NCLEX QOD

A neonate has a large amount of secretions. After vigorously suctioning the neonate, the nurse should assess for what possible result? a) Bradycardia. b) Rapid eye movement. c) Seizures. d) Tachycardia.

a) Bradycardia.

A home health nurse who sees a client with diverticulitis is evaluating teaching about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching? a) "I'll increase my intake of protein during exacerbations." b) "I should increase my intake of fresh fruits and vegetables during remissions." c) "I'll snack on nuts, olives, and popcorn during flare-ups." d) "I'll incorporate foods rich in omega-3 fatty acids into my diet."

b) "I should increase my intake of fresh fruits and vegetables during remissions."

A nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones? a) 7 weeks' gestation b) 11 weeks' gestation c) 17 weeks' gestation d) 21 weeks' gestation

b) 11 weeks' gestation

A nurse is using Doppler ultrasound to assess a pregnant woman. When should the nurse expect to hear fetal heart tones? a) 7 weeks' gestation b) 11 weeks' gestation c) 17 weeks' gestation d) 21 weeks' gestation

b) 11 weeks' gestation

A client has a herniated disk in the region of the third and fourth lumbar vertebrae. Which nursing assessment finding most supports this diagnosis? a) Hypoactive bowel sounds b) Severe lower back pain c) Sensory deficits in one arm d) Weakness and atrophy of the arm muscle

b) Severe lower back pain

The nursing staff has finished restraining a client. In addition to determining whether anyone was injured, the staff is mandated to evaluate the incident to obtain which of the following ultimate outcomes? a) Coordinate documentation of the incident. b) Resolve negative feelings and attitudes. c) Improve the use of restraint procedures. d) Calm down before returning to the other clients.

c) Improve the use of restraint procedures.

Which of the following is a priority during the first 24 hours of hospitalization for a comatose client with suspected drug overdose? a) Educate regarding drug abuse. b) Minimize pain. c) Maintain intact skin. d) Increase caloric intake.

c) Maintain intact skin.

Category: Basic Physical Care A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle accident. His pain is not under control. The client states, "If I could be with my people, I could receive acupuncture for this pain." The nurse should understand that acupuncture in the Asian culture is based on the theory that it: a) Purges evil spirits. b) Promotes tranquility. c) Restores the balance of energy. d) Blocks nerve pathways to the brain.

c) Restores the balance of energy.

A nurse is evaluating a client's electrocardiogram (ECG). Which ECG change can result from amitriptyline (Elavil) therapy? a) Presence of U waves b) Depressed ST segment c) Widening QT interval d) Prolonged PR interval

c) Widening QT interval

When giving an I.M. injection, the nurse should insert the needle into the muscle at an angle of: a) 15 degrees. b) 30 degrees. c) 45 degrees. d) 90 degrees.

d) 90 degrees.

Which of the following statements would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment? a) Activity is resumed gradually, and the client can resume her usual activities in 5 to 6 weeks. b) Activity level is determined by the client's tolerance; she can be as active as she wishes. c) Activity level will be restricted for several months, so she should plan on being sedentary. d) Activity level can return to normal and may include regular aerobic exercises.

a) Activity is resumed gradually, and the client can resume her usual activities in 5 to 6 weeks.

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a significant small and large bowel resection and is currently not taking anything by mouth. The nurse should: a) Administer TPN through a nasogastric or gastrostomy tube. b) Handle TPN using strict aseptic technique. c) Auscultate for bowel sounds prior to administering TPN. d) Designate a peripheral intravenous (IV) site for TPN administration.

b) Handle TPN using strict aseptic technique

A 7 year old with a history of tonic-clonic seizures has been actively seizing for 10 minutes. The child weighs 22 kg and currently has an intravenous (IV) line of D5 1/2 NS + 20 meq KCL/L running at 60 ml/hr. Vital signs are a temperature of 38 degrees C, heart rate of 120, respiratory rate of 28, and oxygen saturation of 92%. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary healthcare provider with a recommendation for: a) Rectal diazepam (Diastat). b) IV lorazepam (Ativan). c) Rectal acetaminophen (Tylenol). d) IV fosphenytoin.

b) IV lorazepam (Ativan).

