NCLEX Questions

A client was admitted to the unit during the night shift with chronic hypertension. At 0830, the unlicensed assistive personnel (UAP) reports that the client's blood pressure is 198/94 mm Hg. What would be the best action for the charge nurse to delegate at this time?

1. Ask a nursing student to put the client back in bed immediately. 2. Tell the UAP to take the BP in the opposite arm in 15 minutes. 3. Have the staff RN administer the 0900 furosemide and enalapril now. 4. Ask the LPN/LVN to assess the client for pain. 3

A client has been admitted with advanced cirrhosis. The nurse's assessment reveals an abdominal girth increase of 5 inches (12.7 cm) and a weight increase of 6 lbs. (2.72 kg) since yesterday's measurements. Based on this data, what would be the nurse's priority assessment?

1. Stool for occult blood 2. Ammonia blood level 3. Blood pressure 4. Level of consciousness 3

A client diagnosed with celiac disease has been prescribed a gluten-free diet. Which meal, if chosen by the client, would indicate to the nurse that the client understands this diet?

1. Poached egg and pancakes 2. Meatloaf and mash potatoes 3. Grilled catfish with mixed vegetables 4. Spaghetti and meatballs 3

A client is admitted with a hip fracture after falling. Based on these lab values, what is the nurse's priority nursing intervention? Na+ 147 mEq/L (147 mmol/L) Specific gravity 1.030 Hct 55%

1. Provide foods high in iron 2. Increase fluid intake 3. Obtain a urine for culture 4. Measure intake and output 2

Which signs and symptoms experienced by the client correlate with chronic renal failure diagnosis?

Select All 1. Fatigue 2. Anorexia 3. Dark skin pigmentation 4. Swollen extremities 5. Hypocalcemia 1,2,4,5

What potential contributing factors for transient urinary incontinence should a nurse assess for in an elderly female client?

Select All 1. Fecal impaction 2. Use of a diuretic 3. Diabetic 4. Urinary retention 5. Vaginitis 1,2,3,5

Which infant in the newborn nursery requires an immediate intervention by the nurse?

1. Four hours old, who has passed a small meconium stool. 2. Three hours old, who is having tremors. 3. Two hours old, who has several episodes of apnea lasting 10 seconds. 4. One hour old, who has acrocyanosis. 2

A client has been prescribed levothyroxine sodium. What should the nurse teach the client about this medication?

Select All 1. Therapy will last six month to one year. 2. Notify the primary healthcare provider for heart rate less than 60/minute. 3. Take medication ½ hour before breakfast. 4. Do not take medication with calcium supplements. 5. Improvement of symptoms will occur within days. 3,4

The client asks the nurse what the primary healthcare provider means when he says that she has right sided heart failure. What should the nurse include in the teaching plan?

Select All 1. There is a backup of blood in the right upper chamber of the heart. 2. There is swelling of lower extremities. 3. The heart rate decreases. 4. You may experience fatigue and depression. 5. You may experience nausea and loss of appetite. 1,2,4,5

A nurse is caring for a client with a suspected MI. What lab work or diagnostics does the nurse anticipate the primary healthcare provider will prescribe to specifically confirm the diagnosis?

Select All 1. ECG 2. Troponin Level 3. Blood Glucose 4. Metabolic Panel 5. CPK-MB 6. CPK-BB 1,2,5

A nurse is attempting to help a client who has self-care difficulty due to left sided paralysis. Which interventions should the nurse plan to include?

Select All 1. Provide the client with a button hook for dressing 2. Have the client wear slip-on shoes 3. Have client comb own hair 4. Offer to take the client to the toilet every 1-2 hours 5. Identify preferences for personal care items and food 6. Have client pivot on left foot to sit in chair placed on right side parallel to the bed. 1,2,3,4,5

A client is being treated for fluid volume deficit with D5W, oral hydration, and management of viral symptoms. Which client data would indicate to the nurse that treatment has been successful?

Select All 1. BP 104/70 lying; 94/68 standing. 2. Moist mucous membranes. 3. Skin turgor recoil below clavicle is 3 seconds. 4. Urine specific gravity of 1.032 5. Serum sodium 152 mEq (152 mmol/L) 1,2

What medications should the nurse anticipate the primary healthcare provider may prescribe for the client with advanced cirrhosis and bleeding esophageal varices?

Select All 1. Oxygen 2. Clopidogrel 3. Pantoprazole 4. Octreotide 5. Lactulose 1,4,5

Following escharotomy of a circumferential burn to the arm, which assessment is the best indicator when evaluating the effectiveness of this procedure?

1. Absence of pain in the extremity. 2. Prompt capillary refill after blanching. 3. Bleeding at the site of the incision. 4. Ability of the client to wiggle his/her fingers. 2

What is the primary electrolyte imbalance that the nurse should monitor for in a client who is receiving an insulin infusion?

1. Hypernatremia 2. Hypokalemia 3. Hypocalcemia 4. hypophosphatemia 2

A nurse is caring for four pediatric clients. In what order should the nurse attend these clients? Prioritize the clients by placing them in order from first to last.

4 year old child with intravenous heparin infusing at a maintenance rate 12 month old child who is due for an inhalation treatment of ribavirin 10 year old child who has been prescribed intravenous cefoxitin 7 year old child needing a consultation with a certified diabetic educator

A client is admitted to an ED after sustaining a head injury in a motor vehicle crash. The client opens eyes and moans as pressure is applied to the nail bed of fingers and then pulls hand away. Based on this information, what Glasgow Coma Scale score should a nurse document for this client? Category Score Response Eye Opening 4 Spontaneous 3 To speech 2 To pain 1 None Verbal Response 5 Oriented 4 Confused 3 Inappropriate words 2 Incomprehensible 1 None Best Motor Response 6 Obeys commands 5 Localizes to pain 4 Withdraws from pain 3 Abnormal flexion 2 Extension 1 None

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In what order should the triage nurse send the following clients into the emergency department for treatment? Place in order from first to last.

Client who has a respiratory rate of 28/min and end-expiratory wheezes noted on auscultation. Client reporting continuing angina after taking three doses of nitroglycerin. Client who has soaked a towel with blood from a thigh laceration. Client with a BP of 92/52. Client with right sided hemiparesis and a BP of 150/88.

A nurse is caring for a client that is lethargic and has the following ABGs: pH = 7.32, PaCO2 = 48, HCO3 = 28, O2 = 93%. What medication could contribute to these blood gases?

Select All 1. Fentanyl 2. Bumetanide 3. Prednisone 4. Promethazine 5. Lorazepam 6. Famotidine 1,4,5

A mother brings her 6 week old infant to the ED and reports that the baby isn't gaining weight, and has not wet a diaper in 12 hours. The baby vomits after every feeding. Which nursing interventions would help this infant?

