NCLEX Practice- Saunders Questions

A client arrives at the clinic for her first prenatal appointment. She states that the first day of her last menstrual period was October 19, 2018. Using the estimated due date rule, what is her expected date for delivery? 1. July 12, 2019 2. July 26, 2019 3. August 12, 2019 4. August 26, 2019

2. July 26, 2019- subtract 3 months from the first day of the last menstrual period and add 7 days, add one year.

The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding her insulin needs during the course of her pregnancy. The nurse determines that further teaching is needed if the client makes which statement? 1. "I will need to increase my insulin dosage during the first 3 months of my pregnancy" 2. "my insulin dose will most likely need to be increased during the second and third trimester" 3. "episodes of hypoglycemia are most likely to occur during the first 3 months of pregnancy" 4. "my insulin needs should return to pre-pregnant levels within 7-10 days after birth if I am bottle feeding my newborn"

1. "I will need to increase my insulin dosage during the first 3 months of my pregnancy" - insulin needs decrease in the first trimester of pregnancy due to increased insulin production by the pancreas and increased peripheral sensitivity to insulin

A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which IV solution to hang with the blood product at the client's bedside? 1. lactated ringer's 2. 0.9% normal saline 3. 5 % dextrose in normal saline 4. 5 % dextrose in 0.45% saline

0.9% normal saline

A client is scheduled for an angioplasty. The client states, "I am so afraid that this procedure will hurt and will make me worse off than I already am." Which response by the nurse is appropriate? 1. "Can you tell me what you understand about this procedure?" 2. "Your fears are a sign that you really should have this procedure performed." 3. "These are normal fears, but please be assured that everything will be okay." 4. "Try not to worry. This is a well-known and easy procedure for the health care provider to perform."

1. "Can you tell me what you understand about this procedure?" - therapeutic communication! Explore the client's feelings and concerns, determine their understanding of the procedure.

The nurse has reinforced discharge instructions to a client who has undergone a right mastectomy with axillary lymph node dissection. Which statement by the client indicates a need for further teaching? 1. "I should use a straight razor to shave under my arms." 2. "I need to be sure not to have my blood pressure measured or blood drawn from my right arm." 3. "I should inform all my other healthcare providers that I have had this surgical procedure completed." 4. "I need to be sure to wear thick mitt hand covers or use thick pot holders when I am cooking or touching hot pans."

1. "I should use a straight razor to shave under my arms." - recall that edema and infection are concerns with this client due to the removal of lymph nodes- identifying possible traumas to the affected arm that could potentially result in edema and/or infection is important and should be prevented.

The nurse is providing postpartum instructions to a client who will be breastfeeding her newborn. The nurse determines the client has understood the instructions if she makes which statement? SATA 1. "I should wear a bra that provides support" 2. "Drinking alcohol can affect my milk supply" 3. "the use of caffeine can decrease my milk supply" 4. "I will start my estrogen birth control pills again as soon as I get home" 5. "I know if my breasts get engorged, I will limit my breast-feeding and supplement the baby" 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easy"

1. "I should wear a bra that provides support" 2. "Drinking alcohol can affect my milk supply" 3. "the use of caffeine can decrease my milk supply" 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easy"

The nurse is providing instructions to a client with HIV infection regarding care to newborn after delivery. The client asks the nurse about feeding options that are available. Which response should the nurse make to the client? 1. "you will need to bottle feed your newborn" 2. "you can breastfeed your newborn after receiving proper treatment for HIV" 3. "you will need to feed your newborn via nasogastric tube" 4. "you will be able to breastfeed your newborn for 6-months and then you will need to switch to bottle feeding."

1. "you will need to bottle feed your newborn"- clients who are diagnosed with HIV are encouraged NOT to breastfeed in order to prevent the transmission of infection to newborn

a client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive & unresponsive. The nurse anticipates that which IV solution will most likely be prescribed? 1. 5% dextrose in LR solution 2. 0.33% sodium chloride (1/3 normal saline) 3. 0.45% sodium chloride (1/2 normal saline) 4. 0.225% sodium chloride (1/4 normal saline)

1. 5% dextrose in LR solution- hypertonic solutions increase intravascular volume, replaces immediate blood loss volume, and increases blood pressure

The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before the beginning transfusion, the nurse assesses which of the following items? 1. Vital signs 2. Skin Color 3. Urine output 4. Latest hematocrit level.