The nurse is caring for a multigravid client who speaks little English. As the nurse enters the client's room, the nurse observes the client squatting on the bed and the fetal head crowning. After calling for assistance and helping the client lie down, which of the following actions should the nurse do next? a) Tell the client to push between contractions. b) Provide gentle support to the fetal head. c) Apply gentle upward traction on the neonate's anterior shoulder. d) Massage the perineum to stretch the perineal tissues.

b) Provide gentle support to the fetal head.

A nurse is assessing a woman in labor. Her cervix is dilated 8 cm. Her contractions are occurring every 2 minutes. She's irritable and in considerable pain. What type of breathing should the nurse instruct the woman to use during the peak of a contraction? a) Deep breathing b) Shallow chest breathing c) Deep, cleansing breaths d) Chest panting

b) Shallow chest breathing

A multigravid client in labor at 38 weeks' gestation has been diagnosed with Rh sensitization and probable fetal hydrops and anemia. When the nurse observes the fetal heart rate pattern on the monitor, which of the following patterns is most likely? a) Early deceleration pattern. b) Sinusoidal pattern. c) Variable deceleration pattern. d) Late deceleration pattern.

b) Sinusoidal pattern.

A 45-year-old single mother of three teenaged boys has metastatic breast cancer. Her parents live 750 miles away and have only been able to visit twice since her initial diagnosis 14 months ago. The progression of her disease has forced the client to consider high-dose chemotherapy. She is concerned about her children's welfare during the treatment. When assessing the client's present support systems, the nurse will be most concerned about the potential problems with: a) Denial as a primary coping mechanism. b) Support systems and coping strategies. c) Decision-making abilities. d) Transportation and money for the boys.

b) Support systems and coping strategies.

Communicating with parents and children about health care has become increasingly significant because: a) Consumers of health care cannot keep up with rapid advances in science. b) The influence of the media and specialization have increased the complexity of managing health. c) Nurse educators have recognized the value of communication. d) Clients are more demanding that their rights be respected.

b) The influence of the media and specialization have increased the complexity of managing health.

After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence of which of the following complications related to pelvic surgery? a) Peritonitis. b) Thrombophlebitis. c) Ascites. d) Inguinal hernia.

b) Thrombophlebitis.

After surgery to treat a hip fracture, a client returns from the postanesthesia care unit to the medical-surgical unit. Postoperatively, how should the nurse position the client? a) With the affected hip flexed acutely b) With the leg on the affected side abducted<> c) With the leg on the affected side adducted>< d) With the affected hip rotated externally

b) With the leg on the affected side abducted<>

The major goal of therapy in crisis intervention is to: a) withdraw from the stress. b) resolve the immediate problem. c) decrease anxiety. d) provide documentation of events.

b) resolve the immediate problem.

The family of an older adult wants their mother to have counseling for depression. During the initial nursing assessment, the client denies the need for counseling. Which of the following comments by the client supports the fact that the client may not need counseling? a) "My doctor just put me on an antidepressant, and I'll be fine in a week or so." b) "My daughter sent me here. She's mad because I don't have the energy to take care of my grandkids." c) "Since I've gotten over the death of my husband, I've had more energy and been more active than before he died." d) "My son got worried because I made this silly comment about wanting to be with my husband in heaven."

c) "Since I've gotten over the death of my husband, I've had more energy and been more active than before he died."

A health care provider orders 0.5 mg of protamine sulfate for a client who is showing signs of bleeding after receiving a 100-unit dose of heparin. The nurse should expect the effects of the protamine sulfate to be noted in which of the following time frames? a) 5 minutes. b) 10 minutes. c) 20 minutes. d) 30 minutes.

c) 20 minutes.

