NCLEX Review Study Guide Comprehensive
A nurse is teaching a client with angina pectoris who is being discharged from the hospital about managing chest pain at home. Which statement by the client indicates a need for further teaching?
"If I get chest pain, I should put 3 nitroglycerin tablets under my tongue and then go to the emergency department if that doesn't work."
The nurse is the first responder at the scene of a bus crash. After a quick assessment of the victims, which one does the nurse care for first?
A victim with an open fracture of the arm that is bleeding profusely
Fluticasone propionate (Advair) and albuterol (Ventolin HFA), administered by inhalation twice daily, are prescribed for a client with asthma. The nurse, providing information to the client about administration of the medication, tells the client to use the:
Albuterol several minutes before inhaling the fluticasone propionate
A Tensilon test is performed on a client with suspected myasthenia gravis. Which finding constitutes a positive result?
An increase in muscle strength
A nurse prepares to administer digoxin (Lanoxin) to a client with congestive heart failure. Which vital sign must be checked before the medication is administered?
Apical pulse
A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is off for the night and will be available in the morning. The nurse should:
Ask the answering service to contact the on-call physician
A nurse is assessing a client who has been taking amantadine hydrochloride (Symmetrel) for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication?
Bilateral lung wheezes
Oral prednisone 5 mg/day has been prescribed for a client with a chronic respiratory disorder, and the nurse provides instructions to the client about the medication. The nurse tells the client to:
Call the physician if a fever, sore throat, or muscle aches develop
A client with a medical history of diabetes mellitus is found to have sarcoidosis, and oral prednisone is prescribed. The nurse provides instructions to the client about the medication and tells the client to:
Closely monitor the blood glucose level
A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply.
Fatigue Low-grade fever
A client calls the emergency department and tells the nurse that he may have come in contact with poison ivy while trimming bushes in his yard. The nurse tells the client to immediately:
Get into the shower and rinse the skin for at least 15 minutes
A nurse is providing information to a client with diabetes insipidus who will be taking desmopressin acetate (DDAVP) by way of the nasal route. For which of the following occurrences does the nurse tell the client to contact the physician?
Headache and nausea
A nurse is providing information on the glycosylated hemoglobin assay and its purpose to a client with diabetes mellitus. The nurse tells the client that this blood test:
Helps predict the risk for the development of chronic complications of diabetes mellitus
A nurse, providing information to a client who has just been found to have diabetes mellitus, gives the client a list of symptoms of hypoglycemia. Which of the following answers by the client, on being asked to list the symptoms, tells the nurse that the client understands the information? Select all that apply.
Hunger Weakness Blurred vision
Cascara sagrada has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to the client about the medication and tells the client to:
Increase fluid intake
A client who has undergone knee-replacement surgery will be self-administering enoxaparin sodium (Lovenox) at home. The nurse teaches the client about the medication and tells the client to:
Lie down to administer the subcutaneous injection
A nurse admitting a newborn to the nursery notes that the physician has documented that the newborn has a gastroschisis. The nurse performs an assessment, expecting to note that the viscera are:
Outside the abdominal cavity, not covered with a sac
A nurse in the cardiac care unit is told that a client with a diagnosis of myocardial infarction will be admitted from the emergency department. Which item does the nurse give priority to placing at the client's bedside?
Oxygen cannula and flowmeter
A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse place the client before inserting the tube?
Fowler's position
The physician will probably withhold the aspirin until the symptoms have subsided, then resume the aspirin at a lower dosage
Notifies the emergency department physician
A male client arrives at the emergency department and reports to the nurse, "I woke up this morning and couldn't move my arms." He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow employee's hands were severed by a machine. What is the priority response by the nurse?
Assessing the client for organic causes of loss of arm movement
Alendronate (Fosamax) is prescribed for a client with postmenopausal osteoporosis. The nurse provides information on the medication to the client. When does the nurse tell the client to take the alendronate?
Every morning before breakfast, with a full glass of water
A nurse is caring for a client who is immobilized in skeletal traction after sustaining a leg fracture in a motor vehicle crash. The nurse notes that the client is restless, and the client complains of being bored. Which problem does the nurse identify on the basis of this information?
Lack of adequate diversional activity
A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician?
Reddish lochia on postpartum day 8
Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the physician with the procedure, expect to note?
Thick and opaque
An emergency department nurse is caring for a client in hypovolemic shock, a result of external hemorrhage caused by a gunshot wound. Which nursing interventions should the nurse take? Select all that apply.
-Ensuring that direct pressure is applied to the external hemorrhage site -Ensuring a patent airway and supplying oxygen to the client as prescribed -Inserting an intravenous (IV) catheter and administering fluids as prescribed
A physician writes a prescription for 1000 mL of 0.9% normal saline solution to be administered intravenously (IV) to a client over 10 hours. The drop factor for the infusion set is 15 gtt/mL. At what drip rate does the nurse set the infusion?
25 gtt/min
A nurse notes documentation in the client's medical record indicating that the client has a stage II pressure ulcer. On the basis of this information, which of the following findings does the nurse expect to note?
A diagram of ulcers, stage II ulcer is characterized by nonintact skin. There is partial-thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister.
A client scheduled for suprapubic prostatectomy has listened to the surgeon's explanation of the surgery. The client later asks the nurse to explain again how the prostate is going to be removed. The nurse tells the client that the prostate will be removed through:
A lower abdominal incision
A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate?