1. Vital signs - obtain baseline and monitor vitals for any changes during and after the procedure

A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The healthcare provider prescribes a contraction stress test, and the results are documented as negative. How should the nurse interpret these findings? 1. a normal test result 2. abnormal test result 3. high risk for fetal demise 4. the need for a c-section

1. a normal test result - negative result =normal, positive = abnormal. Negative test suggest no late decelerations in the fetal heart rate

The nurse monitors a client receiving digoxin for which early manifestation of digoxin toxicity? 1. anorexia 2. facial pain 3. photophobia 4. jaundice

1. anorexia- digoxin is a cardiac glycoside used to manage/treat heart failure and A-fib. The most common early manifestations of toxicity include GI disturbances- nausea, vomiting, anorexia.

A client is to undergo a CT scan of the abdomen with oral contrast, and the nurse is providing pre-procedure instructions. The nurse instructs the client to take which action before having the procedure? 1. avoid eating and drinking after midnight before the test 2. limit self to only 2 cigarettes on the morning of the test 3. have a clear liquid breakfast the morning of the test 4. take all routine medications with a full glass of water on the day of the test

1. avoid eating and drinking after midnight before the test

The nurse is caring for a client who is receiving IV diuretics and suspects that the client is experiencing fluid volume deficit. Which assessment finding supports this condition? 1. weight loss and poor skin turgor 2. lung congestion and increased heart rate 3. decreased hematocrit and increase urine output 4. increased respirations and blood pressure

1. weight loss and poor skin turgor- assessment findings related to fluid volume deficit include increased respirations and HR, decreased CVP, weight loss, poor skin turgor, dry mucous membranes, decreased urine output, altered LOC, increased specific gravity and hematocrit

A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? 1.Place the client in Trendelenburg's position 2.Call the delivery room to notify the staff that the client will be transported immediately 3.Gently push the cord into the vagina 4.Find the closest telephone and stat page the physician

1.Place the client in Trendelenburg's position - priority action is to relieve any pressure that may be compressing the umbilical cord and increase fetal oxygenation

A pregnant client in the first trimester calls the nurse at the healthcare clinic and reports that she has noticed a thin, colorless vaginal discharge. The nurse should make which statement to the client? 1. "come to the clinic and get checked out immediately" 2. "the vaginal discharge may be bothersome, but it is a normal occurrence in pregnancy." 3. "report to the ED at contact the maternity center" 4. "use a pad or tampon to soak up the discharge."

2. "the vaginal discharge may be bothersome, but it is a normal occurrence in pregnancy." - leukorrhea begins in the first trimester of pregnancy and is an expected finding - results in thin, colorless and/or yellow discharge

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 BUN level drops to what value? 1. 3 mg/dL 2. 15 mg/dL 3. 29 mg/dL 4. 35 mg/dL

2. 15 mg/dL- normal BUN level is 6-20 mg/dL

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first? 1. Maintain bed rest with legs elevated. 2. Place the client in high Fowler's position. 3. Increase the rate of infusion of intravenous fluids. 4. Consult with the health care provider (HCP) regarding initiation of oxygen therapy.

2. Place the client in high Fowler's position - sign of transfusion reaction. Place patient is upright position to obtain proper airway FIRST

The nurse developing a plan of care for a client with a cataract understands that which problem is priority? 1. concerns about the loss of eyesight 2. altered vision due to opacity of ocular lens 3. difficulty moving around because of the need for glasses 4. becoming lonely due to decrease in community immersion

2. altered vision due to opacity of ocular lens - physiological needs have priority over psychological needs

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 48-hours, the nurse anticipates a prescription for which medication? 1. nalbuphine 2. betamethasone 3. Rho(D) immune globulin 4. dinoprostone vaginal insert

2. betamethasone- increases production of lung surfactant in fetus

The postpartum nurse is providing instructions to the mother of a newborn diagnosed with hyperbilirubinemia who is currently being breastfed. The nurse should provide which instruction to the mother? 1. feed the newborn less frequently 2. continue to breastfeed newborn every 2-4 hours 3. switch to bottle feeding the infant for 2 weeks and then resume breast feeding 4. stop breast feeding and change to bottle feeding permanently

2. continue to breastfeed newborn every 2-4 hours

A client who experienced a MI is being monitored via cardiac telemetry. The nurse notes the sudden onset of this cardiac rhythm on the monitor and immediately takes which action? 1. take client's blood pressure 2. initiates CPR 3. places a nitroglycerin tablet under the client's tongue 4. continues to monitor client and contacts healthcare provider

2. initiates CPR - CPR is initiated until a defibrillator can be used.

