Select all that apply
Check pain level Check B/P Administer a second Nitroglycerin 0.4mg sublingual
304. A HCP prescribes an IV solution of 5% dextrose and half normal saline(0.45%) with 40mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which PRIORITY assessment before administering this IV prescription?
Check the amount of urine output
317. A child is brought to the ER and the mother reports that the child accidentally swallowed paint thinner after mistaking it for water. The nurse should perform which action FIRST?
Check the circulation, airway and breathing status of the child
518. A client is wearing a continuous cardiac monitor which begins to alarm at the nurses station. The nurse sees no electrocardiograph complexes on the screen. The nurse should do which action FIRST?
Check the client status and lead placement
138. The nurse is caring for a postoperative client who has Jackson-Pratt drain inserted into the surgical wound. Which actions should the nurse take in care of the drain? Select all that apply
Check the drain for patency Check that the drain is decompressed Observe for bright red, bloody drainage Maintain aseptic technique when emptying Empty the drain when it is half full and every 8-12 hrs
551. The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. The nurse should take which action? Select all that apply
Check the level of the drainage bag Reposition the client to his or her side Place the client in good body alignment Check the peritoneal dialysis system for kinks
481. A client with Crohn's disease is scheduled to receive an infusion of infliximab. The nurse assisting with care for the client should take which action to monitor the EFFECTIVENESS of treatment?
Checking frequency and consistency of bowel movements
251. The nurse notes that the 4hr postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse IMMEDIATELY notifies the RN and then performs which action?
Checks the vital signs
432. The client with squamous cell carcinoma of the larynx is receiving bleomycin IV. The nurse caring for the client anticipates that which diagnostic study will be prescribed? Select all that apply
Chest x-ray Pulmonary function studies
330. The nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which meal BEST illustrates the MOST APPROPRIATE diet for a client with CF?
Cheyenne tenders and a bakes potato with butter
94. The nurse is assisting with caring for a client who is receiving a unit of PRBCs. The nurse should tell the client that it is MOST IMPORTANT to report which signs IMMEDIATELY
Chills Itching Rash
320. The nurse reviews the record of an infant seen in the clinic. The nurse notes that the DX of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which MOST LIKELY manifestation of this condition in the medical record?
Choking when feeding
165. The nurse is preparing to administer a medication through NG tube that is connected to suction. Which interventions should be included to accurately administer the medication?
Clamp the NG tube for 30 minutes after medication administration Before medication administration, verify correct placement of tube Flush the NG tube with saline before and after medication administration
225. The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which action FIRST?
Clear and maintain an open airway
53. Which clients would the nurse determine is at risk for development of metabolic alkalosis? Select all that apply
Client who has been vomiting for 2 days Client receiving oral furosemide 40 mg daily
754. A client is brought to the ED by ambulance team after collapse at home. Cardiopulmonary resuscitation is attested but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that their eyes are to be donated. Which action should the nurse take next?
Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes
359. Which lab result would verify the DX of bacterial meninditis?
Cloudy cerebrospinal fluid with high protein and low glucose levels
685. Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply
Communicate expected behaviors to the client Follow through about the consequences of behavior in a nunpunitive manner Assist the client with developing a means of setting limits on personal behavior Be clear with the client regarding the consequences of exceeding limits set regarding behavior
600. The client with a cervical spine injury has Crutchfield tongs applied in the ED. The nurse should perform which essential action when caring for this client?
Comparing the amount of prescribed weights with the amount in use
438. Tamoxifen is prescribed for the client with metastatic breast carcinoma. The nurse understands that which I'd the PRIMARY action of the medication?
Compete with estradiol for binding to estrogen in tissue containing high concentrations of receptors
657. The client DX with AIDS has begun therapy with zidovudine. The nurse should monitor which lab results during treatment with this medication?
Complete blood count
218. While assisting with the measurement of fundal height, the client at 36 weeks gestation states that she is feeling lightheaded. On the basis of the nurses knowledge of pregnancy, the nurse determines that this is MOST LIKELY a result of which reason?
Compression of the vena cava
780. The nurse is assigned to care for an infant with cryptorchidism. One testis cannot be palpated. The nurse anticipates that which diagnostic study will be prescribed to determine where the undescended testis is located in the body?
Computed tomography scan
485. An older client has recently been taking cimetidine. The nurse should monitor the client for which MOST frequent CNS side effect of this medication?
Confusion
555. The nurse is monitoring an older client suspected of having a UTI for signs of infection. Which S/S is likely to present FIRST?
Confusion
341. The nurse assist with admitting a child with a DX of acute stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted?
Conjunctival hyperemia
264. The nurse in the newborn nursery receives a telephone call to prepare for the admission of a neonate born at 43 weeks gestation with Apgar score of 1 and 4. When planning for the admission of this infant, which is the nurses HIGHEST PRIORITY?
Connecting the resuscitation bag to the oxygen outlet
809. A client with chronic kidney disease is receiving ferrous sulfate. The nurse should monitor the client for which common side effect associated with this medication?
Constipation
376. A child with rubeola (mumps) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented? Select all that apply
Contact Airborne
674. The nurse enters a clients room, and the client immediately demands to be released from the hospital. During review of the client record, the nurse notes that the client was admitted 2 days ago for the treatment of anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the RN and expects the RN will take which action?
Contact the PHCP
158. The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water seal chamber. Based on this observation, which action would be appropriate?
Continue to monitor
542. A client has epididiymitis as a complication of a UTI. The nurse is giving the client instructions to prevent recurrence. The nurse determines that the client NEEDS FURTHER TEACHING if the client states the intention to do which action?
Continue to take antibiotics UNTIL the all symptoms are gone
692. A client was admitted to the medical unit with acute blindness. Many test are performed, and there seems to be no organic reason why this client can not see. The nurse later learns that the client became blind after witnessing a hit and run car crash in which a family of three was killed. The nurse suspects that the client maybe experiencing which DX?
Conversion disorder
747. A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, should offer which items during an episode of nausea?
Cool,clear liquids
814. The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made?
Coughing occurs with suctioning
159. The nurse is assigned to assist the PHCP with the removal of a chest tube. Which intervention should the nurse anticipate performing during this processs? Select all that apply
Cover the site with an occlusive dressing after the tube is removed Have the client perform the Valsalva maneuver as the chest tube is pulled out
527. A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink tinged sputum. The nurse listens to breath sounds expecting to hear which breath sounds bilaterally?
Crackles
775.the nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates accurate understanding of this disorder?
Cushing's disease is characterized by an over-secretion of glucocorticoid hormones
547. The nurse is reviewing the medical record of a client with a DX of pyelonephritis. Which disorder noted on the client's record should the nurse identify as risk factor for this diagnosis?
DM
191. When the nurse is collecting data from the older adult, which findings should be considered normal physiological changes? Select all that apply
Decline in visual acuity Increased susceptibility to UTI Increased incidence of awakening after sleep onset
15. The nurse enters a client's room and notes that the clients lawyer is present and that the client is preparing a living will. The living will requires that the clients signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action
Decline to sign the will
556. The client who has a cold is seen in the ED with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which class of medications?
Decongestants
543. The nurse is collecting data from the client who has had benign prostatic hyperplasia (BPH) in the past. To determine whether the client is currently experiencing exacerbation of BPH, the nurse should ask the client about the presence of which EARLY symptom?
Decrease force in the stream of urine
186. An older client has been prescribed digoxin. The nurse determines that which age-related change would place the client at risk for digoxin toxicity?
Decreased lean body mass and glomerular filtration rate
464, desmopressin acetate is prescribed for the treatment of DI (diabetes insipidus). The nurse monitor the client after medication administration for which therapeutic response?
Decreased urinary output
728. The nurse is collecting data for a client, and the client's spouse reports that the client is taking donepezil hydrochloride. Which disorder should the nurse suspect that this client may have based on the use of this medication?
Dementia
671. A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting LET ME OUT there is nothing wrong with me! I don't belong here! The nurse identifies this behavior as which defense mechanism?
Denial
529. The nurse is collecting data on a client with a DX of right sided heart failure. The nurse should expect to note which specific characteristic of this condition?
Dependent edema
549. A client is scheduled for intravenous pyelography (IVP). Which PRIORITY nursing action should the nurse take?
Determine if there is a history of allergies
235. A primigravida's memberanes rupture spontaneously. Which action should the nurse take FIRST?
Determine the fetal heart rate
244. The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. During admission, which action should the nurse take INITIALLY?
Determine the maternal and fetal vital signs
473. The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to see documented in the record?
Diarrhea
458. The homecare nurse is visiting a client who was recently DX with T2DM. The client, prescribed repaglinide metformin, asks the nurse to explain these medications. The nurse should reinforce which instructions to the client? Select all that apply
Diarrhea can occur secondary to metformin The repaglinide is taken 30min before eating The repaglinide if the meal is skipped Candy or other simple sugars is carried and used to treat mild hypoglycemia episodes
762. The nurse reinforces client instructions about ethambutol. The nurses determines that the client understands the instructions if the client indicates to report which occurrence?
Difficulty discriminating the color red from green
789. The nurse has reinforced instructions to a client with TB about proper handling and disposal of respiratory secretions. He nurse determines that the client understands the instructions if the client verbalizes to take which measures
Discard used tissue in a plastic bag
88. The nurse assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and should avoid which while changing the clients hospital gown?
Disconnecting the IV tubing from the catheter in the vein
270. A newborn has just been circumcised and is being discharged home in 2 hrs. Which instructions should the nurse provide to the parents?
Do not wash the penis with soap until the circumcision is healed, which takes 5 to 6 days Change the diaper every 4 hrs or more often to inspect the penis for discharge or infection Monitor the circumcision; penis may appear reddened with small amount of bloody drainage shortly after the procedure.
205. A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse helps determine whether this method of family planning is appropriate?
Do you plan to have any other children?
12. The LPN enters the clients room and finds the client lying on the bathroom floor. The LPN calls the RN who checks the client throughly and the assist the client back into bed. The LPN completes the incident report, and the nursing supervisor and PHCP are notified of the incident. Which is the NEXT nursing action regarding the incident?
Document a complete entry in the clients record concerning the incident
151. The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90ml of residual from the tube. What should the nurse do? select all that apply
Document the amount of residual Reinstall the residual and administer the feeding
183. Upon palpation of the fontanels of a 3m/o newborn, the nurse notes that the anterior fontanel has not closed and is soft and flat. Which action should the nurse take?
Document the findings
335. The nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The nurse notes a small amount of reddish drainage from the child's ear after surgery. On the basis of this finding, which action should the nurse take?
Document the findings
227. The pregnant women complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform with measures?
Dorsiflex the clients foot while extending the knee
716. The nurse is caring for a client with severe depression. Which activity is appropriate for this client?
Drawing
66. A client brought to the ED states that he has accidentally been taking two times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to assist the RN with which action?
Drawing a sample for PT and INR
301. A school aged child with T1DM has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. Which should the nurse tell the child?
Drink a half cup of orange juice before soccer practice
228. The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which BEST measure?
Drink decaffeinated coffee and tea
633. The nurse is monitoring a client receiving baclofen for side effects related to the medication. Which should indicate that the client is experiencing a side effect?
Drowsiness
755. The nurse prepares to administer a prescribed dose of scopolamine. The nurse should monitor for which side effect of this medication?
Dry mouth
452. The nurse educator is asking the nursing student to recall the S/S of hypothyroidism. The nurse educator determines that the nursing student understands this disorder if which statement is included? Select all that apply
Dry skin Constipation Cold intolerance
268. After birth the nurse prevents hypothermia as a result of evaporation by performing which action?
Drying the baby with a warm blanket
792. The nurse is caring for a client hospitalized with acute exacerbation of COPD. Which should the nurse expect to note in this client? Select all that apply.
Dyspnea during exertion Presence of productive cough Difficulty breathing while talking
552. A male client has a tentative DX of urethritis. The nurse should assess the client for which manifestation of the disorder?
Dysuria and penile discharge
808. The nurse is admitting a client with Gillian-Barre syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of this disorder, the nurse should bring which item into the client's room?
Electrocardiographic monitoring electrodes and intubation tray
624. The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and the plaster cast has been applied. In positioning the casted leg, the nurse should perform which intervention?
Elevate the leg on pillows continuously for 24/48 hrs
368. A 4y/o child sustains a fall at home injuring the right arm and is brought to the ED by the mother. The nurse should perform which EMERGANCY action in the care of the child? Select all that apply
Elevate the right arm Check the neuromuscular status of the right extremity Determine the level of pain using a pediatric pain assessment tool
548. The nurse is reviewing the client's record and notes that the PHCP has documented that the client has a renal disorder. Which lab results would indicate a decrease in renal function? Select all that apply
Elevated serum creatinine level Decreased RBC count Elevated BUN levels
629. The nurse is caring for a client with a fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action?
Elevating the limb and applying ice to the affected leg
403. The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn?
Elevation above the level of the heart
164. The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care knowing that which facts are true with the use of a fenstrated tracheostomy tube? Select all that apply
Enables the client to speak Must have the cuff deflated when capped
718. The nurse is preparing to care for a dying client and several family members that are at the clients bedside. Which therapeutic techniques should the nurse use communicating with the family? Select all that apply
Encourage expression of feelings, concerns and fears Extend touch, and hold the client or the family members hands if appropriate Be honest and truthful, and let the client and family know that you will not abandon them
180. The nurse is preparing to care for a dying client and several family members are at the clients bed side. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply
Encourage expression of feelings, concerns, and fears Touch and hold the clients or family members hand if appropriate Be honest and let the client and family know that they will not be abandoned by the nurse
416. The nurse is assisting with developing a plan of care for the client with multiple myeloma. Which nursing intervention should be included to prevent renal failure for this client?