Select All 1. Upright position with feedings and at night 2. Small frequent feedings that are thickened 3. Supine position for sleeping 4. Administration of H2 blockers 5. Give Pedialyte only until vomiting stops 1,2,4

What signs and symptoms of ovarian cancer should a nurse include when educating women?

Select All 1. Urinary frequency. 2. Menorrhagia with breast tenderness. 3. Watery vaginal discharge. 4. Increasing abdominal girth. 5. Fullness after a heavy meal. 1,2,4

A client has sustained burns to the upper torso, face, and neck as a result of a steam injury when a pressure cooker exploded at home. Which intervention is the nurse's priority?

1. Administer fentanyl for pain. 2. Prepare for endotracheal intubation. 3. Administer 1000mL of LR. 4. Drench immediately with running water. 2

A client is admitted to the emergency department following a motor vehicle accident (MVA). The client reports abdominal discomfort, weakness, and nausea. Vital signs: BP 88/52, HR 118/min, RR 24/ min. Which healthcare provider prescription should the nurse implement first?

1. Administer ondansetron 2 mg IV. 2. Insert a foley catheter in order to obtain hourly urinary outputs. 3. Infuse lactated ringers (LR) at 200 mL per hour. 4. Type and cross match for four units of packed red blood cells. 3

What should the nurse monitor for when caring for a client receiving an IV of 1/2 Normal Saline at 100 mL/hr?

1. Hypertension 2. Fluid volume deficit 3. Hypernatremia 4. Pulmonary edema 2

The client is being admitted for a myocardial infarction. Which assessment finding is expected?

1. Initial increase in BP and HR followed by a decrease. 2. Elevated temperature to 102 degrees F (38.89 degrees C) in the first 24 hours. 3. Pain relieved by two nitroglycerin tablets five minutes apart. 4. Myoglobin will be negative. 1

A client presents to the emergency department (ED) with tachycardia, elevated blood pressure, seizures, and a history of chronic alcoholism. Which electrolyte imbalance should be the nurse's priority concern?

1. Magnesium deficit 2. Sodium deficit 3. Potassium excess 4. Calcium excess 1

A client is admitted to the unit from the ED department. What acid base imbalance do the lab values indicate to the nurse? pH 7.48 PaCO2 38 HCO3 30

1. Metabolic alkalosis 2. Compensated metabolic alkalosis 3. Respiratory alkalosis 4. Compensated respiratory alkalosis 1

The nurse admits a client with a cspine injury to the neuro intensive care unit (ICU). The admission assessment is completed. What is the nurse's priority intervention? Client reports blurred vision and a headache rated 9/10. BP 200/110, pulse 55.

1. Monitor BP every 15 minutes 2. Loosen tight clothing 3. Elevate the head of the bed to high fowlers 4. Administer hydralazine 3

A client returns to the med surg unit after having extra corporal lithotripsy. Which assessment finding by the nurse would be the best indicator that the treatment has been effective?

1. Pain only when urinating 2. Negative urine culture 3. Increased urinary output 4. Sediment in the foley catheter bag 4

The nurse is taking care of a client that has been on TPN for 5 days. Upon entering the room, the nurse observes that the TPN has been turned off. What is the nurse's priority assessment?

1. Patency of the IV site 2. Finger stick blood glucose level 3. Check prescription order 4. Air bubbles in the IV tubing 2

The nurse assesses a diabetic client in the emergency department and notes a blood glucose of 400 mg/dL (22.2 mmol/L), muscle twitching, and an increased respiratory rate. What is the nurse's priority concern?

1. Respiratory Acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 3

A client arrives in the emergency department reporting signs and symptoms of nausea, numbness, prolonged muscle spasms, muscle twitching, and hand tremor. Current medications include furosemide 40 mg by mouth every morning. What acid/base imbalance does the nurse anticipate this client as having?

1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis 4

Based on the results of the ABGs, what imbalance does the nurse understand the client to be exhibiting? pH - 7.35 PaO2 - 95% PaCO2 - 49 HCO3 - 30

1. Respiratory acidosis compensated 2. Respiratory acidosis partially compensated 3. Metabolic acidosis compensateed 4. Metabolic acidosis paratially compensated 1

A client returns to the med-surg unit after having extracorporeal lithotripsy. Which would be the best indicator that the treatment has been effective?

1. The client is totally relieved of the pain. 2. The urine is straw colored and free of RBCs per dip stick test. 3. The urinary output has doubled since return to the unit. 4. There is sediment in the Foley catheter tubing and in the bedside drainage bag. 4

A client who comes to the emergency department (ED) reporting chest pain does not have the ability to pay for care. Which action should the nurse implement first?

1. Transfer the client by ambulance to a charity hospital. 2. Request the client sign a contract agreeing to pay the hospital bill. 3. Notify a family member to provide a deposit for care. 4. Connect client to a heart monitor. 4

The client was admitted to CCU with a diagnosis of acute coronary syndrome. Continuous cardiac monitoring has been implemented. Which assessment finding is most significant?

1. Ventricular fibrillation 2. Ventricular tachycardia 3. Premature ventricular contractions 4. ST segment depression of 0.5 mm 1

A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education was successful when a nurse selects which set of ABGs as compensated respiratory alkalosis?

1. pH - 7.4, PaCO2 - 40, HCO3 - 24 2. pH - 7.48, PaCO2 - 29, HCO3 - 22 3. pH - 7.44, PaCO2 - 30, HCO3 - 18 4. pH - 7.46, PaCO2 - 32, HCO3 - 20 3

An intravenous infusion of 0.45% normal saline is prescribed at a rate of 1000 mL in 24 hours. The tubing has a drip factor of 15. How many drops per minute (gtts/min) are delivered? Round your answer to the nearest whole number. Provide your answer using numbers and decimal points only.

10 The formula used to calculate drip rates is the total number of milliliters divided by the total number of minutes multiplied by the drip factor. In this circumstance, the minutes portion must be figured first, that is, 24 hours equals 1440 minutes. Then, dividing 1000 by 1440 equals 0.69. This is multiplied by the drip factor, which is 15. Multiplying 15 by 0.694 equals 10.4, which rounds to 10.

During the admission examination of a client diagnosed with acute pyelonephritis, what signs or symptoms would the nurse expect to find?

Select All 1. Dysuria 2. Costovertebral angle tenderness 3. Pale conjunctiva 4. Chills 5. Urinary frequency 1,2,4,5

Which information should the community health nurse include when explaining to a group of college students living in a dormitory about receiving an immune globulin (IG) injection for hepatitis A virus (HAV)?