A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure? 1. lying in bed on the affected side 2. lying in bed on the unaffected side 3. sims position with the HOB flat 4. prone position with the head turned to the side

2. lying in bed on the unaffected side - client can either be sitting upright leaning over a table, or they may be lying with HOB elevated 30 degrees on the unaffected side in order to drain fluid during the procedure

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? 1. developmental delay due to excessive birth size 2. maintaining safety because of low blood glucose levels 3. choking because of impaired suck and swallow reflex 4. elevated body temperature due to excess fat and glycogen

2. maintaining safety because of low blood glucose levels- new born is at risk of hypoglycemia due to having diabetic mother who uses insulin

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Pco2 30 mm Hg, and HCO3 22 mEq/L. The nurse analyzes these results as indicating which condition? 1. metabolic acidosis, compensated 2. respiratory alkalosis, compensated 3. metabolic alkalosis, uncompensated respiratory acidosis, uncompensated

2. respiratory alkalosis, compensated. Normal pH is 7.35-7.45. In a respiratory condition, an opposite effect will be seen between the pH and Pco2. Compensation occurs when the pH returns to a normal value.

A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching? 1. "I should stay on the diabetic diet throughout my pregnancy" 2. "I should perform routine blood glucose monitoring at home" 3. "I should avoid exercise because of the negative effects of my insulin production during pregnancy" 4. "I should be aware of any infections and report them to my healthcare provider immediately if one is suspected"

3. "I should avoid exercise because of the negative effects of my insulin production during pregnancy"

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? 1. a primiparous client who delivered 4 hours ago 2. a multiparous client who delivered 6 hours 3. a multiparous client who delivered a large baby after oxytocin induction 4. a primiparous client who delivered 6 hours ago and had epidural anesthesia

3. a multiparous client who delivered a large baby after oxytocin induction - causes of postpartum hemorrhage include uterine atony, laceration of vagina, hematoma development in cervix/perineum/labia, or history of hemorrhage

The RN is planning the client assignments for the day. Which is the most appropriate assignment for the UAP? 1. client receiving a colostomy irrigation 2. client receiving continuous tube feedings 3. client who requires a urine specimen collection 4. client with difficulty swallowing

3. client who requires a urine specimen collection

The nurse caring for a client experiencing shoulder dystocia determines that the priority of care is which action? 1. position changes and providing comfort measures 2. explanations to the family members about what is happening to the client and the fetus 3. monitoring for changes in the physical condition of the mother and fetus 4. reinforcement of breathing techniques learned in childbirth prep classes

3. monitoring for changes in the physical condition of the mother and fetus- ALL options would be correct but establishing physiological needs comes first and is priority. Physiological needs include airway, respiratory effort, heart rate/rhythm/strength of contraction, nutrition, elimination.

The nurse is teaching a client in skeletal leg traction about measures to increase bed mobility. Which item would be most appropriate for the client to use? 1. hospital bed remote 2. fracture bedpan 3. overhead trapeze 4. educational reading materials

3. overhead trapeze- useful in assisting the patient with moving up in the bed and/or placing self on bedpan.

The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken by the nurse next? 1. remove the IV line 2. run a solution of 5% dextrose in water 3. run normal saline 4. obtain specimen culture from the IV catheter

3. run normal saline - maintains a patent IV access line and helps maintain the client's intravascular volume

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands signs of true labor if which statement is made? 1. "I won't fully be in labor until my baby's head drops low into my cervix" 2. "My contractions will be felt in my abdominal area" 3. "My contractions won't be as painful if I drink fluids and walk around." 4. "My contractions will increase in duration and in intensity"

4. "My contractions will increase in duration and in intensity"

A client scheduled for a bowel surgery states to the nurse, "I'm not sure if I should have this surgery." Which response by the nurse is appropriate? 1. "It is your decision to have the surgery or not." 2. "Don't worry, everything is going to be fine." 3. "Why don't you want the surgery anymore?" 4. "Tell me what concerns you have regarding the procedure."

4. "Tell me what concerns you have regarding the procedure." - therapeutic communication, establish the client's feelings and concerns first.

A client diagnosed with coronary artery disease has selected guided imagery to help cope with the psychological stress caused from the diagnosis. Which statement made by the client indicates an understanding of this stress reduction measure? 1. "This will help only if I play music at the same time." 2. "This will work for me only if I am alone and in a quiet area." 3. "I need to do this only when I lie down in case I fall asleep." 4. "The best thing about this is that I can use it anywhere at anytime."

4. "The best thing about this is that I can use it anywhere at anytime." - guided imagery involves the client creating an image in the mind, concentrating on that image, and gradually becoming less aware of surrounding stimuli.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse see first? 1. a post-op client preparing for discharge with a new medication 2. a client requiring daily dressing changes of a recent surgical incision 3. a client scheduled for a chest x-ray after insertion of a NG tube 4. a client with asthma who requested a breathing treatment during the previous shift

4. a client with asthma who requested a breathing treatment during the previous shift - airway is highest priority when caring for clients

The nurse is caring for a patient diagnosed with angina pectoris who begins to experience chest pain. The nurse administers a nitroglycerin tablet sublingually as prescribed, but the pain is unrelieved. The nurse should take which action next? 1. reposition the client 2. call the client's family 3. notify the healthcare provider 4. administer additional dose of nitroglycerin

4. administer additional dose of nitroglycerin - remember nitroglycerin can be given up to 3 times at least 5 minutes apart to help relieve chest pain.

