Practice Bank 1-15
An RN from the women's wellness health clinic is temporarily reassigned to an adult medical-surgical unit. Which of these client assignments would be appropriate for this nurse? A newly diagnosed client with type 2 diabetes mellitus who is learning foot care A newly admitted client with a diagnosis of pancreatic cancer and severe dehydration A client admitted for a barium swallow after a transient ischemic attack (TIA) A client from a motor vehicle accident with an external fixation device on the leg
A client from a motor vehicle accident with an external fixation device on the leg
The nurse, who is participating in a community health fair, assesses the health status of attendees. When would the nurse conduct a mental status examination? There are obvious signs of depression As part of every health assessment The individual displays restlessness The individual reports memory lapses
As part of every health assessment
A 25 year-old client, who is unresponsive after diagnosis of traumatic brain injury, is to be transferred from the hospital to a long-term care facility (LTC) today. To which staff member should the charge nurse assign this client? Unlicensed assistive personnel (UAP) Registered nurse (RN) Nursing student in final semester before graduation Licensed practical nurse (LPN)
Registered nurse (RN)
The nurse is caring for a client in a home setting. Which action is most likely to ensure the safety of the nurse during a home visit? Carry a cell phone, pager and/or hand-held alarm Remain alert and leave if cues suggest the home is not safe Review documentation for previous entries about violence Observe for evidence of weapons in the home
Remain alert and leave if cues suggest the home is not safe
As a client is being discharged following resolution of a spontaneous pneumothorax, the client tells a nurse, "I'm going to Hawaii for a vacation next week." The nurse should warn the client to avoid which activity? Swimming Scuba diving Surfing Parasailing
Scuba diving
A nurse is planning care for a 2 year-old hospitalized child. Which issue will produce the most stress at this age? Loss of control Separation anxiety Bodily injury Fear of pain
Separation anxiety
The nurse assesses a full-term, 30 hour-old newborn and reviews its lab results. The nurse knows that the first-time mother is Rh negative and is breastfeeding exclusively. Which of these findings is a priority to report to the health care provider? Positive Coombs test Jaundice is observed Serum bilirubin of 11 mg/dL (188 mmol/L) Hematocrit 52%
Serum bilirubin of 11 mg/dL (188 mmol/L)
A nurse is reviewing laboratory results on a client diagnosed with acute renal failure. Which lab result should be reported immediately? Venous blood pH 7.30 Serum potassium 6 mEq/L (6 mmol/L) Hemoglobin of 9.3 mg/dL (93 g/L) Blood urea nitrogen 50 mg/dL (17.9 mmol/L)
Serum potassium 6 mEq/L (6 mmol/L)
The nurse is caring for a client in the late stages of amyotrophic lateral sclerosis (ALS). Which finding would the nurse expect? Confusion Shallow respirations Tonic-clonic seizures Loss of half of visual field
Shallow respirations
A nurse is working in an OB-GYN clinic. A 40 year-old woman in the first trimester of an unplanned pregnancy provides a health history to the nurse. Which information should receive priority attention? She has been taking an ACE inhibitor for her blood pressure for the past two years. Her father and brother have type 1 diabetes She has taken 800 mcg of folic acid daily for the past year Her husband was treated for tuberculosis as a child
She has been taking an ACE inhibitor for her blood pressure for the past two years.
A nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first? Smoking cessation Stress management Physical exercise Weight reduction
Smoking cessation
A nurse is speaking at a community meeting about personal responsibility for health when a participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse's response? Exercise of joints Spinal column manipulation Mind-body balance Electrical energy fields
Spinal column manipulation
A client has just returned to the medical-surgical unit postop for a segmental lung resection. After assessing the client, which is the first action the nurse should take? Apply the pulse oximeter and monitor oxygen saturation Assist the client to turn, deep breathe and cough Suction excessive tracheobronchial secretions Administer the PRN pain medication
Suction excessive tracheobronchial secretions
The client is prescribed dexamethasone by mouth every other day and asks the nurse for more information about the medication. What information would the nurse want to share with the client? (Select all that apply) Take the medication with food Do not get any immunizations or skin tests Mark your calendar to keep track of doses Take the medication at bedtime Avoid dairy products
Take the medication with food Mark your calendar to keep track of doses
A client is transported to the emergency department after a motor vehicle accident. When assessing the client 30 minutes after admission, the nurse notes several physical changes. Which finding would require the nurse's immediate attention? Tracheal deviation Tachypnea Tachycardia Increased restlessness
Tracheal deviation
During the change-of-shift report, the assigned nurse notes a client of the Catholic religion is scheduled to be admitted for the delivery of a ninth child. Which comment made by a nurse indicates an attitude of prejudice? "All those people indulge in large families!" "I guess she doesn't understand how to use birth control." "I think she needs to go to the city hospital." "I wonder who is paying for this trip to the hospital?"