The American Cancer Society recommends routine screening to detect colorectal cancer. Which screening test for colorectal cancer should a nurse recommend? a) Carcinoembryonic antigen (CEA) test after age 50 b) Proctosigmoidoscopy after age 30 c) Annual digital examination after age 40 d) Barium enema after age 20

c) Annual digital examination after age 40

During rounds, a nurse finds that a client with hemiplegia has fallen from the bed because the nursing assistant failed to raise the side rails after giving a back massage. The nurse assists the client to the bed and assesses for injury. As per agency policies, the nurse fills out an incident report. Which of the following activities should the nurse perform after finishing the incident report? a) Attach a copy to the client's records. b) Highlight the mistake in the client's records. c) Include the time and date of the incident. d) Mention the name of the nursing assistant in the client records.

c) Include the time and date of the incident.

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? a) Shock b) Encephalitis c) Increased intracranial pressure (ICP) d) Status epilepticus

c) Increased intracranial pressure (ICP)

According to Erikson's psychosocial theory of development, an 8-year-old child would be in which stage? a) Trust versus mistrust b) Initiative versus guilt c) Industry versus inferiority. d) Identity versus role confusion

c) Industry versus inferiority

Which medication is considered safe during pregnancy? a) Aspirin b) Magnesium hydroxide c) Insulin d) Oral antidiabetic agents

c) Insulin

An 8-year-old child is suspected of having meningitis. Signs of meningitis include: a) Cullen's sign. b) Koplik's spots. c) Kernig's sign. d) Chvostek's sign.

c) Kernig's sign.

An 18-year-old high school senior wishes to obtain birth control through her parents' insurance but does not want the information disclosed. The nurse tells the client that under the Health Information Portability and Accountability Act (HIPAA) parents: a) Have the right to review a minor's medical records until high school graduation. b) Have the right to review a minor's medical record if they are responsible for the payment. c) May not view the medical record, but may learn of the visit through the insurance bill. d) May not view the minor's medical record or the insurance bill.

c) May not view the medical record, but may learn of the visit through the insurance bill.

The physician ordered I.V. naloxone (Narcan) to reverse the respiratory depression from morphine administration. After administration of the naloxone the nurse should: a) Check respirations in 5 minutes because naloxone is immediately effective in relieving respiratory depression. b) Check respirations in 30 minutes because the effects of morphine will have worn off by then. c) Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone. d) Monitor respirations each time the client receives morphine sulfate 10 mg I.M

c) Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone

A client has been diagnosed with degenerative joint disease (osteoarthritis) of the left hip. Which of the following factors in the client's history would most likely increase the joint symptoms of osteoarthritis? a) A long history of smoking. b) Excessive alcohol use. c) Obesity. d) Emotional stress.

c) Obesity.

The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to: a) Keep their home warmer than usual. b) Encourage plenty of outdoor activities. c) Promote interactions with one friend instead of groups. d) Limit bathing to prevent skin irritation.

c) Promote interactions with one friend instead of groups.

A client who is undergoing radiation therapy develops mucositis. Which of the following interventions should be included in the client's plan of care? a) Increase mouth care to twice per shift. b) Provide the client with hot tea to drink. c) Promote regular flossing of teeth. d) Use half-strength hydrogen peroxide on mouth ulcers

c) Promote regular flossing of teeth.

A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38 weeks and gives birth. Which priority intervention should be included in the care plan for the neonate during his first 24 hours? a) Administer insulin subcutaneously. b) Administer a bolus of glucose I.V. c) Provide frequent early feedings with formula. d) Avoid oral feedings.

c) Provide frequent early feedings with formula.

Which of the following alert the nurse to possible internal bleeding in a client who has undergone pulmonary lobectomy 2 days ago? a) Increased blood pressure and decreased pulse and respiratory rates. b) Sanguineous drainage from the chest tube at a rate of 50 ml/hour during the past 3 hours. c) Restlessness and shortness of breath. d) Urine output of 180 ml during the past 3 hours.

c) Restlessness and shortness of breath.

The nurse walks into a client's room to administer the 9:00 a.m. medications and notices that the client is in an awkward position in bed. What is the nurse's first action? a) Ask the client his name. b) Check the client's name band. c) Straighten the client's pillow behind his back. d) Give the client his medications.

c) Straighten the client's pillow behind his back.