Quinapril hydrochloride is a prescribed adjunctive therapy in the treatment of heart failure. After administering the first dose, the nurse should monitor which item as priority? 1. weight 2. urine output 3. lung sounds 4. blood pressure

4. blood pressure - medication is an ACE inhibitor, ends in "-pril" and one use for these medications is to control hypertension.

The nurse analyzes the lab results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child? 1. platelet count 2. hematocrit level 3. hemoglobin level 4. partial thromboplastin time

4. partial thromboplastin time - hemophilia is a blood disorder that results in coagulation deficiency

A diagnosis of Hodgkin's disease is suspected in a 12-year-old child. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test result will confirm diagnosis of Hodgkin's disease? 1. elevated vanillylmandelic acid urinary levels 2. presence of blast cells in the bone marrow 3. presence of epstein-barr virus in the blood 4. presence of reed-sternberg cells in the lymph nodes

4. presence of reed-sternberg cells in the lymph nodes - these cells are indicators of Hodgkin's lymphoma

The nurse administers erythromycin ointment to the eyes of a newborn and the other asks the nurse why this action is necessary. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1. protects the newborn's eyes from possible infections acquired during hospitalization 2. prevents the formation of cataracts in the newborn born to a woman who is susceptible to rubella 3. minimizes the spread of microorganisms to the newborn from invasive procedures during labor 4. prevents an infection that may develop in the infant which occurs after birth with a woman who is untreated for a gonococcal infection

4. prevents an infection that may develop in the infant which occurs after birth with a woman who is untreated for a gonococcal infection - prevents the development of ophthalmia neonatorum caused by gonorrhea

A MRI is ordered for a patient with a suspected brain tumor. The nurse should implement which action to prepare the patient for this test? 1. shave the groin for insertion of a femoral catheter 2. remove all metal-containing objects from the client 3. keep the client NPO before procedure 4. instruct the client of inhalation techniques for the administration of the radioisotope.

2. remove all metal-containing objects from the client

The nurse is assessing a client's peripheral IV site after completion of a vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best? 1. check for presence of blood return 2. remove the IV and restart at another site 3. document the findings and continue to monitor the site closely 4. call the healthcare provider and request the medication be given a different route

2. remove the IV and restart at another site - signs of phlebitis require intervention by nurse- remove the IV line and use a different site

The nurse is providing discharge instructions to a Chinese-American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action? 1. continue with the instructions, verifying client's understanding 2. walk around the client so that the nurse is constantly face-to-face with the client 3. give the client a dietary booklet to look over and return later with further instructions 4. tell the client about the importance of the instructions for the maintenance of care.

1. continue with the instructions, verifying client's understanding - due to their cultural background, eye contact and face-to-face conversations is unusual during conversation. Respect cultural preferences and continue on with your duties, respectfully.

The nurse is a newborn nursery is monitoring for respiratory distress syndrome in a newborn. Which assessment findings support this diagnosis? 1. cyanosis 2. retractions 3. tachypnea 4. hypotension 5. audible grunts 6. presence of barrel chest

1. cyanosis 2. retractions 3. tachypnea 5. audible grunts nasal flaring may also be present in a newborn with respiratory distress syndrome

The nurse is monitoring the status of a postoperative client in the immediate postoperative phase. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. increasing restlessness 2. a pulse of 86 bpm 3. blood pressure of 110/70 mm Hg 4. hypoactive bowel sounds in all quadrants

1. increasing restlessness - could indicate possible hemorrhage, shock, or pulmonary embolism; must be closely monitored

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? 1. naloxone 2. morphine sulfate 3. betamethasone 4. hydromorphone sulfate

1. naloxone- antidote for any opioid overdose

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse notifies the healthcare provider and he prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? SATA 1. peas 2. nuts 3. cheese 4. cauliflower 5. processed oat cereals

1. peas 2. nuts 4. cauliflower processed anything is high in sodium, as well as cheese.

The nurse notes blanching, coolness, and edema at the peripheral IV site. On the basis of these findings, the nurse should implement which action? 1. remove the IV 2. apply a warm compress 3. check for blood return through the line 4. measure the area of infiltration

1. remove the IV - prevent any further damage that may be caused by infiltration

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1. twitching 2. hypoactive bowel sounds 3. negative Trousseau's sign 4. hypoactive deep tendon reflexes

1. twitching- normal calcium level is 9-10.5 mg/dL. Signs of hypocalcemia include paresthesia, followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's sign, muscle cramps, twitching, tetany, seizures, hyperactive bowel sounds, diarrhea.