"All those people indulge in large families!"
The nurse is caring for a 4 year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best comment by the nurse should include which point? "Bones of children are more porous than adults' and often have incomplete breaks." "Compression of porous bones produces a buckle or torus type break." "A child's bone is more flexible and can be bent 45 degrees before breaking." "Bone fragments often remain attached by a periosteal hinge."
"Bones of children are more porous than adults' and often have incomplete breaks."
The mother of a 4 month-old infant asks the nurse about the dangers of sunburn while they are on vacation at the beach. Which of these statements is the best advice about sun protection for this child? "Liberally apply a sunscreen with a minimum sun protective factor of 15 all over the body." "Dress the infant in lightweight long pants, long-sleeved shirts and brimmed hats." "Sunscreen should not be used on children." "You should keep the baby inside unless it's cloudy outside."
"Dress the infant in lightweight long pants, long-sleeved shirts and brimmed hats."
The order is for ibuprofen oral drops 10 mg/kg of body weight. The client weighs 62 lbs. Motrin oral drops are supplied in bottles containing 40 mg/mL. How many milliliters will the nurse administer? (Report to the nearest whole number.)
7ml
A client has just received an extracorporeal shock-wave lithotripsy (ESWL) procedure. What is the priority information the nurse should teach ? "Restrict milk and dairy products for one to two months." "Increase intake of citrus fruits to three servings per day for two months." "Limit fluid intake to 1,000 mL each day for two months." "Drink 3,000 to 4,000 mL of fluid each day for one month."
"Drink 3,000 to 4,000 mL of fluid each day for one month."
A 35 year-old female client talks to the nurse in her health care provider's office about her new diagnosis of uterine fibroids. What statement by the woman is incorrect and indicates that more teaching is needed? "Fibroids occur more frequently in women my age but no one knows what causes them." "I sometimes experience pelvic pressure and pain, heavy menstrual bleeding, and I feel the need to urinate more often." "Even if the fibroids cause no problems, they will still need to be taken out." "Uterine fibroids are noncancerous tumors that grow slowly."
"Even if the fibroids cause no problems, they will still need to be taken out."
A client is started on long-term corticosteroid therapy. Which comment by the client indicates a need for more teaching? "I will be sure to eat foods high in potassium." "I will keep a weekly weight record." "The medication needs to be taken with food." "For one week every month I will stop taking the medication."
"For one week every month I will stop taking the medication."
A client who lives in an assisted living facility tells the nurse, "I am so depressed. Life isn't worth living anymore." What is the best response by the nurse to this statement? "Have you thought about hurting yourself?" "Think of the many positive things in life today." "Did you tell any of this to your family?" "Come on, it is not that bad."
"Have you thought about hurting yourself?"
The nurse is providing information to a client about a prescribed medication. Which one of these statements, if made by a client, indicates that teaching about propranolol (Inderal) has been effective? "I may experience seizures if I stop the medication abruptly." "I will expect to feel nervousness the first few weeks." "I can have a heart attack if I stop this medication suddenly." "I could have an increase in my heart rate for a few weeks."
"I can have a heart attack if I stop this medication suddenly."
The nurse is admitting a client who is newly diagnosed with a frontal lobe brain tumor. Which statement made by a spouse may provide important information about this diagnosis and should be communicated to the health care provider? "I find the mood swings and the change from being a calm person to being angry all the time hard to deal with." "It seems our sex life is nonexistent over the past six months." "In the morning and evening he complains that reading is next to impossible because the print is blurry." "His breathing rate is usually below 12."
"I find the mood swings and the change from being a calm person to being angry all the time hard to deal with."
At a senior citizen's group meeting the nurse talks with a client who has type 1 diabetes. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity? "I give my insulin to myself in my thighs and belly and alternate sites." "Here are my glucose test readings that I wrote on my calendar." "I had a penny in my shoe all day last week, and I didn't even realize it until I took my shoes off!" "If I bathe more than once a week my skin feels too dry."
"I had a penny in my shoe all day last week, and I didn't even realize it until I took my shoes off!"
A client expresses anger when a call light is not answered within five minutes. The client demanded a blanket. How should the nurse respond? "I am surprised that you are upset. The request could have waited a few more minutes." "I apologize for the delay. I was involved in an emergency." "Let's talk. Why are you upset about this?" "I see this is frustrating for you. I have a few minutes so let's talk."
"I see this is frustrating for you. I have a few minutes so let's talk."
