PassPoint PrepU

A client with hyperemesis gravidarum is on a clear liquid diet. The nurse instructs the unlicensed assistive personnel (UAP) to observe her tray for which food selections?

tea and gelatin

A school-age child has a fever, joint inflammation, and a nonpruritic rash. Knowing that these are signs of rheumatic fever, the nurse should ask the parents:

"Has your child had strep throat recently?"

A nurse is reinforcing education to a client diagnosed with renal calculi. Which statement made by the client suggests further instruction is indicated?

"I do not need to limit my intake of tea or cola."

The health care provider has just removed the cast from a client's lower leg. During the removal, a small superficial abrasion occurred over the ankle. Which statement by the client indicates the need for additional client education?

"I must use a moisturizing lotion on the dry areas."

A nurse is reinforcing the education plan with the parent of a child who has asthma triggered by a dust mite allergy. Which statement by the parent indicates that education has been effective?

"I'll wash all of the bedding in hot (130° F (54 degrees C)) water every week."

Which statement made by a parent of a child with short stature would indicate to the nurse the need for further education?

"Obtaining blood studies won't aid in proper diagnosis."

A client is admitted to the hospital in the manic phase of bipolar disorder. Which foods are most appropriate for this client?

A cheese sandwich, carrot sticks, grapes, and cookies

The nurse reinforces instructions about how to feed a client with a self-care deficit for the client's family members. Which instruction should the nurse stress to the family?

Determine which foods the client tolerates best and offer those foods.

The nurse is caring for a client with a fever of 103°F (39°C) due to a respiratory infection. The client states, "I am freezing and I have a terrible headache!" What is the appropriate nursing action?

Administer acetaminophen as prescribed.

Which nursing action should be included in the care plan to promote comfort in a 4-year-old child hospitalized with meningitis?

Avoid making noise when in the child's room.

When teaching the mother of a 17-month-old child about toilet training, which instruction would initially be most appropriate?

Be sure the child is ready before starting to toilet train.

An older adult client has experienced an episode of acute pulmonary edema. Fearful of a repeat episode, the client asks what precautions should be taken to prevent another episode. What instruction should the nurse give to this client?

Call the health care provider if he gains more than 3 lb (1.4 kg) in 1 day.

The nurse is caring for a neonate with a tracheoesophageal fistula who has undergone repair surgery. Postoperatively, which nursing intervention should be implemented first?

Change the infant's position every 2 hours from the back to either side, keeping the head slightly elevated.

A 9-year-old child is being discharged from the hospital after severe urticaria caused by an allergy to nuts. Which instructions would be included in discharge education for the child's parents?

Instruct parents and child on how to use an epinephrine administration kit.

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?

Expect protamine sulfate to be ordered.

When contributing to the development of an education session on glaucoma for the community, which statement would the nurse emphasize?

Glaucoma can be painless with loss of peripheral vision.

The nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care?

Using a peri bottle to clean the perineum after each voiding or bowel movement

The nurse is assisting a client with ambulation in the hallway. The client walks 10 feet and becomes short of breath. The nurse performs a pulse oximetry check, and the results are 86% oxygen saturation. What is the priority action by the nurse?

Have the client sit in a chair and apply supplemental oxygen as ordered prn.

A nurse is reinforcing information about breastfeeding and ways to prevent breast engorgement with a postpartum client. Which client statement best indicates to the nurse that the client understands how to prevent this condition?

I'll be sure to breastfeed every 2 to 3 hours."

For an 8-month-old infant, which toy promotes cognitive development?

Jack-in-the-box

The nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct?

Maintain a high-carbohydrate, low-fat diet."

A client with hyperparathyroidism declines surgery and is to receive hormone replacement therapy with estrogen and progesterone. Which instruction would be most important to include in the client's teaching plan?

Maintain a moderate exercise program.

A nurse is caring for a client during the fourth stage of labor. Which intervention by the nurse can prevent uterine atony?

Massage the fundus.

A client who fell while washing windows has a fractured right ankle that requires a cast. After assisting with the cast application, the nurse should reinforce which instructions to the client?

Move the right toes for several minutes every hour.

A neonate of a diabetic mother was born full-term and weighing 10 lb, 1 oz (4.6 kg). While caring for this large-for-gestational age (LGA) neonate, the nurse checks the clavicles for which reason?

One of the neonate's clavicles may have been broken during birth.

The nurse is inserting an indwelling catheter into a female client before a surgical procedure. There is difficulty with the insertion and the nurse inserts the catheter into the vagina. Which action by the nurse should be performed next?

Perform the procedure again using a new catheter and kit.

A 33-year-old male client on a psychiatric unit throws a chair at a staff member and shouts, "If any of you come close to me, I'll make sure that you never walk again." What is the nurse's first priority?

Placing the client in restraints with the assistance of other staff members who are specially trained in restraint application

The nurse is caring for a client who reports of lower back pain. Which instructions should the nurse give the client to prevent back injury?

Stand close to the object you are lifting."

A client is reporting severe flank, abdominal pain and is diagnosed with urolithiasis. Which intervention should the nurse instruct the client to perform?