Asking the child to point to the face, on a spectrum ranging from smiling to very sad, that best describes the pain
A nurse caring for a client 24 hours after a radical neck dissection notes the presence of serosanguineous drainage in the portable wound suction device attached to the surgical site. On the basis of this finding, the nurse should:
Document the findings
A nurse is assigned to conduct an admission assessment of a client with a diagnosis of bipolar disorder. What does the nurse plan to do first?
Establish a trusting nurse-client relationship
A nurse reviews the medical record of a client with histoplasmosis. Which clinical manifestation of this infection does the nurse expect to see documented?
Flulike pulmonary symptoms
A client with advanced chronic renal failure (CRF) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use:
Herbs and spices
A nurse has provided information about exercise to a client with a diagnosis of degenerative joint disease (osteoarthritis). Which of the following types of exercise does the nurse tell the client to avoid?
High-impact exercise
A client being seen in the clinic complains of fatigue and weakness. Laboratory studies are performed because the physician suspects iron-deficiency anemia. Which finding indicative of this type of anemia does the nurse expect to find on reviewing the laboratory results?
Microcytic red blood cells (RBCs)
A child with a diagnosis of Wilms' tumor is being admitted to the pediatric unit. The nurse prepares the room for the child and places a sign at the child's bedside that tells staff to avoid:
Palpating the abdomen
A client is found to have hypoxemic respiratory failure. Which finding does the nurse expect to note on review of the results of the client's arterial blood gas analysis?
Pao2 of 49 mm Hg, Paco2 of 32 mm Hg
A nurse discovers that a client receiving heparin sodium by way of continuous intravenous (IV) infusion has removed the IV tubing from the infusion pump to change his hospital gown. After assessing the client and placing the tubing back in the infusion pump, which medication does the nurse check for in the medication room in case a heparin overdose has occurred?
Protamine sulfate
After delivering a normal, healthy newborn, a client complains of severe pelvic pain and a feeling of extreme fullness in the vagina, and uterine inversion is suspected. For which immediate intervention does the nurse prepare the client?
Replacement of the uterus through the vagina into a normal position
A nurse provides dietary instructions to a client with osteoporosis who has sustained a fracture about foods that will promote healing. The nurse tells the client that it is best to consume foods that are high in:
Vitamin C
Alprazolam (Xanax) is prescribed for a client to treat an anxiety disorder. Which side effect does the nurse warn the client of?
Lightheadedness
A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication?
"Are you having any difficulty hearing?"
A nurse is performing an assessment of a client with Ménière disease. Which question does the nurse ask to elicit data about the manifestations of this disease?
"Do you have episodes of dizziness?"
A client has been scheduled for an electronystagmography (ENG), and the nurse provides instructions to the client about the test. Which statement by the client tells the nurse that the client understands the instructions?
"I need to not drink coffee before the test."
A nurse provides home care instructions to a client with coronary artery disease (CAD) who is being discharged from the hospital. Which statement by the client indicates a need for further instruction?
"I need to participate in aerobic and weightlifting exercise three times a week."
Calcium disodium edetate (EDTA) and British antilewisite (BAL, dimercaprol) is prescribed for a child with lead poisoning. What does the nurse ask the child's mother before administering the medications?
"Does your child have an allergy to peanuts?"
A hospitalized female client with mania enters the unit community room and says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse?
"Don't say that. If you can't control yourself, we'll help you."
A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder?
"Have you ever worked in a mine?"
A client with diabetes mellitus calls the clinic nurse and reports that she has been vomiting during the night and now has diarrhea. Which question does the nurse make a priority of asking the client?
"Have you tested your blood glucose?"
A client experiencing delusions says to the nurse, "I am the only one who can save the world from all of the terrorists." What is the appropriate response by the nurse?
"I don't think anyone can save the world from the terrorists by himself."
A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply.
"I need to avoid salt in my diet." "It's fine to take any over-the-counter medication with the lithium." "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned."
A nurse provides skin care instructions to a client with acne vulgaris. Which statement by the client indicates a need for further instruction?
"I should use oil-based cosmetics."
A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction?
"I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test."
A nurse has given a client with viral hepatitis instructions about home care. Which of the following statements by the client indicates to the nurse that the client needs further teaching?
"I need to eat three meals a day with foods high in protein, fat, and carbs."
A client with type 1 diabetes mellitus is instructed by the physician to obtain glucagon hydrochloride (Glucagon) for emergency home use. The nurse provides information to the client's wife about the medication. Which statement by the client's wife indicates that she understands the information?
"I need to give this if he has signs of low blood sugar and goes into a coma."
A nurse is providing instruction about insulin therapy and its administration to an adolescent client who has just been found to have diabetes mellitus. Which statement by the client indicates a need for further instruction?
"I need to keep any unopened bottles of insulin in the freezer."
Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information?
"I need to stop the medication and call my doctor if I have severe diarrhea."
A nurse provides information to a client with coronary artery disease (CAD) about smoking-cessation measures. Which statement by the client indicates a need for further information?
"I should drink a cup of coffee if I feel the urge to smoke."
A client with depression is being encouraged to attend art therapy as part of the treatment plan. The client refuses, stating, "I can't draw or paint." Which of the following responses by the nurse is therapeutic?
"Perhaps you could attend and talk to the other clients and see what they're drawing and painting."
A nurse provides information to a client with peripheral vascular disease about ways to limit the disease's progression. Which of the following measures does the nurse tell the client to take? Select all that apply.
-Engaging in exercise such as walking on a daily basis -Washing the feet daily with a mild soap and drying them well
A nurse is measuring intraocular pressure by means of tonometry in a client who has just been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note in this client?
28 mm Hg
A nurse is performing an assessment of a client with suspected pheochromocytoma. Which clinical manifestation does the nurse expect to note?