Before an incisional cholecystectomy is performed, the nurse instructs the client in the correct use of an incentive spirometer. Why is incentive spirometry essential after surgery in the upper abdominal area? a) The client will be maintained on bed rest for several days. b) Ambulation is restricted by the presence of drainage tubes. c) The operative incision is near the diaphragm. d) The presence of a nasogastric tube inhibits deep breathing.

c) The operative incision is near the diaphragm.

Before preparing a client for surgery, the nurse assists in developing a teaching plan. What is the primary purpose of preoperative teaching? a) To determine whether the client is psychologically ready for surgery b) To express concerns to the client about the surgery c) To reduce the risk of postoperative complications d) To explain the risks associated with the surgery and obtain informed consent

c) To reduce the risk of postoperative complications

A newborn admitted with pyloric stenosis is lethargic and has poor skin turgor. The primary care provider has ordered I.V. fluids of dextrose water with sodium and potassium. The baby's admission potassium level is 3.4Meq/ L. The nurse should: a) Notify the primary care provider. b) Administer the ordered fluids. c) Verify that the infant has urinated. d) Have the potassium level redrawn.

c) Verify that the infant has urinated.

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The primary health care provider is notified because the nurse suspects which of the following? a) Phimosis. b) Hydrocele. c) Epispadias. d) Hypospadias

d) Hypospadias

A client with a history of polysubstance abuse is admitted to the facility. He complains of nausea and vomiting 24 hours after admission. The nurse who assesses the client notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through withdrawal from which substance? a) Alcohol b) Cannabis c) Cocaine d) Opioids

d) Opioids

A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse anticipates that the physician will order which laboratory test? a) Total iron-binding capacity b) Hemoglobin (Hb) c) Total protein d) Sweat test

c) Total protein Reason: The nurse anticipates the physician will order a total protein test because negative nitrogen balance may result from inadequate protein intake. Measuring total iron-binding capacity and Hb levels would help detect iron deficiency anemia, not a negative nitrogen balance. The sweat test helps diagnose cystic fibrosis, not a negative nitrogen balance.

The client is taking risperidone (Risperdal) to treat the positive and negative symptoms of schizophrenia. Improvement of which of the following negative symptoms indicate the drug is effective? a) Abnormal thought form. b) Hallucinations and delusions. c) Bizarre behavior. d) Asocial behavior and anergia.

d) Asocial behavior and anergia.

A client with type 1 diabetes must undergo bowel resection in the morning. How should the nurse proceed while caring for him on the morning of surgery? a) Administer half of the client's typical morning insulin dose as ordered. b) Administer an oral antidiabetic agent as ordered. c) Administer an I.V. insulin infusion as ordered. d) Administer the client's normal daily dose of insulin as ordered.

a) Administer half of the client's typical morning insulin dose as ordered

A client with a bleeding ulcer is vomiting bright red blood. The nurse should assess the client for which of the following indicators of early shock? a) Tachycardia. b) Dry, flushed skin. c) Increased urine output. d) Loss of consciousness.

a) Tachycardia.

A pregnant client in her third trimester is started on chlorpromazine (Thorazine) 25 mg four times daily. Which of the following instructions is most important for the nurse to include in the client's teaching plan? a) "Don't drive because there's a possibility of seizures occurring." b) "Avoid going out in the sun without a sunscreen with a sun protection factor of 25." c) "Stop the medication immediately if constipation occurs." d) "Tell your doctor if you experience an increase in blood pressure."

b) "Avoid going out in the sun without a sunscreen with a sun protection factor of 25."

Before discharge, which instruction should a nurse give to a client receiving digoxin (Lanoxin)? a) "Take an extra dose of digoxin if you miss one dose." b) "Call the physician if your heart rate is above 90 beats/minute." c) "Call the physician if your pulse drops below 80 beats/minute." d) "Take digoxin with meals."

b) "Call the physician if your heart rate is above 90 beats/minute."

A nurse is assessing a client's pulse. Which pulse feature should the nurse document? a) Timing in the cycle b) Amplitude c) Pitch d) Intensity

b) Amplitude

A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position? a) Head of the bed elevated 45 degrees b) Prone c) Supine with feet raised d) Supine with the head lower than the trunk

a) Head of the bed elevated 45 degrees

Which of the following is an early symptom of glaucoma? a) Hazy vision. b) Loss of central vision. c) Blurred or "sooty" vision. d) Impaired peripheral vision.

d) Impaired peripheral vision.

