NU 300 NCLEX challenge questions

What is the order of fire safety that a nurse should go in, in the hospital setting?

Rescue the clients, pull the fire alarm, confine the fire, extinguish the fire.

A nurse is caring for an infant who has been prescribed a one-time dose of ceftriaxone 50 mg/kg IM. the infant weighs 17.6 lb. Available is 500 mg/mL. How many mL should the nurse administer?

0.8 mL

A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? A . Repeat auscultation after asking the client to breathe deeply and cough B. Instruct the client to limit fluid intake to less than 2,000 mL/day. C. prepare to administer antibiotics D. Place the client on bed rest in semi-Fowler's position.

A . Repeat auscultation after asking the client to breathe deeply and cough Although crackles often indicate fluid in the alveoli, they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breath or a cough.

A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict? A. "I need to talk to you about unit expectations regarding delegating and completing tasks." B. "several staff members have commented that you don't do your fair share of the work" C. "If you don't do your share of the work, I will have to inform the nurse manager." D. "You have been very inconsiderate of others by not completing your share of the work."

A. "I need to talk to you about unit expectations regarding delegating and completing tasks."

A nurse is teaching a client about how to use a patient-controlled analgesia (PCA) pump. which of the following instructions should the nurse include in the teaching? A. "Use the pain scale to determine if you need self-administer" B. "ask a family member to push the patient-control button when the client is sleeping" C. "there is a 30 minute lock-out limit programmed on your PCA pump" D. "several bolus doses are infused if the button is pushed repeatedly within a 5 to 10 minute timeframe before lock-out"

A. "Use the pain scale to determine if you need self-administer"

A nurse is caring for a client who is receiving oxygen at 2L/min via a NC. The nurse recognizes the client is receiving which of the following inspired oxygen concentration? A. 28% B. 26% C. 50% D. 70%

A. 28% The nurse should recognize that a flow rate of 2 L/min via nasal cannula delivers an oxygen concentration of about 28%.

A nurse is teaching a client about the seven warning signs of cancer. Which of the following signs should the nurse include as manifestations of cancer? (Select all that apply) A. A nonhealing sore B. Bloating C. Change in bowel pattern D. Change in moles E. Nagging cough

A. A nonhealing sore C. Change in bowel pattern D. Change in moles E. Nagging cough

A nurse is working with administration to enhance the quality of care provided to clients during the prenatal period. In which of the following roles is the nurse functioning? A. advocate b. clinician c. educator d. manager

A. advocate

A nurse is assessing a client who reports acute pain. The nurse should anticipate which of the following findings? A. Increased heart rate B. Decreased respiratory rate C. Hyperactive bowel sounds D. Decreased blood pressure

A. Increased heart rate

A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients' cultures? A. Nurses should focus on clients' cultures, rather than their ethnicity, when providing care. B. Nonverbal communication is important in few cultures. C. culture plays no role in determining when a client will seek medical care. D. Nurses should expect clients to adapt to the care provided regardless of culture.

A. Nurses should focus on clients' cultures, rather than their ethnicity, when providing care.

A nurse has several tasks to delegate to an assistive personnel (AP). which of the following tasks should the nurse ask the AP to perform first? A. Take an Arterial blood gas (ABG) specimen to the laboratory B. transport a client to the radiology department for an x-ray C. Pass fresh water to clients on the unit D. obtain a routine urine sample from a newly-admitted client.

A. Take an Arterial blood gas (ABG) specimen to the laboratory When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority action is to take the ABG blood sample to the laboratory. ABG samples are placed on ice and must be transported to the laboratory immediately or the specimen will deteriorate, making any results inaccurate.

A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which of the following findings should the nurse report to the provider? A. WBC 2300/ mm3 B. RBC 5 million/mm3 C. Hemoglobin 12 g/dL D. Platelets 155,000/ mm3

A. WBC 2300/ mm3

A nurse is teaching a client who is receiving radiation therapy about skin care. Which of the following instructions should the nurse include? A. Walk outside in the early mornings. B. Wash the irradiated area following treatment sessions to remove the markings. C. Vigorously rub the skin dry after bathing D. Keep the temperature in the home at least 33 C (91.4F).

A. Walk outside in the early mornings. A client who is receiving radiation treatment has special skin care needs due to the drying and irritation that occurs to the skin. The client's skin is especially prone to burning, and he should be encouraged to limit time outdoors in the sun. The nurse should instruct the client to go outside during the early morning or evening to avoid intense sun rays and should encourage the client to stay under awnings, umbrellas, and other forms of shade during the time when the sun's rays are most intense.

After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions? A. apply hydrating lotions B. apply moist heat C. sit in the sun for 10 min per day. D. wash with plain soap and water.

A. apply hydrating lotions

A nurse is reinforcing teaching to a client who is newly diagnosed with hypertension and has been prescribed captopril (Capoten). The nurse should reinforce that which of the following medications has the potential to reduce the antihypertensive effect of captopril? A. aspirin b. acetaminophen c. guaifenesin d. diphenhydramine hydrochloride

A. aspirin

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5L/min via NC. which of the following actions should the nurse take? A. attach a humidifier bottle to the base of the flow meter B. Remove the nasal cannula while the client eats C. Secure the oxygen tubing to the bed sheet near the client's head D. apply petroleum jelly to the nares as needed to soothe mucous membranes

A. attach a humidifier bottle to the base of the flow meter

A nurse in a provider's office is reviewing lab results of a client who takes furosemide for HTN. the nurse notes that the client's potassium level is 3.3. The nurse should monitor the client for which of the following complications? A. cardiac dysrhythmias B. hypoglycemia C. seizures D.neurogenic shock