The nurse is collecting data during an admission assessment for a patient pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks, and tells the nurse that she has no history of abortion or fetal demise. Using GTPAL, what should the nurse document for this client? 1. G3,T2, P0, A0, L1 2. G2, T1, P0, A0, L1 3. G1, T1, P1, A0, L1 4. G2, T1, P0, A0, L3

2. G2, T1, P0, A0, L1

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? 1. sustained tissue damage 2. requires nasogastric suctioning 3. history of Addison's disease 4. uric acid level of 9.4 mg/dL

2. requires nasogastric suctioning- potassium-rich gastrointestinal fluids are lost through GI suction

The nurse is assisting a client undergoing induction of labor at 41 weeks gestation. The client's contractions are moderate and occurring every 2-3 minutes and are moderate in intensity. The contractions are lasting about 60 seconds and an internal fetal monitor has been placed. The baseline heart rate is 122 beats/minute. What is the priority action for the nurse to take? 1. notify healthcare provider 2. discontinue the oxytocin infusion 3. place oxygen on client at 8-10 L/min via non-rebreather 4. contact client's primary support person if they aren't already present

2. discontinue the oxytocin infusion- oxytocin can cause more forceful contractions and can lead to a decrease in oxygen to the placenta, resulting in decreased variability

A client with renal insufficiency has a Mg+ level of 3.5 mEq/L. On the basis of this laboratory result, the nurse expects which client symptom? 1. hyperpnea 2. drowsiness 3. hypertension 4. physical hyperactivity

2. drowsiness- normal Mg+ level is 1.5-2.5 mEq/L. This client's level indicates hypermagnesemia- leads to neurological manifestations such as neurological depression- drowsiness, sedation, lethargy, muscle weakness, respiratory depression

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. red, hard skin 2. serous drainage 3. purulent drainage 4. warm, tender skin

2. serous drainage- this type of drainage is expected after surgery

The ED nurse is caring for a child suspected of acute epiglottitis. Which interventions apply in the care of the child? SATA. 1. obtain a throat culture 2. ensure a patent airway 3. prepare the child for a chest x-ray 4. maintain child in supine position 5. obtain a pediatric-size tracheostomy tray 6. place the child on an O2 monitor

2. ensure a patent airway 3. prepare the child for a chest x-ray 5. obtain a pediatric-size tracheostomy tray 6. place the child on an O2 monitor acute epiglottitis- serious obstructive inflammatory process that requires immediate intervention- interventions pertaining to AIRWAY IS PRIORITY

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? 1. infection 2. hemorrhage 3. chronic hypertension 4. disseminated intravascular coagulation (DIC)

2. hemorrhage- patient is prone to bleeding

The nurse is caring for a client who just returned from the recovery room after undergoing abdominal surgery. The nurse should monitor for which EARLY sign of hypovolemic shock? 1. sleepiness 2. increased pulse rate 3. increased depth of respirations 4. increased orientation to surroundings

2. increased pulse rate- restlessness is one of the earliest signs, followed by cardiovascular changes such as increase HR and decrease BP. Increased depth of respirations does occur with hypovolemic shock, but it is NOT an early sign.

The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? 1. elevate the client's legs 2. massage the fundus until it is firm 3. ask the client to turn on the left side 4. push on the uterus to assist in expressing clots

2. massage the fundus until it is firm

The nurse is caring for a client with a NG tube that is attached to low suction. The nurse monitors the client for signs of which disorder that the client is at risk for? 1. metabolic acidosis 2. metabolic alkalosis 3. respiratory acidosis 4. respiratory alkalosis

2. metabolic alkalosis- caused by conditions resulting in hypovolemia- nasogastric suctioning or vomiting causes loss of gastric fluids.

The maternity nurse is preparing for the admission of a client in the third trimester who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the healthcare provider's orders and questions which prescription? 1. prepare client for abdominal ultrasound 2. obtain equipment for a manual pelvic examination 3. prepare to draw a hemoglobin and hematocrit blood sample 4. obtain equipment for external fetal heart rate monitoring

2. obtain equipment for a manual pelvic examination- if this diagnosis is suspected, ALL vaginal exams are prohibited due to vaginal bleeding

The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial action should the nurse take? 1. call the healthcare provider 2. place tubing in bottle of sterile water 3. replace chest tube immediately 4. place sterile dressing over the chest tube site

2. place tubing in bottle of sterile water - place in bottle of sterile water if tube becomes disconnected, make sure the bottle is below the level of the chest

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium, and tells the client to consume which of the following? SATA 1. peas 2. raisins 3. potatoes 4. cantaloupe 5. cauliflower 6. strawberries

2. raisins 3. potatoes 4. cantaloupe 6. strawberries Common foods high in potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes.