A blood pressure higher than the normal range
The mother of a newborn found to have a congenital diaphragmatic hernia asks the nurse to explain the diagnosis. The nurse tells the mother that in this condition:
Abdominal contents herniate through an opening of the diaphragm
A nurse is providing morning care to a client who has undergone surgery to repair a fractured left hip. Which item is most important for the nurse to use in turning the client from side to side to change the bed linens?
Abduction device
A client with chronic back pain asks a nurse about the use of complementary and alternative therapies to treat the pain. The nurse would initially:
Identify the client's treatment goals
A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which of the following menu selections by the client tells the nurse that the client understands the instructions?
Cheeseburger
A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse's priority?
Contacting the physician
A nurse is monitoring a client receiving terbutaline (Brethine) by intravenous infusion to stop preterm labor. The nurse notes that the client's heart rate is 120 beats/min and that the fetal heart rate is 170 beats/min. The appropriate action by the nurse is:
Contacting the physician
A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk?
Count wet diapers to be sure that the infant is having at least six to 10 each day
A nurse provides information to a client who will be undergoing endoscopic retrograde cholangiopancreatography (ERCP). The nurse tells the client that:
Dye may be injected during the procedure to permit visualization of the pancreatic and biliary ducts
A client with HIV infection who has been found to have histoplasmosis is being treated with intravenous amphotericin B (Fungizone). Which parameter does the nurse check to detect the most common adverse effect of this medication?
Intake and output
Warfarin sodium (Coumadin) is prescribed for a hospitalized client. While transcribing the physician's prescription, the nurse notes that the client is taking levothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the physician to confirm the prescription for warfarin sodium because:
Levothyroxine amplifies the effect of warfarin sodium
A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper alignment is being maintained. Which of the following actions should the nurse take next?
Notifying the physician
Ergotamine (Cafergot) is prescribed to a client with cluster headaches. Which of the following occurrences does the nurse tell the client to report to the physician if she experiences them while taking the medication?
Numbness and tingling of the fingers or toes
A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse reviews the physician's instructions, understanding that the gait was selected after assessment of the client's:
Physical and functional abilities
A client with heart failure suddenly experiences profound dyspnea, pallor, audible wheezing, and cyanosis, and the nurse suspects pulmonary edema. The nurse would first:
Raise the head of the client's bed
A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the following diagnoses, if noted on the client's record, would indicate a need to contact the physician who is scheduled to perform the ECT?
Recent stroke
A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would:
Recheck the temperature in 4 hours
A client is brought to the emergency department by ambulance, and diabetic ketoacidosis is suspected. Blood samples are taken, and the nurse obtains supplies that will be needed to treat the client. Which type of insulin does the nurse take from the medication supply room for intravenous (IV) administration?
Regular (Humulin R)
A nurse is performing an assessment of a client being admitted to the hospital with a diagnosis of multiple sclerosis. The client tells the nurse that she took baclofen (Lioresal) for the past 9 months but completely stopped the medication 2 days ago because it was making her feel weak. On the basis of this information, the nurse notes in the plan of care that the client should be monitored most closely for:
Seizure activity
A nurse is reviewing the laboratory results of a client in the emergency department with diabetic ketoacidosis (DKA). Which laboratory result would the nurse expect to note?
Serum bicarbonate of 12 mEq/L
A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which of the following risk factors does the nurse include in the pamphlet? Select all that apply.
Smoking High alcohol intake White or Asian ethnicity
A client with a history of angina pectoris tells the nurse that the chest pain usually occurs with moderate to prolonged exertion and is generally relieved by nitroglycerin or rest. Which type of angina does the nurse recognize in the client's description?
Stable
A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does the nurse instruct the client to limit consumption of while taking this medication?
Steak
A nurse is monitoring a client with bronchogenic carcinoma for signs of superior vena cava syndrome. For which early sign of this oncological emergency does the nurse assess the client?
Stokes sign
A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately:
Stops the oxytocin infusion
A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply.
Tachycardia Diminished peripheral pulses
A nurse working the evening shift is helping clients get ready for sleep. A female client with mania is hyperactive and pacing the hallway. The appropriate nursing action is to:
Take the client to the bathroom and provide her with a warm bath
A client is taking prescribed ibuprofen (Motrin), 300 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. The nurse should tell the client to:
Take the medication with food
A nurse is caring for a client who has had a stroke and is experiencing hemianopsia. Which of the following measures does the nurse take in the care of the client?
Teaching the client to move the head from side to side (scan) when eating
A client on the mental health unit says to the nurse, "Everything is contaminated." The client scrubs her hands if she is forced to touch any object. While planning care, the nurse remembers that compulsive behavior:
Temporarily eases anxiety in the client
A client with multiple sclerosis has been started on baclofen (Lioresal) for muscle spasms. The client calls the physician's office 1 week after beginning the medication and tells the nurse that she feels extremely drowsy. The nurse most appropriately tells the client:
That drowsiness usually diminishes with continued therapy
The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother:
That the child should eat a carbohydrate snack about a half-hour before each soccer game
A nurse is providing home care instructions to a client with coronary artery disease (CAD) who will be discharged home and will be taking 1 aspirin daily. The nurse tells the client:
The answer for this question should be something relating to toxicity that may present itself as tinnitus, ie., ringing in the ears.
A nurse is monitoring a client who has undergone subtotal thyroidectomy for signs of postoperative complications. Which of the following findings would be a matter of concern for the nurse as an indication of hypocalcemia?
The client complains of a tingling sensation around the mouth.
A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which of the following findings would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy?