A nurse who cares for clients undergoing treatment for cancer might expect clients diagnosed with cancer to make the following statements. Based on an understanding of the stages of the grieving process, place the statements in the correct order. "I don't know where to go or what to do." "I think the tests got mixed up." "I am so mad at everyone for always reminding me that I have it." "If I eat a more balanced diet, I can live longer." "I will just go on with my life."
"I think the tests got mixed up." "I am so mad at everyone for always reminding me that I have it." "If I eat a more balanced diet, I can live longer." "I don't know where to go or what to do." "I will just go on with my life."
A 15 year-old client has been placed in a Milwaukee brace. Which statement made by the client is incorrect and indicates a need for additional teaching? "I can take it off when I shower or take a bath." "I should inspect my skin under the brace every day" "The brace has to be worn all day and night." "I will only have to wear this for six months."
"I will only have to wear this for six months."
Two hours after receiving the first does of lithium, the client reports fine hand tremors. What is the nurse's best explanation for these findings? "These are common and expected side effects and should subside in a few days." "Taking lithium on an empty stomach should help minimize these symptoms." "Reducing dietary intake of sodium and fluids should minimize any side effects." "You are probably having an allergic reaction. The medication should be discontinued."
"These are common and expected side effects and should subside in a few days."
The nurse is examining a 2 year-old child with a tentative diagnosis of Wilm's tumor. The nurse would be most concerned about which statement by the mother? "My child has lost three pounds in the last month." "The child prefers some salty foods more than others." "All the pants have become tight around the waist." "Urinary output seems to be less over the past two days."
"Urinary output seems to be less over the past two days."
A client has had a positive reaction to purified protein derivative (PPD). When the client asks, "What does this mean?" the nurse should respond with which statement? "You have been exposed to the organism Mycobacterium tuberculosis." "This means you have never had or been around someone with tuberculosis." "You most likely have a resistant form of active tuberculosis." "You are mostly likely have a natural immunity to the bacteria."
"You have been exposed to the organism Mycobacterium tuberculosis."
A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the mother sits in a nearby chair. The mother states, "This is not my baby, and I do not want it." After repositioning the child safely, the nurse should respond with which comment? "You seem upset. Tell me what the pregnancy and birth were like for you." "Many women have postpartum blues and need some time to love the baby." "What a beautiful baby! Her eyes are just like yours and so is her smile." "This is a common occurrence after birth, but you will come to accept the baby."
"You seem upset. Tell me what the pregnancy and birth were like for you."
At the client's request, the nurse performs a fingerstick to test the client's blood glucose and the results are 322 mg/dL. Following standing orders, the nurse administers 3 units of insulin lispro at 11 am. When does the nurse anticipate the insulin lispro will begin to act? 12 noon 1:00 pm 11:15 am 3:00 pm
11:15 am
Which individual is at greatest risk for the development of hypertension? 55 year-old Hispanic teacher 40 year-old Caucasian nurse 60 year-old Asian-American shop owner 45 year-old African-American attorney
45 year-old African-American attorney
A nurse is working with one licensed practical nurse (LPN) and a mental health tech (an unlicensed assistive personnel). Which newly admitted client would be appropriate to assign to the mental health tech? An adolescent diagnosed with dehydration and anorexia A young adult who reports to be a heroin addict and states, "I am in withdrawal and seeing spiders." A middle-aged client diagnosed with an obsessive compulsive disorder A 76 year-old client diagnosed with severe depression
A middle-aged client diagnosed with an obsessive compulsive disorder
An external disaster has occurred in the town. The triage nurse from the emergency department is transported to the site and assigned to triage the injured. Which of these clients would the nurse tag as "to be seen last" by the providers at the scene? A middle-aged person with deep abrasions that are over 90% of the body An infant with bilateral fractured lower legs with no active bleeding An older adult person with a open fracture of the left arm A teenager with small amount of bright red blood dripping out of the nose
A middle-aged person with deep abrasions that are over 90% of the body
The clients listed below are all using patient-controlled analgesic (PCA) pump for pain control. Which of these clients is least appropriate to use a PCA pump? A preschooler with intermittent episodes of alertness A teenager who reads at a 4th-grade level An older adult client with numerous arthritic nodules on the hands A young adult with a history of Down syndrome
A preschooler with intermittent episodes of alertness
An internal disaster has occurred at the hospital. Which of these clients would the nurse recommend to stay in the facility? An adolescent diagnosed with sepsis seven days ago and whose vital signs are maintained within low normal limits A young adult in the second day of treatment for an overdose of acetaminophen (Tylenol) A middle-aged client known to have had an uncomplicated myocardial infarction four days ago An older adult client admitted two days ago with an acute exacerbation of ulcerative colitis
A young adult in the second day of treatment for an overdose of acetaminophen (Tylenol)