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis? a) The client sees his physician for a check-up yearly. b) The client has never traveled outside of the country. c) The client had a liver transplant 2 years ago. d) The client works in a health care insurance office.

c) The client had a liver transplant 2 years ago.

A parent asks the nurse about head lice (pediculosis capitis) infestation during a visit to the clinic. Which of the following symptoms should the nurse tell the parent is most common in a child infected with head lice? a) Itching of the scalp. b) Scaling of the scalp. c) Serous weeping on the scalp surface. d) Pinpoint hemorrhagic spots on the scalp surface

a) Itching of the scalp

When caring for a client after a closed renal biopsy, the nurse should? a) Maintain the client on strict bed rest in a supine position for 6 hours. b) Insert an indwelling catheter to monitor urine output. c) Apply a sandbag to the biopsy site to prevent bleeding. d) Administer I.V. opioid medications to promote comfort.

a) Maintain the client on strict bed rest in a supine position for 6 hours.

Compared to the food requirements of preschoolers and adolescents, the food requirements of school-age children are not as great because these children have a lower: a) Growth rate. b) Metabolic rate. c) Level of activity. d) Hormonal secretion rate.

a) Growth rate.

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should: a) provide instructions on eye patching. b) assess the client's visual acuity. c) demonstrate eyedrop instillation. d) teach about intraocular lens cleaning.

c) demonstrate eyedrop instillation.

On initial assessment of a 7-year-old child with rheumatic fever, which of the following would require contacting the primary care provider immediately? a) Heart rate of 150 beats/minute. b) Swollen and painful knee joints. c) Twitching in the extremities. d) Red rash on the trunk.

a) Heart rate of 150 beats/minute.

During assessment of a small infant admitted with a diagnosis of meningitis, the infant becomes less responsive to stimuli and exhibits bradycardia, slight hypertension, irregular respirations, and a temperature of 103.2° F (39.6° C). The infant's fontanel is more tense than at the last assessment. What should the nurse do first? a) Ask another nurse to verify the findings. b) Notify the primary care provider of the findings. c) Raise the head of the bed. d) Administer an antipyretic.

c) Raise the head of the bed.

A client with a tentative diagnosis of psychosis is admitted to the psychiatric unit. A physician orders the phenothiazine thioridazine 50 mg by mouth three times per day. Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing: a) deeper sleep than CNS depressants. b) greater sedation than CNS depressants. c) a calming effect from which the client is easily aroused. d) more prolonged sedative effects, making the client more difficult to arouse.

c) a calming effect from which the client is easily aroused

A client with major depression sleeps 18 to 20 hours per day, shows no interest in activities he previously enjoyed and reports a 17-lb (7.7-kg) weight loss over the past month. Because this is the client's first hospitalization, the physician is most likely to order: a) phenelzine (Nardil). b) thiothixene (Navane). c) nortriptyline (Pamelor). d) trifluoperazine (Stelazine).

c) nortriptyline (Pamelor).

On the second postpartum day a gravida 6, para 5 complains of intermittent abdominal cramping. The nurse should assess for: a) endometritis. b) postpartum hemorrhage. c) subinvolution. d) afterpains.

d) afterpains.

The nurse is assessing a client's testes. Which of the following findings indicate the testes are normal? a) Soft. b) Egg-shaped c) Spongy. d) Lumpy.

b) Egg-shaped

A client is experiencing an early postpartum hemorrhage. Which item in the client's care plan requires revision? a) Inserting an indwelling urinary catheter b) Fundal massage c) Administration of oxytocics d) Pad count

d) Pad count

Which of the following laboratory findings is present in nephrotic syndrome? a) Decreased total serum protein. b) Hypercalcemia. c) Hyperglycemia. d) Decreased hematocrit.

a) Decreased total serum protein.