The client reports a history of sexual abuse by her father
Iodine solution (Lugol solution) is prescribed to a client who is scheduled for subtotal thyroidectomy. The client calls the nurse at the clinic and complains of a burning sensation in the mouth and soreness of the gums and teeth. The nurse most appropriately tells the client:
To contact the physician
A nurse is caring for a client who has undergone transsphenoidal hypophysectomy to remove a microadenoma of the pituitary gland. Which of these findings would be of greatest concern to the nurse?
Urinary specific gravity is low
A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that:
Urine output must be measured and that the physician should be notified if output is less than 500 mL in a 24-hour period
A nurse is reviewing the medical record of an infant in whom hypertrophic pyloric stenosis (HPS) is suspected. Which characteristics associated with the disorder does the nurse expects see documented in the infant's medical record? Select all that apply.
Weight loss Projectile vomiting Distended upper abdomen
A client with acute gouty arthritis is being started on medication therapy with indomethacin (Indocin). The nurse, providing medication instructions, and tells the client to take the medication:
With food
Tolbutamide (Orinase) is prescribed to a client whose type 2 diabetes mellitus has not been controlled with diet and exercise alone. The nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instruction?
"I can have a beer or glass of wine as long as I stay within my daily dietary restrictions."
A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction?
"I need to contact my surgeon immediately if I feel any numbness in my genital area."
A nurse has provided nutrition instructions to a mother of an infant. Which statement by the mother indicates to the nurse that the mother requires further instruction?
"It's best to use cow's milk, as long as it's whole milk and not skim."
A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information?
"Wearing the brace is really important in curing the scoliosis."
A nurse is providing morning care to a client in end-stage renal failure. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic?
"What are your feelings right now?"
A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that apply.
-Drink copious amounts of fluid and void frequently -Avoid contact with any individual who has signs or symptoms of a cold
A physician prescribes a dose of morphine sulfate 2.5 mg stat to be administered intravenously to a client in pain. The nurse preparing the medication notes that the label on the vial of morphine sulfate solution for injection reads "4 mg/mL." How many milliliters (mL) must the nurse draw into a syringe for administration to the client? Type the answer in the space provided.
0.625mL
A nurse is monitoring a hospitalized client who is being treated for preeclampsia. Which items of the following information elicited during the assessment indicate that the condition has not yet resolved? Type the option number that is the correct answer.
1
A nurse developing a plan of care for a client with HIV infection identifies several concerns. List them in order of priority, from highest to lowest.
1 Possible infection 2 Decreased nutrition 3 Fatigue 4 Despair
An emergency department nurse has a physician's prescription to irrigate a client's ears. List in order of priority the steps that the nurse should take in performing this procedure.
1 Use an otoscope to ensure that the tympanic membrane is intact. 2 Warm tap water to body temperature. 3 Fill an irrigating syringe with warm water. 4 Insert the irrigating solution by directing the solution toward the wall of the ear canal. 5 Document the completion of the procedure and how the client tolerated it.
A nurse is teaching a client with left-side weakness how to walk with the use of a quad-cane. The nurse ensures that:
30-degree flexion of the client's elbow is maintained when the client is holding the cane
An adult client with renal failure who is oliguric and undergoing hemodialysis is under a fluid restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to have between 7 a.m. and 3 p.m.? Type your answer in the space provided.
350mL
A registered nurse is planning client assisgnments for the day. There is a licensed practical nurse and a nursing assistant on the team. Which client is the appropriate choice for the nursing assistant?
A client with rheumatoid arthritis who needs assistance with feeding and ambulation
A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which of the following observations indicates to the nurse that placental separation has occurred?
A sudden gush of dark blood from the introitus
NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should:
Administer the antihypertensive with a small sip of water
The nurse is performing a sterile change of an abdominal dressing. Once the dressing has been removed and discarded in a waterproof bag, which action should the nurse take next?
Assessing the wound
A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg. On the basis of the ABG result, the nurse prepares to:
Assist in intubating the client and beginning mechanical ventilation
A client who was involved in a high-speed motor vehicle crash is brought to the emergency department. Which of the following findings indicates to the nurse that the client has sustained flail chest?
Asymmetrical chest movement
Testing of the plasma theophylline level in a client who is receiving a continuous intravenous infusion of theophylline reveals a level of 20 mcg/mL. The nurse interprets this result as:
At the top of the therapeutic range
A client is receiving an intravenous infusion of alteplase (tissue plasminogen activator, recombinant; tPA). For which adverse effect of the medication does the nurse monitor the client most closely?
Bleeding
A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to:
Call the radiography department to obtain a chest x-ray
An intravenous dose of adenosine (Adenocard) is prescribed for a client to treat Wolff-Parkinson-White syndrome. Which piece of equipment does the nurse make a priority of obtaining before administering the medication?
Cardiac monitor
A nurse taking the vital signs of a client immediately after she has delivered a newborn notes that the client's heart rate is 110 beats/min. The nurse would first:
Check the uterus and amount of lochia discharge
Methylergonovine (Methergine) is prescribed for a client to control postpartum bleeding. Which action does the nurse take before administering the medication?
Checking the client's blood pressure
An emergency department nurse assessing a client with Bell's palsy collects subjective and objective data. Which of the following findings does the nurse expect to note?
Complaints of inability to close the eye on the affected side
A nurse in a physician's office is talking to a client who underwent mastectomy of the right breast 2 weeks ago. The client says to the nurse, "I hate looking at this incision. I feel that I'm not even myself anymore." The nurse interprets this statement to mean that the client is experiencing which problem?