A. cardiac dysrhythmias

a nurse is assessing a client who has obstructive sleep apnea (OSA). which of the following findings should the nurse expect? A. decreased energy B. pneumonia C. hypotension d. thyroid dz

A. decreased energy

A nurse is reviewing a client's lab report of blood gas findings: hco3 18, PaCO2 28. which of the following pH values and conditions should the nurse expect when interpreting these findings? A. decreased ph and metabolic acidosis B. decreased ph and respiratory acidosis C. elevated ph and metabolic alkalosis D. elevated ph and respiratory alkalosis

A. decreased ph and metabolic acidosis

A nurse is reviewing the laboratory results of a client who has acute leukemia and received an aggressive chemotherapy treatment 10 days ago. Which of the following hematologic laboratory values should the nurse expect? (Select all that apply) A. decreased platelet count b. increased hemoglobin count c. decreased leukocyte count d. increased platelet count e. decreased erythrocyte count

A. decreased platelet count, c. decreased leukocyte count, e. decreased erythrocyte count

A nurse is collecting data on a child who is diagnosed with bacterial epiglottitis. Which of the following clinical findings are associated with the illness? (Select all that apply.) A. drooling b. stridor c. difficulty swallowing d. croupy cough e. high grade fever

A. drooling b. stridor c. difficulty swallowing e. high grade fever

A nurse is assessing a client who has a pleural effusion. Which of the following findings should the nurse expect? A. dullness percussed over the client's lung fields B. Crepitus palpated on the client's chest C. Crackles auscultated over the client's lungs fields D. substernal retractions noted on the client's chest

A. dullness percussed over the client's lung fields

A nurse is preparing an in-service about communication for a group of staff nurses. Which of the following information should the nurse include when discussing the electronic mode of communication? A. electronic communication includes video conference calls with clients B. Electronic communication does not have a risk of privacy violations C. providers can send prescriptions to a pharmacy on an unencrypted device D. social media is not a form of electronic communication

A. electronic communication includes video conference calls with clients

A nurse finds radioactive pellets on the floor of the surgical. Which of the following actions should the nurse take first? A. follow safety data sheet (SDS) instructions B. place pellets in the biohazard area C. contact environmental services D. notify the surgical department director.

A. follow safety data sheet (SDS) instructions

A nurse is teaching a class on professionalism. The nurse should include that which of the following is an example of accountability? A. following the rights of medication administration to administer a medication to a client B. Acting as a mediator between the client and the provider C. Ensuring a client understands the adverse effects of their medication D. Supporting a client's right to refuse a medication.

A. following the rights of medication administration to administer a medication to a client

A nurse is assessing a client who has obstructive sleep apnea. Which of the following findings should the nurse expect? A. headache B. nausea C. constipation D. hypotension

A. headache

A nurse is caring for a client who has a flaccid bladder following a spinal cord injury. Which of the following actions should the nurse take first? A. initiate a bladder training schedule b. administer solifenacin c. insert an indwelling urinary catheter d. perform intermittent catheterization

A. initiate a bladder training schedule least invasive

A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. which of the following client data is most important for the nurse to monitor? A. maternal respirations b. fetal heart rate c. maternal deep-tendon reflexes d. maternal urinary output

A. maternal respirations Think A,b,c priority setting framework

What type of imbalance is present with a pH of 7.30, HCO3 at 18, PaCO2 at 28? A. metabolic acidosis B. respiratory acidosis C. metabolic alkalosis D. respiratory alkalosis

A. metabolic acidosis

A nurse is assessing a client who has oxygen toxicity. Which of the following findings should the nurse expect? A. muscle twitching B. periorbital edema C. metallic taste in mouth D. facial flushing

A. muscle twitching

A nurse is assessing a client who has a sodium level of 116 mEq/L. Which of the following findings should the nurse expect? A. nausea and vomiting B. extreme thirst C. flushed skin D. fever

A. nausea and vomiting

A nurse is discussing potential barriers to effective communication with a newly licensed nurse. Which of the following barriers should the nurse include? Select all that apply A. noise from nearby monitoring equipment B. adequate lighting in a client's room C. cultural differences between a client and nurse D. use of medical terminology when speaking to a client E. Nurse facing the client when speaking F. a client who has dementia with memory loss

A. noise from nearby monitoring equipment C. cultural differences between a client and nurse D. use of medical terminology when speaking to a client F. a client who has dementia with memory loss

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take? A. perform the tracheostomy care for the client every 4 hrs B. preoxygenate the client for 10 seconds prior to trach care. C. place the client in a lateral recumbent position prior to trach care. D. clean the trach stoma with a chlorhexidine solution.

A. perform the tracheostomy care for the client every 4 hrs

a nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply) A. poor skin turgor B. bradycardia C. hypotension D. pale yellow urine E. flat neck veins

A. poor skin turgor, C. hypotension, E. flat neck veins

A nurse is teaching a class about pulmonary circulation. The nurse should include that the blood flows from the heart to the lungs from the right ventricle starting from which of the following locations? A. pulmonary artery B. left atrium C. left ventricle D. pulmonary veins

A. pulmonary artery

A nurse overhears two assistive personnels (AP) from the medical-surgical unit discussing a hospitalized client while in the cafeteria. Which of the following is the priority nursing action? A. quietly tell the APs that this is not appropriate B. Ask the nurse manager to provide an inservice program about confidentiality to the staff on the unit C. Complete an incident report D. document the occurrence in a personal log.