Select All 1. Immune globulin contains antibodies that destroy the hepatitis A virus (HAV), preventing infection. 2. Immune globulin protection is permanent, so no other injection is required. 3. Common side effects of the injection include soreness and swelling around the injection site. 4. The sooner you get a shot of IG after being exposed to HAV, the greater the likelihood that infection will be prevented. 5. Crowded living environments such as dormitories place people at risk for HAV. 1,3,4,5

A client has sublingual nitroglycerin added to his medication regimen. Which statements made by this client indicates teaching has been effective?

Select All 1. "I will take this medication if I have an episode of chest pain." 2. "I will wait at least 1 hour after I take my erection agent before using Nitroglycerin." 3. "I can take up to 3 tablets every 5 minutes if my angina occurs." 4. "I know that I must put this tablet under my tongue for it to work." 5. "I will keep my medication handy, in my pants pocket." 1,4

A client who has been diagnosed with chronic venous insufficiency has received teaching regarding how to prevent venous stasis ulcerations. Which statements by the client indicate to the nurse that teaching has been effective?

Select All 1. "Stationary standing should be kept to a minimum." 2. "It is important to avoid wearing constricting clothes longer than 2 hours." 3. "Elevation of my legs should be done for 15 minutes every 4-6 hours." 4. "Protecting my legs from trauma is very important." 5. "I will wear compression stockings every day." 6. "I will elevate the foot of my bed 6 inches (15.24 cm) when I sleep." 1,4,5,6

A nurse, planning an educational seminar on chronic kidney disease, should invite the client with which medical conditions?

Select All 1. Atherosclerosis 2. Diabetes 3. Hypertension 4. Glomerulonephritis 5. Acute urinary tract infections 1,2,3,4

Standard orders on the nurse's unit include an intravenous infusion of D5 1/4 NS 1000 mL with 20 mEq (20 mmol/L) potassium chloride to run at 100 mL per hour. This IV solution would be appropriate for which clients?

Select All 1. Client diagnosed with Addison's disease. 2. Client diagnosed with hypertension. 3. Client diagnosed with chronic renal failure. 4. Client diagnosed with Cushing's disease. 5. Client diagnosed with hypokalemia. 4,5

What teaching points should the nurse include when educating a client how to prevent a venous stasis ulcer?

Select All 1. Dangle legs for 30 minutes, three times a day. 2. Perform leg exercises regularly. 3. Wear graduated compression stockings. 4. Treat itching with prescribed topical corticosteroids. 5. Minimize stationary standing. 2,3,4,5

As a member of the emergency preparedness planning team at the hospital, which action should the nurse encourage the team to implement?

Select All 1. Developing a response plan for each potential disaster. 2. Providing education to employees on the response plan. 3. Practicing the response plan on a regular basis. 4. Evaluating the hospital's level of preparedness. 5. Preparing every hospital for all the same emergencies. 2,3,4

A client was admitted two days ago in the oliguric phase of acute kidney injury (AKI). What evaluation by the nurse would indicate that treatment has been effective?

Select All 1. Fixed urine specific gravity 2. Serum K+ 4.9 mEq (4.9 mmol/L) 3. Serum Na+ 143 mEq (143 mmol/L) 4. Minimal crackles auscultated in bases of left lung 5. Urine output = 1250 mL/24 hours 2,3,5

The charge nurse recognizes that a new nurse can properly perform a linear wound dressing change on a surgical client when the new nurse performs which interventions correctly?

Select All 1. Hand hygiene is done prior to the dressing change. 2. Dressing tape is removed in the direction opposite of the hair growth. 3. The soiled dressing is discarded in a biomedical waste bag. 4. Clean gloves are donned in order to clean the wound. 5. The center of the wound is cleaned first, then the wound area farthest from the nurse, then the area closest to the nurse. 6. New sterile dressing is applied to the wound. 1,3,5,6

What should a nurse include when planning an educational program for a group of women on how to prevent a urinary tract infection (UTI)?

Select All 1. Increase daily intake to at least 9 cups (2160 mL) of water. 2. Urinate within one hour after sexual intercourse. 3. Help soothe the peritoneum using bubble baths. 4. Wipe from the anal area to the vaginal area after a bowel movement. 5. Void when the urge occurs. 1,5

A client's arterial blood gas report has arrived at the nurses' station. Based on the results what interventions are required by the nurse? pH - 7.47 PaCO2 - 29 HCO3 -23 PO2 95%.

Select All 1. Oxygen at 4 liters/min 2. Instruct slow deep breaths 3. Re-breath into a paper bag 4. Calm the client 5. Administer anxiolytic 2,3,4,5

A nurse is attempting to help a client who has self-care difficulty due to left-sided paresthesia. Which interventions should the nurse plan to include?

Select All 1. Provide the client with a button hook for dressing. 2. Encourage client to complete eating within 30 minutes. 3. Have client comb own hair. 4. Offer to take the client to the toilet every four hours. 5. Identify preferences for personal care items and food. 1,3,5

A construction worker comes into the occupational health nurse's clinic reporting chest heaviness. What additional signs and symptoms should the nurse assess for?

Select All 1. Severe headache 2. Dry, flushed skin 3. Lightheadedness 4. Dyspnea 5. Irregular pulse 3,4,5

A nurse is caring for a client who was admitted with severe dehydration due to excessive vomiting. Which data noted by the nurse validates this diagnosis?

Select All 1. Urine specific gravity - 1.036 2. Hematocrit - 53% (0.53 volume fraction) 3. Bradycardia 4. Tachypnea 5. Postural hypotension 6. Distended neck veins 1,2,4,5

What is the nurse's first priority when treating a client with a chemical burn?

1. Attach client to a cardiac monitor. 2. Apply a sterile bandage to prevent infection. 3. Rinse the area with copious amounts of water. 4. Remove the client's clothing. 3

A client is admitted for treatment of fluid volume excess. The nurse reviews the admitting lab work and the primary healthcare provider's prescriptions. Which prescription would be of concern to the nurse? Sodium 138 mEq/L Potassium 5.4 mEq/L Calcium 9.0 mg/dL Glucose 108 mg/dL Bedrest 2 gm Na diet Spironolactone 25 mg by mouth once per day KCL 20 mEq by mouth twice a day

1. Bedrest 2. 2 gm Na diet 3. Spironolactone 4. KCL 4

A client has been admitted with advanced Cirrhosis. The nurse's assessment of the abdominal girth verifies an increase in 5 inches (12.7 cm) and an increase in 6 lbs. (2.72 kg) since yesterday's measurements. Which interventions would the nurse expect to see in this client's plan of care?