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? a) Endotracheal suctioning b) Encouragement of coughing c) Use of a cooling blanket d) Incentive spirometry

a) Endotracheal suctioning

Which of the following client statements indicates that the client with hepatitis B understands discharge teaching? a) "I will not drink alcohol for at least 1 year." b) "I must avoid sexual intercourse." c) "I should be able to resume normal activity in a week or two. d) "Because hepatitis B is a chronic disease, I know I will always be jaundiced."

a) "I will not drink alcohol for at least 1 year."

The wife of a 67-year-old client who has been taking imipramine (Tofranil) for 3 days asks the nurse why her husband isn't better. The nurse should tell the wife: a) "It takes 2 to 4 weeks before the full therapeutic effects are experienced." b) "Your husband may need an increase in dosage." c) "A different antidepressant may be necessary." d) "It can take 6 weeks to see if the medication will help your husband."

a) "It takes 2 to 4 weeks before the full therapeutic effects are experienced."

A primiparous woman has recently delivered a term infant. Priority teaching for the patient includes information on: a) Sudden infant death syndrome (SIDS) b) Breastfeeding c) Infant bathing d) Infant sleep-wake cycles

b) Breastfeeding

When developing a care plan for a client with a do-not-resuscitate (DNR) order, a nurse should: a) withhold food and fluids. b) discontinue pain medications. c) ensure access to spiritual care providers upon the client's request. d) always make the DNR client the last in prioritization of clients.

c) ensure access to spiritual care providers upon the client's request.

A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for: a) nausea and vomiting. b) dyspnea and cyanosis. c) fatigue and weakness. d) thrush and circumoral pallor.

c) fatigue and weakness.

Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that suggests necrotizing fasciitis is: a) erythema. b) leukocytosis. c) pressurelike pain. d) swelling.

c) pressurelike pain

Which of the following should the nurse use to determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Deficient fluid volume related to passage of profuse amounts of watery diarrhea? a) Moist mucous membranes. b) Passage of a soft, formed stool. c) Absence of diarrhea for a 4-hour period. d) Ability to tolerate intravenous fluids well.

a) Moist mucous membranes.

Before cataract surgery, the nurse is to instill several types of eye drops. The surgeon writes orders for 5 gtts of antibiotic in OD, and 3 drops of topical steroid drops in OD. The nurse should: a) Contact the surgeon to rewrite the order. b) Administer the antibiotic in the left eye and the steroid in the right eye. c) Administer both types of drops in the right eye. d) Contact the pharmacist for clarification of the order.

a) Contact the surgeon to rewrite the order.

Which of the following laboratory findings is present in nephrotic syndrome? a) Decreased total serum protein. b) Hypercalcemia. c) Hyperglycemia. d) Decreased hematocrit.

a) Decreased total serum protein

The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client finding indicates a problem at this time? a) Firm fundus at the symphysis. b) White, thick vaginal discharge. c) Striae that are silver in color. d) Soft breasts without milk.

a) Firm fundus at the symphysis.

While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. Which of the following should the nurse do next? a) Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. b) Ask the client to assume a side-lying position with the knees flexed. c) Perform massage vigorously at the level of the umbilicus if the fundus feels boggy. d) Place the client on a bedpan in case the uterine palpation stimulates the client to void.

a) Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.

A 10-year-old child diagnosed with acute glomerulonephritis is admitted to the pediatric unit. The nurse should ensure that which action is a part of the child's care? a) Taking vital signs every 4 hours and obtaining daily weight b) Obtaining a blood sample for electrolyte analysis every morning c) Checking every urine specimen for protein and specific gravity d) Ensuring that the child has accurate intake and output and eats a high-protein diet

a) Taking vital signs every 4 hours and obtaining daily weight

A client with obsessive-compulsive disorder may use reaction formation as a defense mechanism to cope with anxiety and stress. What typically occurs in reaction formation? a) The client assumes an attitude that contradicts an impulse he harbors. b) The client believes his thoughts can control other people and events. c) The client persistently thinks and talks about a particular idea or subject. d) The client uses a specific act to negate a previous act

a) The client assumes an attitude that contradicts an impulse he harbors.