A. quietly tell the APs that this is not appropriate

A nurse is preparing to delegate tasks to an assistive personnel (AP). The nurse should identify which of the following as one of the five rights of delegation? A. right communication B. right documentation C. right time D. right room

A. right communication

A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider? A. sodium 126 B. potassium 3.6 C. magnesium 1.9 D. chloride 99

A. sodium 126

A nurse is assessing a client for manifestations of pain. Which of the following findings is a subjective indicator of pain? A. the client reports a burning sensation B. the client's pupils are dilated C. the client is restless D. the client is grimacing

A. the client reports a burning sensation

A nurse in a long-term care facility is assisting with an educational program regarding common sites of health care associated infections for a group of newly hired assistive personnel. Which of the following sites should be included in the teaching? (Select all that apply.) A. urinary tract b. surgical wound c. musculoskeletal system d. respiratory tract e. blood stream

A. urinary tract b. surgical wound d. respiratory tract e. blood stream

A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings? A. urine specific gravity 1.035 B. Hematocrit 44% C. BUN 19 mg/dL D. sodium 155 mEq/L

A. urine specific gravity 1.035

A nurse is admitting a client who reports flu-like symptoms with hyperactive reflexes and a new onset of confusion. The nurse should recognize that the client is experiencing which of the following conditions? A. Metabolic acidosis B. Metabolic alkalosis c. respiratory acidosis D. respiratory alkalosis

B. Metabolic alkalosis

A nurse is assessing a client who has circulatory overload. Which of the following findings should the nurse expect? A. weight loss B. tachycardia C. diaphoresis D. hypotension

B tachycardia

A nurse is caring for a client who is being treated with a cesium implant. The client tells the nurse, "I feel so isolated and alone in this room." After acknowledging the client's feelings of loneliness, which of the following responses should the nurse provide? A. "I will come and sit with you for 10 minutes each hour." B. "Do you have a cell phone you can talk to friends and family on?" C. "I'll ask the charge nurse to admit someone to your room for company." D. "You're scheduled for discharge in 2 days so this isolation will be over soon."

B. "Do you have a cell phone you can talk to friends and family on?"

A nurse in a pediatric unit is planning care for a group of clients. Which of the following clients should the nurse plan to use the Crying, Requires Oxygen, increased vital signs, expression, sleeplessness (CRIES) pain scale? A. a 4yo preschooler who had a tonsillectomy B. A 4 day old infant who had a repair of a birth defect C. a 10 yo client who had an appendectomy D. a 3 yo toddler who has a broken elbow

B. A 4 day old infant who had a repair of a birth defect CRIES is a good pain scale to monitor pain levels in infants.

A nurse is teaching a class about the use of pain medications for clients who have an opioid addiction. Which of the following medications are a nonopioid analgesic? select all that apply A. codeine B. Acetaminophen C. ibuprofen d. fentanyl e. oxycodone

B. Acetaminophen C. ibuprofen

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first? A. Call the clients provider B. Assess the client C. notify the nurse manager D. complete an incident report

B. Assess the client

A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects? A. Anorexia and malnutrition B. Bleeding from the gums C. Diarrhea and dehydration D. Full body alopecia

B. Bleeding from the gums Bleeding from the gums is directly related to myelosuppression due to inhibited bone marrow production of blood cells and platelets.

A nurse is caring for a client who is receiving hydromorphone HCL via PCA pump and reports continuous pain of 6 on a scale from 0 to 10. Which of the following actions should the nurse take first? A. Administer a bolus of medication B. Check the display on the PCA pump C. Obtain an order for another pain medication for breakthrough pain D. Encourage the client to administer a demand dose.

B. Check the display on the PCA pump

A nurse is planning to learn about a culture by observing the cultural practices from the outside. The nurse is planning to obtain which of the following types of information? A. Emic knowledge B. Etic Knowledge c. root cause analysis d. health disparity data

B. Etic Knowledge Etic knowledge is information about a culture obtained from an outsider observing cultural practices.

A nurse is preparing to review discharge instructions with a client who reports having hearing loss. Which of the following actions should the nurse plan to take? A. Stand next to the client when speaking B. Guide the client away from background noise C. Provide a copy of the instructions printed in Braille D. Repeat any phrases that the client misunderstands

B. Guide the client away from background noise

A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching? A. I will eat smaller meals if I feel nauseated B. I will eat foods that are served at room temperature C. I will drink more liquids with my meals D. I will increase the amount of unsaturated fats in my diet.

B. I will eat foods that are served at room temperature The nurse should instruct the client to eat foods served at room temperature or chilled. Foods served hot may contribute to nausea.

A nurse is teaching an older adult client who has a new prescription for a pain medication. Which of the following actions should the nurse take? A. provide the information at a 10th grade reading level B. Instruct the client to keep a pain diary C. Instruct the client to take pain medication after the pain becomes severe D. Provide written materials that are printed

B. Instruct the client to keep a pain diary

A nurse is observing an assistive personnel performing postmortem care for a client who is Muslim. Which of the following actions should prompt the nurse to intervene? A. Leaves dentures in the mouth B. Prepares to cleanse the body C. Disconnects the cardiac monitor D. removes soiled linens from the room.

B. Prepares to cleanse the body

A nurse is receiving a telephone prescription for a client from a provider. Which of the following actions should the nurse take when transcribing the prescription? A. repeat the prescription to the provider B. Read back the prescription to the provider C. Write the prescription in shorthand D. use the provider's initials after the prescription

B. Read back the prescription to the provider

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain? A. vital signs B. Self-report of pain C. Severity of the condition D. Nonverbal behavior

B. Self-report of pain

A nurse is providing education on priority setting framework to a group of newly licensed nurses. Which of the following statements should the nurse make regarding the acute vs. chronic priority setting framework? Select all that apply A. this framework helps clients to establish order in their individual environment B. This framework guides care by recognizing conditions that can worsen rapidly. C. this framework follows a specific algorithm for prioritizing care D. this framework recognizes when client conditions have less time to adapt E. this framework will guide your care using a sequential process.