Select All 1. Elevate HOB to a semi-fowlers position. 2. Provide oral hygeine before meals. 3. Turn every 2 hours. 4. Instruct about a 1200 calorie diet. 5. Monitor creatinine levels daily. 1,2,3,5

The nurse is planning care for a client with bipolar disorder in the manic phase. Which interventions are appropriate for this client?

Select All 1. Engage in a knitting class 2. Sign up for large group activities 3. Provide frequent snacks 4. Sit with client for long periods of time 5. Provide a structured schedule 6. Decrease stimulation 3,5,6

A client is admitted from the emergency department to a medical unit. What acid base imbalance do the lab values indicate? pH = 7.44 PaCO2 = 30 HCO3 = 20

1. Metabolic acidosis 2. Compensated metabolic alkalosis 3. Respiratory acidosis 4. Compensated respiratory alkalosis 4

Which client would be appropriate for the charge nurse to assign to the LPN/VN?

Select All 1. The client with a leg cast who needs neurovascular checks. 2. The client diagnosed with arthritis who needs pain medication and heat application. 3. The client reporting abdominal pain and rebound tenderness after a bicycle accident. 4. The client diagnosed with anorexia nervosa who is experiencing muscle weakness and decreased urinary output. 5. The client experiencing nausea and vomiting after receiving chemotherapy. 2,5

What teaching should the nurse provide the client regarding prevention of deep vein thrombosis when traveling by plane for a long period of time?

Select All 1. Do not cross legs longer than 15 minutes at a time. 2. Get up and move around the plane every 4 hours. 3. Wear compression stockings while traveling. 4. Move legs frequently while sitting. 5. Avoid alcohol and coffee while traveling. 3,4,5

Which signs or symptoms would a nurse expect to find in a client admitted to the hospital in the oliguric phase of acute kidney injury (AKI)?

Select All 1. Edema 2. Hypotension 3. Hyperkalemia 4. Decreased blood urea nitrogen 5. Metabolic acidosis 1,3,5

Following vaginal birth, a neonate has a large area of diffuse swelling over the left occiput that crosses the sagittal suture line. When discussing this finding with the neonate's parents, which statements by a nurse are accurate?

Select All 1. "No treatment will be required to resolve swelling." 2. "Due to the swelling, hyperbilirubinemia may occur." 3. "The swelling lies above the periosteum that covers the skull bone." 4. "Pressure on the fetal head before delivery caused the swelling." 5. "Your infant has a collection of blood under the skull bone." 1,3,4

How should the nurse interpret the ABG results of a client admitted with dehydration? pH - 7.49 PaO2 - 99% PaCO2 - 29 HCO3 - 23

1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 4

An elderly, bed-bound client receiving G-tube feedings at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway?

1. Seizure precautions 2. Monitor for signs of increased intracranial pressure 3. Orient to time, place, and person 4. Obtain vital signs q 15 minutes 1

Which assessment findings would the nurse expect in a client diagnosed with Paget's disease?

Select All 1. Severe back pain 2. Walking with a limp 3. Upper extremity grip weakness 4. A shuffled gait 5. Difficulty hearing 1,2,5

What should the nurse include in the teaching plan for a client receiving external beam radiation?

Select All 1. Small marks will be placed on the skin to mark the treatment area. 2. Lotion may be used around the treatment area to decrease dryness. 3. The radiation therapist can see, hear, and talk with you at all times during treatment. 4. Stay away from babies for 24 hours. 5. You will have to hold your breath during radiation treatment. 1,3

How should the nurse interpret this blood gas report? pH - 7.33 PaO2 - 95% PaCO2 - 28 HCO3 - 18

1. Partially compensated metabolic acidosis 2. Fully compensated metabolic acidosis 3. Partially compensated metabolic alkalosis 4. Fully compensated metabolic alkalosis 1

A client who is experiencing paranoia is very agitated with aggressive behavior and shouts at others when it is time for a group therapy session. Which action by the nurse is correct?

1. Have the client sit with you and say a prayer. 2. Explain that shouting is not allowed. 3. Redirect the client to another activity. 4. Call for assistance and put the client in seclusion. 3

The nurse is caring for a client that is 3 days post tonsillectomy and reports a 2 pound (0.91 kg) weight loss, lethargy, and frequent swallowing. What is the nurse's priority assessment?

1. Urinary Output 2. Daily weight 3. Heart rate 4. Breath sounds 3

What information about cast care should the nurse provide to the client?

Select All 1. Keep the cast uncovered until it is completely dried. 2. Use the palms of your hands to position the cast for the first 24 hours. 3. Place an ice pack on top of the cast to keep the limb from swelling. 4. Elevate the extremity on a pillow, but make sure it is not plastic. 5. Be careful not to do anything that would indent the cast. 1,2,4,5

A nurse is planning discharge education for a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which instructions should the nurse include when teaching this client?

Select All 1. Limit fluid intake. 2. Report muscle twitching. 3. Measure intake and output. 4. Perform mouth care once a day. 5. Report weight gain of 2 pound (0.9 kg) over 24 hours. 1,2,3,5

A client who has been receiving care for cirrhosis arrives to the clinic for follow-up care. Which signs and symptoms noted by the nurse would indicate that the client's condition is worsening?

Select All 1. A musty breath odor 2. Poor concentration 3. Fatigue 4. Slow movements 5. Asterixis 6. Anorexia 1,2,4,5

A confused client falls out of bed. When the nurse arrives, the side rails are up, the client has urinated on the floor, and an abrasion is noted on the client's forehead. Which information should be included in the incident report?

Select All 1. Abrasion on the client's forehead. 2. Nurse's perspective as to how the client fell. 3. Client's confused state. 4. Presence of urine on the floor. 5. Side rails were up. 1,3,4,5

Standard orders on the nurse's unit include an intravenous infusion of 1000 mL normal saline with 20 mEq (20 mmol) potassium chloride to run at 100 mL per hour. These IV fluids would be appropriate for which client diagnosis?

Select All 1. Addison's disease 2. Psychogenic polydipsia 3. Abdominal cramping 4. Graves' disease 5. Hypokalemia 3,4,5

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy for equipment needs upon discharge home for hospice care. Which equipment should the case manager obtain for this client?

Select All 1. Alternating pressure mattress 2. Hospital bed 3. Walker 4. Suction equipment 5. Oxygen 1,2,4,5

Which signs and symptoms would concern the nurse if assessed in a client post radical neck surgery?

Select All 1. Bradypnea 2. Flaccid muscle tone 3. Flushed, warm skin 4. Positive trousseau's sign 5. Dysphagia 6. Decreased deep tendon reflexes 4,5

Which client would the nurse monitor for the development of hypovolemic shock?