Encourage fluids Monitoring serum calcium and uric acid levels
293. The nurse caring for a child with aplastic anemia is reviewing the lab results and notes a WBC count of 6000mm3 and a platelet count of 20,000mm3. Which nursing intervention should be incorporated into the care plan?
Encourage quiet play activites
303. The mother of a 6y/o child who has T1DM calls the clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action?
Encourage the child to drink liquids
774. The nurse is assisting with preparing a plan of care for a 4 y/o child hospitalized with nephrotic syndrome. Which intervention is MOST APPROPRIATE for this child?
Encourage the child to eat in the playroom
773. In planning activities for the depressed client, especially during the early stages of hospitalization, which action is BEST?
Encourage the client to participate in a structure daily program of activites
46. A client has the following lab values: a pH of 7.55, an HCO3 level of 22 mEq/L and a PCO2 of 30 mm Hg. Which action should the nurse plan to take?
Encourage the client to slow down breathing
693. A manic client announces to everyone in the day room that a stripper is coming to perform that evening. When the psychiatric nurse's aide firmly states the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aide. Based on this analysis of the situation, the nurse determines that the appropriate action should be which intervention?
Escort the manic client to his or her room
740. Before administering an intermittent tube feeding through the NGT, the nurse checks for gastric residual volume. Which is the BEST rationale for checking for gastric residual volume before administering the tube feeding?
Evaluate absorption of the last feeding
706. A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which findings?
Evidence of the client's altered and distorted body image
715. The police arrives at the ED with a client who has seriously lacerated both wrists. Which is the INITIAL nursing action?
Examine and treat the wound sites
337. The nurse reviews the record of a child who was just seen by the PHCP. The PHCP has documented a DX of suspected aortic stenosis. Which specific S/S of aortic stenosis should the nurse anticipate?
Exercise intolerance
597. The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in ICP if the nurse observes the client doing which activity?
Exhaling during repositioning
154. A LVN is preparing to assist the RN with removing a NG tube from the client. Which interventions should be included in the procedure? Select all that apply
Explain the procedure to the client Ask the client to take a deep breath and hold Pull the tube out in one continuous steady motion Remove the device or tape securing the tube from the nose
160. The nurse is planning to begin a continuous tube feeding on a client with a NG tube. Which interventions should the nurse perform before initiating the feeding? Select all that apply
Explain the procedure to the client Irrigate the NG tube with saline Elevate the head of the bed to 45 degrees
783. Skin breakdown occurs on a client's hand at the site of an IV catheter that had medication infusing. The nurse determines that which adverse effect occurred?
Extravasation
436. The client with ovarian cancer is being treated with vincristine. The nurse monitors the client, knowing that which adverse effect is specific to this medication?
Extremity numbness
567. The nurse is assisting with developing a teaching plan for a client with glaucoma. Which instruction should the nurse suggest to include in the plan of care?
Eye medication may need to be administered for the rest of your life
211. A primipara is being evaluated in the clinic during her 2nd trimester of pregnancy. Which occurrence indicates an abnormal physical finding that necessitates further testing?
FHR of 180bpm
794. The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions should the nurse use for communicating with the client?
Face the client when talking Speak slowly and maintain eye contact Use gestures when talking to enhance words Give the client directions using short phrases and simple terms
76. A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client?
Fat free beef broth
426. The client is admitted to the hospital with a DX of suspected Hodgkin's disease. Which S/S of the client are associated with this disease? Select all that apply
Fatigue Weakness Night sweats Enlarged lymph nodes
717. A client experiencing a severe major depressive episode is unable to address activities of daily living. Which is the appropriate nursing intervention?
Feed, bathe, and dress the client as needed until the client can perform these activities independently
313. A mother of a child with a DX of intussusception calls the nurse into the hospital room because the child is screaming in pain. Which manifestation of perforation should the nurse report immediately? Select that all apply
Fever Increased heart rate Change in the LOC
731. A hospitalized client is prescribed phenelzine sulfate for the treatment of depression. The nurse reinforces instructions to the client and tells the client to avoid consuming which foods while taking this medication? Select all that apply
Figs Yogurt Aged cheese
292. The nurse monitors a 5y/o child admitted to the hospital for a neuroblastoma for S/S related to the location of the tumor in the adrenal gland. Which description would the nurse expect to be documented in the child's record specific to the tumor? Select all that apply
Firm, nontender, irregular mass in the abdomen Urinary frequency or retention from compression on the bladder
651. The client is DX with stage 1 Lyme disease. The nurse should check the client for which characteristic of this stage?
Flu like symptoms
291. The nurse reinforces instructions to the parents of a child with sickle cell anemia regarding the precipitating factors related to pain crisis. Which, if identified by the parent as a precipitating factor, indicates the NEED FOR FURTHER TEACHING?
Fluid overload
278. The nurse is monitoring a client in preterm labor who is receiving IV magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply
Flushing Depressed respirations Extreme muscle weakness
384. Which home care instructions should the nurse plan to reinforce to the mother of a child with AIDS? Select all that apply
Frequent hand washing is important The child should avoid exposure to other illnesses Clean up body fluid spills with bleach solution (10/1)water to bleach
6. The nurse is planning to reinforce nutrition instructions to an African American client. Which reviewing the plan, the nurse is aware that which food maybe common dietary practice of the clients African American heritage?
Fried foods
305. An adolescent client with T1DM is admitted to the ED for the treatment of diabetes ketoacidosis. Which assessment findings should the nurse expect to note?
Fruity breath odor and decreased level of consciousness
208. The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5y/o child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse should document which as the GTPAL for this client?
G=2, T=1, P=0,A=0,L=1
665. The client who is DX with HIV seropositive has been taking stavudine. The nurse should monitor which parameter closely while the client is taking this medication?
Gait
735. The nurse is preforming a follow up teaching session with a client discharged 1 month ago who is taking fluoxetine. Which information should be important for the nurse to gather regarding the adverse effects related to this medication?
Gastrointestinal dysfunctions
350. The nurse is assisting with gather admission assessment data on a 2y/o child who has been DX with nephrotic syndrome. The nurs collects data knowing that which is a common characteristic with nephrotic syndrome?
Generalized edema
43. The nurse is caring for a client with a suspected DX of hypercalcemia. Which S/S would be an indication of this electrolyte imbalance?
Generalized muscle weakness
101. While collecting data related to the cardiac system on a client, the nurse hears a murmur. Which BEST describes the sound of a heart murmur?
Gentle, blowing or swooshing noise
676. Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the RN and expects that the RN will take which action?
Get a written prescription from the PHCP and obtain an consent
310. The nurse should implement which intervention. For a child older than 2y/o with T1DM who has a blood glucose of 60mg/dl. Select all that apply
Give the child a tsp of honey Prepare to administer glucagon subcutaneously if unconsciousness occurs
638. Cyclobenzaprine is prescribed for a client to treat muscle spasms, and the nurse is reviewing the clients record. Which disorder would indicate a need to contact the PHCP regarding the administration of this medication?
Glaucoma
174. A child remarks I share my toys and snacks with my friends so they will like me more. The nurse determines the child is in which stage of moral development?
Good boy nice girl orientation
209. The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3y/o child who was born at 39 weeks gestation. The nurse should document which gravida and para status on this client?
Gravida 2, para 1
71. A client is having problems with blood clotting. Which food items should the nurse encourage the client to eat?
Green leafy vegetables
339. The nurse is told a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF?
Has the child has a sore throat or a fever within the past 2 months
131. The nurse is developing plan of care for a client who is scheduled for surgery. The nurse should include which activities in the nursing care plan for the client on the day of the surgery? Select all that apply
Have client void before surgery Determine that the client has signed the informed consent for the surgical procedure
367. The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother ask the nurse if the child should perform ROM exercises at this time? The nurse should make which response to the mother?
Have the child perform simple isometric exercises during this time
194. The nurse should implement which activity to promote reminiscence amount older clients?
Having storytelling hours
599. The nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in which position postoperative?
Head of bed elevated 30-40 degrees, head and neck midline
594. The nurse observes the UAP positioning the client with ICP. Which position would require intervention by the nurse?
Head turned to the side
347. The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which findings are associated with the DX of glomerulonephritis. Select all that apply
Headache Red brown urine Periorbital edema
660. Amikacin is prescribed for a client with a DX bacterial infection. The nurse instructs the client to contact PHCP IMMEDIATELY if which occurs?
Hearing loss
811. The nurse is preparing to administer digoxin, 0.125 mg PO, to a client with heart failure. Which vital sign is MOST IMPORTANT for the nurse to check before administering the medication?
Heart rate
488. The client has been taking omeprazole for 4 weeks. The nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom?
Heartburn
745. The nurse is explaining causes and reasons of hemophilia A to the parents of the child with this disease. The nurse should make which statement about hemophilia A?
Hemophilia A results from deficiency of factor V111
476. It has been determined that a client with hepatitis has contracted the infection from contaminated food. Which hepatitis is the client MOST LIKEY experiencing
Hep A
147. The nurse is assisting with the insertion of a NG tube into a client. The nurse should be place the client in which position for insertion?
High flowers position
56. A client with A-fib who is receiving maintenance therapy of warfarin sodium has a PT time of 35 seconds and an INR of 3.5. On the basis of the lab values, the nurse anticipates which prescription?
Holding the next dose of warfarin
701. The nurse is caring for a client who is suspected of being dependent on drugs. Which question should be appropriate for the nurse to ask when collecting data from the client regarding drug abuse?
How much do you uses and what effect does it have on you
544. The nurse is instructing a client with DM about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complications?
Hyperglycemia
606. The client with myasthenia gravis is suspected of having cholinergic crisis. Which S/S indicates this crisis is taking place?
Hypertension
409. A burn client is receiving treatments of topical mafenide acetate to the site of the injury. The nurse monitors the client, knowing that which findings indicates the occurrence of a systemic effect?
Hyperventilation
540. The nurse is preparing to administer hydrochlorothiazide to a client. Which are concerns related to the administration of this medication?
Hypokalemia, hyperglycemia, sulfa allergy
338. The nurse has reinforced home care instructions to the parent of a child who is being discharged after cardiac surgery. Which statement from the parent indicates the NEED FOR FURTHER TEACHING?
I can apply lotion or powder to the incision if its itchy
686. The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self and others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement?
I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone
451. The nurse is reinforcing discharge teaching to a client who has Cushing's syndrome. Which statement by the cleint indicates that the instructions related to dietary management were understood?
I can eat foods that contain potassium
463. The home care nurse visits a client at home who has been prescribed prednisone 5mg orally daily. The nurse reinforces teaching for the client about the medication. Which statement made by the client that indicates FURTHER EDUCATION
I can take aspirin or my antihistamine if I need it.
680. The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, How is Carol doing? She is my best friend and is seen at your clinic every week. Which is the appropriate nursing response?
I cannot discuss any client situation with you
763. The nurse is caring for an older client with a DX of myasthenia gravis and has reinforced self care instructions. Which statement by the client indicates a NEED FOR FURTHER TEACHING?
I cant change the time of my medication on the mornings that i feel strong
677. The nurse is providing care for a client admitted to the hospital with a DX of anxiety disorder. The nurse is talking with a client and the client says I have a secret to tell you. You wont tell anyone about it will you? Which is the best nursing response?
I cant promise to keep a secret
248. A postpartum client is getting ready for discharge. The nurse suspects that the client NEEDS FURTHER EDUCATION related to breastfeeding when she makes which statement?
I don't need birth control because i will be breastfeeding
725an older client is a victim of elder abuse, and the clients family has been attending weekly counseling sessions. Which statement by the abusive family member indicates that he or she has learned positive coping skills?
I feel better able to care for my farther now that I know where to obtain assistance
365. The nurse provides home care instructions to the parent of a child with attention deficit hyperactivity disorder (ADHD) regarding behavioral therapy interventions. Which statement by the parents indicates a NEED FOR FURTHER TEACHING?
I hear that, the side effects of the medication that my child will be on can cause overeating
340. The nurse providing instructions to a parent of a child with patent ductus arteriosus (PDA). Which statement by the parent would indicate a NEED FOR FURTHER TEACHING?
I know my child will outgrow this problem, just give it time
630. A client is being discharged after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement?
I need to avoid getting the cast wet
395. The nurse reinforces instruction to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need FOR FURTHER TEACHING?
I need to avoid sun exposure before 10am and after 4pm
372. The nurse provides information to the parent of a 2w/o infant who was DX with clubfoot at the time of birth. Which statement of the parent indicates the NEED FOR FURTHER TEACHING?
I need to bring my child back to the clinic in 1 month for a new cast
445. The nurse provides dietary instructions to a client with DM regarding the prescribed diabetic diet. Which statement made by the client indicates the NEED FOR FURTHER TEACHING?