B. This framework guides care by recognizing conditions that can worsen rapidly. D. this framework recognizes when client conditions have less time to adapt

A nurse is preparing an in-service about communication for a group of staff nurses. Which of the following techniques should the nurse include when discussing therapeutic communication? A. offering sympathy B. using silence C. offering personal opinions D. providing passive responses

B. Using silence

A nurse is caring for a client who had radiation therapy and is experiencing painful dermatitis. The nurse should identify the client is experiencing which of the following types of pain? A. neuropathic pain B. cancer pain C. acute pain D. Chronic pain

B. cancer pain

A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care? A. all visitors from entering the client's room B. fresh flowers and potted plants in the room C. oral fluid intake to between meals only D. Activities that could result in bleeding

B. fresh flowers and potted plants in the room Clients who are receiving chemotherapy and radiation therapy are likely to become immunocompromised as a result of neutropenia, a decreased white blood cell (WBC) count. Because micro-organisms are likely to be present on fresh flowers and plants, immunocompromised clients are instructed not to accept such gifts into the room. In addition, the client is instructed to eat only thoroughly cooked meats and thoroughly washed fruits and vegetables. Immunocompromised clients are more susceptible to infection and illness from food-borne bacteria than other clients.

A nurse is planning care for a client who has leukemia and a platelet count of 130,000/ mm 3. which of the following interventions should the nurse include in the plan of care? A. check the IV site for bleeding every 8 hrs B. Limit IM injections C. Obtain a rectal temperature every 8 hrs D. Check the client for proteinuria

B. limit IM injections The nurse should plan to limit IM injections or venipunctures to prevent harm to the client. If venipuncture is necessary, the nurse should hold pressure to the sire for 10 min afterward.

A nurse is caring for a 17 yo client who is experiencing a relapse of leukemia and is refusing treatment. the client's mother insists that the client receive treatment. Which of the following actions should the nurse take? A. initiate the IV per the parent's request B. notify the provider of the situation C. Administer a sedative to calm the client D. offer the client an antiemetic

B. notify the provider of the situation

A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take? A. review laboratory test results for low hemoglobin B. observe for signs of infection C. monitor the mouth for signs of xerostomia D. examine the skin for generalized urticaria

B. observe for signs of infection Radiation therapy to sites containing bone marrow (such as the sternum) can lower the WBC count (leukopenia), thus increasing the client's risk for infection. Screening the client for signs of infection is essential at this time.

A nurse is caring for a client who has chemotherapy- induced peripheral neuropathy. The nurse should expect the client to report having experienced which of the following symptoms? A. extremities that turned blue when exposed to cold B. tingling feeling in the extremities C. jerking movements of the extremities D. spasms of the extremities

B. tingling feeling in the extremities Peripheral neuropathy is a neurological disorder resulting from damage to the peripheral nerves. It may be caused by diseases of the nerves, systemic illnesses, or it may be a side-effect from chemotherapy. If a sensory nerve is damaged, the client is likely to experience pain, numbness, tingling, burning, or a loss of feeling in the extremities.

A nurse is discussing interprofessional collaboration with a group of nurses. The nurse should include that which of the following is a core competency of the Interprofessional Education Collaborative (IPEC)? a. autonomy b. values and ethics c. decision making d. shared governance

B. values and ethics

A nurse in a long-term care facility has assigned a task to an assistive personnel (AP). The AP refuses to perform the task. Which of the following is an appropriate statement for the nurse to make? A. "I feel you are being inconsiderate of the other team members." B. "I have to let the the director of nursing know about this situation." C. "I need to talk to you about the unit policies regarding client assignments." D. "You always get your choice of assignment and don't work your fair share."

C. "I need to talk to you about the unit policies regarding client assignments." This statement opens the conversation in a nonthreatening way and places the focus on the issue of policies rather than on any personal desire or characteristic of the individual.

A nurse is discussing factors that influence communication with a group of newly licensed nurses. Which of the following information should the nurse include? A. Hearing loss is considered a development factor that has minimal effect on nurse-client communication B. Nurses caring for clients experiencing a highly emotional situation report that communication is rarely affected. C. Nurses might focus on a client's physiological needs over psychosocial needs when communicating during care. D. Clients who have developmental deficits are less distracted by environmental noises than client who do not have these deficits.

C. Nurses might focus on a client's physiological needs over psychosocial needs when communicating during care.

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? A. lactated ringer's B. Dextrose 5% in 0.9 sodium chloride C. 0.45% sodium chloride D. Dextrose 10% in water

C. 0.45% sodium chloride A client who has an elevated sodium level and is NPO requires a hypotonic IV solution, such as 0.45% sodium chloride or 0.225% sodium chloride.

A nurse is reviewing a client's laboratory values and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate? A. initiating an IV potassium infusion. B. Encouraging the client to eat bananas C. Administering sodium polystyrene sulfonate D. Administering a potassium- sparing diuretic

C. Administering sodium polystyrene sulfonate The nurse should expect to administer sodium polystyrene sulfonate, which absorbs excessive potassium and excretes it through the stool. Other treatments include hemodialysis and IV glucose and insulin.