Select All 1. Client admitted with acute myocardial infarction. 2. Elderly client post-operative hip replacement with spinal anesthesia. 3. Client diagnosed with Addisonian crisis. 4. A 10 year old client with 40% Total body surface area (BSA) burns. 5. Client with Type 2 diabetes, who has a current blood sugar of 425 mg/dL (2.359 mmol/L) 3,4,5

A nurse is planning care for a client admitted to the unit after application of a halo apparatus to immobilize the cervical spine. What interventions should the nurse include?

Select All 1. Insert the index finger between the vest and client's skin to make sure it is not too loose. 2. Turn the client in bed every 2 hours using the log roll technique. 3. Provide a soft diet to prevent pain from chewing. 4. Assess tolerance to upright position. 5. Teach client to use eye, rather than head and neck movements, for visual scans. 6. Inspect skin under halo vest. 2,3,4,5,6

What activities would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP) caring for a client post-cholecystectomy?

Select All 1. Measuring and recording intake and output. 2. Assisting with ambulation in the hallway. 3. Reinforce information about a low fat diet. 4. Assisting with daily hygiene. 5. Measuring and recording vital signs. 6. Inserting a foley catheter. 1,2,4,5

Which statements should the nurse include when teaching a client about osteomyelitis?

Select All 1. Osteomyelitis is a risk factor for people who have chronic illnesses. 2. Activity restriction is necessary to avoid stress on the affected bone. 3. Oral antibiotics must be taken for at least 3 to 6 weeks. 4. High calcium levels may occur so report muscle weakness, anorexia, nausea and vomiting. 5. Osteomyelitis requires subcutaneous administration of calcitonin to reverse the course of the disease. 1,2

A client's absolute neutrophil count (ANC) is 750/mm3. Which measure should the nurse take to protect the client?

Select All 1. Prohibit the client from shaving. 2. Instruct the client to wear a mask when leaving the hospital room. 3. Remove fresh flowers and plants from the client's room. 4. Ask visitors to perform hand hygiene before entering the client's room. 5. Instruct client to avoid vigorous flossing of teeth. 2,3,4

The nurse is monitoring the client's heart rhythm. The monitor shows sinus tachycardia. What is expected with this assessment finding?

Select All 1. Regular rhythm 2. Rate of 101-200 3. P-wave normal 4. P-R interval not measurable 5. QRS complex normal 1,2,3,5

A client who is four days post-op cholecystectomy complains of severe abdominal pain. During the initial assessment the client states, "I have had two almost black stools today." Which nursing action is most important?

1. Start an IV with D5W at 125 mL/hr 2. Insert a nasogastric tube 3. Contact the primary healthcare provider 4. Obtain a stool specimen 3

A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure?

Elevate head of bed to Fowler's position. Measure distal NG tube from nose tip to earlobe to xiphoid process. Lubricate 2-3 inches (5.08-7.62 cm) of distal NG tube. Insert NG tube into unobstructed naris. Advance NG tube upward and backward until resistance is met. Rotate catheter and advance into nasopharynx. Have client swallow ice as NG tube advances into stomach. Secure NG tube.

A nurse is assigned to care for a client with bipolar disorder in the manic phase. Which behavior by the client would require immediate intervention by the nurse?

1. Talking rapidly, jumping from one subject to another 2. Suggestive, sexual remarks to the staff 3. Aggressive physical activity 4. Telling other clients they own the hospital 3

A client who is being evaluated for a recent head injury requests hydrocodone with acetaminophen for a headache. What response by the nurse is most appropriate?

1. "A hydrocodone and salicylate combination would probably provide better relief." 2. "Due to the impact that your head received, the healtcare provider may want to order a narcotic to be given intravenously for a more rapid relief." 3. "Acetaminophen is not recommended for clients with head injuries, but I can ask for a substitution." 4. "Hydrocodone is an opioid which is usually avoided because it could cause drowsiness and possibly prevent recognition of a worsening condition." 4

An unlicensed assistive personnel (UAP) has been assigned to take vital signs on several clients. Which instruction would be most important for the RN to provide to the UAP?

1. "Notify me if the pulse oximetry reading drops below 95% in the client who has emphysema." 2. "The client in room 210 has dizziness and faintness when standing, so I need you to obtain a blood pressure reading with the client in the lying, sitting, and standing position." 3. "The client in room 212 has a pacemaker. Let me know if the apical heart rate is greater than 70 bpm." 4. "Let me know immediately if any client has a temperature of 101. 5 degrees F (38.6 degrees C) or higher." 4

A nurse monitors the heart rates of four children on a pediatric unit. Which client requires additional assessment by the nurse?

1. 1 year old child who has a heart rate of 150 bpm and is crying 2. 2 year old child who has a heart rate of 165 bpm and is being rocked 3. 5 year old child who has a heart rate of 100 bpm and is playing quietly 4. 13 year old adolescent who has a heart rate of 90 and is watching television 2

The nurse is to administer a fluid bolus to a 25 pound (11.36 kg) child. The primary healthcare provider prescribes a bolus of 20 mL/kg.

1. 500 mL isotonic solution 2. 500 mL hypotonic solution 3. 227 mL isotonic solution 4. 227 mL hypotonic solution 3

The post-operative craniotomy client's urinary output suddenly increases to 325 mL in 30 minutes. Which nursing action takes priority?

1. Check urine specific gravity 2. Measure ICP level 3. Obtain blood pressure 4. Monitor CVP 3

Which client should the RN assess first?

1. Client experiencing unstable angina. 2. Client with chronic emphysema experiencing mild shortness of breath. 3. Client five days post right-sided cerebral vascular accident. 4. Client diagnosed with Bell's palsy scheduled to be discharged. 1

An emergency department nurse has just received report on assigned clients. Which client should the nurse assess first?

1. Client reporting back pain of 6 on a scale of 0/10 after falling down from a patch of ice. 2. Client reporting a stiff neck and has a fever of 103 ° F (39.4 ° C). 3. Client vomiting after eating at a restaurant. 4. Client with a history of migraines reporting a headache. 2

Which client would be appropriate for the charge nurse to assign to a room with a client who has undergone debulking of a tumor?

1. Client who is one day post laminectomy. 2. Client scheduled for a bone marrow transplant. 3. Client admitted with neutropenia. 4. Client being treated with intracavity radiation therapy. 1

What is the nursing priority for the client experiencing hyperparathyroidism crisis?

1. Continuous cardiac monitoring for arrhythmias. 2. Initiate fall precautions. 3. Diagnostic testing and imaging studies to find the cause. 4. Hurried preparations for emergency parathyroidectomy. 1

The nurse is caring for a client who sustained a head injury with possible seizure activity. The primary healthcare provider prescribes an EEG. Which item on the breakfast tray, delivered prior to the EEG, should the nurse remove from the tray?