I need to but special diabetic foods
770. The nurse reinforces home care instructions to the mother of a child recovering from Reye's syndrome. Which statement by the mother indicates a NEED FOR FURTHER TEACHING?
I need to give frequent, small, nutritional meals if my child starts to vomit
224. During the prenatal visit, the nurse is explaining dietary management to a client with DM. The nurse determines that the teaching has been effective when the client makes which statement?
I need to increase the fiber in my diet to control my blood glucose and prevent constipation
315. The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of transmission of the virus. Which statement by the parents indicate the NEED FOR FURTHER TEACHING?
I need to provide. A well balanced, high fat diet to my child
804. A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further INSTRUCTIONS ARE NEEDED about skin care if the client makes which statement?
I need to scrub the skin vigorously with soap and water
295. The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the NEED FOR FURTHER TEACHING?
I need to take my child's rectal temperature daily
334. The nurse has provided instructions to the mother of a child who has been DX with bacterial conjunctivitis. Which statement by the mother indicated the NEED FOR FURTHER TEACHING?
I need to use hot compresses to relieve the eye irritation
705. The nurse determines that the wife of an alcoholic client is benefiting from attending an AA group when the nurse hears the wife make which statement?
I no longer feel that i deserve the beatings my husband inflicts on me
592. The client has just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of postoperative care?
I should drink extra fluids for the remainder of the day
504. The nurse is reinforcing discharge teaching to a client DX with TB who has been taking medication for 1 1/2 weeks. The nurse knows that the client has understood the information if which statement is made?
I should not be contagious after 2-3 weeks of medication therapy
455. A client with T1DM calls the nurse to report recurrent episodes of hypoglycemia. Which statement by the client indicates correct understanding of Humulin N insulin and exercise?
I should not exercise in the late afternoon
653. The nurse, a Cub Scout leader, is preparing a group of cub scouts for an overnight camping trip and instructs them about the methods to prevent Lyme disease. Which statement by one of the cub scouts indicates NEED FOR FURTHER TEACHING?
I should not use insect repellent because it will attract the ticks
729. Fluoxetine is prescribed, and the nurse reinforces instructions to the client regarding the administration of this medication. Which statement by the client indicates an understanding about the administration of this medication?
I should take the medication in the morning when I first arise
356. A parent with a 6y/o child DX with enuresis discusses with the nurse the measures that are being taken to help her child. Which statement by the parent indicates the NEED FOR FURTHER TEACHING?
I take away privileges such as TV time when the bed is wet in the morning
329. The nurse has provided instructions to the mother of an infant with viral pneumonia. Which statement by the mother would indicate the NEED FOR FURTHER TEACHING?
I understand I will need to have my baby on antibiotics for this pneumonia
287. The nurse is reinforcing home care instructions to the parents of a 3y/o child with scabies. Which statement by the parent indicates FURTHER TEACHING?
I understand that I need to leave the scabicide on for 4 hours before washing it off
373. The nurse reinforces home care instructions to the parents of a child with a brace for scoliosis. Which statement by the parents indicate the NEED FOR FURTHER TEACHING?
I understand that my child needs to wear this brace for 12 hrs a day
385. The nurse reviews the home care instructions with a parent of a 3y/o with pertussis. Which statement by the parents indicates the NEED FOR FURTHER TEACHING?
I understand this whooping cough is viral and I have to let it run it's course
366. The nurse is reinforcing instructions to the parents of aa child with scoliosis regarding the use of a brace. Which statement by the parent indicates the NEED FOR FURTHER TEACHING?
I will apply lotion under the brace to prevent skin breakdown
294. The nurse reinforces home care instructions to the parents of a 3y/o child who has been hospitalized with hemophilia. Which statement by a parent indicates the NEED FOR FURTHER TEACHING?
I will avoid immunizations and dental hygiene treatments for my child
273. A pregnant HIV positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that ADDITIONAL GUIDANCE IS NEEDED?
I will breastfeed, especially for the firsts 6 weeks postpartum
601. The nurse has provided discharge instructions to a client with an application of a hole device. The nurse determines that the client NEEDS FURTHER TEACHING If which statement is made?
I will drive only during the daytime
279. The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates FURTHER TEACHING IS NEEDED?
I will flush the eyes after instilling the ointment
327. The nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which statement by the mother indicates a NNED FOR FURTHER TEACHING?
I will give my child cough syrup if a cough develops
383. The nurse reviews measures to prevent tick bites with a parent of a child with Rocky Mountain spotted fever. Which statement from the parent indicates the NEED FOR FURTHER TEACHING?
I will have my child wear dark colored clothing so the tick will not be attracted to the colors
422. The nurse provides skin care instructions to the client who is receiving external radiation therapy. Which statement by the client indicates the NEED FOR FURTHER TEACHING? Select all that apply
I will limit sun exposure to 1 hour daily I will apply moisturizer with a cotton tipped applicator for itching
360. The nurse reinforces instructions to the parent of a child with meningococcal meningitis. Which statement by the parent indicates the NEED FOR FURTHER TEACHING?
I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is only 3m/o
357. The nurse instructs a mother of a child who has seizures regarding seizure precautions. Which statement by the mother indicated a NEED FOR FURTHER TEACHING?
I will need to give antiseizure medications when my child has a seizure
296. The nurse is providing discharge instructions to the parents of a 14y/o child who is undergoing radiation for Hodgkin's disease. Which statement by a parent indicates the NEED FOR FURTHER TEACHING?
I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days
382. The nurse is reviewing instructions to a parent of a 6y/o child on how to prevent influenza. Which statement by the parents indicates the NEED FOR FURTHER TEACHING?
I will not let my child play with other children who have the flu unless they're taking acetaminophen
143. The nurse is reinforcing home care instructions to a client and family regarding care after left cataract surgery with lens implant. Which statement made by the client indicates an understanding of the instructions? Select all that apply
I will not sleep lying on my left side I will set at the table to eat breakfast I will set in my recliner with my feet elevated I will not lift anything heavier than 10 pounds
448. When the nurse is reinforcing instructions to a client who has been newly DX with T1DM, which statement by the client would indicate that teaching has been EFFECTIVE?
I will notify my PHCP if my blood glucose is consistently greater than 250
326. The nurse reinforces instructions to the mother of a child with croup about measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the NEED FOR FUTHER TEACHING?
I will place a steam vaporizer in my child's bedroom
531. The nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium. Which statement made by the client reflects the NEED FOR FURTHER TEACHING?
I will take enteric coated aspirin for my headaches because its coated
507. A client has a prescription to take Guaifenesin q 4 hrs, as needed. The nurse determines that the client understands the MOST EFFECTIVE use of this medication If the client makes which statement?
I will take the tablet with a full glass of water
217. The client at 28 weeks gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement?
I will tell the nurse at the hospital that I had an Rh shot during pregnancy
610. Phenytoin, 100mg PO 3 times daily, has been prescribed for a client for seizure control. The nurse reinforces instructions regarding the medication to the client. Which statement by the client indicates an understanding of the instructions?
I will use a soft toothbrush to brush my teeth
538. The home health care nurse is visiting a client with elevated triglycerides levels and a serum cholesterol level of 398 mg/dl. The client is taking cholestyramine. Which statement made by the client that indicates FURTHER TEACHING?
I'll continue my nicotinic acid from the health food store
352. The nurse is reinforcing discharge instructions to the parent of a 2y/o child who has had an orchiopexy to correct cryptorchidism. Which statement by the parent indicates the NEED FOR FURTHER TEACHING?
I'll let him decide when to return to his play activites
449. The nurse is monitoring a client who has been newly DX with DM for signs of complications. Which statement made by the client would indicate hyperglycemia and thus warrant PHCP notification?
I'm urinating a lot
539. A client is taking nicotinic acid hyperlipidemia, and the nurse reinforces instruction to the client about the medication. Which statement by the client indicates an understanding of the instructions
Ibuprofen taken 30 min before the nicotinic acid should decrease the flushing
779. A depressed client verbalizes feelings of low self esteem and self worth typified by statements such as I'm such a failure. I cant do anything right! Which action should the nurse take?
Identify recent behaviors or accomplishments that demonstrate skill or ability
345. The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin. Which statement by a parent indicates the NEED FOR FURTHER TEACHING?
If my child vomits after medication administration, i will repeat the dose
617. The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is PRIORITY?
Immobilize the leg before moving the client
623. A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain maybe caused by which condition?
Impaired tissue perfusion
609. Carbidopa-levodopa is prescribed for a client with Parkinson's disease, and the nurse monitors the client for adverse effects of the medication. Which S/S indicates the client is experiencing an adverse effect?
Impaired voluntary movements
791. The nurse is preparing a 2y/o child with suspected nephrotic syndrome for a renal biopsy to confirm the DX. The mother asks the nurse will my child ever be thin again? The nurse should respond by giving which statement?
In most cases, the medication and diet will control fluid retention
593. The nurse is caring for a client with increased ICP. Which change in vital signs would occur if ICP is rising?
Increased temp, decreased pulse, decreased respirations, increased B/P
418. The nurse is reviewing the lab results of a client with leukemia who has received a regimen of chemotherapy. Which lab finding is indicative of the massive cell destruction that occurs with chemotherapy?
Increased uric acid levels
166. Which statement by a nursing student about Kohlberg's theory of moral development indicates the NEED FOR FURTHER TEACHING about the theory?
Individuals move through all 6 stages in a sequential fashion
803. The nurse is assisting with identifying clients in the community at risk for latex allergy. Which client population is at MOST risk for developing this type of allergy?
Individuals with spina bifida
798. A client who has begun taking fosinopril is very distressed, telling the nurse that he cannot taste food normally since beginning the medication 2 weeks ago. Which suggestion would provide the BEST support for the client?
Inform the client that impaired taste is expected and generally disappears in2-3 months
316. The nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions does the nurse anticipate to be prescribed? Select all that apply
Initiate an IV line Maintain NPO status Administer IV antibiotics Administer preoperative medications
748. To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse should include which in the plan of care.?
Initiating seizure precautions
667. The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis?
Inquiring about the clients feelings that may affect coping
459. The nurse is monitoring a client receiving leveothyroxine sodium for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply
Insomnia Weight loss Mild heat intolerance
467. The nurse is preparing to perform an abdominal examination. Which step should be taken first?
Inspection
576. A client arrives at the ED with a foreign body in the left ear that has been determined to be an insect. Which INITIAL intervention should the nurse anticipate to be prescribed?
Installation of mineral oil or diluted alcohol
425.the client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. Besides treatment of the lung cancer, the nurse anticipates that which interventions maybe prescribed to treat the SIADH? Select all that apply
Institute safety measures Frequent monitoring of sodium blood levels Gather data about the neurological status frequently Medication that is antagonistic to antidiurectic hormone (ADH)
807. The nurse should expect to note which interventions in the plan of care for a client with hypothyroidism? Select all that apply
Instruct the client about thyroid replacement therapy Encourage the client to consume fluids and high fiber foods Instruct the client to contact the PHCP if episodes of chest pain occur
652. The client arrives at the health care clinic and states to the nurse that they were just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that they removed the tick and flushed it down the toilet. Which nursing action is appropriate?
Instruct the client to return in4-6 weeks to be tested, because testing before this time is not reliable
369. The nurse assist to create a nursing care plan for the child with an arm cast and should include which interventions in the plan? Select all that apply
Instruct the parents to keep the cast clean and dry Monitor the extremity for circulation impairment instruct the child not to stick objects down the cast Notify the RN immediately if circulation impairment occurs
696. The nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push ups. Which nursing action is appropriate?
Interrupt the client and offer to take her for a walk
282. The nurse is preparing to administer Beractant to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which route?
Intratracheal
68. An adult female client has a hemoglobin level of 10.8 g/dl. The nurse interprets that this result is MOST LIKEY caused by which condition noted in the clients history?
Iron deficiency anemia
788. The nurse is caring for an older client who is terminally ill. Which signs indicate to the nurse that death maybe imminent?
Irregular, noisy breathing and cold, clammy skin
572. A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which IMMEDIATE measure?
Irrigating the eye with sterile NS
470. The nurse is caring for a client after a Billroth 2 (gastrojejunostomy) procedure. During review of the postoperative prescriptions, which should the nurse clarify?
Irrigation the NGT
342 the nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which EARLY sign of HF? Select all that apply
Irritability Scalp diaphoresis Tachypnea Tachycardia
133. The nurse is collecting data from the client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and should be reported to the PHCP before surgery? Select all that apply
Is allergic to penicillin Quit smoking 3 months earlier Wonders if the surgery could cause incontinence History of DVT in right leg 10 years earlier
201. A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venous. The instructor determines that the student understands the structure of the ductus venous if the student states which about the ductus venous?
It connects the umbilical vein to the vena cava
355. The parents of a newborn have been told that their child was born with bladder exstrophy and the parents asks the nurse about this condition. Which response should the nurse give to the parents about bladder exstrophy?
It is an extrusion of the urinary bladder to the outside of the body through a defect in the lower abdomen wall
649. The nurse is assigned to care for a client DX with systemic lupus erythematosus (SLE). The nurse should plan care considering which factor regarding the DX?