Distorted body image
Cyclobenzaprine (Flexeril) is prescribed to a client with multiple sclerosis for the treatment of muscle spasms. For which common side effect of this medication does the nurse monitor the client?
Drowsiness
A mother calls the emergency department and tells the nurse that her 3-year-old child drank ammonia from a bottle while the mother was cleaning house. The nurse tells the mother to immediately:
Encourage the child to drink water or milk in small amounts
A client says to the nurse, "My doctor just left. He told me that my abdominal scan showed a mass in my pancreas and that it's probably cancer. Does this mean I'm going to die?" The nurse interprets the client's initial reaction as:
Fear
A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, the nurse tells the client that this technique involves:
Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening
A client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall out?" The nurse responds by telling the client that:
Her hair may fall out but will regrow after the chemotherapy is discontinued
A home care nurse prefills syringes containing NPH (Humulin N) and regular (Humulin R) insulin for a client with diabetes mellitus who will be administering his own insulin but has difficulty seeing and accurately preparing doses. The nurse places the medication in the client's refrigerator with the syringes:
In a vertical position with the needles pointing up
A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume sexual intercourse. The nurse tells the client that sexual intercourse may be resumed:
In about 6 weeks, when the vaginal vault is satisfactorily healed
Oral prednisone 10 mg/day is prescribed for a client with an acute exacerbation of rheumatoid arthritis. The nurse, providing information to the client about the medication, tells the client that it is best to take it:
In the morning, before 9:00 a.m.
A nurse provides instructions to a client who will be taking levothyroxine (Synthroid) for hypothyroidism. The nurse tells the client that it is best to take the medication:
In the morning, before breakfast
A client with hypoparathyroidism is taking calcium gluconate to treat hypocalcemia. The client calls the clinic nurse and complains of becoming constipated since starting the medication. The nurse tells the client to:
Increase intake of high-fiber foods
Laboratory studies are performed on a client with suspected sickle cell disease, and electrophoresis reveals a large percentage of hemoglobin S (HbS). Which additional laboratory finding will the nurse expect to note that is a characteristic of this disease?
Increased white blood cell (WBC) count
Desmopressin (DDAVP) is prescribed to a client with diabetes insipidus. Which parameter does the nurse tell the client that it is important to monitor while she is taking the medication?
Intake and output
A client with suspected HIV infection has positive results on enzyme-linked immunosorbent assay (ELISA) and Western blot tests. The plasma HIV RNA level is assessed, and the result is reported as 8000 copies/mL. The nurse interprets the results of the HIV RNA test as indicating that the client:
Is at low risk for AIDS
A community health nurse is preparing a poster for a health fair that will include information about the ways to prevent ear infection or ear trauma. Which prevention measures does the nurse include on the poster? Select all that apply.
Keep the volume of headphones at the lowest setting. Avoid environmental conditions involving rapid changes in air pressure. Clean the external ear and canal daily in the shower or while washing the hair.
Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply.
Keeping the room slightly darkened Monitoring the client for changes in alertness or mental status Restricting visits to close family members and significant others and keeping visits short
A nurse is monitoring a client who was brought to the emergency department in an unresponsive state and is now being treated for hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Which of the following findings indicates to the nurse that fluid replacement is inadequate?
Level of consciousness remains unchanged
Although previously well controlled with glyburide (Diabeta), a client's fasting blood glucose has been running 180 to 200 mg/dL. On reviewing the client's record, which medication, recently added to the client's regimen, does the nurse recognize as a possible contributor to the hyperglycemia?
Lithium carbonate (Lithobid)
A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of tube, does the nurse implement?
Maintaining cuff pressure
Captopril (Capoten) is prescribed for a hospitalized client with heart failure. Which action is a priority once the nurse has administered the first dose?
Maintaining the client on bed rest for 3 hours
A nurse is assessing a client with hepatitis for signs of jaundice. Which area does the nurse check, knowing that it will provide the best data regarding the presence of jaundice?
Mucous membranes
A client with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs?
Offering high-calorie and high-protein foods and fluids frequently throughout the day
A client is found to have iron-deficiency anemia, and ferrous sulfate (Feosol) is prescribed. The nurse tells the client that it is best to take the medication with:
Orange juice
A nurse is caring for a client who has had a cast applied to the left leg and is at risk for acute compartment syndrome. For which early sign of this complication does the nurse monitor the client?
Paresthesia
A nurse developing a nursing care plan for a client with abruptio placentae includes initial nursing measures to be implemented in the event of the development of shock. After contacting the physician, which of the following does the nurse specify as the first action in the event of shock?
Placing the client in a lateral position with the bed flat
A postoperative client with deep-vein thrombosis is at risk for pulmonary embolism. For which characteristic sign or symptom of this complication does the nurse monitor the client?
Pleuritic chest pain
A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client?
Positive result on d-dimer study
A nurse is transcribing a physician's prescription for oral prednisone 5 mg/day that was written in the chart of a client with type 2 diabetes mellitus who is already taking an oral hypoglycemic medication. The nurse contacts the physician to ask about the prescription because:
Prednisone can increase the blood glucose level
A nurse is developing a plan of care for a client admitted to the nursing unit with a diagnosis of paranoid personality disorder. On which characteristic of the disorder does the nurse base the plan of care?
Projecting blame, possibly becoming hostile
A nurse reviews arterial blood gas values and notes a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse interprets these values as indicative of:
Respiratory alkalosis
A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which of the following findings would the nurse expect to note on assessment of the client?
Soft, relaxed, nontender uterus
Propylthiouracil (PTU) has been prescribed for a client with Graves disease, and the nurse provides instructions to the client about the medication. For which of the following occurrences does the nurse tells the client to contact the physician?