The nurse is teaching effective stress management techniques to a client one hour before surgery. Which of these actions should the nurse recommend? Distraction Deep breathing Imagery Biofeedback
Deep breathing
The nurse is caring for a client who is experiencing a hypertensive crisis. The priority assessment in the first hour of care after admission to the critical care unit should focus on which factor? Lung sounds Heart rate Pedal pulses Cognitive function
Cognitive function
The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal bypass graft procedure. Which of the following assessments requires immediate notification of the health care provider? Absent left pedal pulse using Doppler analysis Inability to palpate the left pedal pulse Left foot is cool to the touch Acute pain in the left lower leg
Absent left pedal pulse using Doppler analysis
A nurse is teaching an older adult client to use a metered-dose inhaler (MDI) and is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What should the nurse recommend to improve the delivery of the medication? Request a visiting nurse to follow the client at home Add a spacer device to the MDI canister Ask a family member to assist the client with the MDI Nebulized treatments for home care
Add a spacer device to the MDI canister
The client needs to be moved up in bed. The client is able to partially assist and weighs 135 pounds. Which action by the nursing staff best supports an awareness of ergonomics and safe client handling? (Select all that apply.) Adjust the height of the bed for caregivers Use a friction-reducing device Coordinate lifting the client by counting to 3 Move the bed into the flat position Pull the client up from the head of the bed
Adjust the height of the bed for caregivers Use a friction-reducing device Move the bed into the flat position
The client, diagnosed with an acute anterior MI, has a triple lumen infusing with nitroglycerin, alteplase and heparin. The client reports experiencing angina. Which intervention is the priority? Administer intravenous morphine sulfate as ordered Review and compare serial ECG strips Administer antidysrhythmic drugs as indicated Auscultate heart and lung sounds
Administer intravenous morphine sulfate as ordered
A client is admitted with severe injuries resulting from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. What should be the initial nursing intervention? Administer oxygen as ordered Initiate continuous blood pressure monitoring Institute continuous cardiac monitoring Initiate the ordered intravenous therapy
Administer oxygen as ordered
The nurse is caring for a toddler who is diagnosed with an infection and whose temperature is 103 F (39.4 C). Which intervention would be most effective in lowering the client's temperature and promoting comfort? Give a tepid sponge bath prior to giving an antipyretic medication Apply extra layers of clothing to prevent shivering Administer the prescribed antipyretic medication Immerse the child in a tub containing cool water
Administer the prescribed antipyretic medication
A newborn is diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize which point? Administration of thyroid hormone will prevent complications They can expect the child will be mentally retarded Physical growth and development will be delayed This rare problem is always hereditary
Administration of thyroid hormone will prevent complications
The nurse is developing a teaching plan for parents on safety and risk-reduction in the home. Which of the following should the nurse give priority consideration to during teaching? Age of children in the home Number of children in the home Age and knowledge level of the parents Proximity to emergency services
Age of children in the home
An 8 year-old child is brought to the clinic by a parent who states: "This child was so sick last year with cold and the flu. I want her to have the influenza vaccine this year." The nurse assesses the child and reviews the child's history. What information would the nurse recognize as a contraindication for giving the child this vaccine? Family history of convulsions Persistent, inconsolable crying after receiving other immunizations Allergy to eggs Recent exposure to an infectious disease
Allergy to eggs
A 67 year-old client is admitted with substernal chest pressure that radiates to the jaw. The admitting diagnosis is acute myocardial infarction (MI). What should be the priority nursing diagnosis for this client during the first 24 hours? Altered tissue perfusion Anxiety Activity intolerance Risk for fluid volume excess
Altered tissue perfusion
At the beginning of the shift, the nurse is reviewing the status of each of the assigned clients in the labor and delivery unit. Which of these clients should the nurse check first? A young woman, first-time para, cervical dilation to 1 cm and contractions 15 minutes apart A middle-aged woman with a history of two prior vaginal term births and who is 2 cm dilated An adolescent who is 18-weeks pregnant with a report of no fetal heart tones and is coughing up frothy sputum A young woman who is a grand multipara, cervical dilation to 4 cm and is 50% effaced
An adolescent who is 18-weeks pregnant with a report of no fetal heart tones and is coughing up frothy sputum
Following an alert of an internal disaster and the need for beds, the charge nurse is asked to list the clients who can potentially be discharged. Which one of these clients should the charge nurse select? An adolescent admitted the previous evening with Tylenol intoxication An older adult client with an implantable cardiac defibrillator (ICD) admitted yesterday after receiving multiple shocks An adult client, diagnosed with type 1 diabetes at age 10, admitted 36 hours ago with diabetic ketoacidosis A school-aged child admitted earlier today with a diagnosis of suspected bacterial meningitis
An adult client, diagnosed with type 1 diabetes at age 10, admitted 36 hours ago with diabetic ketoacidosis
Which is the appropriate injection site to give an influenza vaccine to an adult?