1. Eggs 2. Orange juice 3. Bacon 4. Hot tea 4

A client with schizophrenic disorder begins to talk about fantasy material. What would be the most appropriate nursing action?

1. Encourage the client to focus on reality-based issues. 2. Allow the client to continue to talk so as not to interrupt the fantasy. 3. Ask the client to explain the meaning behind what he is saying. 4. Persuade the client that his thoughts are not true. 1

Which condition requires the nurse to discontinue an intravenous infusion of oxytocin to a laboring client?

1. Fetal heart rate baseline of 140-160 bpm 2. Contraction frequency of 1-1/2 minutes with a duration of 70-80 seconds 3. Maternal temperature of 101.2 degrees F (38.44 degrees C) 4. Early decelerations in the fetal heart rate 2

Which discharge referral would be a priority for the nurse to make in order to promote continuity of care for a client following a colectomy and colostomy formation due to colon cancer?

1. Home health 2. Meals on Wheels 3. Hospice care 4. Registered dietitian 1

A nurse is caring for a poorly controlled type 2 diabetic client. The client is noncompliant with diet and for the past 3 months HbA1c has been 8%. The serum glucose at this visit is 218mg/dl (12.09 mmol/L). The client is currently taking metformin and exenatide. Based on this history, what should the nurse anticipate will be the first strategy implemented to improve glucose control for this client?

1. Nutritional counseling to help improve his diet compliance 2. Addition of the alpha-glucosidase inhibitor, acarbose to his current medications 3. Client teaching for a new prescription of insulin using the basal/bolus dosing method 4. A prescription for detemir, once daily SQ 1

A 13 year old found unresponsive in the park is brought into the emergency department. The nurse sees a medical alert bracelet stating "Diabetic", and notes a fruity smell to the breath. There are no family members available to obtain consent for treatment and attempts to call them have been unsuccessful. What action should the nurse take?

1. Obtain consent from the social worker on duty in the emergency department. 2. Begin treatment by inserting two large bore IVs of normal saline. 3. Give Glucagon IM and then wait for the arrival of a parent to consent to further treatment. 4. Withhold treatment until a parent arrives to the emergency department. 2

What is priority for the client experiencing hyperparathyroid crisis?

1. Support for airway and breathing. 2. Continuous cardiac monitoring for arrhythmias. 3. Provide safety precautions. 4. Prepare for emergency tracheostomy. 1

The nurse is caring for a poorly controlled type 2 diabetic client. Lab results include a BUN of 22mg/dL (7.85 mmol/L) and a creatinine of 1.9 mg/dL (0.67 mmol/L). The nurse checks the client's blood sugar and it is 218mg/dL (12.09 mmol/L). Current medications include metformin and exenatide. What is the priority concern with this client taking metformin?

1. The metformin is not controlling his blood sugar. 2. Metformin can cause GI complaints. 3. Metformin can cause a decrease in appetite. 4. Metformin is contraindicated with an elevated creatinine level. 4

A nurse educator is teaching first responders about disaster management, and provided the following scenario: A small community has experienced a severe tornado that hit a shopping mall and caused extreme damage and suspected mass casualties and injuries. First responders arrive on the scene. The nurse educator recognizes education has been successful when the first responders identify which action as priority?

1. Triage victims and tag according to injury. 2. Assess the immediate area for electrical wires on the ground and in vicinity of victims. 3. Activate the community emergency response team. 4. Begin attending to injuries as they are encountered. 3

A small community has experienced a severe tornado that hit a shopping mall and caused extreme damage and suspected mass casualties and injuries. What should be done first?

1. Triage victims and tag according to injury. 2. Assess the immediate area for electrical wires on the ground and in vicinity of victims. 3. Activate the community emergency response team. 4. Begin attending to injuries as they are encountered. 3

The nurse is caring for a client who has been intubated and placed on a ventilator. The nurse hears the ventilator alarm and enters the client's room to find the high pressure alarm sounding. The client is very agitated with a respiratory rate of 40/min, arterial BP 98/48, oxygen saturation 82%, cardiac monitor showing sinus tachycardia at 138 bpm. What action should the nurse take first?

1. Turn off alarm, then check ventilator settings. 2. Increase FiO2 settings to 100%. 3. Hyperventilate client, then suction ET tube. 4. Auscultate lung sounds. 4

A client was admitted to CCU with a diagnosis of acute coronary syndrome. Continuous cardiac monitoring has been implemented. Which assessment finding by the nurse is most significant?

1. Ventricular fibrillation 2. Ventricular tachycardia 3. 3rd degree AV block 4. Atrial fibrillation 1

The nurse's assessment of a client post-op abdominoplasty reveals tachycardia, restlessness and shallow slow breaths. The client was medicated with morphine 2 mg for pain 1 hour ago. The primary healthcare provider prescribes arterial blood gases (ABG). Which ABG report is consistent with this clinical picture?

1. pH 7.30, PaCO2 40, HCO3 29 2. pH 7.33, PaCO2 48, HCO3 25 3. pH 7.47, PaCO2 35, HCO3 29 4. pH 7.50, PaCO2 33, HCO3 22 2

Which tasks can the RN safely delegate to an LPN/LVN when caring for a client scheduled for an adrenalectomy?

Select All 1. Check fingerstick glucose level. 2. Administer regular insulin SQ based on sliding scale prescription. 3. Assess client's cardiac rhythm. 4. Reinforce teaching regarding postoperative care. 5. Review client's pre-surgical laboratory values. 1,2,4

The nurse instructs a client diagnosed with chronic obstructive pulmonary disease (COPD) about positions to use during times of dyspnea. Which statement by the client indicates that teaching is successful?

Select All 1. "Lying on my side, propped up on three pillows is a good resting position." 2. "While sitting up, I will rest my elbows on my knees." 3. "If I become short of breath while walking, I will lean slightly forward and place my hands against the wall." 4. "I will sit up and lean over a table." 5. "Lying on my stomach will help drain secretions." 1,2,3,4

What assessment findings would the nurse expect when evaluating whether treatment has been effective for a client hospitalized with systolic heart failure?

Select All 1. 3+ pedal edema 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.9 kg) 4. Purse-lip breathing 5. Pale conjunctiva 6. Urine output at 50 mL/hr 2,3,6

Which clients would the nurse monitor for the development of hypovolemic shock?