Sore throat
Calcium carbonate (Os-Cal 500) is prescribed for a client with mild hypocalcemia. What food does the nurse instruct the client to avoid consuming while taking this medication?
Spinach
A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client?
Spontaneous bruising
A nurse is preparing medication instructions for a client who will be taking a daily oral dose of digoxin (Lanoxin) 0.25 mg in the treatment of congestive heart failure (CHF). Which instructions should the nurse include on the list? Select all that apply.
Take your pulse before taking each dose. Take the digoxin at the same time each day. Notify the physician if you experience loss of appetite, muscle weakness, or visual disturbances.
A female client with rheumatoid arthritis is taking 3.6 g of acetylsalicylic acid (aspirin) daily in a divided dose. At the physician's office, the client tells the nurse that she has been experiencing ringing in the ears over the past few days. The nurse tells the client that:
The physician will probably withhold the aspirin until the symptoms have subsided, then resume the aspirin at a lower dosage
A nurse develops a list of home care instructions for a client who is wearing a halo fixation device after sustaining a cervical fracture. Which instructions should the nurse include? Select all that apply.
Use a straw to drink. Use caution when leaning forward or backward. Do not drive, because full range of vision is impaired with the device.
A nurse is reviewing the laboratory results of a client with ovarian cancer who is undergoing chemotherapy. Which finding indicates to the nurse that the client is experiencing an adverse effect of the chemotherapy?
White blood cell count of 2500 cells/mm3
A nurse transcribing the prescriptions of a client admitted to the nursing unit notes that metformin (Glucophage) 850 mg/day has been prescribed. The nurse makes a note in the client's medication record that the medication should be administered:
With the morning meal
A client living in a long-term care facility shouts at the nurse, "Get out of my room! I don't need your help!" What is the appropriate way for the nurse to document this occurrence in the client's record?
Writing down the client's words and placing them in quotation marks
An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply.
Skin tenting Flat neck veins Weak peripheral pulses
A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta?
"The placenta maintains the body temperature of my baby."
A client with schizophrenia says to the nurse, "I decided not to take my medication because it can't help. I am the only one who can help me." Which nursing response is therapeutic in this situation?
"Your doctor wants you to continue this medication because it's helping you. Do you recall needing to be hospitalized because you stopped your medication?"
A rape victim being treated in the emergency department says to the nurse, "I'm really worried that I've got HIV now." What is the appropriate response by the nurse?
"Let's talk about the information that you need to determine your risk of contracting HIV."
A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply.
Spinach Legumes Whole grains
Ciprofloxacin hydrochloride (Cipro) is prescribed to a client with a urinary tract infection. The nurse, providing instruction about the medication, tells the client that it is best to take the medication:
2 hours after meals
A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-hour period?
1670mL
A child is brought to the emergency department by ambulance after swallowing several capsules of acetaminophen (Tylenol). Which medication does the nurse prepare, anticipating that it will be prescribed to treat the child?
Acetylcysteine (Mucomyst)
An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client?
Administering 100% oxygen
A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify?
Anxiety
A client with emphysema is receiving theophylline (Theo-24). While providing dietary instructions, the nurse tells the client that it is acceptable to consume:
Apple juice
A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client's bedside?
Calcium gluconate
A nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm really thirsty — may I have something to drink?" Before giving the client a drink, the nurse should:
Check for the presence of a gag reflex
The nurse is preparing to administer a tube feeding by way of a nasogastric tube. Which action does the nurse carry out as a priority before starting the flow of the solution?
Checking for gastric residual volume and assessing tube placement
A nurse administers nitroglycerin sublingually to a client with angina pectoris who complains of chest pain. The medication is ineffective, so the nurse prepares to administer a second dose. Before administering the nitroglycerin, which action does the nurse make a priority?
Checking the client's blood pressure
A client receiving parenteral nutrition (PN) suddenly experiences chest pain and dyspnea, and the nurse suspects an air embolism. The nurse immediately places the client in a lateral Trendelenburg position, on the left side. What action does the nurse take next?
Clamping the intravenous catheter
A nurse preparing to administer digoxin (Lanoxin) to a client calls the laboratory for the result of the digoxin assay performed on a specimen that was drawn at 6 a.m. The laboratory reports that the result was 2.4 ng/mL. On the basis of this result, the nurse would:
Contact the physician
A school nurse observing a child with Down syndrome is participating in a physical education class and notes that the child is experiencing a diminution in motor abilities. The nurse asks to see the child and conducts an assessment, during which the child complains of neck pain and loss of bladder control. What is the appropriate action by the nurse in this situation?
Contacting the child's physician to report the findings
A client arrives in the emergency department and tells the nurse that she is experiencing tingling in both hands and is unable to move her fingers. The client states that she has been unable to work because of the problem. During the psychosocial assessment, the client reports that 2 days earlier her husband told her that he wanted a separation and that she would have to support herself financially. The nurse concludes that this client is exhibiting signs compatible with:
Conversion disorder
A nurse is providing instructions to a client with glaucoma who will be using acetazolamide (Diamox) daily. Which of the following findings, an adverse effect, does the nurse instruct the client to report to the physician?
Dark urine
A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client?
Epistaxis
A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the medication, does the nurse monitor the client?
Fever
A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record? Select all that apply.
Fever Vasculitis Abdominal pain
A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client?
Hearing loss
A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele's rule, the nurse determines that the estimated date of delivery (EDD) is:
July 2, 2013
Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse?