It is an inflammatory disease of collagen contained in connective tissue
306. A mother brings her 3w/o infant to a clinic for phenylketonuria rescreening blood test. The test indicates a serum phenylketonuria level of 0mg/dl. The nurse reviews this results and makes which interpretation?
It is negative
215. The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term?
It is the fetal movement that is felt by the mother
684. A client is admitted to the inpatient unit and is being considered for electrocunvulsive therapy (ECT) the client appears calm, but the family is hyper vigilant and anxious. The client's mother beings to cry and stress, my child's brain will be destroyed. How can the doctor do this ? The nurse should make which therapeutic response?
It sounds as though you may have concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may be having
203. The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormonal changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen?
It stimulates uterine development to provide an environment for the fetus and stimulates the breast to prepare for lactation.
393. A client returns to the clinic for follow up treatment after a skin biopsy of a suspicious lesion that was performed 1 eek ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which characteristic describes this type of a lesion? Select all that apply
It's highly metastatic Lesion is a nexus that has changed in color
413. The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid. The nurse determines that which client complaint may be associated with the use of this medication?
Itching
206. The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her LMP was October 20, 2019. Using Nagels rule, the nurse determines the estimated date of birth is which date?
July 27, 2020
237. The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9cm and is experiencing precipitous labor. Which is the PRIORITY nursing action?
Keep client in a side lying position
626. The nurse is preparing a list of cast care instructions for a client who just had plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply
Keep the cast and extremity elevated Keep clean and dry Allow the wet cast 24/72 hrs to dry
252. The nurse is assisting with caring for postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action?
Keep the client and her family members informed of her progress
362. The nurse is reviewing the postoperative prescriptions for an infant with hydrocephalus, who came back from surgery with a venticularoperitoneal shunt. Which of the PHCP prescriptions does the nurse question?
Keep the head of the bed elevated at 45 degress
51. The nurse observes that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, rapid respirations. How should the nurse correctly document this observation in the medical record?
Kussmaul's respirations
453. The nurse is caring for a postoperative parathyroidectomy client. Which would require the nurse's IMMEDIATE attention?
Laryngeal strider
497. The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client?
Lateral position
806. A client has had Skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which area as a high risk area for pressure and breakdown of skin?
Left heal
466. The nurse is reinforcing teaching to a client about an upcoming colonoscopy procedure. The nurse should include in the instructions that the client will be placed in which position for the procedure?
Left sims position
236. Which findings indicate to the nurse that placenta separation has occurred? Select all that apply
Lengthening of the umbilical cord Sudden trickle or spurt of blood Fetal membranes are seen at the introitus
394. The nurse is reviewing the health care record of a client with a lesion that has been DX as basal cell carcinoma. The nurse should expect which characteristic of this type of lesion to be documented in the clients record? Select all that apply
Lesion have a waxy border An irregularly shaped lesion
226. The client is in her 2nd trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse should recommend which measure to help relieve both discomforts?
Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle
468. The nurse reinforces postoperative liver biopsy instructions to a client. Which should the nurse tell the client?q
Lie on the right side for 2 hours
144. After a client undergoes a liver biopsy, the nurse places the client in the prescribed right side lying position. The nurse understands that the purpose of this intervention is to accomplish which?
Limit bleeding from the biopsy site
471. The nurse is reinforcing discharge instructions to a client after a gastrectomy. Which measure should the nurse including during client teaching to help prevent dumping syndrome?
Limit the fluids taken with meals
603. The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action?
Limiting bladder catheterization to once every 12 hrs
523. The nurse is assisting with caring for a client immediately after insertion of a permanent pacemaker via the right subclavical vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention?
Limiting movement and abduction of the right arm
161. The nurse is preparing to administer an intermittent tube feeding to a client with a NG tube. The nurse checks the residual and obtains an amount of 200 ml. Which actions should the nurse take? Select all that apply
Listen to the clients bowels sounds Question the client about nausea Determine whether the client has abdominal distention Hold the feeding after flushing the tubing with 30 ml saline
514. A client with TB is being started on antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse ensures that which baseline study has been completed?
Liver enzyme level
636. The nurse is reviewing the lab studies on a client receiving dantrolene sodium. Which lab test(s) would identify an adverse effect associated with the administration of this medication?
Liver functions test
188. Which data indicate to the nurse that a client is experiencing EFFECTIVE coping following the loss of a spouse? Select all that apply
Looks at old snapshots of family Visits spouses grave once a month Visits the senior citizens center once a month
767. A client with DM who has been controlled with daily insulin has been placed on atenolol for the control of angina pectoris. Because of the effects of atenolol, the nurse determines that which is MOST reliable indicator of hypoglycemia?
Low blood glucose level
579. The nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which would MOST LIKELY be prescribed for the client?
Low sodium diet
478. A client with hiatal hernia chronically experiences heart burn after meals. Which should the nurse teach the client to avoid?
Lying down after meals
650. The camp nurse prepares to instruct a group of children about lyme disease. Which information should the nurse include in the instructions?
Lyme disease is caused by a tick carried by deer (Rocky Mountain fever)
381. A child is DX with chicken pox. The nurse collects data regarding the child. Which findings is characteristic of chicken pox?
Macular rash on the trunk and scalp
565. The nurse is reinforcing discharge instructions to a client receiving sulfadiazine. Which should be included in the list of instructions?
Maintain a high fluid intake
739. The nurse is reinforcing discharge instructions to a client receiving sulfisoxazole. Which should be included in the plan of care for instructions?
Maintain a high fluid intake
655. The client brought to the ED is experiencing an anaphylactic reaction from eating shellfish. The nurse should implement which IMMEDIATE action?
Maintain airway
443. A client is admitted to the ED and a DX of myxedema coma is made. Which action should the nurse prepare to carry out INITIALLY?
Maintain patient airway
263. The nurse assigned to assist with the caring of a neonate born to a mother who is HIV positive. The nurse understands that which should be included in the plan of care?
Maintain standard precautions at all times while caring for the neonate
10. The nursing student is asked to ID the practice and beliefs of the Amish society. Which should the student ID, select all that apply
Many choose not to have health coverage They believe heath is a gift from God They use both traditional and alternative healthcare, such as healers, herbs, and massage Funerals are conducted in the home without a eulogy, flower decorations, or any other display, without adornment
256. A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement?
Massage the breast before feeding to stimulate let-down
564. A client with chronic kidney disease is receiving epoetin also. Which lab result would indicate a therapeutic effect of the medication?
Mematocrit. Of 33%
784. The nurse is reviewing the health record of a pregnant client at 16 weeks gestation. The nurse should expect to document that the fundus of the uterus is located at which area?
Midway between the symphysis pubis and the umbilicus
598. The client was seen and treated in the ED for a concussion. Before discharge, the nurse explains the S/S of worsening condition. The nurse determines that the family NEEDS FURTHER TEACHING if they state they will return to the ED if the client experiences which S/S?
Minor headache
266. The nurse is reinforcing instructions to a new mother about cord care and how to monitor for the presence of an infection. The nurse should tell the mother that which is a sign of infection?
Moist cord with discharge
450. The nurse is reinforcing instructions to a client with DM who is recovering from diabetic ketoacidosis (DKA) regarding measures to prevent recurrence. Which instruction is important for the nurse to emphasize?
Monitor blood glucose level frequently
536. A client is DX with acute MI and is receiving tissue plasminogen activator, alteplase. Which action is a PRIORITY nursing intervention?
Monitor for signs of bleeding
664. Ketoconazole is prescribed for a client with a DX of candidiasis. Which interventions should the nurse include when administering this medication? Select all that apply
Monitor liver function studies Instruct the client to avoid alcohol Instruct the client to avoid exposure to the sun
269. The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply
Monitor skin temperature closely Reposition the newborn every 2 hrs Cover the newborns eyes with shields or patches
430. The nurse is reviewing the lab results of a client who is receiving chemotherapy and notes that the platelet count is 10,000mm3. On the basis of this lab value, the nurse should perform which intervention? Select all that apply
Monitor stools for occult blood Instruct the client not to bend over at the waist or lift Instruct the client to blow nose very gently without blocking either nostril
737. A client enters the ED confused, twitching, and having seizures. Upon assessment, flushed skin, dry mouth and elevated temperature and poor skin turgur is noted. The serum sodium level is 172 mEq. Which interventions should the PHCP likely prescribe? Select all that apply
Monitor vital signs Monitor intake and output Increase water intake orally Provide a sodium reduced diet
697. Which appropriate interventions for caring for the client undergoing alcohol withdrawal? Select all that apply
Monitor vital signs Provide a safe environment Address hallucinations therapeutically Provide reality orientation as appropriate
581. Betaxolol hydrochloride eyedrops have been prescribed for the client with glaucoma. Which nursing action is MOST APPROPRIATE related to monitoring for the side/adverse effects of this medication?
Monitoring B/P
628. The nurse is evaluating the client's use of a cane for left sided weakness. The nurse should intervene and correct the client if the nurse observes that the client performed which action?
Moves the cane when the right leg is moved
526. The nurse has reinforced instructions to the client with Raynaud's disease about self management of the disease process. The nurse determines that the client NEEDS FURTHER TEACHING if the client makes which statement?
Moving to a warmer client should help
333. The nurse is instructing a mother of a 1y/o child with strabismus about treatment options. Which statement by the mother indicates the NEED FOR FURTHER TEACHING?
My child will outgrow this by the time he is 2y/o and be able to see just fine
483. The client has an as needed prescription for ondansetron. For which condition should the nurse administer this medication?
N/V
307. A child with T1DM is brought to the ED by the mother, states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is DX. Anticipating the plan of care, the nurse prepares to administer which type of IV infusions?
NS infusion
283. An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory depression occurs?
Naloxone
760. The nurse assist with developing a plan of care for the child with meningitis. Which would be the PRIORITY client problem for a child with meningitis DX?
Neurological dysfunction
262. A client asks the nurse why her newborn baby needs an injection of vitamin K (phytonadione) the nurse should make which statement to the client?
Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding
486. A histamine (H2) receptor antagonist will be prescribed for a client. The nurse understands that which medications are H2 receptor antagonist? Select all that apply
Nizatidine Ranitidine Famotidine Cimetidine
732. A client taking buspirone for one month returns to the clinic for a follow up visit. Which should indicate medication EFFECTIVENESS?
No rapid heartbeats or anxiety
528. The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hrs after undergoing an aortoiliac bypass graft. The affected leg is warm and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. Based on this data, the nurse should make which determination about the clients neurovascular status?
Normal, caused by increased blood flow through the leg
299. The nurse is monitoring for bleeding in a child after surgery to remove a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which nursing action is appropriate?
Notify the RN
375. The nurse is performing a neurovascular check on a hospitalized child who had a cast applied to the lower leg. The child complains of tingling in the toes distal to the fracture site. Which action should the nurse take?
Notify the RN
152. The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which actions should the nurse take? Select all that apply
Notify the RN Discontinue suctioning until the client is stabilized
243. A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The FHR between contractions is 100 bpm. On the basis of these findings which is the PRIORITY nursing action?
Notify the RN immediately
431. The nurse is caring for a client who is receiving an IV infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. During an inspection of the site, the nurse notes redness and swelling. The nurse should take which appropriate action?
Notify the RN immediately
258. The nurse is caring for a postpartum client. At 4hrs postpartum, the client's temperature is 102F. Which is the appropriate nursing action?
Notify the RN who will the contact the PHCP
380. A child is DX with infectious mononucleosis. The nurse reinforces home care instructions to the parents about care of the child. Which instruction should the nurse provide to the parents?
Notify the pediatrician if the child develops abdominal or left shoulder pain
27. The nurse attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team based model of nursing practice?
Nursing staff are led by the nurse when providing care to a group of clients
698. The nursing student is creating a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which intervention in the plan that is not specific to this disorder?
Observe for excessive exercise
710. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action?
Observing rigid rules and regulations
802. The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client. Which instructions should be included in this list? Select all that apply
Obtain a medicAlert bracelet Prevent debris from entering the stoma Avoid exposure to people with infections Avoid swimming and use care when showering
584. The nurse is providing instructions to a client who will be self administering eyedrops. To minimize the systemic effects that eyedrops can produce, the client is instructed to perform which action?
Occlude the nasolacrimal duct with a finger over the inner can thus for 30-40 seconds after installing the drops
742. A client is admitted to the hospital with a DX of major depression. During the admission interview, the nurse determines. That a major concern is the client's poor nutritional intake? Which nursing intervention related to poor nutrition should be the INITIAL choice?
Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.
670. An intoxicated client is brought to the ED by local police. The client is told that the PHCP will be into see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHCP immediately. The nurse assisting to care for the client should take which appropriate nursing intervention?
Offer to take the client to an examination room until he or she can be treated
570. A client arrives in the ED after an automobile crash. The clients forehead hit the steering wheel and hyphema has been DX. Which position should the nurse prepare to position the client?
On bed rest, semi Fowler's position
319. An infant returns to the nursing unit after the surgical repair of a Clift lip located on the right side of the lip. Which is the BEST position to place this infant at this time?
On his/her left side
490. The client with a gastric ulcer has a prescription for sucralfate 1g by PO four times a day. The nurse should sheduale the medication to be administered at which times?