An influenza (or flu) vaccine is less than 1 mL of fluid, so it is acceptable to administer this injection in the deltoid muscle. The deltoid muscle of the upper arm is a site that is easily accessible in public settings where mass vaccinations are administered.
The charge nurse is scheduled duties in the unit. Which of these clients should a charge nurse assign to a licensed practical nurse (LPN)? A confused client whose family complains about the nursing care two days after the client's surgery An older adult client diagnosed with cystitis and an indwelling urethral catheter A client admitted with the diagnosis of possible transient ischemic attack with unstable neurological signs A trauma victim with multiple lacerations that require complex dressings
An older adult client diagnosed with cystitis and an indwelling urethral catheter
The nurse is preparing to administer albuterol inhaled to a 11 year-old with asthma. Which assessment by the nurse indicates there is a need for the health care provider to adjust the medication? Temperature of 101 F (38.3 C) Lethargy Apical pulse of 112 Lower extremity edema
Apical pulse of 112
The nurse is assessing a client with a stage II skin ulcer. Which of these approaches should be most effective to promote healing? Apply a hydrocolloid or foam dressing Cover the wound with a dry dressing Use hydrogen peroxide soaks Leave the area open to dry
Apply a hydrocolloid or foam dressing
A 3 year-old has just returned from surgery for application of a hip spica cast. What nursing action will be the priority? Drying the cast using a hair dryer set to "warm" Use the crossbar to help turn the child from side to side Position the child flat in bed, repositioning from back to stomach every two to four hours Apply waterproof plastic tape to the cast around the genital area
Apply waterproof plastic tape to the cast around the genital area
A woman, who delivered five days ago and who had been diagnosed with pregnancy induced hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She states, "I have had the worst headache for the past two days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps." What should the nurse do next? Ask the client to explain what she has taken and how often, and then evaluate other specific complaints Advise the client to have someone bring her to the emergency room as soon as possible Ask the client to stay on the line, get the address, and send an ambulance to the home Advise the client that the swings in her hormones may be the problem; suggest that she call her health care provider
Ask the client to stay on the line, get the address, and send an ambulance to the home
A client is admitted for first- and second-degree burns on the face, neck, anterior chest and hands. What should be the nurse's priority action? Administer pain medication Cover the areas with dry sterile dressings Initiate intravenous therapy Assess for dyspnea or stridor
Assess for dyspnea or stridor
An 88 year-old client is admitted to the telemetry unit following a minor surgical procedure. The client's history includes insulin dependent diabetes and a previous myocardial infarction. The nurse responds to the client's ECG alarm and finds the client's rhythm shows asystole and the client obtunded but responsive. Prioritize the actions of the nurse (with 1 being the top priority). Initiate emergency response system if indicated Assess respirations and pulse Look at a different ECG lead to confirm rhythm Check a blood glucose level
Assess respirations and pulse Look at a different ECG lead to confirm rhythm Check a blood glucose level Initiate emergency response system if indicated
A nurse is caring for a client two hours after a right lower lobectomy. During the assessment of the chest drainage unit (CDU), the nurse notes bubbling in the water-seal chamber. What is the first action the nurse should take? Check for any increase in the amount of drainage Call the health care provider as soon as possible Reposition the client to improve the level of comfort Assess the chest tube dressing, tubing and drainage system
Assess the chest tube dressing, tubing and drainage system
The client is scheduled for coronary artery bypass. Based on principles of teaching and learning, what is the best initial approach by the nurse during pre-op teaching? Assess the client's learning style Mail a videotape to the home Tour the coronary intensive unit Administer a written pretest
Assess the client's learning style
The RN is planning the care of an 80 year-old client with skin abrasions from a fall in the home. What aspect of this client's care is the primary responsibility of the nurse? Assessment of the integumentary condition Report the finding of any break in the skin Apply lotion to unaffected areas Identification of a change in skin color
Assessment of the integumentary condition
A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and who becomes dyspneic. The nurse should take which action? Assist the client with pursed-lip breathing Place the client in a low Fowler's position Administer oxygen at six liters per minute via nasal cannula Instruct the client to breathe into a paper bag
Assist the client with pursed-lip breathing
While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of these assessments is appropriate for the nurse to perform on the mass? Measure the length Percuss Auscultate Palpate
Auscultate