Multiple sexual partners
An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which of the following characteristics of the disorder does the nurse expect the client to exhibit? Select all that apply.
Nausea Eye pain Vomiting Headache
Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the physician immediately if she experiences:
Neck stiffness or soreness
A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client's breast?
Pick the photo that has the nipple that resembles a sunburned orange peel. Peau d'orange means orange peel in French.
A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that:
Pitting edema is present
A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem?
Powerlessness
While being seen by a physician, a client complains of persistent fever, malaise, and night sweats. On physical examination, the physician palpates enlarged lymph nodes, and the client states that the nodes are painless. Hodgkin's lymphoma is suspected, and several diagnostic studies are performed. Which characteristic of this type of lymphoma does the nurse expect to note while reviewing the results of the diagnostic studies?
Reed-Sternberg cells on biopsy of a lymph node
The nurse administers intravenous morphine sulfate to a client in pulmonary edema. For which intended effect of the medication does the nurse monitor the client?
Relief of anxiety
A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. The nurse tells the client that one food item high in calcium is:
Sardines
A nurse is providing information to a client who will be self-administering regular insulin about storage of the insulin. The nurse tells the client:
That the vial in current use may be kept at room temperature for as long as 1 month without significant loss of activity
A nurse assessing the wound of a client with a stage 3 pressure ulcer and notes that the wound bed is pale. The nurse interprets this finding as a possible indication that:
The client's hemoglobin level is low
A nurse is assessing a client who is experiencing chest pain. Which of the following observations indicates to the nurse that the pain is most likely a result of angina?
The pain is relieved by rest and nitroglycerin.
A child with growth hormone deficiency will be receiving somatropin (Humatrope). The nurse provides information to the mother about the medication. Which of the following laboratory values does the nurse tell the mother will require monitoring?
Thyroid-stimulating hormone (TSH)
A nurse is preparing the room of a client in skeletal traction who will be admitted to the nursing unit. Which item for use by the client does the nurse identify as the most important?
Trapeze bar
A nurse caring for a woman in labor is reading the fetal monitor tracing (see figure). How does the nurse interpret this finding?
Uteroplacental insufficiency during a contraction
A client with tuberculosis will be taking pyrazinamide (Pyrazinamide), and the nurse provides instructions about the adverse effects of the medication. For which of the following occurrences does the nurse tell the client to contact the physician?
Yellow skin
A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse's initial action should be:
Helping the woman empty her bladder
A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines that the client is gaining a therapeutic effect from the medication after noting:
Improved swallowing function
A nurse is providing information to a client with acute gout about home care. Which of the following measures does the nurse tell the client to take? Select all that apply.
Drinking 2 to 3 L of fluid each day Resting and immobilizing the affected area
As a nurse prepares to administer medications to an assigned client, the client asks, "Why don't you just leave me alone?" What is the best response by the nurse?
"I can see that you're upset. Would you like to talk about it?"
A client who has undergone extensive gastrointestinal surgery is receiving intermittent enteral tube feedings that will be continued after he is discharged home. When the nurse tells the client that he will be taught how to administer the feedings, the client states, "I don't think I'll be able to do these feedings by myself." Which response by the nurse is appropriate?
"Tell me more about your concerns regarding the tube feedings."
A nurse provides information to a client with chronic obstructive pulmonary disease (COPD) about methods of alleviating shortness of breath while the client is eating. Which statement by the client indicates a need for further instruction?
"I should eat three meals a day, and the biggest meal should be at suppertime."
A nurse provides information about activity and exercise to the wife of a client with Parkinson's disease. Which statement by the spouse indicates a need for further instruction?
"I should encourage him to keep his hands hanging at his side when he walks."
Oral candidiasis (thrush) develops in a client infected with HIV, and the nurse provides instruction to the client about measures to relieve the discomfort. Which statement by the client indicates a need for further instruction?
"I should put ice in my drinks to help soothe the discomfort."
A nurse assigns a nursing assistant to care for a client who is hearing impaired and provides instructions to the nursing assistant about the effective methods for communicating with the client. Which statement by the nursing assistant indicates that further instruction is needed?
"I should raise the volume of my voice and stand on the client's affected side when I'm talking to him."
A client with post-traumatic stress disorder tells the nurse that he has stopped taking his prescribed medication because he didn't like how the medication was making him feel. Which of the following initial responses by the nurse is appropriate?
"Tell me more about how the medication was making you feel."
A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic?
"Tell me more about what you're feeling."
Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed and administers the medication over a period of:
3 minutes
A nurse is caring for a client who sustained burn injuries on the anterior lower legs and anterior thorax. What percentage of the client's body, according to the Rule of Nines, has been affected?
36%
A client with myasthenia gravis who has been taking pyridostigmine bromide (Mestinon) for the treatment of the disorder comes to the emergency department complaining of severe muscle weakness, and cholinergic crisis is diagnosed. Which medication does the nurse prepare for immediate use in treating the crisis?
Atropine sulfate
A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time?
Anxiety
An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is:
Asking the ED physician to check the client
A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate (Parnate). Which of the following foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply.
Beer Yogurt Pickled herring
A client is found to have posttraumatic stress disorder (PTSD) after witnessing a terrorist attack that caused the deaths of hundreds of people. The nurse, developing a plan of care for the client, identifies posttrauma syndrome as a concern and identifies a client outcome that states, "The client will cope effectively with thoughts and feelings of the event." Which nursing interventions will assist the client in achieving this outcome? Select all that apply.