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? A. an upper respiratory infection B. pulmonary edema C. Atelectasis D. delayed gastric emptying

C. Atelectasis

A nurse is preparing an advocacy plan of care for a client. Which of the following actions should the nurse plan to take first? A. communicate the client's needs to other members of the health care team. B. Verify the client's goals C. Determine the client's needs. D. Conduct an evaluation of the outcomes of the plan.

C. Determine the client's needs.

A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take? A. perform suctioning for up to 4 passes B. apply suction to the catheter when advancing it into the trachea C. preoxygenate the client with 100% oxygen for up to 3 min D. limit each suction pass to 25 seconds.

C. preoxygenate the client with 100% oxygen for up to 3 min

A nurse is teaching a newly licensed nurse about a nonrebreather oxygen mask. Which of the following instructions should the nurse include? A. a nonrebreather mask dries a client's mucous membranes B. The reservoir bag on a nonrebreather mask should collapse with exhalation. C. a nonrebreather mask should fit snugly over a client's face D. Use a nonrebreather mask to deliver low-flow oxygen

C. a nonrebreather mask should fit snugly over a client's face

A nurse is caring for a child who has a trach. After suctioning the trach, the nurse should use which of the following findings to determine that the procedure was effective? A. increased RR B. stable oxygen sat C. clear breath sounds D. Brisk capillary refill

C. clear breath sounds

A nurse in the ED is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these findings are consistent with which of the following conditions? Na= 152 , k= 3.6, Cl=105, glucose=102, BUN=18, Creat=0.7 A. Renal failure B. Low-protein diet C. Dehydration D. syndrome of inappropriate antidiuretic hormone (SIADH)

C. dehydration

A nurse is caring for a client who has an O2 sat of 88%. which of the following actions should the nurse take? A. request a prescription for an opioid analgesic B. decrease the head of the client's bed C. encourage the client to take deep breaths D. ask the client to cough every 4 hrs

C. encourage the client to take deep breaths

A nurse is preparing a client for a radiation treatment who is post operative following a mastectomy. the nurse should inform the client to expect which of the following adverse effects from the treatment? A. alopecia b. diarrhea c. fatigue d. anorexia

C. fatigue

A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings? A. decreased urine specific gravity B. decreased Hgb C. increased BUN D. Increased urine ketones

C. increased BUN

A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? A. Blockage of the ET tube by the client's tongue B. Passage of the ET tube into the esophagus C. movement of the ET tube into the right main bronchus D. Infection of the vocal cords

C. movement of the ET tube into the right main bronchus

A nurse is caring for a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicate the intervention was effective? A. respiratory rate 28/min B. Restlessness C. pink mucous membranes D. Heart rate 110/min

C. pink mucous membranes

A nurse is providing a handoff report using the introduction, situation, background, assessment, recommendation, and readback (I-SBSR-R) on a client. Which of the following information should be included in the situation component? A. request prescription for opioid medication for pain relief B. client admitted with ruptured disc at L5 C. provider notified of client's back pain D. Client is grimacing due to pain

C. provider notified of client's back pain

A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? A. hypotension B. numbness C. shivering D. reduced blood viscosity

C. shivering

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer? A. lactulose B. sevelamer C. sodium polystyrene D. darbepoetin alfa

C. sodium polystyrene Sodium polystyrene is used for the treatment of hyperkalemia., It removes excess potassium by ion exchange through the bowel. The client's serum potassium level of 6.8 mEq/L is significantly above the reference range of 3.5 - 5.0 mEq/L..

A nurse is teaching a class about professionalism. The nurse should include that leaving a computer terminal unattended after logging on is an example of which of the following? A. defamation of character B. malpractice C. unprofessionalism D. negligence

C. unprofessionalism

A nurse is caring for a 3 yo child who was admitted with acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective? A. heart rate 130/min B. Respiratory rate 24/min C. urine specific gravity 1.015 D. capillary refill greater than 3 seconds

C. urine specific gravity 1.015

A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment? A. sodium 165 meq/l B. potassium 5.2 meq/l C. urine specific gravity 1.020 D. Hct 62%

C. urine specific gravity 1.020

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? A. hyperactive reflexes B. extreme thirst C. Weak, irregular pulse D. hyperactive bowel sounds

C. weak irregular pulse

A nurse is caring for a client who has fallen out of their hospital bed. 1030:Client admitted to the medical-surgical unit yesterday for syncope. Client fell out of bed while trying to get up without assistance. Client is confused to person and place. Requires frequent reorientation. Call light is within reach; however, frequent reminders to use the call light is required. Client's room is close to nurses' station for close monitoring. Client has bruising on left knee. Skin is intact. Vitals signs obtained. Bed alarm applied to bed and raised x2 siderails. 1030:Blood pressure 132/68 mm Hg Heart rate 72/min Respiratory rate 22/min Temperature 37.1º C (98.9º F) Oxygen saturation 92% on room air After the nurse has assessed the client, which of the following actions should the nurse take? Select all that apply A. document the occurrence in the client's medical record B. include your opinion of the occurrence on the incident report C. write factual statements in the incident report D. Notify the client's provider of the incident E. notify the charge nurse before filing the incident report.

C. write factual statements in the incident report D. Notify the client's provider of the incident E. notify the charge nurse before filing the incident report.

A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission? A. 3.1 mg/dL B. 10 mg/dL C. 16.5 mg/dL D. 35 mg/dL

D. 35 mg/dL

A nurse is teaching a newly licensed nurse about ethical principles. Which of the following is an example of beneficence? A. a nurse provides nonpharmacological pain interventions to each client equally. B. A nurse fulfills a promise to a client that they will return with their pain medication. C. A nurse gives a client the choice to take a pain medication via intramuscular or oral route. D. A nurse administers scheduled pain medication for a client who is having pain.