A client who is two days postop, has these vital signs: blood pressure of 120/70, heart rate of 110 BPM, respiratory rate of 26, and a temperature of 100.4 F (38 C). The client suddenly becomes profoundly short of breath (SOB) and the skin color becomes grayish in color. Which assessment should the a nurse do first based on the client's change in condition? Assess the pupils for unequal responses to light Check for orthostatic hypotension Palpate the pulses for bounding and irregularity Auscultate for diminished breath sounds
Auscultate for diminished breath sounds
The nurse manager informs the nursing staff that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care, and all staff are invited to participate in the study if they wish. This affirms which ethical principle? Autonomy Anonymity Beneficence Justice
Autonomy
The client is diagnosed with gastroesophageal reflux disease (GERD). Which recommendation made by the nurse would be most helpful? Maintain a diet of soft foods and cooked vegetables Avoid liquids unless a thickening agent is used Sit upright for at least half an hour after eating Avoid eating two hours before going to sleep
Avoid eating two hours before going to sleep
The nurse is teaching a client with coronary artery disease about nutrition. What information should the nurse be sure to emphasize? Add complex carbohydrates to each meal Avoid large and heavy meals Limit sodium to 7 grams per day Eat three balanced meals a day
Avoid large and heavy meals
A nurse is teaching a client to select foods rich in potassium to prevent digitalis toxicity. Which choice indicates the client understands this dietary requirement and recognizes which foods are highest in potassium? Naval orange Baked potato Small banana Three apricots
Baked potato
The nurse working in the intensive care unit (ICU) is told that a client is being newly admitted with a diagnosis of hyperglycemic hyperosmolar nonketotic state (HHNS). The nurse would expect which of the following clinical findings in this client? (Select all that apply.) Blood glucose level of at least 600 mg/dL Ketonuria History of type 1 diabetes mellitus Metabolic acidosis Severe dehydration
Blood glucose level of at least 600 mg/dL Severe dehydration
The nurse is caring for a client diagnosed with acute angina. The client is receiving an intravenous infusion of nitroglycerin. What is the priority assessment during this treatment? Heart rate Neurologic status Blood pressure Urine output
Blood pressure
The nurse is caring for a child who is diagnosed with coarctation of the aorta. Which finding would the nurse expect when assessing the child? Diminished carotid pulses Normal femoral pulses Bounding pulses in the arms Strong pedal pulses
Bounding pulses in the arms
Two members of the interdisciplinary team are arguing about the plan of care for a client. Which action could any one of the members of the team use as a de-escalation strategy? Interrupt, apologize for interruption, and change the subject Adjourn the meeting and reschedule when everyone has calmed down Tell the violators they must calm down and be reasonable Bring the communication focus back to the client
Bring the communication focus back to the client
The nurse is caring for a client who is in the advanced stage of multiple myeloma. Which action should be included in the plan of care? Monitor for hyperkalemia Careful repositioning Administer diuretics as ordered Place in protective isolation
Careful repositioning
A child is treated with succimer for lead poisoning. Which of these assessments should the nurse perform first? Test deep tendon reflexes Check blood calcium level Check complete blood count (CBC) with differential Check serum potassium level
Check complete blood count (CBC) with differential
The client with a T-2 spinal cord injury reports having a "pounding" headache. Further assessment by the nurse reveals excessive sweating, rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. What action should the nurse take next? Place the client into the bed and administer the ordered PRN analgesic Measure the client's respirations, blood pressure, temperature and pupillary responses Check the client for bladder distention and the urinary catheter for kinks Assist client with relaxation techniques
Check the client for bladder distention and the urinary catheter for kinks
The nurse needs to accurately assess gastric placement of a nasogastric tube prior to the administration of an enteral feeding. What is the priority action the nurse should take before starting the infusion? Measure the length of tubing from nose to epigastrium Check the pH of the aspirate Auscultate the abdomen while instilling 10 mL of air into the tube Place the end of the tube in water to check for air bubbles
Check the pH of the aspirate
The client is a new admission diagnosed with Alzheimer's disease (AD). The nurse reviews all drugs (including complementary and alternative treatments or therapies) routinely taken at home with a family member. Which of the following treatments would be a concern for the nurse? Ginkgo biloba Coconut oil Omega-3 fatty acids Donepezil (Aricept)
Coconut oil
The client with cancer is being treated with a biological response modifier. Which of the following side effects does the nurse anticipate with biologic therapy? Photophobia and sun sensitivity Constipation Hematuria Chills and fever
Chills and fever
A nurse is teaching adolescents about sexually transmitted diseases. What should the nurse emphasize is the most common infection? Gonorrhea Human immunodeficiency virus (HIV) Herpes Chlamydia
Chlamydia
The 72 year-old client has an estimated blood loss of 600 mL during a gastric resection. The surgeon orders two units of packed cells (PC) to be administered in the post anesthesia care unit. During the administration of the second unit of PC, the nurse notes the following findings: hypertension, a bounding pulse, and increasing dyspnea. What is the probable cause of these findings? Bacterial transfusion reaction Circulatory overload Transfusion-associated graft-versus-host disease Hemolytic transfusion reaction