The nurse is performing an assessment on a client who suspects that she is pregnant, and is checking for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? SATA 1. ballottement 2. chadwick's sign 3. uterine enlargement 4. positive pregnancy test 5. fetal heart rate detected by doppler 6. outline of fetus via ultrasound

1. ballottement - rebounding of fetus against examiner's finger's upon palpation 2. chadwick's sign- violet coloration of cervix , vagina, vulva 3. uterine enlargement 4. positive pregnancy test

The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item? 1. client's temperature 2. expiration date of the PN bag 3. time of the last dressing change 4. connection of tubing

1. client's temperature- redness is possible indication of infection, so you need to assess for other signs of infection like fever.

A client who has had abdominal surgery complains of feeling as though "something gave away" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which actions should the nurse take? SATA 1. contact the surgeon 2. instruct the client to remain quiet 3. prepare the client for wound closure 4. document the findings and the nursing actions taken 5. place a sterile saline dressing with ice packs over the wound 6. place the client in supine position without a pillow under the head

1. contact the surgeon 2. instruct the client to remain quiet 3. prepare the client for wound closure 4. document the findings and the nursing actions taken nurse should call for help and stay with the client, surgeon should be contacted, client should be kept quiet and refrain from movement and coughing, organs should be covered with sterile dressing but NO icepacks should be applied

The nurse is assessing a pregnant client in the second trimester who was admitted to the unit with a suspected diagnosis of placental abruption. Which assessment finding should the nurse expect if this condition is present? 1. soft abdomen 2. uterine tenderness, abdominal guarding 3. absence of abdominal pain 4. bright red vaginal bleeding

2. uterine tenderness, abdominal guarding- patient will present with rigid, board-like abdomen, uterine tenderness, dark red vaginal bleeding

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately evacuates the client from the room. What is the next appropriate course of action? 1. call for help 2. extinguish fire 3. activate fire alarm 4. confine the fire by closing the door to the room

3. activate fire alarm- RACE- rescue, alarm, confine, extinguish

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction should the nurse provide? 1. strict bed rest required after the procedure 2. hospitalization is necessary for 24-hours after the procedure is completed to monitor for complications 3. an informed consent needs to be signed prior to the procedure 4. a fever is expected after the procedure due to the trauma occurring in the abdomen

3. an informed consent needs to be signed prior to the procedure

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? SATA 1. contractions are regular 2. membranes have ruptured 3. cervical dilation is complete 4. client begins to expel clear vaginal fluids 5. client feels the urge to push due to perineal pressure

3. cervical dilation is complete 5. client feels the urge to push due to perineal pressure second stage begin with the complete dilation of cervix and ends once the fetus is delivered

A mother calls a neighbor who is a nurse and tells the nurse that her 3-year old son has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action? 1. induce vomiting 2. Notify pediatrician 3. contact poison control 4. bring child to the ED

3. contact poison control

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss from evaporation? 1. warming the crib pad 2. closing the doors and windows to the room 3. drying off newborn after birth 4. turning on overhead radiant warmer

3. drying off newborn after birth- evaporation of moisture from a wet body can cause heat loss, drying the newborn after birth prevents hypothermia from evaporation

The nurse is caring for a client with a diagnosis of heart failure who suddenly complains of shortness of breath and dyspnea. The nurse should take which immediate action? 1. administer O2 to the client 2. prepare to administer furosemide 3. elevate the HOB 4. call the healthcare provider

3. elevate the HOB - eliminate the "what ifs" and focus solely on what you can do for that patient right in that moment, without a provider's order.

The nurse prepares to care for a client on contact precautions admitted with MRSA. The client has an abdominal wound that requires irrigation and has a tracheostomy that is hooked up to a mechanical ventilator, which requires frequent suctioning. The nurse should don which protective equipment before entering the patient's room? 1. gloves and gown 2. gloves and face shield 3. gloves, gown, and face shield 4. gloves, gown, shoe protectors

3. gloves, gown, and face shield

A client receiving PN complains of a headache. The nurse notes that the client has an increased blood pressure, bounding pulse, JVD, and crackles upon auscultation. The nurse determines that the client is experiencing which complication of parenteral nutrition (PN)? 1. sepsis 2. air embolism 3. hypervolemia 4. hyperglycemia

3. hypervolemia - assess for signs of fluid overload

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to see in this client if excess fluid volume is present? 1. weight loss and dry skin 2. flat neck and hand veins, decreased urinary output 3. increase in blood pressure and respirations 4. weakness and decreased CVP

3. increase in blood pressure and respirations- assessments associated with fluid volume excess include cough, dyspnea, tachycardia, tachypnea, bounding pulse, elevated CVP, weight gain, edema, neck vein distention, altered LOC.