One hour before meals and at bedtime
719. The nurse is assisting with planning the care of a client being admitted to the nursing unit who has attempted suicide. Which PRIORITY nursing intervention should the nurse include in the plan of care?
One to one suicide precautions
666. The nurse is assigned to care for a client experiencing disturbed thought process. The nurse is told that the client believes that their food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat?
Open ended questions and silence
813. The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? Select all that apply
Open the distal flap of the sterile package first Prepare the sterile field just before the planned procedure Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field
440. The client with small cell lung cancer is being treated with etoposide and the nurse is assisting with caring for the client during administration. The client gets up to use the bathroom and is dizzy and very weak. The nurse understands these S/S are likely the results of which side/ adverse effect that is specifically associated with this medication?
Orthostatic hypertension
777.the nurse is assisting with collecting data on a client with seizures. The nurse is interviewing the child's parents to establish their adjustment to caring for their child with a chronic illness. Which statement by the parents indicates the need for FURTHER TEACHING?
Our child sleeps in our bedroom at night
769. Which data would indicate a potential complication associated with age-related changes in the musculoskeletal system?
Overall sclerotic system
776. The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response by the student indicates an understanding of this process?
Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high
302. The nursing instructor asks the nursing student about PKU. Which statement made by the student indicates a NEED FOR FURTHER TEACHING?
PKU primarily affects the gastrointestinal system
591. A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply
Pad bedside rails Place and airway at the bedside Place oxygen equipment at the bedside Place suction at the bedside
314. A child with a DX of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible incarcerated hernia. The nurse tells the parents that which manifestation requires PHCP notification by the parents?
Pain
156. The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the clients room to ensure that which PRIORITY item is at the bedside?
Pair of scissors
546. A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse monitors this client for which S/S of this disorder?
Pallor, diminished pulse, and pain in the left hand
297. A 4y/o child is hospitalized with a suspected DX of Wilms' tumor. The nurse reviews the plan of care and should question which intervention that is written in the plan?
Palpate the abdomen for a mass
163. The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus. (Subcutaneous emphysema) which method should be used to monitor the client for crepitus?
Palpitating the skin around the chest and neck for crackling sensations
437. The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase, an antineoplastic agent. The nurse consults with the RN regarding the administration of the medication if which is documented in the clients history?
Pancreatitis
397. The evening nurse reviews the nursing documentation in the clients chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. Which should the nurse expect to find when checking the clients sacral area?
Partial thickness skin loss of the epidermis
379. A child DX with scarlet fever. The nurse collects data regarding the child. Which is characteristic of scarlet fever?
Pastia's sign
103. The nurse is reinforcing instruction for a client in how to perform a testicular self examination (TSE). Which instructions should the nurse include? Select all that apply
Perform TSE after a shower or bath Perform TSE on the same day each month Perform TSE by rolling each testicle between the thumb and fingers
621. The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client NEEDS FURTHER TEACHING if the nurse observes the client doing which activity?
Performing active ROM to the right ankle or knee
29. The nurse has delegated several nursing tasks to staff members. Which is the nurses PRIMARY responsibility after delegation of tasks?
Performing follow up with each staff member regarding the performance and outcome of the task.
509. A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?
Peripheral neuritis
790. A client who has been taking isoniazid for 1.5 months complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which adverse effects?
Peripheral neuritis
285. Methlergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse contacts the PHCP who prescribed the medication if which condition is documented in the clients medical history?
Peripheral vascular disease
625. A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention?
Petaling the cast edges with adhesive tape
222. The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intrvascular coagulopathy (DIC). The nurse should suspect DIC if which is observed?
Petechiae oozing from injection site, and hematuria
90. The nurse is checking the insertion site of a peripheral IV catheter. The nurse notes the site to be reddened, warm, painful and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which?
Phlebitis of the vein
423. The client is hospitalized for the insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. Which is the immediate nursing action?
Pick up the implant with long-handle forceps and place it into a lead container
324. The nurse is preparing for the admission of an infant with a DX of bronchiolitis caused by the respiratory syncytial virus (RSV). Which interventions should be included in the plan of care?
Place infant in a private room Place the infant in a room near the nurses station
343. The nurse was caring for an infant who had come to the nursing unit for observation and treatment of tetralogy of Fallot. The child suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. The nurse should perform which action FIRST?
Place the child in a knee chest position
113. The nurse applies wrist restraints, prescribed to prevent a client from pulling out a NG tube. How should the nurse determine that the restraints are not too constrictive?
Place two fingers under the restraints to determine snugness
153. The nurse inserted a NG tube in a client and is checking for the correct placement of the NG tube. Which is the MOST reliable data to ensure that the end of the tube is in the stomach?
Placement is verified by X-ray
374. The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for this child?
Placing the bed linens on the traction ropes
801. The nurse administers an injection to a client with a DX of AIDS. After administering the medication, the nurse should dispose of the used needle by which method?
Placing the needle and syringe in a puncture resistant container
454. The nurse notes that a client with T1DM has lipodystrophy on both upper thighs. Which further information should the nurse obtain from the client during data collection?
Plan for injection rotation
501. The client is DX with pleurisy. The nurse should expect to see which S/S? Select all that apply
Pleural friction rub Sharp, knife like pain Pain occurs most often during inspiration
137. The nurse monitors the 3 day postoperative client who underwent abdominal surgery. Vital signs are: T 37.9c (100.2F) P104, R22 and B/P 128/74. Oxygen saturation 93% on RA. The client feels tired and has a productive cough. Fine crackles are audible in the base of the lungs posteriorly. The nurse considers the client has developed which postoperative problem?
Pneumonia
477. The nurse is reviewing the PHCP's prescriptions written for a client admitted with acute pancreatitis. Which PHCP prescription should the nurse verify if noted in the client's record?
Position the client supine and flat
751. A mother is breastfeeding her newborn. The mother complains to the nurse that she is experiencing severe nipple soreness. The nurse should provide which suggestion to the client?
Position the newborn infant with the ear, shoulder, and hip in a straight alignment and with the baby's stomach against the mothers
405. The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive DX was made by which diagnostic test?
Positive culture results
462. A client with DM visits the healthcare clinic. The clients DM previously had been well controlled with glyburide daily, but recently the FBS level has been 180 mg/dl to 200 mg/dl. Which medication, added to the clients regimen, may have contributed to the hyperglycemia.
Prednisone
421. The nurse is caring for a client with an internal radiation implant. The nurse should observe which principles? Select all that apply
Pregnant women are not allowed into the clients room Wear a lead apron while delivering beside care to the client
517. The nurse is preparing to ambulated a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to BEST tolerate the ambulation?
Premeditates the client with an analgesic before ambulating
259. The nurse is assisting with planning care for a postpartum woman who has small vulvar hematoma. To assist with reducing the swelling, the nurse should perform which action?
Prepare an ice pack for application to the area
246. The client received an epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the clients systolic B/P dropped 20 points, the diastolic B/P dropped 10 points, and her pulse is 120bpm. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on the DX, the nurse should plan which action?
Prepare the client for surgery
622. The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection?
Presence of a "HOT SPOT" on the cast
351. The child with cryptorchidism is being discharged after orchiopexy, which was performed on an outpatient basis. The nurse should reinforce instructions to the parents about which PRIORITY care measure?
Preventing infection at the surgical site
197. The nurse instructor asks a nursing student to list the functions of the amniotic fluid. The student NEEDS FURTHER EDUCATION if which responses are made? Select all that apply
Prevents large particles such as bacteria from passing to the fetus Provides an exchange of nutrients and waste products between the mother and fetus
261. The nurse administered erythromycin ointment (0.5%) to the newborns eyes and the mother asks the nurse why this is done. The nurse should give which response to the client?
Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection
512. The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states to report which occurrence IMMEDIATELY?
Problems with visual acuity
321. The nurse is reviewing the record of a child with a DX of pyloric stenosis. Which data should the nurse expect to note as having been documented in the child's record?
Projectile vomiting
42. The nurse reviews the clients serum calcium level and notes that the level is 8.0 mg/dl. The nurse understands that which condition would cause this serum calcium level?
Prolonged bed rest
495. The nurse is instructing a client about pursed lip breathing and the client asks the nurse about its purpose. The nurse should tell the client that the PRIMARY purpose of pursed lip breathing is which?
Promote carbon dioxide elimination
646. The nurse is assisting with planning the care of a client with a DX of immunodeficiency. The nurse should incorporate which intervention as a PRIORITY in the plan of care?
Protecting the client from infection
230. The nurse is monitoring a pregnant client with gestational hypertension (GH) who is at risk for preeclampsia. The nurse should check the client for which stage of preeclampsia? Select all that apply
Proteinuria Hypertension
479. The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred?
Protruding and swollen
364. A child is DX with Reye's syndrome. The nurse assist with developing a nursing care plan for the child and should include which intervention in the plan?
Provide a quite atmosphere with dimmed lighting
349. The nurse is planning care for a child with hemolytic uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to include which interventions in the care of the child? Select all that apply
Provide adequate nutrition Restriction of fluids as prescribed Institute measures to prevent infections Administer blood products to treat severe anemia Anticipate the child will have CNS involvement
687. The nurse observes that the client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's effect is belligerent. Based on these observations, which is the nurse's IMMEDIATE PRIORITY of care?
Provide safety for the client and other clients on the unit
179. Which interventions are appropriate for the care of an infant? Select all that apply
Provide swaddling Hang mobiles with black and white contrast designs Caress the infant while bathing or during diaper changes
199. The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client knowing which about the placenta?
Provides an exchange of nutrients and waste products between mother and fetus
618. A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction has which PRIMARY function?
Provides comfort by reducing muscle spasms and provides fracture immobization
683. The nurse is caring for a client with a DX of depression. The nurse monitors or signs of constipation and urinary retention, knowing that these problems are likely caused by which situation?
Psychomotor retardation and side effects of medication
336. The nurse assist to prepare a teaching plan regarding the administering of ear drops for the parents of a 2y/o child with otitis media. Which should be included in the plan of care?
Pull the earlobe DOWN and BACK before instilling the ear drops
573. The nurse is preparing to administer ear drops to an adult client. The nurse administers the ear drops by which technique?
Pulling the pinna UP and BACK
524. A client DX with thrombophlebitis 1 day ago suddenly complains of chest pain and SOB and the client is visibly anxious. Which life threatening complication that could be occurring?
Pulmonary embolism
654. The client with acquired immunodeficiency syndrome (AIDS) is DX with cutaneous Kaposi's sarcoma. Based on this DX, the nurse should determine that this has been confirmed by which findings?
Punch biopsy of the cutaneous lesions
172. The nurse is observing a parent and child interaction in the clinic waiting room. The child begins to bounce on the couch. The parent removes the child from the couch stating firmly, couches are for sitting not for jumping. The parent gives the child a toy to play with on the carpet. The child plays with the toy until called by the nurse. The nurse determines the child is acting within which Kohlbergs stage of moral development?
Punishment obedience stage
108. The nurse is caring for a client with healthcare associated infection caused by methicillin resistant staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions should the nurse use to perform this procedure? Select all that apply
Put on mask Don gown and gloves Wear a pair of protective googles
604. The client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the vital signs, which IMMEDIATE action should be taken?
Raise the head of the bed and remove the noxious stimulus
656. The client DX with AIDS is taking navirapine. The nurse should monitor for which side/adverse effect of this medication? Select all that apply
Rash Hepatotoxicity
643. The client is suspected of having systemic lupus erythematous (SLE) the nurse monitors the client, knowing that which is one of the INITIAL characteristic signs of SLE?
Rash on the face across the nose and on the checks
744. The nurse assist with creating a plan of care for a client with hyperparathyroidism receiving calcitonin-human. Which outcome has the HIGHEST PRIORITY regarding this medication?
Reaching normal serum calcium levels
442. The nurse is collecting data regarding a client after a thyroidectomy and notes the development of a hoarse and weak voice. Which nursing action is appropriate?
Reassure the client that this is usually a temporary condition
312. The nurse is monitoring for signs of dehydration in a 1y/o child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided?
Rectal
253. The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note?
Red
484. The client has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed?
Reduction of steatorrhea
457. The homecare nurse visits a client currently DX with DM who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should provide which information?
Refrigerate the insulin
487. The client who frequently uses non steroidal anti inflammatory drugs (NSAIDs) has been taking misoprostol. The nurse determines that this medication is having the intended therapeutic effect if which is noted?
Relief of epigastric pain
18. A client has died, and the nurse asks a family member about the funeral arrangement. The family member refuses to discuss the issue. Which is the appropriate nursing action?
Remain with the family members without discussing funeral arrangements
308. The nurse has just administered ibuprofen to a child with a temperature of 38.8c (102F) The nurse should also take which action?
Remove excess clothing and blankets from the child
502. The nurse notes that a hospitalized client has experienced a positive reaction to the TB skin test. Which action by the nurse is PRIORITY?
Report the findings
574. The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse should take which appropriate action?
Report the findings to the RN
17. The nurse observes that a client received pain medications 1 hour ago from another nurse, but the client still has severe pain. The nurse previously observed the same occurrence several times. Based on the nurse practice act, the observing nurse should plan to take which action?