A client is irritable and hostile. He becomes agitated and verbally lashes out when his personal needs are not immediately met by the staff. When the client's request for a pass is refused by the primary care provider, he utters a stream of profanities. Which of the following statements best describes the client's behavior? a) The client's anger is not intended personally. b) The client's anger is a reliable sign of serious pathology. c) The client's anger is an intended attack on the primary care provider's skills d) The client's anger is a sign that his condition is improving.

a) The client's anger is not intended personally.

A nurse is caring for a family whose infant has anencephaly. The most appropriate nursing intervention is to: a) help the family prepare for the infant's imminent death. b) implement measures to facilitate the attachment process. c) provide emotional support so the family can adjust to the birth of an infant with health problems. d) prepare the family for the extensive surgical procedures the infant will require.

a) help the family prepare for the infant's imminent death.

Of the following findings in the client's history, which would be the least likely to have predisposed the client to renal calculi? a) Having had several urinary tract infections in the past 2 years. b) Having taken large doses of vitamin C over the past several years. c) Drinking less than the recommended amount of milk. d) Having been on prolonged bed rest after an accident the previous year.

c) Drinking less than the recommended amount of milk.

A nurse is developing a nursing diagnosis for a client. Which information should she include? a) Actions to achieve goals b) Expected outcomes c) Factors influencing the client's problem d) Nursing history

c) Factors influencing the client's problem

Nurses teach infant care and safety classes to assist parents in appropriately preparing to take their neonates home. Which statement about automobile restraints for infants is correct? a) An infant should ride in a front-facing car seat until he weighs 20 lb (9.1 kg) and is 1 year old. b) An infant should ride in a rear-facing car seat until he weighs 25 lb (11.3 kg) or is 1 year old. c) An infant should ride in a front-facing car seat until he weighs 30 lb (13.6 kg) or is 2 years old. d) An infant should ride in a rear-facing car seat until he weighs 20 lb and is 1 year old.

d) An infant should ride in a rear-facing car seat until he weighs 20 lb and is 1 year old.

During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. Which of the following should the nurse do first? a) Start mouth-to-mouth resuscitation. b) Contact the neonatal resuscitation team. c) Raise the neonate's head and pat the back gently. d) Clear the neonate's airway with suction or gravity.

d) Clear the neonate's airway with suction or gravity.

After teaching the parents of an 18-month-old who was treated for a foreign body obstruction about the three cardinal signs indicative of choking, the nurse determines that the teaching has been successful when the parents state that a child is choking when he or she cannot speak, turns blue, and does which of the following? a) Vomits. b) Gasps. c) Gags. d) Collapses.

d) Collapses.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? a) Nausea or vomiting b) Abdominal pain or diarrhea c) Hallucinations or tinnitus d) Light-headedness or paresthesia

d) Light-headedness or paresthesia

Which condition or characteristic is related to the cluster of symptoms associated with disorganized schizophrenia? a) Odd beliefs b) Flat affect c) Waxy flexibility d) Systematized delusions

b) Flat affect

A nurse is teaching a client with diabetes mellitus about self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every: a) 10 g of carbohydrates. b) 15 g of carbohydrates. c) 20 g of carbohydrates. d) 25 g of carbohydrates.

b) 15 g of carbohydrates.

During the health history interview, which of the following strategies is the most effective for the nurse to use to help clients take an active role in their health care? a) Ask clients to complete a questionnaire. b) Provide clients with written instructions. c) Ask clients for their description of events and for their views concerning past medical care. d) Ask clients if they have any questions.

c) Ask clients for their description of events and for their views concerning past medical care.

A nurse should monitor a client receiving lidocaine (Xylocaine) for toxicity. Which signs or symptoms in a client suggest lidocaine toxicity? a) Nausea and vomiting b) Pupillary changes c) Confusion and restlessness. d) Hypertension

c) Confusion and restlessness

A client in the triage area who is at 19 weeks' gestation states that she has not felt her baby move in the past week and no fetal heart tones are found. While evaluating this client, the nurse identifies her as being at the highest risk for developing which problem? a) Abruptio placentae. b) Placenta previa. c) Disseminated intravascular coagulation. d) Threatened abortion.

c) Disseminated intravascular coagulation.