Strain all urine.

During a teaching session, the nurse demonstrates how to change a tracheostomy dressing. Then, the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure?

The client cleans around the incision site, using gauze squares moistened with normal saline.

A client who is paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?

The client uses a mirror to inspect skin.

A nurse instructs a pregnant client about the importance of doing frequent pelvic floor muscle exercises (Kegel exercises). Pelvic floor muscle exercises are important for which reason?

They help maintain good perineal muscle tone by tightening the pubococcygeus muscle

A client who is being treated for unilateral lower extremity deep vein thrombophlebitis is being discharged. Which statement made by the client indicates to the nurse that additional discharge education is needed?

Tight compression hose rolled down behind the knee won't fall down and improves the circulation in my legs."

A nurse is caring for a client with left-sided heart failure. Which intervention takes priority in this client's care?

administering diuretics

The nurse correctly instructs a client with peripheral vascular disease that stress-reduction techniques:

are helpful because stress stimulates the release of vasoconstricting catecholamines.

An infant is diagnosed with a congenital hip dislocation. The nurse should expect to note:

asymmetrical thigh and gluteal folds.

A client is admitted to the labor unit in early labor. The nurse would encourage the client to assume which position to promote tissue perfusion?

side-lying

A client presents to the emergency department with weight gain, lethargy, and goiter. When reviewing laboratory values, in which major mineral would the nurse anticipate this client to be deficient?

iodine

A primigravida client is in labor. Her cervix is 5 cm dilated and 75% effaced; the fetus is at 0 station. The client requests medication to relieve the discomfort of contractions, and the health care provider prescribes an epidural regional block. When assisting with the procedures, which position should the nurse help the client to assume when the epidural is administered?

lateral

The nurse is caring for a neonate of a diabetic mother. For which condition should the nurse monitor the neonate?

macrosomia

A client diagnosed with glossitis is prescribed a diet high in folic acid. When assisting with the development of a teaching plan for this client, which food products will the nurse reinforce to fulfill the need for increased folic acid?

spinach

A nurse is collecting past medical history data on a client. Which preexisting condition places the client at risk for colorectal cancer?

polps

A postpartum client is scheduled for discharge tomorrow. The nurse is reinforcing discharge instructions with the client. The nurse determines that the client understands the information when stating that she will report which finding to her health care provider?

redness, warmth, and pain in a breast

A nurse gathers data on a client who has developed a paralytic ileus. Which type of bowel sounds should the nurse anticipate hearing?

three to four peristaltic sounds per minute

An unconscious client is admitted to the emergency department. The nurse suspects which source is the cause of airway obstruction in this client, as it is the most common source of airway obstruction in the unconscious victim?

tongue

The nurse correctly identifies which as belonging to the dorsal cavity?

vertebrae canal

A child's parents state that they childproofed their home for their 2-year-old boy. During a home visit, the nurse discovers some situations that show the parents don't fully understand the developmental abilities of their toddler. Which of the following situations displays misunderstanding by the parent?

Toy chest in front of a second-story, locked window

A 9-month-old admitted with pneumonia cries when his parents aren't holding him. He's also unable to sleep. The parents have two other young children at home and can't stay with the infant continually. Which suggestion by the nurse might help the infant sleep?

can one of you stay and the other go home?

Which intervention takes priority when caring for a neonate immediately after birth?

covering the neonate's head with a cap

The nurse is gathering data from a neonate. The nurse determines that the neonate is adequately hydrated based on which finding?

smooth and soft skin

A nurse is caring for a client with anorexia nervosa who requires a high-protein, high-calorie diet. When offering appropriate choices for snacks, which snack would be best for this client?

egg salad and peanuts

When caring for a client with the nursing diagnosis Impaired swallowing related to neuromuscular impairment, the nurse should:

elevate the head of the bed 90 degrees during meals.

A nurse is reinforcing education for a client on how to perform tracheostomy care. What is the most important principle of client education that the nurse needs to utilize?

Determine the client's readiness to learn new information.

A family of four involved in a house fire is brought to the hospital for treatment of burns. The local media arrives at the hospital requesting information about the condition of the family members. Which response by the nurse is most appropriate?

"I need to obtain permission from the parents or their representative before I can release any information."

An oncology nurse educator is speaking to a women's group about breast cancer. Questions and comments from the audience reveal a misunderstanding of some aspects of the disease. Various members of the audience have made all of the following statements. Which statement is accurate?

Men can develop breast cancer.

A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first?

Notify hospital security or the local authorities.

A client has just undergone a bronchoscopy. Which priority nursing intervention will the nurse perform at this time?

chech airway

The nurse is performing a dressing change as prescribed for a client with a red, granulating foot ulcer. Which action should the nurse perform when changing the dressing?

clean with normal saline

A nurse is caring for a client with multiple myeloma. Which intervention should be stressed when reinforcing education to the client?

drinking 3 qt (2.8 L) of fluid daily

nurse is caring for a hypertensive client who has been placed on a low-sodium diet. Which menu selection demonstrates the client's understanding of this diet?

fresh green beans and chicken salad