Circulatory overload
Following a surgical procedure, a pneumatic compression device is applied to the adult client. The client reports that the device is hot and the client is sweating and itching. Which of the following steps should the nurse take? (Select all that apply.) Confirm pressure setting of 45 mm Hg Collaborate with health care provider for anti-embolism stockings to be worn under the sleeves of the device Inform the client that removing the device will likely result in the formation of deep vein thrombosis Explain that the health care provider ordered the device and it cannot be removed Check for appropriate fit
Confirm pressure setting of 45 mm Hg Collaborate with health care provider for anti-embolism stockings to be worn under the sleeves of the device Check for appropriate fit
A client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care? Compromised host precautions Airborne precautions Contact precautions Droplet precautions
Contact precautions
The parents of a 6 year-old child who normally enjoys school tells a nurse that the child has not been doing well since a grandmother died two months ago. Which statement most accurately describes thoughts on death and dying at this age? Death is personified as the bogeyman or devil The child is worried that the child, too, might die Death is perceived as being irreversible The child feels guilty for the grandmother's death
Death is personified as the bogeyman or devil
A nurse is preparing a client for discharge following inpatient treatment for pulmonary tuberculosis (TB). Which of these instructions should be given to the client? Avoid contact with children, pregnant women or immunosupressed persons Continue taking medications as prescribed Continue taking medications until findings are relieved Take medication with aluminum hydroxide (Amphojel) if epigastric distress occurs
Continue taking medications as prescribed
A client has a chest tube inserted immediately after surgery for a left lower lobectomy. During the repositioning of the client during the first postop check, the nurse notices 75 mL of a dark, red fluid flowing into the collection chamber of the chest drain system. What is the appropriate nursing action? Turn the client back to the original position Continue to monitor the rate of drainage Check to see if the client has a type and cross match Call the surgeon immediately
Continue to monitor the rate of drainage
The nurse is caring for a child diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome or infantile polyarteritis). The nursing care plan should be based on the knowledge that this child is at risk for developing what complication? Chronic vessel plaque formation Coronary artery aneurysm Occlusions at the vessel bifurcations Pulmonary embolism
Coronary artery aneurysm
A nurse is caring for a postoperative client who develops evisceration of the abdominal incision. Which intervention should the nurse implement first to prevent additional complications? Call the health care provider within the hour Place the client in dorsal recumbent position Medicate the client for pain with PRN order Cover the wound with a sterile saline-soaked dressing
Cover the wound with a sterile saline-soaked dressing
The clinic nurse is assisting with medical billing. The nurse uses the DRG (Diagnosis Related Group) manual for which purpose? Implement nursing care based on case management protocol Determine reimbursement for a medical diagnosis Classify nursing diagnoses from the client's health history Identify findings related to a medical diagnosis
Determine reimbursement for a medical diagnosis
A nurse, who is assigned for five days to a client who has exhibited manipulative behaviors, becomes aware of feeling reluctance to interact with the client. The nurse should take what action next? Discuss the feelings of reluctance with an objective peer or supervisor within the next 24 hours Limit contacts with the client to avoid reinforcement of the manipulative behavior during the work times Talk with the client about the negative effects of manipulative behaviors on other clients and staff within the next few days Develop a behavior modification plan for the client that will promote more functional behavior within the next week
Discuss the feelings of reluctance with an objective peer or supervisor within the next 24 hours
The nurse is providing discharge teaching to a client who has had a total hip prosthesis implanted. During teaching, the nurse should include which content in the instructions for home care? Ambulate using crutches only Sleep only on your back and not on your side Avoid climbing stairs for three months Do not cross your legs at the ankles or knees
Do not cross your legs at the ankles or knees
The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. What is the most important instruction about exercise? Use exercise to strengthen muscles and protect bones Exercise to reduce weight over a few months Avoid exercise activities that increase the risk of fracture Do weight-bearing or resistance activities
Do weight-bearing or resistance activities
A nurse is teaching a class on human immunodeficiency virus (HIV) prevention. Which activity should be cautioned against since it is shown to increase the risk of HIV? Use of public bathrooms in any city Engaging in unprotected sexual encounters Physical touch of a person with autoimmune deficiency syndrome (AIDS) Donation of blood to the state agencies