D. A nurse administers scheduled pain medication for a client who is having pain. Beneficence is doing good or acting in the best interest of the client.

A nurse is teaching a newly licensed nurse about ethical principles. Which of the following is an example of autonomy? A. a nurse administers a scheduled pain medication for a client who is having pain. B. a nurse fulfills a promise to a client that they will return with their pain medication. C. A nurse provides nonpharmacological pain interventions to each client equally. D. A nurse gives a client the choice of when to take a pain medication.

D. A nurse gives a client the choice of when to take a pain medication.

A nurse is teaching a newly licensed nurse about ethical principles. Which of the following is an example of justice? A. a nurse administers scheduled pain medication for a client who is having pain. B. A nurse gives a client the choice to take a pain medication via intramuscular or oral route. C. A nurse fulfills a promise to a client that they will return with their pain medication D. A nurse provides nonpharmacological pain interventions to each client equally.

D. A nurse provides nonpharmacological pain interventions to each client equally. Treating each client equally is an example of the ethical principle of justice. The nurse should provide fair and adequate pain relief to clients regardless of age, ethnicity, or history, such as substance use disorder, or limited social and economic resources.

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level? A. pulse and blood pressure findings B. Behavioral indicators and effect C. scheduled treatments and client illness D. A self-report pain rating scale

D. A self-report pain rating scale

A nurse is performing a medication reconciliation while admitting an older adult client transferred from a long-term care facility. Which of the following should the nurse identify as part of the medication reconciliation process? A. discontinuation of medications B. medications for another pharmacy C. recommendation for prescribed medications D. medications from another facility

D. medications from another facility

A nurse receives a call from a parent of a child who has von Williebrand disease and has having a nosebleed. Which of the following instructions should the nurse give to the parent? A. place your child in a sitting position with her head tilted back B. Apply ice at the base of the nose for 5 min and then check for bleeding C. place your child in a supine position with a pillow under her head D. Have your child sit with her head tilted forward and hold pressure on her nose for 10 min.

D. Have your child sit with her head tilted forward and hold pressure on her nose for 10 min.

A nurse is discussing advancing interprofessional communication on the unit. Which of the following should the nurse identify as a barrier to this adjustment? A. Burnout B. privacy laws C. Scope of practice D. Misunderstanding of roles

D. Misunderstanding of roles

A nurse is teaching a client who has a prescription for home oxygen therapy. Which of the following instructions should the nurse include? A. Use petroleum-based ointments to moisturize lips B. keep oxygen tanks 4 ft away from an electric stove C. Choose a wool blanket when using oxygen D. Store oxygen tanks upright

D. Store oxygen tanks upright

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? A. the client who has been NPO since midnight for endoscopy. B. The client who has left sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/ml C. The client who has end-stage renal failure and is scheduled for dialysis today D. The client who has gastroenteritis and is febrile.

D. The client who has gastroenteritis and is febrile. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration.

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. which of the following findings should the nurse recognize as a potential causative factor? A. a client is currently prescribed spironolactone. B. a client has a history of alcohol abuse disorder C. client reports drinking 3.5 to 4 L of water each day D. client has an NG tube to gastric suction

D. client has an NG tube to gastric suction

A nurse is assessing a client who is nonverbal for acute pain. Which of the following findings is a manifestation of pain? A. decreased heart rate B. reduced respiratory rate C. constricted pupils D. elevated blood pressure.

D. elevated blood pressure

A nurse on a med-surg unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer? a. delivering meal trays to clients in their rooms b. assisting a client who has difficulty seeing the foods on the tray while eating c. delivering a routine urine specimen to the laboratory D. observing a postoperative client who is confused

D. observing a postoperative client who is confused

A nurse is discussing time management strategies with another nurse. The nurse should include which of the following as an example of a time management strategy? A. Skip a meal break to catch up on charting B. Offer to complete another nurse's task. C. complete the easiest tasks first D. plan time for disruptions

D. plan time for disruptions

A nurse is assessing a client prior to administration of morphine. the nurse should recognize that which of the following assessments is the priority? A. pupil reaction B. urine output C. bowel sounds D. respiratory rate

D. respiratory rate.

A nurse is reviewing the medication administration records of four clients who have a prescription for morphine PRN. which of the following findings should the nurse identify as a contraindication to this medication? A. the client is experiencing a myocardial infarction B. the client who is 24 hr post op following hip arthroplasty C. the client who has bronchitis pleurisy D. the client has a paralytic ileus

D. the client has a paralytic ileus Morphine is contraindicated in clients who have a paralytic ileus because morphine suppresses the propulsive contractions of the intestinal tract and inhibits secretion of fluids into the intestinal tract.

A nurse is caring for a client who has sustained blood loss. Which of the following is a manifestation of hypovolemia? A. decreased HR B. dyspnea C. increased BP D. weak pulse

D. weak pulse

A nurse is caring for a client who has a fractured hip and a respiratory rate of 26/min. Which of the following actions should the nurse take first? a. evaluate LOC b. place the client on bed rest c. encourage increased fluid intake d. initiate continuous ECG monitoring

a. evaluate LOC Clients who have a fractured hip are at risk for fat embolism syndrome because of the release of fat globules from the yellow bone marrow. These globules enter the blood stream where they can travel and occlude small vessels and impair perfusion to vital organs, including the lungs. A change in the level of consciousness is the earliest manifestation of fat embolism syndrome.