Report the information to the nursing supervisor
168. The nurse notes that a 6y/o child does not recognize that objects exist even when the objects are outside of the visual field. Based on this observation, which action should the nurse take?
Report the observation to the PHCP
510. A client is to begin a 6 month course of therapy with isoniazid. The nurse should plan to provide which information to the client?
Report yellow eyes or skin immediately
277. A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted during assessment? Select all that apply
Respirations of 10 bpm Urine output of 20 ml/hr
52. The nurse is caring for a client with a DX of COPD. The nurse should monitor the client for which acid base disorder?
Respiratory acidosis
47. The nurse is told that the atrial blood gas (ABG) results indicate a pH of 7.50 and a PCO2 of 32mm Hg. The nurse determines that these results are indicative of which acid based disturbance?
Respiratory alkalosis
377. The mother of a toddler with mumps asks the nurse what she needs to watch for in her child with this disease. The nurse bases the response on the understanding that mumps is which type of communicable disease?
Respiratory disease caused by a virus involving the parotid gland
498. The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which?
Respiratory distress
247. The nurse is preparing a list of self-care instructions for postpartum client who has been DX with mastitis. Which instructions should be included on the list? Select all that apply
Rest during the acute phase Wear supportive, nonunderwire bras Maintain a fluid intake of at least 3000 ml Continue to breastfeed if the breast are not too sore
678. The nurse in the mental health unit reviews the therapeutic and non therapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply
Restating Listening Maintaining neutral response Providing acknowledgment and feedback
563. Oxybutynin chloride is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication?
Restlessness
424. The nurse is assisting with creating a plan of care for a client with pancytopenia as a result of chemotherapy. The nurse should suggest including which in the plan of care? Select all that apply
Restricting fresh fruit and vegetables in the diet Applying a face mask to the client if outside the clients room
323. The nurse reinforces home-care instructions to the parents of a child with celiac disease. Which food item should the nurse advise the parents to include in the child's diet?
Rice
7. The nurse consults with the dietitian regarding the dietary preferences of an Asian American client. Which food should the nurse suggest to include in the diet plan?
Rice
363. The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. During data collection about the child, the nurse expects to note which characteristic of this type of posturing?
Rigid extension and pronation of the arms and legs
435. The LVN is assisting the RN to create a teaching plan for the client receiving an antineoplastic medication. The LVN expects which information to be included? Select all that apply
Rinse mouth after each meal and use a soft toothbrush Maintain oral hygiene and inspect the mouth for sores daily Consult the PHCP before receiving immunizations
446. A client who has been newly DX with DM has been stabilized with daily insulin injections. Which teaching information should the nurse reinforce upon discharge?
Rotate injections sites systematically
198. The nurse working in a prenatal clinic reviews a clients chart and notes that the PHCP documents that the client has a gynecoid pelvis. The nurse plan care understanding that which findings are characteristic of the type of pelvis? Select all that apply
Round shape Diagonal conjugate measures 12.5 cm to 13 cm Blunt, somewhat widely separated ischial spines
499. The nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis. The nurse knows that the client understands the information If the client verbalizes which EARLY sign of exacerbation?
SOB
105. A Spanish speaking client arrives at triage desk in the ED and states to the nurse "NO speak English, need interpreter. Which action should the nurse take?
Seek a interpreter from the hospitals interpreter services
734. A client arrives at the health care clinic and tells the nurse that they have been doubling their daily dosage of bupropion hydrochloride to help them get better faster. The nurse understands that the client is now at risk for which problem?
Seizure activity
148. The nurse is assisting with caring for a client after a craniotomy. Which are the positions that can be used for the client? Select all that apply
Semi flowers position With foot of the bed flat
149. The nurse is caring for a client following a craniotomy in which a large tumor was removed from the left side. In which position can the nurse safely place the client?
Semi flowers with the head of the bed no more than 30 degrees
595. The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is CSF if the fluid meets which criteria?
Separates into concentric rings and test positive for glucose
619. The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which findings?
Serous drainage
658. The nurse is reviewing the results of serum lab studies drawn on a client DX with AIDS who is receiving didanosine. The nurse determines that the client may have the medication discontinued by the PHCP if which significant elevated results is noted?
Serum amylase
661. The nurse is assigned to care for the client DX with cytomegalovirus retinitis and AIDS who is receiving foscarnet. The nurse should monitor the results of which lab study while the client is taking this medication?
Serum creatinine level.
170. The parent of a 3y/o tells the nurse that the child is constantly rebelling and having temper tantrums. Which instruction should the nurse reinforce to the parent?
Set limits on the child's behavior
602. The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which S/S is noted?
Severe throbbing headache
447. The nurse reinforces teaching to a client with DM regarding differentiating between hypoglycemia and ketoacidosis. The client demonstrates and understanding of the teaching by stating that glucose will be taken if which symptoms develop?
Shakiness
286. The school nurse prepares a list of home care instructions for the parents of school children who have been DX with pediculosis (head lice) which should be included in the list?
Siblings may also need treated Grooming items such as combs and brushes should not be shared Launder all bedding and clothing in hot water and dry on high heat Vacuum floors, play areas and furniture to remove any hairs that may carry live nits
233. The nurse is caring for a client who is in labor. The nurse rechecks the clients blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position?
Side lying
605. The client is having a lumbar puncture performed. The nurse should place the client in which position for the procedure?
Side lying, with legs pulled up and chin to the chest
505. Rifabutin is prescribed for a client with active mycobacterium avium complex (MAX) disease and TB. The nurse should monitor for which side/adverse effects of the medication? Select all that apply
Signs of hepatitis Flu like symptoms/syndromes Low neutrophil count Ocular pain or blurred vision
398. The nurse inspects the skin of a client who is suspected of having psoriasis. Which findings should the nurse note if this disorder is present?
Silvery white scaly lesions
741. A postoperative client request medication for flatulence. Which medication from the PRN list should the nurse administer for this client?
Simethicone
688. The nurse is caring for a client DX with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. Which is the appropriate nursing intervention?
Sit beside the client in silence and verbalize occasional open ended questions
491. The nurse is reinforcing instructions to a hospitalized client with a DX of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position should the nurse instruct the client to assume?
Sitting on the side of the bed leaning on an over bed table
805. A client has placed in Buck's extension traction. Which technique provided by the nurse will provide countertraction?
Slightly elevate the foot of the bed
810. The nurse is attempting to communicate with a hearing impaired client. Which strategy by the nurse would be least helpful when talking to this client?
Smiling continuously during conversation
525. A 24 y/o man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. NEXT, the nurse should check the client's medical history for which item?
Smoking history
682. The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time?
Sometimes people hear things or voices others cant hear
559. Trimethroprim-sulfamethoxazole is prescribed for a client. The nurse should instruct the client to report which symptom if it developed during the course of this medication therapy?
Sore throat
419. The client is receiving external radiation to the neck for cancer of the larynx. The nurse monitors the client knowing that which are side/ adverse effects of external radiation? Select all that apply
Sore throat Red and dry skin over the neck
575. The nurse is caring for a client who is hearing impaired and should take which approach to facilitate communication?
Speak in a normal tone
492. The nurse is gathering data on a client with a DX of TB. The nurse should review the results of which diagnostic test to confirm this DX?
Sputum culture
189. The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented INITIALLY?
Stand in front of the client
521. The nurse is monitoring a client following carioversion. Which observation should be of HIGHEST PRIORITY to the nurse?
Status of airway
616. The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action?
Stay with the person and encourage the person to remain still
91. The nurse has been instructed to remove an IV line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item?
Sterile 2x2 gauze
796. A client is admitted to the hospital with possible rheumatic endocarditis. The nurse should check for a history of which type of infection?
Streptococcal infection
515. A client is receiving acetylcysteine, 20% solution diluted in 0.9% NS by nebulizer. The nurse should have which item available for a possible adverse event after giving this medication?
Suction equipment
761. The nurse is caring for a postoperative client who has been NPO and the PHCP has prescribed a clear liquid diet. When planning to initiate this diet, which PRIORITY item should the nurse place at the clients bedside?
Suction equipment
358. A child has a basilar skull fracture. Which PHCP prescription should the nurse question?
Suction via the nasotracheal route as needed
508. A postoperative client has received a dose of naloxone hyrochloride for respiratory depression shortly after transfer to the nursing unit from the post anesthesia care unit. After administration of the medication, the nurse should check the client for which S/S?
Sudden increase in pain
242. The client who is being prepared for a c-section delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse should place the client in which position?
Supine position with a wedge under the right hip
142. The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. The nurse should plan to maintain bed rest for this client in which position?
Supine with head elevated no greater than 30 degrees
150. A client has just returned to a nursing unit after an above knee amputation of the right leg. The nurse should plan to place the client in which position?
Supine, with the residual limb supported by pillows
234. After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened?
Support the mother in her reaction to the newborn
472. The nurse is monitoring a client for the EARLY S/S of dumping syndrome. Which indicates this occurrence?
Sweating and color changes (pallor= pale)
634. During the monitoring of a clients response to disease-modifying antirheumatic drugs (DMARDs) which findings should the nurse interpret as acceptable response? Select all that apply
Symptom control during periods of emotional stress Normal WBC, Platelets and neutrophil counts Radiological findings that show no progression of joint degeneration An increased ROM in the effected joints 3 months into therapy
271. The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn?
Tachypnea and retractions
787. A client with T1DM is to begin an exercise program, and the nurse is reinforcing instructions to the client regarding the program. Which instruction should the nurse include?
Take a blood glucose test before exercising
535. Isosorbide mononitrate is prescribed for client with angina pectoris. The client tells the nurse that the medication is causing a chronic headache. Which action should the nurse suggest to the client?
Take medication with food
311. The nurse is receiving the postoperative PHCP prescriptions for a 3w/o infant with Hirschsprung's disease admitted to the hospital for surgery. Which prescriptions documented in the child's record should the nurse question? Select all that apply
Take temperature measurements rectally Start clear liquid diet after 8hrs postoperative
632. Alendronate is prescribed for a client with osteoporosis and the nurse is providing instructions for the administration of the medication. Which instruction should the nurse reinforce?
Take the medication with a full glass of water after rising in the morning
429. The nurse is reinforcing discharge instructions to a client with cancer of the prostate after a suprapubic prostatectomy. The nurse should reinforce which discharge instructions? Select all that apply
Take the prescribed stool softener everyday. Avoid lifting objects heavier than 20lbs for 6 weeks
612. Ibuprofen is prescribed for a client. Which instructions should the nurse give the client about taking this medication?
Take with 8 oz of milk
19. A nurse lawyer provides an education session to the nursing staff regarding client rights with emphasis on invasion of clients rights. The nurses lawyer asks a staff nurse to identify a situation that represents an example of invasion of a clients privacy. Which situation, if identified by the student, indicates an understanding of a violation of this clients rights?
Taking a photograph of the client without consent
59. A LVN is explaining the appropriate methods for measuring an accurate temperature to an UAP. Which method, if noted by the UAP as being an appropriate method, indicates the NEED FOR FURTHER TEACHING?
Taking an oral temperature for a client with a cough and nasal congestion
213. A pregnant client is seen in the health care clinic for a regular period visit. The client tells the nurse that she's experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on the findings, which nursing action is appropriate?
Tell the client that these are common and they may occur throughout the pregnancy
102. The nurse is preparing to assist the HCP to test the extraocular movements in a client and muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done?
Testing the 6 cardinal positions of gaze
596. The client is admitted to the hospital for observation with a probable head injury after an automobile accident. The nurse expects the cervical collar will remain in place until which time?
The PHCP reviews the X-ray
216. The client is undergoing an amniocentesis at 16 weeks gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client?
The bladder must be full during the examination
254. After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination should the nurse make?
The bright red blooding is abnormal and should be reported
401. The nurse is caring for a client who has just been admitted to the nursing unit after receiving flameburns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless and his color is becoming dusky. Based on this data, which interpretation should the nurse make?
The burn has probably caused laryngeal edema, which has occuluded (blocked) the airway
298. The nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the student indicates the NEED TO FURTHER RESEARCH the disease?
The child does not experience pain at the primary tumor site
181. The parents of a 2y/o arrived at the hospital to visit their child. The child is in the play room and ignores the parents during the visit. The nurse tells the parents that this behavior in a 2y/o child indicates which characteristic about the child?
The child is exhibiting a normal pattern
229. The nurse is monitoring a client with mild gestational hypertension. (GH) which data indicates that GH is a concern?
The client complains of a headache and blurred vision
713. Which behaviors observed by the nurse might lead to suspicion that a depressed adolescent client could be suicidal?
The client gives away a DVD and cherished autographed pictures of the performer
757. A client with a DX of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior?
The client is at increased risk for suicide
146. A client is being prepared for a thoracentesis. The nurse reinforces instructions with the client given by the RN. Which points should be included in the instructions? Select all that apply
The client leans over the bedside table The client should sit on the edge of the bed A time out is performed before the procedure A local anesthetic is administered before the procedure
675. A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, which would the nurse expect to note?
The client presents a harm to self
104. The nurse notes the physical assessment findings for a client with a DX of possible meningitis. Which findings should the nurse expect to observe because meningeal irritation. Select all that apply
The client reports stiffness and soreness in the neck area The client reports pain in the vertebrae column and passively flexes the hip and knee in response to neck flexion The client flexes a leg at the hip and knee and reports pain in the vertebrae column when the leg is extended
530. ThePHCP is going to perform carotid massage on a client with rapid rate atrial fibrillation. Which interventions should the nurse anticipates? Select all that apply
The client should be placed on cardiac monitor Rhythm strips should be obtained before, during, and after the procedure Monitor the vital signs, cardiac rhythm, and level of consciousness after the procedure
673. The nurse in the psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. During review of the client's record, the nurse notes that the admission was voluntary one. Based on this type of admission, which would the nurse expect to note?