Select All 1. 50 year old having an allergic reaction form multiple wasp stings 2. Elderly client post-operative hip replacement with spinal anesthesia 3. 40 year old in Addisonian crisis 4. 10 year old with 40% total body surface area (TBSA) burns 5. Adult with type 2 diabetes and a urinary tract infection (UTI) 3,4,5

Which clients would be appropriate for the RN to assign to the LPN/VN?

Select All 1. A client admitted for lithotripsy. 2. A client diagnosed with severe anemia. 3. A client with partial thickness burns over 35% of the body. 4. A client diagnosed with cystitis who has been prescribed antibiotics intramuscularly. 5. A client who needs enemas to decrease bacteria in the GI tract. 4,5

A client with a severe cough is suspected of having lung cancer. When preparing the client for testing to confirm a diagnosis of cancer, which tests should a nurse anticipate?

Select All 1. Chest x-ray 2. Arterial blood gas 3. Bronchoscopy 4. Pulmonary arteriogram 5. Pulmonary function test 1,3

A nurse is performing eye care for a comatose client. Which interventions should the nurse include?

Select All 1. Administer moist compresses to cover eyes every 2 hours. 2. Clean eyes with saline and cotton balls, wiping from outer to inner canthus. 3. Use a new cotton ball for each cleansing wipe. 4. Instill artificial ears into the lower eye lids as prescribed. 5. Protect the eyes with a protective shield. 6. Monitor eyes for redness, and exudate. 1,3,4,5,6

A long-term care nurse is planning care for a newly admitted client diagnosed with alzheimer's disease. What should the nurse include in the plan of care?

Select All 1. Assess client's ability to perform activities of daily living. 2. Educate nursing staff to facilitate client's independence in activities. 3. Place a clock and calendar in client's room. 4. Limit family visits to once a week. 5. Have nursing staff spend time talking and listening to client. 1,2,3,5

What should be the priority nursing actions when caring for a child following a tonsillectomy and adenoidectomy?

Select All 1. Encourage oral intake of fluids. 2. Suction the mouth and throat as needed. 3. Administer pain medication around the clock. 4. Apply ice collar to the front of the neck as needed. 5. Encourage coughing and deep breathing every two hours. 1,3,4

An occupational health nurse is planning to teach a group of manufacturing workers how to prevent back injuries. What teaching points should the nurse plan to include?

Select All 1. Assistive devices should be used when lifting greater than 50 pounds (22.72 kg). 2. When sitting, keep knees slightly lower than the hips. 3. Avoid movements that require spinal flexion with straight legs. 4. Squarely face the direction of anticipated movement. 5. Pivot to turn while holding an object. 6. Wear comfortable, low-heeled shoes. 3,4,5,6

The nurse is caring for a client with increased intracranial pressure (ICP). Which actions would increase the client's ICP?

Select All 1 . Using restraints 2. Elevating head 3. Performing Valsalva 4. Blowing nose 5. Keeping client supine 6. Suctioning 1,3,4,5,6

What should the nurse emphasize when teaching clients with chronic obstructive pulmonary disease?

Select All 1. Avoid exposure to individuals with respiratory infections. 2. Increase intake of Vitamin C. 3. Eliminate exposure to second hand smoke. 4. Maintain a healthy weight. 5. Get a yearly pneumonia vaccination. 1,2,3,4

Which clients would be appropriate for the charge nurse to assign to the LPN/VN?

Select All 1. Client admitted with exacerbation of asthma. 2. Client needing oral antibiotics for a diagnosis of gastroenteritis. 3. Client 4 hours post lobectomy. 4. Client with terminal cancer refusing pain medication. 5. Client with arthritis who needs scheduled pain medication around the clock. 6. Client who has a chronic graft versus host disease. 2,5,6

In which client should the nurse question a prescription for an oxytocin challenge test?

Select All 1. Client at 26 weeks gestation. 2. Client at 38 weeks with 4 Cesarean section deliveries. 3. Client at 38 weeks with a history of gestational diabetes. 4. Client at 37 weeks gestation. 5. Client that is 35 weeks gestation and has preeclampsia. 6. Client with a current history of placenta previa. 1,2,6

A client is admitted with arterial disease of the lower extremities. Which client teachings should the nurse initiate?

Select All 1. Elevate extremities above the level of the heart. 2. Discourage use of tobacco. 3. Protect extremities from cold exposure. 4. Assess need for stress management. 5. Avoid isometric exercise. 2,3,4

Which client instruction is important when the client is scheduled for a vanillylmandelic (VMA) test?

Select All 1. Eliminate sweets and pastries 2 to 3 days before and throughout the test. 2. A 24 hour urine specimen requires starting with an empty bladder. 3. Limit physical exercise throughout the test. 4. Avoid all commercially prepared foods for 24 hours prior to testing. 5. Add HCL acid to specimen as preservative. 1,2,3,5

The client's EEG revealed epileptiform abnormalities predictive of seizure activity and was started on valproic acid 500 mg PO twice a day. What nursing interventions should the nurse include in this client's plan of care?

Select All 1. Instruct client to report insomnia 2. Assess for abdominal pain and Grey Turner's sign 3. Monitor ALT and AST 4. Teach client not to discontinue medication abruptly 5. Administer acetaminophen 650 mg PO for mild pain 6. Obtain daily weights 2,3,4,6

Which nursing interventions will help to prevent a contracture post-operatively in a client with a below the knee amputation?

Select All 1. Keep the residual limb elevated on a pillow at all times 2. Ensure the residual limb is positioned flat on the bed 3. Position the client prone several times a day 4. Assess the client for phantom pain every 4 hours 5. Apply anti-embolism stockings to the unaffected leg 2,3

What nursing interventions should a nurse initiate for a client diagnosed with pyelonephritis?

Select All 1. Monitor for dark, cloudy, foul smelling urine. 2. Monitor intake and output. 3. Decrease fluid intake to 1 liter/day. 4. Advise that urine may turn blue with administration of nitrofurantoin. 5. Monitor for hypotension, tachycardia, and chills. 1,2,5

A nurse is assigned to care for a client diagnosed with obsessive compulsive disorder. Which interventions should be part of the treatment plan?

Select All 1. Provide a structured schedule 2. Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants should be considered 3. Discuss why the ritual is harmful for the client 4. Allow as much time as necessary for the ritual 5. Encourage relaxation techniques 1,2,5

The client reports intense headaches with increasing pain for the past month. A magnetic resonance imaging (MRI) is ordered. In reviewing the client's history, which information is of concern to the nurse?

Select All 1. Shellfish allergy 2. Has a cardiac pacemaker 3. Prescribed glimepiride every morning 4. Client is pregnant 5. History of working with metal fragments 1,2,4,5

The nurse is preparing a seminar for a group of clients diagnosed with irritable bowel syndrome. Which points should the nurse include?