A nurse is caring for a child who has sickle cell disease and has been admitted in a vaso-occlusive crisis. Which of the following is the nurse's priority concern? A. promoting oxygenation b. management of pain c. maintaining hydration d. preventing infection

a. promoting oxygenation

A nurse in the rehabilitation center is caring for a client who has just had a cerebrovascular accident. Based on a review of the client's medical record, which of the following findings should be immediately reported to the provider? a. temperature 99.8F b. blood glucose level 144mg/dl c. dry mouth d. headache

a. temperature 99.8F

A nurse has been assigned to care for four clients on a medical-surgical floor. Which of the following clients should the nurse evaluate first? A. a client 48 hr following abdominal surgery with redness and swelling at the edges of the incision b. a client following knee replacement surgery complaining of pain and warmth in the calf c. a client admitted with cholecystitis who reports frequent N and V. d. a client admitted w a GI bleed receiving packed RBC's for hemoglobin of 7.8 gm/dl

b. a client following knee replacement surgery complaining of pain and warmth in the calf

A nurse is reviewing the laboratory results of four clients. Which of the following should be immediately reported to the provider? A. a client who has DM with a fasting blood glucose of 150 mg/dl b. a client who is prescribed digoxin and furosemide with a potassium of 3.1 mEq/L c. a client who is prescribed oxygen therapy and albuterol with a PCO2 of 50 mmHg d. a client who has urosepsis with a WBC count of 15,000 mm

b. a client who is prescribed digoxin and furosemide with a potassium of 3.1 mEq/L

A nurse is preparing to provide tracheostomy care for a client who has nondisposable tracheostomy tube. Which of the following equipment should the nurse plan to use? select all that apply A. sterile cotton balls B. clean gloves C. sterile water D. sterile cotton-tipped applicators E. sterile basin

b. clean gloves, D. sterile cotton-tipped applicators, E. sterile basin

A nurse is caring for a client who is from a culture different than his own. Which of the following actions by the nurse is most important in the provision of culturally competent care? A. include the family in the client's care b. identify one's own beliefs and values c. determine the client's cultural beliefs d. encourage the client to discuss the influence of illness on cultural practices

b. identify one's own beliefs and values

A nurse is teaching a newly licensed nurse about ethical principles. The nurse should include that working to not cause harm to a client, while trying to achieve the best possible outcome, is an example of which of the following ethical principles? A. fidelity b. nonmaleficence C. justice D. autonomy

b. nonmaleficence

Following morning report, a nurse assigns completion of several tasks to an assistive personnel (AP). Which of the following tasks should the nurse have the AP perform first? A. bathe a client who is scheduled for physical therapy at 9am b. perform the fingersticks for glucose levels on clients who have DM c. Stock procedure rooms d. distribute clean linens.

b. perform the fingersticks for glucose levels on clients who have DM

A nurses caring for a client who is newly diagnosed with bipolar disorder and is currently experiencing an acute manic episode. Which of the following is a priority concern of the nurse? A. enhancing self esteem b. preventing injury c. encourage problem solving d. promoting usefulness

b. preventing injury

A nurse checks a client to evaluate the effectiveness of a pain medication. Which of the following components of professionalism is the nurse demonstrating? A. confidence B. responsibility C. advocacy D. fairness

b. responsibility

A nurse is reinforcing teaching regarding foods containing complete protein to a client. Which of the following should be included in the teaching? A. lentils b. soybeans c. broccoli d. oatmeal

b. soybeans

A school nurse is reinforcing teaching regarding bicycle safety to a group of school age children. Which of the following is the most important concept to include in the teaching? A. place proper lights and reflectors on the bicycle b. use a proper fitted bicycle helmet c. wear light-colored clothing at night d. use hand signals when turning

b. use a proper fitted bicycle helmet

A nurse working the 7 PM to 7 AM shift on the pediatric unit has received report on four post operative clients. Which of the following requires immediate intervention? A. an adolescent who is post op following an appendectomy and has refused to ambulate for the past 8 hr b. a school age child who is postop following a herniorrhaphy with an infiltrated peripheral IV that has been clamped c. a preschooler who is post op following a tonsillectomy and is experiencing frequent swallowing d. an infant who is post op following a cleft palate repair with a heart rate of 146/min and a respiratory rate of 28/min

c. a preschooler who is post op following a tonsillectomy and is experiencing frequent swallowing - remember to catch that d is an infant and A preschooler who is experiencing frequent swallowing following a tonsillectomy could be bleeding, placing the client at risk for hemorrhage. Bleeding from the surgical site can cause the dripping of blood down the back of the throat, which results in frequent swallowing or clearing of the throat and indicates the client could be unstable.

A nurse is caring for a client who is 48 hr post op from an abdominal aortic aneurysm resection. Which of the following findings is the most urgent? A. absent bowel sounds b. serun BUN level 22 mg/dl c. absent dorsalis pedis pulses d. Serum creatinine level of 1.3 mg/dl

c. absent dorsalis pedis pulses

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? a. reposition the client b. administer the medication c. determine the location of the pain d. review the effects of the pain medication

c. determine the location of the pain

A public health nurse is triaging clients at the site of an explosion. The client with which of the following injuries should be the nurses priority concern? A. facial abrasions b. penetrating head wound c. incomplete amputation of the foot d. tibia fracture requiring open reduction

c. incomplete amputation of the foot

A nurse is caring for toddler who has laryngotracheobronchitis and is having difficulty breathing. Which of the following should be the first action of the nurse? A. administer nebulized epinephrine (racemic epinephrine) b. ensure adequate hydration c. obtain an oxygen saturation level d. encourage parents to comfort the client