The client will participate in the treatment plan
668. The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse should identify which as a PRIORITY concern?
The clients report of self destructive thoughts
756. The nurse is caring for a newborn DX with Down syndrome. The parents are asking questions about this disorder. The nurse should provide which information when discussing Down syndrome?
The condition is congenital and results in moderate to severe retardation and has been linked to an extra chromosome 21 (group G)
720. The nurse is reviewing the health care record of a client admitted to the psychiatric unit. The nurse notes that the admission nurse has documented that the client is experiencing anxiety as a result of a situational crisis. The nurse should determine that this type of crisis could be caused by which event?
The death of a loved one
534. The nurse is monitoring a client who is taking propranolol. Which data collection finding would indicate a potential serious complications associated with this medication?
The development of audible expiratory wheezes
371. The nurse is assisting a PHCP during an examination of an infant with hip dysplasia. The PHCP performs the ortolani maneuver. Which data should the nurse expect to note during the examination?
The dislocated femoral head pops back into acetbulum
386. Morphine sulfate 2.5 mg is prescribed for a child. The safe range is 0.05 mg/kg/dose to 0.1 mg/kg/dose. The child weighs 50kg. Which statement accurately describes the prescribed dosage for this child? 0.05 mg/kg/dose x 50kg = 2.5 mg/dose 0.1 mg/kg/dose x 50 kg = 5 mg/dose
The dose is within the safe range
818. A client suspected of having an abdominal tumor is scheduled for a CT scan with dye injection. The nurse should tell the client which information about the test?
The dye injected may cause a warm and flushing sensation
145. The nurse administering a cleansing enema to a client with fecal impaction. Before administering the enema, the nurse asks the client to assume a left Sims position. The nurse explains that this positioning is preferred because of which reason?
The enema will flow into the bowel easily
782. A client asks the nurse about the cause of acne. The nurse should respond by making which statement to the client?
The exact cause of acne is not known
694. The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristic of which thoughts?
The false belief that one is being singled out for harm by others
503. The client being discharged from the hospital to home with a DX of TB is worried about the possibility of infecting family members and others. Which information should reassure the client that contaminating family members and others is not likey?
The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy
786. The nurse is reinforcing instructions to the parents of an infant with club foot about the care of a plaster cast. Which statement should the nurse include in the instructions. Select all that apply
The foot should be kept elevated for the first 24-48 hrs Reposition the infant q 2-4 hrs until cast is throughly dried The edges of the cast can be petaled with small pieces of moleskin or adhesive tape
331. The nursing instructor asks the nursing student about SIDS. Which statement by the student indicates FURTHER TEACHING IS NEEDED?
The incidences if SIDS has been found to be higher in breastfed infants and infants that use a pacifier
223. The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which statement indicates successful learning?
The iron is needed for the RBC
232. Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information should the nurse provide to the client about leopolds maneuvers?
The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall
590. A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which purpose?
The medication causes the pupil to constrict and will lower the pressure in the eye
414. Silver sulfadiazine is prescribed for a client with partial thickness burn and the nurse provides teaching about medication. Which statement made by the client indicates the NEED FOR FURTHER TEACHING?
The medication is likely to cause stinging initially
460. The PHCP prescribes exenatide for a client with T1DM who takes insulin. The nurse knows that which is the MOST APPROPRIATE intervention?
The medication is withheld and the PHCP is called to question the prescription for the client.
489. A client with a peptic ulcer is DX with a helicobacter pylori infection. The nurse is reinforcing teaching for the client about the medication prescribed, including clarithromycin, esomeprazole and amoxicillin. Which statement by the client indicates the BEST understanding of the medication regimen?
The medication will kill the bacteria and stop the acid production
173. The nurse determines a child is in the preoperational phase of Piagets cognitive developmental theory when the child makes which statement ?
The moon follows me, and goes to bed when I go to bed
300. The nurse observes a mother giving an oral iron supplement to her 6y/o child with a iron deficiency anemia. Which action by the mother indicates the NEED FOR FURTHER TEACHING?
The mother administers the iron with milk
689. A mother of a teenage client with an anxiety disorder is concerned about her daughters progress during discharge. She states that her daughter stashes food, and eats all the wrong foods that make her hyperactive. And hangs out with the wrong crowd. While helping the mother prepare for her daughters discharge, the nurse should make which statement?
The mother should restrict the amount of chocolate and caffeine in the home
772. The nurse reinforces medication instructions to a client with a peptic ulcer disease. Which statement by the client indicates the BEST understanding of the medication therapy?
The nizatidine will cause me to produce less stomach acid
613. The nurse is caring for a client who is taking phenytoin for control of seizures. During data collection, the nurse notes that the client is taking birth control pills. Which information should the nurse provide to the client?
The potential for decrease effectiveness of the birth control pills exist while taking phenytoin
139. The nurse checks postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply
The presence of purulent drainage Tender firmness palpable around the incision
275. The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother which about cord care?
The process of keeping the cord clean and dry will decrease bacterial growth
255. The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client?
The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1cm/day
112. The nurse obtains a prescription to restrain a client using a belt (safety) restraint and instructs the UAP to apply the restraints. Which observation, if made by the nurse, indicates unsafe application of the restraint.
The restraint straps are safely secured to the side rails
402. Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?
The return of distal pulse
480. An ultrasound of the gallbladder is scheduled for a client with suspected DX of cholecystitis. Which should the nurse explain to the client about the test?
The test requires the client to lie still for short intervals
219. A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the MOST accurate description of the test?
The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation
204. The nursing student is asked to describe the size of the uterus in a non pregnant client. Which response indicates an understanding of the anatomy of this structure?
The uterus weighs about 2 ounces
185. The parent of a 4y/o child expresses concern because her hospitalized child has started sucking his thumb. The mother states that this behavior began 2 days after hospital admission. Which is the appropriate nursing response.
This is common during hospitization
764. The nurse should implement which in the care of a child who is having seizures? Select all that apply
Time the seizures Stay with the child Loosen clothing around the child's neck
406. Salicylic Acid is prescribed for a client with a DX of psoriasis. The nurse monitors the client, knowing which findings indicates the presence of systemic toxicity from this medication?
Tinnitus
820. The nurse is caring for a client who has been prescribed furosemide and is monitoring for adverse effects associated with this medication. Which should the nurse recognized as potential adverse effects? Select all that apply
Tinnitus Hypotension Hypokalemia
434. The nurse is assisting with caring for a client with cancer who is receiving cisplatin. Which adverse effects are associated with this medication? Select all that apply
Tinnitus Ototoxicity Nephrotoxicity Hypomagnesemia
566. The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply
To avoid activities that require bending over To take acetaminophen for minor eye discomfort To place an eye shield on the surgical eye at bedtime To contact the surgeon if a decrease in visual acuity occurs
583. In preparation for cataract surgery, the nurse is to administer cyclopentolate eyedrops. The nurse administers the eyedrops knowing that which is the purpose of this medication?
To dilate the pupil of the operative eye
513. Cycloserine is added to the medication regimen for a client withTB. Which instruction should the nurse reinforce in the client teaching plan regarding this medication?
To return to the client weekly for serum drug level testing
9. An Hispanic American mother brings her child to the clinic for an examination. Which is the MOST IMPORTANT when gathering data about the child?
Touching the child during the examination
733. A client taking lithium carbonate reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is checked as a part of routine follow up, and the level is 3.0 mEq. The nurse knows that this is which level?
Toxic
441. The nurse is caring for a client after a thyroidectomy and notes that calcium gluconate is prescribed. The nurse determines that this medication has been prescribed for which reason?
Treat hypocalcemic tetany
607. The client is receiving meperidine hydrochloride for pain. Which S/S are side/adverse effects of this medication? Select all that apply
Tremors Drowsiness Hypotension
797. A client who is taking hydrochlorothiazide has also been prescribed triamterene. The client asks the nurse why both medications are required. Which response is the MOST accurate to give the client?
Triamterene is a potassium retaining (sparing) diuretic, whereas hydrochlorothiazide is a potassium excreting diuretic
410. Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which lab test will be prescribed?
Triglyceride levels
328. The nurse is working in the ED and is caring for a child who has been DX with epiglottitis. Which is an indication that the child may be experiencing airway obstruction?
Tripod positioning and dyspnea
325. After a tonsillectomy, the child begins to vomit bright red blood. Which is the INITIAL nursing action?
Turn the child to the side
241. The nurse is assisting with caring for a client with abruptio placentae. While caring for the client the nurse notes that the client begins to develop signs of shock. The nurse should take which action FIRST?
Turn the client onto her side
200. The nurse is describing the process of fetal circulation to a client during prenatal visit. The nurse should tell the client that fetal circulation consists of which components?
Two umbilical arteries and one umbilical veins
758. Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq?
U waves
48. A client is scheduled for blood to be drawn from the radial artery for an ABG determination. The nurse assist with performing Allens test before drawing the blood to determine the adequacy of which?
Ulnar circulation
817. The nurse reinforces instructions to the client about breast self examination (BSE). The nurse instructs the client to lie down and examine the left breast. Which is correct area for placing a pillow when examining the left breast?
Under the left shoulder
474. A client ascites is scheduled for a paracentesis. The nurse is assisting the PHCP with performing the procedure. Which position should the nurse assist the client for the procedure?
Upright
192. The nurse is planning to feed an older client who is at risk for aspiration of food. During the meal how should the nurse position the client?
Upright in the chair
433. The client with acute myelocytic leukemia is being treated with busulfan. Which lab value should the nurse specifically monitor during treatment with this medication?
Uric acid levels
561. Bethanechol chloride is prescribed for a client with urinary retention. Which disorder should be a contraindication to the administration of this medication?
Urinary strictures
404. The nurse is assisting with caring for a client who is receiving IV fluids and who has sustained full thickness burn injuries of the back and legs. The nurse understands that which would provide the MOST reliable indicator for determining the adequacy of fluid resuscitation?
Urine output
141. The nurse is preparing to reposition a dependent client who weighs more than 250lbs. Which interventions should the nurse use to move this client? Select all that apply
Use a friction-reducing slide sheet Use a mechanical lift to move the client Keep elbows close and work close to the body Obtain assistance of a second caregiver to assist with mechanical aids
681. A client with delirium becomes agitated and confused at night. The BEST INITIAL intervention by the nurse is which action?
Use a night light and turn off the TV
795. The nurse observes that a client with a NGT connected to continuous gastric suction is mouth breathing, has dry mouth and has a foul breath odor. When planning care, which nursing intervention would be the BEST to maintain the integrity of this clients oral mucosa?
Use diluted mouthwash and water to swab the mouth after bushing teeth
190. Which intervention should be implemented for the older client with presbycusis who has a hearing loss?
Use low pitched tones
645. Which intervention should be implemented in the care of the client in high risk for an allergy response to a latex allergy? Select all that apply
Use nonlatex gloves Use medications from glass ampules Do not puncture rubber stoppers with needles Keep a latex safe supply cart available in the clients room
407. The heath education nurse provides instruction to a group of clients regarding measures that will assist with prevention skin cancer. Which instructions should the nurse provide? Select all that apply
Use sunscreen when participating in outdoor activities wear a hat, opaque clothing and sunglasses when in the sun Examine your body monthly for any lesions that maybe suspicious
554. A client with prostatitis resulting from kidney infection has received instructions on management of the condition at home and prevention of reoccurrence. Which statement indicates that the client understood the instructions?
Use warm site baths and analgesics to increase comfort
276. The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to IMMEDIATELY discontinue the oxytocin infusion? Select all that apply
Uterine hyper stimulations Late deceleration of the FHR
239. The nurse assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placentae is accompanied by which additional findings?
Uterine tenderness on palpation
4. The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the PHC provider?
Valerian
496. The low pressure alarm sounds on the ventilator. The nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. Which INITIAL action should the nurse take?
Ventilate the client manually
569. The nurse is assigned to care for a client with a DX detached retina. Which findings would indicate that bleeding has occurred as a result of retinal detachment? Select all that apply
Vision may be cloudy Complains of a burst of black spots or floaters
532. A client is receiving digoxin daily. The nurse suspects digoxin toxicity after noting which S/S? Select all that apply
Visual disturbances N/V Serum digoxin level of 2.3 ng/ml
249. The nurse is caring for a postpartum client with a DX of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should INITIALLY check which item?
Vital signs
81. The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is MOST IMPORTANT for the nurse to check which item?
Vital signs
411. A client with severe acne is seen in the clinic and the PHCP prescribes isotretinoin. The nurse reviews the clients medication record and would contact the PHCP if the client is also taking which medication?