The nurse is assessing the urine of a client who has had an ileal conduit and notes that the urine is yellow with a moderate amount of mucus. Based on these data, the nurse should? a) Change the appliance bag. b) Notify the physician. c) Obtain a urine specimen for culture. d) Encourage a high fluid intake.

d) Encourage a high fluid intake.

A 75-year-old client is newly diagnosed with diabetes. The nurse is instructing him about blood glucose testing. After the session, the client states, "I can't be expected to remember all this stuff." The nurse should recognize this response as most likely related to which of the following? a) Moderate to severe anxiety. b) Disinterest in the illness. c) Early-onset dementia. d) Normal reaction to learning a new skill.

a) Moderate to severe anxiety.

A group of nurses has established a focus group and pilot study to examine the potential application of personal data assistants (PDAs) in bedside care. This study is a tangible application of: a) Nursing informatics. b) Electronic medical records. c) Telemedicine. d) Computerized documentation

a) Nursing informatics.

The nurse should assess the client who is taking risperidone (Risperdal) 1 mg, orally twice a day for: a) Insomnia. b) Headache. c) Anxiety. d) Orthostatic hypotension.

d) Orthostatic hypotension.

A client is scheduled for an excretory urography at 10 a.m. An order directs the nurse to insert a saline lock I.V. device at 9:30 a.m.. The client requests a local anesthetic for the I.V. procedure and the physician orders lidocaine-prilocaine cream (EMLA cream). The nurse should apply the cream at: a) 7:30 a.m. b) 8:30 a.m. c) 9 a.m. d) 9:30 a.m.

a) 7:30 a.m.

A nurse is performing a baseline assessment of a client's skin integrity. What is the priority assessment parameter? a) Family history of pressure ulcers b) Presence of pressure ulcers on the client c) Potential areas of pressure ulcer development d) Overall risk of developing pressure ulcers

d) Overall risk of developing pressure ulcers

A home health nurse who sees a client with diverticulitis is evaluating teaching about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching? a) "I'll increase my intake of protein during exacerbations." b) "I should increase my intake of fresh fruits and vegetables during remissions." c) "I'll snack on nuts, olives, and popcorn during flare-ups." d) "I'll incorporate foods rich in omega-3 fatty acids into my diet."

b) "I should increase my intake of fresh fruits and vegetables during remissions."

A client with an incomplete small-bowel obstruction is to be treated with a Cantor tube. Which of the following measures would most likely be included in the client's care once the Cantor tube has passed into the duodenum? a) Maintain bed rest with bathroom privileges. b) Advance the tube 2 to 4 inches at specified times. c) Avoid frequent mouth care. d) Provide ice chips for the client to suck.

b) Advance the tube 2 to 4 inches at specified times.

A client with a tracheostomy tube coughs and dislodges the tracheostomy tube. The nurse's first action should be to: a) Call for emergency assistance. b) Attempt reinsertion of tracheostomy tube. c) Position the client in semi-Fowler's position with the neck hyperextended. d) Insert the obturator into the stoma to reestablish the airway.

b) Attempt reinsertion of tracheostomy tube.

A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), the physician orders diagnostic testing of the vaginal discharge. Which STD must be reported to the public health department? a) Bacterial vaginitis b) Gonorrhea c) Genital herpes d) Human papillomavirus (HPV)

b) Gonorrhea

A nurse is monitoring a client receiving tranylcypromine sulfate (Parnate). Which serious adverse reaction can occur with high dosages of this monoamine oxidase (MAO) inhibitor? a) Hypotensive episodes b) Hypertensive crisis c) Muscle flaccidity d) Hypoglycemia

b) Hypertensive crisis

A 4-year-old boy presents to the emergency department. His father tearfully reports that he was in the driveway and had his son on his shoulders when the child began to fall. The father grabbed him by the leg, swinging him toward the grass to avoid landing on the pavement. As the father swung his son, the child hit his head on the driveway and twisted his right leg. After a complete examination, it is determined that the child has a skull fracture and a spiral fracture of the femur. Which of the following actions should the nurse take? a) Restrict the father's visitation. b) Notify the police immediately. c) Refer the father for parenting classes. d) Record the father's story in the chart.

d) Record the father's story in the chart.

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

d) The client will receive medication to relieve pain.