Select All 1. Teach a low fiber diet to fight the constipation. 2. Emphasize the importance of eating at regular times. 3. Drink at least one 8 ounce (240 mL) glass of water with meals. 4. Become active in yoga classes for stress reduction. 5. Keep a food diary for 1 week to determine irritating foods. 2,4,5

A client is preparing to be discharged after a total hip replacement. Which client statements would indicate teaching has been successful regarding prevention of hip prosthesis dislocation?

Select All 1. "I should not cross my affected leg over my other leg." 2. "I should not bend at the waist more than 90 degrees." 3. "While lying in bed, I should not turn my affected leg inward." 4. "It is necessary to keep my knees together at all times." 5. "When I sleep, I should keep a pillow between my legs." 1,2,3,5

Which statements made by a client diagnosed with Addison's disease indicates to the nurse that the client understands fludrocortisone therapy?

Select All 1. "Taking my medicine at night will help me sleep." 2. "It is important to wear a medical alert bracelet all of the time." 3. "I will limit my sodium intake to 200 mg per day." 4. "My medication dose will change based on my daily weight." 5. "I may need more medication if I feel weak or dizzy." 2,4,5

What interventions can an occupational health nurse discuss with a client in an effort to improve lateral epicondylitis (tennis elbow) pain?

Select All 1. Avoid activities that make the pain worse. 2. The primary healthcare provider may prescribe an oral nonsteroidal anti-inflammatory drug. 3. Apply an epicondylitis strap 2 to 3 centimeters above the elbow. 4. Stretching and strengthening the muscle and tendon should be started immediately. 5. If pain persists, a cortisone injection into the inflamed area may be recommended by the healthcare provider. 6. Apply ice for 45 minutes six times a day. 1,2,5

A client is admitted with atrial fibrillation and heart failure secondary to chronic hypertension. Current medications include: Digoxin, Captopril, Carvedilol, Furosemide, and Warfarin. Based on this profile, what lab work is essential for the nurse to monitor?

Select All 1. Digoxin level 2. Potassium level 3. PT/INR 4. aPTT 5. CPK-MB 6. BNP 1,2,3,6,

After a cholecystectomy, a client experiences palpitations, weakness and diarrhea following meals. Which teachings would be appropriate for the nurse to provide the client?

Select All 1. Drink minimum fluids with meals. 2. Follow a high carbohydrate, high protein meal plan. 3. Avoid electrolyte replacement sports drinks. 4. Lie down on right side after meals. 5. Eat at least six small meals per day. 1,3,5

A client with acute pancreatitis is prescribed total parenteral nutrition (TPN), methylprednisolone, and sliding scale insulin. What is the rationale for the insulin prescribed?

Select All 1. Impaired endocrine function of the pancreas 2. Inability of the liver to convert glucose 3. Steroid therapy side effects 4. Dextrose concentration of TPN 5. Re-establish potassium concentration 1,3,4

The nurse cares for a client after a gastroscopy examination. Which nursing interventions are appropriate post-procedure?

Select All 1. Maintain NPO status until the gag reflex returns. 2. Observe for hematemesis. 3. Monitor intake and output. 4. Assess bowel elimination. 5. Monitor respirations. 6. Connect to oxygen saturation monitor. 1,2,5,6

A client at 28 weeks gestation reports swollen hands and feet during her prenatal visit. Which additional signs/symptoms would be of concern to the nurse?

Select All 1. Nasal congestion 2. Hiccoughs 3. Capillary blood glucose of 150mg/dL (8.32 mmol/L) 4. Muscle spasms 5. Headache and blurred vision 2,4,5

A nurse is assigned a client who is one day post thyroidectomy. While taking the blood pressure, the client's hand starts to tremble. On auscultation of the heart, the nurse notes an arrhythmia. What actions should the nurse take?

Select All 1. Pad the side rails 2. Monitor potassium level 3. Take blood pressure in opposite arm 4. Place trach set at bedside 5. Check for airway patency 1,4,5

Which interventions should the nurse initiate to lessen acid reflux in a client diagnosed with gastric esophageal reflux disease (GERD)?

Select All 1. Provide small, frequent meals. 2. Avoid carbonated beverages. 3. Administer omeprazole as prescribed. 4. Assist with smoking cessation. 5. Place in left lateral position for 2 hours after eating. 1,2,3,4

A client with a long standing history of diabetes presents to the emergency department (ED) with a serum blood sugar of 400 mg/dL (22.19 mmol/L). What lab values for this client are consistent with diabetic ketoacidosis (DKA)?

Select All 1. Serum sodium 140 mEq/L 2. Decreased urine specific gravity 3. Serum potassium 5.3 mEq/L 4. PaCO2 48 5. pH 7.33 2,3,5

The nurse recognizes that Rho(D)immune globulin would be indicated for which Rh negative clients?

Select All 1. Sixteen weeks gestation and has an elective abortion 2. Involved in a major car accident 3. Requires amniocentesis 4. Diagnosed with an ectopic pregnancy 5. Forty-eight hours post delivery of a term Rh positive baby 6. Twenty weeks gestatation 1,2,3,4,5

A client is admitted with abdominal pain, distention, fever, dehydration, (+) Cullen's sign and a rigid boardlike abdomen. Which interventions would help control the client's pain in the acute period?

Select All 1. Small frequent feedings 2. NG tube to low suction 3. Cimetidine 300 mg IV four times a day 4. Hydromorphone by PCA pump 5. IV isotonic solutions 2,3,4

A petite female client presents to the clinic with symptoms of back pain and states, "I think I am getting shorter." Which teachings would be appropriate for the nurse to provide?

Select All 1. Spend time in the sunlight twice a week for 5 to 30 minutes. 2. Wear rubber sole shoes for traction. 3. Walk at least 30 minutes most days. 4. Include yogurt and hard cheese in diet. 5. Take regularly scheduled prescribed corticosteroids. 1,2,3,4

A nurse is assigned to care for a client with bi-polar disorder in the manic phase. Which behavior by the client would be a concern for the nurse?

Select All 1. Tearful with poor concentration 2. Easily distracted 3. Excessive physical exercise 4. Irritable mood 5. Decreased intake of meals 3,5

A nurse is reviewing the lab values for a group of clients in a psychiatric emergency department. Which findings should be of greatest concern to the nurse? Rank each lab result from most to least important.

The client with schizoaffective disorder and a potassium level of 7.0 mEq/L (7 mmol/L The client taking clozapine and a WBC count of < 3000 mm³ (3 x 10^9/L) The client with bipolar disorder and a lithium level of 1.3 mEq/L. The client with a blood alcohol level of 0.08% (80 mg/dL)