Being honest, nonjudgmental, and empathetic Assessing the immediate posttraumatic reaction Encouraging the client to keep a journal focused on the trauma Asking the client about the use of alcohol and drugs before and since the event
A nurse is monitoring a client with pheochromocytoma who is receiving an intravenous (IV) infusion of phentolamine. Which vital sign does the nurse monitor most closely during the infusion?
Blood pressure
A nurse is providing dietary instructions to the mother of a child with celiac disease. The nurse tells the mother that it is acceptable to give the child:
Boiled rice
A nurse reviews the results of a total serum calcium determination in a client with renal failure. The results indicate a level of 12.0 mg/dL. In light of this result, which finding does the nurse expect to note during assessment?
Bounding, full peripheral pulses
The nurse notes the presence of drainage on the mustache dressing of a client who has undergone transsphenoidal hypophysectomy. The initial nursing action is to:
Check the drainage for glucose
Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication?
Checking the client's blood pressure
Vasopressin (Pitressin) is prescribed to a client with diabetes insipidus. For which sign, indicative of an adverse effect of the medication, does the nurse monitor the client?
Chest pain
A nurse provides home care instructions to a client who has undergone fluorescein angiography. The nurse determines that the client needs further instruction if the client states that he must:
Contact the physician if the skin appears yellow
A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally:
Decrease
A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority?
Decreased fluid volume
A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client most likely has a history of:
Depression
A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should:
Document the findings
A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would:
Document the findings
A nurse in a physician's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to:
Document the findings
The blood serum level of imipramine is determined in a client who is being treated for depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should:
Document the laboratory result in the client's record
A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which of the following actions should the nurse take as a result of this observation?
Documenting the finding
A nurse is performing an assessment of a newborn with a diagnosis of esophageal atresia (EA) and tracheoesophageal fistula (TEF). Which findings does the nurse expect to note in the infant? Select all that apply.
Drooling Excessive oral secretions
Chlorpromazine (Thorazine) has been prescribed to a client with Huntington's disease for the relief of choreiform movements. Of which common side effect does the nurse warn the client?
Drowsiness
A nurse is preparing to care for a client who has undergone abdominal hysterectomy for the treatment of endometrial cancer. The nurse determines that the priority in the 24 hours after surgery is:
Encouraging the client to deep-breathe, cough, and use an incentive spirometer
A nurse in a physician's office is reviewing the medical record of a child with a diagnosis of lactose intolerance. Which of the following findings does the nurse expect to see documented in the child's record?
Episodes of cramping abdominal pain and excessive flatus
A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder. Which of the following behaviors is a characteristic of the disorder?
Hypersensitivity to negative evaluation
A nurse is monitoring a child with intussusception for signs of peritonitis. For which of the following findings, indicative of this complication, does the nurse notify the physician?
Increased heart rate
A nurse is preparing to provide information to a client who has been found to have stable angina. The nurse plans to tell the client that this type of angina:
Is often managed medically with medications such as calcium channel blockers and beta-blocking medications
A pediatric nurse is caring for a hospitalized toddler. Which of the following activities does the nurse deem the most appropriate for the toddler?
Large building blocks
A female client admitted to the mental health unit tells the nurse that she cannot leave the house without checking to be sure that she has shut off the coffee maker and unplugged her curling iron. The client states that she even leaves the house, gets into her car, and then has to go back into the house to check these appliances again and that these behaviors are interfering with her work and social commitments. With which of the following anxiety disorders does the nurse associate this client's symptoms?
Obsessive-compulsive disorder
A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse
Place small pieces of tape over the rough edges of the cast
The wife of a client with diabetes mellitus calls the nurse and reports that her husband's blood glucose level is 60 mg/dL and that her husband is awake but groggy. The nurse tells the client's wife to immediately:
Place some honey in her husband's mouth, between his gums and cheek
A client is brought to the emergency department after sustaining smoke inhalation injury during a fire in the client's home. The nurse plans to first:
Provide the client with 100% oxygen by mask
A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which of the following recommendations does the nurse include on the poster? Select all that apply.
Seek medical advice if you find a skin lesion.
A hospitalized client scheduled for surgery is told by the physician that she is extremely anemic and will need a blood transfusion. The client, a Jehovah's Witness, tells the nurse that she is refusing the transfusion. What is the most appropriate initial nursing action?
Supporting the client's decision to refuse the transfusion
Disulfiram (Antabuse) is prescribed to a client with an alcohol abuse problem. The nurse provides information about the medication and tells the client:
That the medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol
A client undergoing therapy with carbidopa/levodopa (Sinemet) calls the nurse at the clinic and reports that his urine has become darker since he started taking the medication. The nurse should tell the client:
That this is an occasional side effect of the medication
Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client's medical record would prompt the nurse to contact the prescribing physician before administering the medication?
The client takes a prescribed antihypertensive.
A client has a physician's appointment to get a prescription for sildenafil (Viagra). The nurse obtains the health history from the client. Which finding indicates that the medication is contraindicated?
The client takes isosorbide dinitrate (Isordil).
A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine:
The degree of fetal lung maturity
Levothyroxine (Synthroid) is prescribed to a client with hypothyroidism. One week after beginning the medication, the client calls the physician's office and tells the nurse that the medication has not helped. The nurse most appropriately tells the client that:
The full therapeutic effect may take 4 weeks
A nurse is providing instruction in how to perform Kegel exercises to a client with stress incontinence. The nurse tells the client to:
Tighten the pelvic muscles for a slow count of 10, then relax for a slow count of 10
Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take the medication with:
Tomato juice
A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which of the following findings does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client?
Tongue protrusion
The nurse, auscultating the breath sounds of a client, hears these sounds. What are they?
Wheezes