The nurse is choosing age-appropriate toys for a toddler. Which toy selection is the best choice for this age? 1. puzzle 2. toy soldiers 3. large stacking-blocks 4. card game with large pictures

3. large stacking-blocks- identify safety risks when interacting with smaller children- choking hazards, inability to comprehend rules, etc.

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which foods on the list? SATA 1. oranges 2. broccoli 3. margarine 4. cream cheese 5. luncheon meats 6. broiled haddock

3. margarine 4. cream cheese 5. luncheon meats

The nurse should place the patient in what position before administering an enema? 1. prone position 2. supine position 3. sims position 4. dorsal recumbent position

3. sims position - left side-lying position allows enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum.

A client admitted to the hospital is diagnosed with urethritis caused by a chlamydial infection. The nurse should implement which precaution to prevent contraction of the infection during patient care? 1. enteric precautions 2. contact precautions 3. standard precautions 4. wearing gloves and mask

3. standard precautions

The nurse is performing an assessment of a pregnant client who is 28 weeks gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How should the nurse interpret these findings? 1. the client is measuring large for gestational age 2. the client is measuring small for gestational age 3. the client is measuring normal for gestational age 4. more evidence is needed to determine the size for gestational age

3. the client is measuring normal for gestational age- during the second and third trimester, fundal height should equal or be around the same height as gestational weeks

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the healthcare provider of the incident, and completes an accident report. Which statement should the nurse document in the report? 1. the client fell out of bed 2. the client fell while ambulating to the bathroom 3. the client was found lying on the floor 4. the client became restless and tried to get out of bed without assistance.

3. the client was found lying on the floor- incident report should only include facts observed by the nurse- description of what was seen, who was involved, any injuries that occurred.

The nurse is caring for a group of clients. On review of the clients' medical records, the nurse determines that which client is at risk for excess fluid volume? ' 1. the client taking diuretics 2. the client with an ileostomy 3. the client with kidney disease 4. the client undergoing GI suctioning

3. the client with kidney disease- all the other clients are losing fluid. Disturbance to kidney function will cause the patient to retain fluid instead of lose it.

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? SATA 1. fatigue 2. drowsiness 3. uterine hyperstimulation 4. late decelerations of the FHR 5. early decelerations of the FHR

3. uterine hyperstimulation 4. late decelerations of the FHR late decelerations indicate fetal distress, uterine hyperstimulation can cause complications to mother/fetus because there is no relaxation period

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sound would the nurse expect to hear upon auscultation? 1. stridor 2. crackles 3. wheezes 4. diminished lung sounds

3. wheezes - high pitched musical sound heard when air passes through an obstructed and/or narrowed airway

A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: 1.Place the mother in the supine position 2.Document the findings and continue to monitor the fetal patterns 3.Administer oxygen via face mask 4.Increase the rate of pitocin IV infusion

3.Administer oxygen via face mask- late decelerations are due to placental insufficiency, occurs when there is a decrease in blood flow and oxygen to the fetus

The nurse provides medication instruction to a patient receiving digoxin. Which statement by the patient indicates understanding of possible adverse effects of this medication? 1. "blurred vision is expected." 2. "if I am nauseated or vomiting, I should stay on an all-liquid diet and take an antacid until resolved." 3. "this medication may cause headache and weakness, but I should not be worried." 4. "if my pulse rate drops below 60 bpm I should notify my healthcare provider and withhold the medication."

4. "if my pulse rate drops below 60 bpm I should notify my healthcare provider and withhold the medication."

The nurse prepares to administer a vitamin-k injection to a newborn, and the mother asks the nurse why her infant needs the injection. What response should the nurse provide? 1. "your newborn needs this medication to help develop immunity" 2. "the medicine will protect your newborn from becoming jaundice" 3. "newborns have sterile bowels, and this medicine promotes the growth of bacteria in the bowel tract" 4. "newborns are deficient in vitamin k when they are born, so this medicine helps prevent your baby from bleeding"

4. "newborns are deficient in vitamin k when they are born, so this medicine helps prevent your baby from bleeding" - vitamin k helps body synthesize coagulation factors

A client who had an application of a right arm cast complains of pain at the wrist when the arm is passively moved. What action should the nurse take first? 1. elevate arm 2. document findings in patient's chart 3. medicate with dose of an opioid/pain analgesic 4. check for paresthesia and paralysis of the right arm

4. check for paresthesia and paralysis of the right arm - notice the word "first"- determine existence of any abnormalities first, before continuing assessment and relaying information

The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the healthcare provider? 1. urinary output has increased 2. dependent edema has resolved 3. blood pressure reading is at prenatal baseline 4. client complains of headache and blurred vision

4. client complains of headache and blurred vision

Which client is at risk for the development of a potassium level of 5.5 mEq/L? 1. client with colitis 2. client with Cushing's syndrome 3. client who is overusing laxatives 4. client who sustained traumatic burns

4. client who sustained traumatic burns- cellular shifting of potassium occurs in the early stages of clients who suffer from massive cell destruction; trauma, burns, sepsis, acidosis.