c. obtain an oxygen saturation level

A nurse is caring for a client who was admitted to the unit three hours ago following a total hip arthroplasty. Which of the following findings should be the nurse's priority concern? A. urinary output of 75 ml over the past 3 hrs b. 8 pt elevation in the pre-surgery diastolic bp c. oxygen saturation of 90% on oxygen at 2L per NC d. core body temp of 36.2 (97.2F)

c. oxygen saturation of 90% on oxygen at 2L per NC

A nurse is assisting with the care of a client who is in labor. Following spontaneous rupture of membranes, the nurse visualizes the umbilical cord protruding from the vagina and the fetal heart rate is 50/min. After calling for assistance and notifying the provider, which of the following is the priority action by the nurse? A. wrap the cord in a towel saturated with 0.9% sodium chloride b. apply oxygen via face mask c. place client in knee-chest position d. increase IV fluid rate

c. place client in knee-chest position

A nurse caring for a client who has been off the unit for physical therapy for the past hour notes that the infusion pump for the client's total parenteral nutrition (TPN) is turned off. The client tells the nurse that the battery went dead while she was in physical therapy. The nurse should monitor the client for which of the following manifestations? A. HTN and crackles b. excessive thirst c. shakiness and diaphoresis d. twitching muscles

c. shakiness and diaphoresis

A nurse is reinforcing teaching to parents of a child who is admitted with rheumatic fever. Which of the following statements by the parent indicates a need for further teaching? A. my child will need to be followed medically for at least 5 yrs b. my child can resume moderate activity after his fever subsides c. this illness will not recur because my child has now had it d. in a few weeks or months my child could experience sudden, involuntary movements

c. this illness will not recur because my child has now had it

A nurse is a caring for a client who has borderline personality disorder. Which of the following is a manifestation of the disorder? A. grandiose sense of self importance b. reckless disregard for safety of others c. unstable interpersonal relationships d. lack of empathy

c. unstable interpersonal relationships

A nurse is caring for a client who has a compound fracture of the tibia and fibula and is in skin traction. The client reports pain of a 6 on a scale of 0 to 10 under the traction bandage. Which of the following actions should the nurse take first? A. administer an analgesic b. assist the client to shift positions c. check pedal pulse d. distract the client with music therapy.

check pedal pulse

A nurse on a medical unit has received report on four clients. Which of the following clients should the nurse evaluate first? A. a client who has COPD with an oxygen saturation of 90% b. a client who has DM with a HbA1C of 9% c. a client who has HF w 2+ pitting edema of the lower extremities d. A client who has a fever of 38.4 C (101.2 F) with tenderness in the Right lower quadrant.

d. A client who has a fever of 38.4 C (101.2 F) with tenderness in the Right lower quadrant. This question reminds nurses to think acute v. chronic priority setting framework.

A nurse is reinforcing teaching about methods to decrease nausea to a client who is receiving chemotherapy. Which of the following statements by the client indicates a need for further teaching? A. "I should eat frequently" B. I should avoid eating 1-2 hrs prior to my treatment c. i should eat foods served cold d. I should eat low carbohydrate foods

d. I should eat low carbohydrate foods

A nurse in a providers office is collecting data on a group of clients who are pregnant. Which of the following clients should be the nurses priority concern? a. a client who is 26 wks of gestation and reporting leukorrhea b. a client who is 10 wks of gestation and reporting urinary frequency c. a client who is 37 wks of gestation and reporting perineal discomfort d. a client who is 34 wks of gestation and reporting abdominal tenderness

d. a client who is 34 wks of gestation and reporting abdominal tenderness Abdominal, or uterine tenderness, is an early clinical finding associated with abruption placenta, which could lead to an unstable status.

A nurse is caring for a group of pediatric clients. which of the following requires immediate intervention? A. a client who has cystic fibrosis and has a paroxysmal cough b. a client who has prescribed cromolyn sodium (Crolom) and has a peak expiratory flow rate of 79% c. a client who has celiac disease and abdominal distention d. a client who is prescribed digoxin (lanoxin) and has had three episodes of vomiting

d. a client who is prescribed digoxin (lanoxin) and has had three episodes of vomiting

A nurse is collecting data on a client who has a diagnosis of myasthenia gravis. For which of the following complications is it most important for the nurse to monitor? A. diplopia b. loss of bladder control c. paresthesias d. decreased respiratory effort

d. decreased respiratory effort

A nurses caring for a client who is experiencing panic level anxiety. Which of the following actions should the nurse take first? A. administer an anti-anxiety medication b. take the client to a place of seclusion c. obtain an order for soft wrist restraints d. engage the client in physical activity

d. engage the client in physical activity Think least restrictive and invasive nursing intervention

A nurse is assessing a client who is postoperative following a gastric bypass. Which of the following findings indicates the client could be experiencing an anastomotic leak? A. lethargy b. neuralgia c. bradycardia d. oliguria

d. oliguria

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations? A. finger B. earlobe C. toe D. skin fold

earlobe The earlobe is rarely edematous, is the least affected by decreased blood flow, and has greater accuracy when measuring oxygen saturation.

A nurses caring for a client who has a radial head fracture. Which of the following should be the priority action by the nurse following application of the cast? A. promote adequate intake of calcium b. Evaluate neurovascular status c. elevate the extremity above the heart d. apply ice intermittently for the first 24 hrs

evaluate neurovascular status

A nurse is caring for a client who is prescribed lithium (Eskalith). Which of the following clinical findings should be immediately reported to the provider? A. fine hand tremors b. mild thirst c. weight gain d. slurred speech

slurred speech

A nurse is caring for a client who is admitted with acute alcohol withdrawal. Which of the following findings should the nurse report to the provider? A. tachycardia b. vomiting c. hypotension d. dilated pupils

tachycardia