Vitamin A
469. The nurse is caring for a client with a DX of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency?
Vitamin B12
631. The client has been taking medication for RA for 3 weeks. During the administration of etanercept, it is MOST IMPORTSANT for the nurse to collect which data?
WBC and platelets count
726. A hospitalized client taking clozapine for the treatment of a schizophrenic disorder. Which lab study prescribed for the client should the nurse specifically review to monitor for adverse effect associated with the use of this medication?
WBC count
614. The client with trigeminal neuralgia is being treated with carbamazepine. Which lab result indicates that the client is experiencing an adverse effect of the medication?
WBC count, 3000mm3
408. Silver sulfadiazine is prescribed for a client with a burn injury. Which lab findings requires the need for monitoring by the nurse?
WBC of 3000mm3
193. The nurse is providing and education class to healthy older adults. Which exercise will BEST promote health maintenance?
Walking three to five times a week for 30 minutes
582. The nurse assists with preparing the client for ear irrigation as prescribed by the PHCP. Which action should the nurse plan to take?
Warm the irrigating solution to 98F
587. The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? Select all that apply
Wash hands Put on gloves Place the drop in the conjunctival sac Pull the lower lid down against the cheekbone
736. The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by. The parents indicates NEED FOR FURTHER TEACHING?
We need to maintain respiratory precautions and a quiet environment for at least 2 weeks
178. The nurse is reinforcing discharge instructions to the parents of a 2y/o child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement?
We will be sure not to leave hot liquid unattended
635. A client with acute muscle spasms has been taking baclofen. The client calls the clinic nurse because of continuous feelings of weakness and fatigue and asks the nurse about discontinuing the medication. The nurse should make appropriate response to the client?
Weakness and fatigue commonly occur and will diminish with continued medication use
399. The nurse is told that an assigned client is suspected of having MRSA. Which precautions should the nurse institute during the care of the client?
Wear gloves and gown
109. The nurse should institute which interventions for a client DX with clostridium difficile? Select all that apply
Wear gloves and gown while in the room caring for the client Use soap and water not alcohol based hand rub, for hand hygiene
642. The nurse prepares to give a bath and change the bed lines for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which should the nurse include in the plan during the bathing of this client?
Wear gown and gloves
114. The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply
Wearing gloves when emptying the clients bedpan Keeping all linens in the room until the implant is removed Wearing a film (dosimeter) badge when in the clients room Wearing a lead apron when providing direct care to the client
344. The nurse is monitoring the daily weight of an infant with HF. Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the RN?
Weight gain of 1 lbs in 1 day
691. A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurses observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which assessment?
Weight loss
700. The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse I should get out of this bad situation. The MOST helpful response by the nurse should be which statement?
What do you find difficult about this situation
723. The nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallways, and making aggressive and belligerent gestures at other clients. Which statement is appropriate to make to this client?
What is causing you to become agitated
721. The nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, which is the MOST APPROPRIATE question to ask?
What leads you to seek help now
346. A HCP has prescribed oxygen as needed for a 10m/o infant with HF. In which situation should the nurse administer the oxygen to the child?
When drawing blood for electrolyte levels
727. Disulfiram is prescribed for a client and the nurse is collecting data on the client and is reinforcing instructions regarding the use of this medication. Which is MOST IMPORTANT for the nurse to determine before administration of this medication?
When the last alcoholic drink was consumed
196. The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the Fallopian tubes. Which is the accurate response the nurse should make?
Where fertilization occurs
290. The nurse is assisting in performing pediculosis capitis (head lice) checks. Which findings indicates that a child has a positive head check?
Whites sacs attached to the hair shafts in the occipital area
456. The nurse is reinforcing teaching for a client regarding how to mix regular insulin in insulin in the same syringe. Which action performed by the client indicates the NEED FOR FURTHER TEACHING?
Withdraws the NPH insulin first (cloudy)
704. The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse asks the nurse, When will the first signs of withdrawal appear? The nurse should reply?
Within a few hours
709. The nurse is caring for a client who has a history of opioid abuse an is monitoring the client for signs of withdrawal. Which manifestation are specifically with withdrawal from opioids?
Yawning Irritability Diaphoresis Cramps Diarrhea
800. A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, I don't feel any better than I did before the surgery. Which response by the nurse is the MOST APPROPRIATE?
You are concerned that you don't feel any better after surgery
370. The mother of a child with Marfan syndrome asks the nurse what can be done to help her child. Which is the BEST response by the nurse? Select all that apply
You may need to consider surgery in the future You will need to make regular pediatric appointments for your child You will need to make regular ye examinations appointments for your child You will need to have your child take cardiac medications to decrease stress on the aorta You will need to let the dentist know that antibiotics should be given before and procedure
711. The nurse is caring for an adult client who has recently lost her husband. The client says no one cares about me anymore. All the people I loved are dead. Which response by the nurse is therapeutic?
You must be feeling all alone at this point
724. During a conversation with a depressed client on a psychiatric unit, the client says to the nurse My family would be better off without me. The nurse should make which therapeutic response to the client?
You sound very upset. Are you thinking of hurting yourself
695. A client who is DX with pedophilla and recently has been paroled as a sex offender says, I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime. Which is an appropriate response by the nurse?
You understand that people fear for their children, but you're feeling unfairly treated?
274. A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which information to the client?
You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a c-section delivery will be needed
220. The nurse is talking to a pregnant client with HIV infection regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to this client?
You will need to bottle feed your newborn
8. An Antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is MOST IMPORTANT to provide to the client?
You will need to talk to your PHC provider before using an herbal substance
672. A client says to the nurse I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying. Which therapeutic response should the nurse make to the client?
You're feeling angry that your family continues to hope for you to be cured
55. The RN reviews the results of the ABG values with the LVN and tells the LVN that the client is experiencing respiratory infection acidosis. The LVN should expect to note which on the lab result report?
pH 7.25, PCO2 50 mm Hg
86. A client has prescription to receive 1000 ml of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action FIRST before spiking the IV bag with the tubing.
Close the roller clamp on the IV tubing
40. The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional S/S should the nurse expect to note in this client if hyponatremia is present?
Postural B/P changes
85. Which of these clients is/are MOST LIKELY to develop fluid overload. Select all that apply
Premature infant 100 y/o man Client with heart failure A client receiving renal dialysis
64. A client with DM has a glycosylated hemoglobin A1C level of 9%. On the basis of this test result, the nurse plans to reinforce teaching the client about the need for which measure?
Preventing and recognizing hyperglycemia
5. The nurse is assisting with collecting data from an African American client admitted to the ambulatory care unit who is scheduled for hernia repair. Which information about the client is the lowest priority during data collection?
Psychosocial
61. A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the clients lab report, should be reported before administering the dose of furosemide?
3.2 mEq/l
98. The nurse is reviewing the client health record and notes that the client elicited a positive Romberg sign. Based on this finding, the nurse should institute which intervention? Select all that apply
Collect data to determine factors for fall risk Instruct the client to ask for assistance when getting up to walk
73. A hospitalized client is lacto-vegetarian. Which food item should the nurse remove from the meal tray?
Eggs
89. The nurse is making a worksheet and listing the tasks that need to be performed for assigned adults clients during the shift. The nurse writes on the plan to check the IV of an assigned client who is receiving fluid replacement therapy how frequently?
Every hour
1. A client is DX with cancer and is told that surgery followed by chemo is necessary. The client states to the nurse "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statements?
Tell me what you know about complimentary therapies
83. A client who is receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for a client to which area?
The blood bank
84. The nurse takes a clients temperature before giving a blood transfusion. The temp is 100F orally. The nurse reports the findings to the RN and anticipates that which action will take place?
The blood will be held, and the PHCP will be notified
32. The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit?
The client receiving NG suction
11. Which identifies accurate nursing documentation notations? Select all that apply
The client slept through the night Abdominal wound dressing is dry and intact without drainage The clients left lower medial leg wound is 3cm in length without redness, drainage or edema
54. The nurse is caring for a client with respiratory insufficiency. The ABG result indicates a pH of 7.50 and a PCO2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which additional lab values should the nurse expect to note?
A potassium level of 3.0 mEq/L
72. When reinforcing dietary instructions to a client with IBS who's primary symptom is alternating constipation and diarrhea, the nurse would tell the client that which foods are BEST to include in the diet for this disorder? Select all that apply
Apple Whole grain bread
58. A client has been admitted to the hospital for UTI and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to which value?
15 mg/dl
93. Client is going to be transfused with a unit of PRBCs. The nurse understands that it is necessary to remain with the client for the time period after the transfusion started?
15 minutes
95.the nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting MOST from the therapy if the client exhibits which findings?
A decrease in oozing from puncture sites and gums
67. A LVN is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient controlled analgesia (PCA) pump for pain control. The nurse enters the clients room and finds the client drowsy and records the following vital signs: T 36.2C (97.2F) orally, P 52BPM, B/P 101/58 mm Hg, R 11BPM, and SPO2 93% on 3 liters of oxygen via NC. Which action should the nurse take FIRST?
Attempt to wake the client
28. A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style?
Autocratic
77. A client with heart disease is instructed regarding a low fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item?
Cheese
79. A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encourages the cleint to eat which dietary items to promote wound healing?
Chicken breast, broccoli, strawberries and milk
99. The nurse learns in report that the client is exhibiting Cheyenne-strokes respirations. Based on this data, which action is MOST APPROPRIATE for the nurse to take initially?
Determine the clients ability to follow verbal commands
80. The nurse has completed diet teaching for a client who has been prescribed a low sodium diet to treat hypertension. The nurse determines that there is a NEED FOR FURTHER TEACHING when the client makes which statement?
Fresh foods such as fruits and vegetables are high in sodium
20. An older woman is brought into the ED. When caring for the client, the nurse notes old and new ecchymotic areas on both of the clients arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing action?
I have a legal obligation to report this type of abuse
57. The LVN is precepting a student assigned to care for a client with chronic pain. Which statement, if made by the student, indicates the NEED FOR FURTHER TEACHING regarding pain management?
I will be sure to cue in to any indicators that the client may be exaggerating their pain
38. The nurse is caring for a client who has been taking diuretics on a long term basis. Which finding should the nurse expect to note as a result of this long term use?
Increased specific gravity of the urine
87. The nurse is doing a routine assessment of a clients peripheral IV site. The nurse notes that the site is cool, pale and swollen and that the IV stopped running. The nurse determines that which has probably occurred?
Infiltration
41. The nurse is caring for a client with a DX of hyperparathyroidism. Laboratory studies are performed and the serum calcium level is 12.0 mg/dl. Based on this lab value, the nurse should take which action?
Inform the RN of the lab value
60. A client receiving a continuous IV of heparin sodium to treat DVT. The clients aPTT time is 65 seconds. The LVN reviews the lab results with the RN, anticipating that which action is needed?
Leaving the rate of heparin infusion as is
26. The nurse is educating a new nurse about mass casualty events (disaster). Which statement by the new nurse indicates a NEED FOR FURTHER TEACHING? Select all that apply
Mass casualty events do not require an increase in the number of staff that are needed A mass casualty event occurs only within the health care facility and could endanger staff A mass casualty event occurs if a fight between visitors occurs in the ED
50. The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid base disorder?
Metabolic acidosis
49. The nurse is caring for a client with a NG tube that is attached to low suction. The nurse monitors the client closely for which acid base disorder that is MOST LIKEY to occur in this situation?
Metabolic alkalosis
78. The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse should tell the client to select which food item that is high in riboflavin?
Milk
34. The nurse reviews a clients electrolyte results and notes that the potassium level is 5.4 mEq/L. What should the nurse look for on the cardiac monitor as a result of his lab values?
Narrow, peaked T waves
69. A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3. The nurse should take which action after seeing the lab results?
Place the normal report in the clients medical record
62. Several lab test are prescribed for a client and the nurse reviews the results of the test. Which lab tests results should the nurse report? Select all that apply
Platelets 35,000 mm3 Sodium 150 mEq/l Segmented neutrophils 40% Serum creatinine 1mg/dl
14. The Nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action?
Report to the pediatric unit and identify tasks that can be safely performed
75. The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food items?
Scallops
35. The nurse is reading the PHCP progress notes in the clients record and sees that the PHCP has documented " insensible fluid loss of approximately 800 ml daily" which client is at risk for this loss?
The client with a fast respiratory rate
36. The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for development of third spacing?
The client with diabetes mellitus
37. The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit?
The client with ileostomy
39. The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse expects that this sodium level would be noted in a client with which condition?
The client with the syndrome of inappropriate secretion of antidiuretic hormone
82. A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings?
Transfusion reaction
13. An unconscious client, bleeding profusely, is brought into ED after a serious accident. Surgery is required immediately to save the clients life. With the regard to informed consent for the surgical procedure, which is the BEST action?
Transport the client to the OR immediately without obtaining an informed consent
33. The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that potassium value level would be noted with which condition?
Traumatic burn
63. The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the clients medication history and determines it is necessary to consult with a RN if the client is also taking which medication? Select all that apply
Warfarin Glimepiride Amlodipine
97. A client with a DX of asthma is admitted to the hospital with respiratory distress. Which signs should the nurse expect to note in the health record when collecting data related to the respiratory system for the client?
Wheezes Use of accessory muscles