The ED nurse is assigned to triage clients coming into the emergency department for treatment. The nurse should assign priority to which client? 1. client complaining of muscle aches, a headache, and a history of seizures 2. client who twisted her ankle when rollerblading and is requesting something for the pain 3. client with minor laceration on the hand which was sustained when preparing dinner 4. client with chest pain who states that he just ate pizza that was made with very spicy sauce

4. client with chest pain who states that he just ate pizza that was made with very spicy sauce - ALWAYS prioritize chest pain and eliminate any serious conditions that may be present

A client with Parkinson's disease develops akinesia (freezing or no movement) while ambulating, increasing the risk for falls. Which suggestion by the nurse would cause the client to alleviate this problem? 1. use a wheelchair when moving around 2. stand erect and use a cane while ambulating 3. keep feet close together when walking and use a walker 4. consciously think about walking over imaginary lines on the floor

4. consciously think about walking over imaginary lines on the floor- clients with Parkinson's develop bradykinesia (moving slowly) or akinesia. Having these clients imagine lines on the floor to walk over can keep them moving forward while remaining safe.

A client with a diagnosis of cancer is receiving morphine sulfate for pain. The nurse should employ which priority action in the care of this client? 1. monitor stools 2. encourage fluid intake 3. monitor urine output 4. encourage deep breathing and coughing

4. encourage deep breathing and coughing- helps prevent atelectasis and respiratory depression during the client's hospital stay- ensures adequate oxygen ABC's- Airway, breathing, circulation

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? SATA 1. avoid stimulation 2. decrease fluid intake 3. expose all of the newborn's skin 4. monitor skin temperature closely 5. reposition the newborn every 2 hours 6. cover the newborn's eyes with shield or patches

4. monitor skin temperature closely 5. reposition the newborn every 2 hours 6. cover the newborn's eyes with shield or patches

The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary modifications if which food is selected from the menu? 1. nuts and milk 2. coffee and tea 3. cooked rolled oats and fish 4. oranges and dark green leafy vegetables

4. oranges and dark green leafy vegetables

A client who is found unresponsive has ABGs drawn and the results indicate the following: pH= 7.12, PaCO2= 90 mm Hg, HCO3= 22 mEq/L. The nurse interprets the results as which condition? 1. metabolic acidosis with compensation 2. respiratory acidosis with compensation 3. metabolic acidosis without compensation 4. respiratory acidosis without compensation

4. respiratory acidosis without compensation

A client has just returned to the nursing unit after an above-the-knee amputation of the right leg. The nurse should place the patient in what position? 1. prone 2. reverse Trendelenburg 3. supine with residual limb flat 4. supine with the residual limb elevated

4. supine with the residual limb elevated - first 24-hours the limb needs to be elevated with a pillow to promote venous return and limit edema

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussion with the client? 1. inhale as rapidly as possible 2. keep a loose seal between the lips and the mouthpiece 3. after maximum inspiration, hold breath for 15 seconds and then exhale 4. the best results are achieved when sitting up or with the HOB 45-90 degrees

4. the best results are achieved when sitting up or with the HOB 45-90 degrees- client should assume semi fowler's or high fowler's position to assist with opening airway

The nurse has received the client assignments for the day. Which client should the nurse see first? 1. the client who needs SC insulin before breakfast 2. the client who has a NG tube set on intermittent suction 3. the client who is 2 days post-op and is complaining of pain at the incision site 4. the client with a blood glucose of 50 mg/dl and is complaining of blurred vision

4. the client with a blood glucose of 50 mg/dl and is complaining of blurred vision- hypoglycemia can be life threatening, so intervene and treat this first!

The nurse is monitoring a client in labor. The nurse suspects an umbilical cord compression if which is noted on the external fetal monitor? 1. variability 2. accelerations 3. early decelerations 4. variable deceleration

4. variable deceleration

The nurse monitors the client receiving parenteral nutrition (PN) for complications of the therapy and should assess the client for which manifestations of hyperglycemia? 1. fever, weak pulse, thirst 2. nausea, vomiting, oliguria 3. sweating, chills, abdominal pain 4. weakness, thirst, increased urine output

4. weakness, thirst, increased urine output - signs of hyperglycemia include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul respirations, coma