Engaging in unprotected sexual encounters
A client taking isoniazid for tuberculosis (TB) asks the nurse about the side effects of this medication. The client should be instructed to report which of these findings? Double vision and visual halos Confusion and light-headedness Photosensitivity and photophobia Extremity tingling and numbness
Extremity tingling and numbness
The nurse and family members, who will be providing care at home, are discussing the client's continuing care needs after discharge to home. Which of these aspects of the discharge planning evaluation should receive priority consideration? Client's health insurance and prescription coverage Coordination of follow-up care with interdisciplinary team Family's understanding of the client's health care needs Availability of community-based services
Family's understanding of the client's health care needs
A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) four hours ago. At the time of rupture, maternal vital signs were within normal limits, she was dilated to 2 centimeters, and the baseline fetal heart rate (FHR) was 150 beats per minute (BPM). The nurse is now reassessing the client. Which of these assessment findings may be an early indication that the client is developing a complication of the labor process? Fetal heart rate is 188 beats/minute Cervical dilation of 4 centimeters Blood pressure is 138/88 mm Hg Maternal temperature is 100 F (37.7 C)
Fetal heart rate is 188 beats/minute
The respiratory technician arrives to draw blood for arterial blood gas (ABG) analysis. What should the nurse understand about the procedure? Firm pressure is applied over the puncture site for at least five minutes after the sample is drawn Supplemental oxygen should be turned off 30 minutes prior to collecting the sample The femoral artery is the preferred sample site The blood sample must be kept at room temperature and delivered to the lab as soon as possible
Firm pressure is applied over the puncture site for at least five minutes after the sample is drawn
The nurse is preparing to administer a feeding through a percutaneous endoscopic gastrostomy (PEG) tube. What nursing action is needed before starting the infusion? (Select all that apply.) Flush the tube with 30 mL of warm water Keep the feeding product refrigerated until ready to use Palpate the abdomen Milk or massage the tube Elevate the head of the bed 30-45 degrees Verify the length and placement of the tube
Flush the tube with 30 mL of warm water Elevate the head of the bed 30-45 degrees Verify the length and placement of the tube
Parents of a 4 year-old boy have just been informed that their son has a congenital neurologic demyelinating disorder that is terminal. The nurse anticipates their reaction to be in which phase of the crisis process? Impact phase Resolution phase Pre-crisis phase Crisis phase
Impact phase
A nurse is caring for a 74 year-old client with benign prostatic hypertrophy (BPH). Which finding would the nurse anticipate when assessing this client? Large volume of urinary output with each voiding Frequent urination Involuntary voiding with coughing and sneezing Urine is dark and concentrated
Frequent urination
A client has received two units of whole blood today after an episode of gastrointestinal bleeding. Which laboratory report should the nurse be sure to monitor closely? Platelets Hemoglobin and hematocrit White blood cells Bleeding time
Hemoglobin and hematocrit
A pregnant client, at 34-weeks gestation, is diagnosed with a pulmonary embolism (PE). Which of these medications does the nurse anticipate the health care provider will initially order? Warfarin (Coumadin) therapy every other day to maintain a PT at 1.5 to 2 times the control value Subcutaneous heparin 5000 units twice a day Heparin infusion to maintain the aPTT at 1.5 to 2 times the control value Low dose aspirin therapy
Heparin infusion to maintain the aPTT at 1.5 to 2 times the control value
The client is diagnosed with cystic fibrosis (CF). The nurse would expect the client to be treated with oral pancreatic enzymes and which type of diet? Sodium-restricted Dairy-free High fat, high-calorie Gluten-free, low fiber
High fat, high-calorie
There is an order to administer intravenous gentamicin three times a day. What diagnostic finding indicates the client may be more likely to experience a toxic side effect of this medication? High serum creatinine Low serum blood urea nitrogen Low serum albumin High gastric pH
High serum creatinine
A client is about to have an intravenous pyelogram (IVP). After the contrast material is injected, which client reaction should be acted upon immediately by a nurse? Face turning a deep ruddy red color Feeling of excessive warmth Excessive salty taste in the mouth Hives with severe itching over the body
Hives with severe itching over the body
A hospitalized 8 month-old infant is receiving digoxin to treat tetralogy of Fallot. Prior to administering the next dose of medication, the parent reports that the baby vomited one time, just after breakfast. The heart rate is 72 BPM. What should be the initial response of the nurse? Hold the medication Give the dose after lunch Reduce the next dose by half Double the next dose
Hold the medication
A nurse is teaching home care to the parents of a child diagnosed with acute spasmodic croup. What type of care would be most important to emphasize? Sedation as needed to prevent exhaustion Humidified air with an increase in oral fluids Antibiotic therapy for 10 to 14 days Antihistamines to decrease allergic responses
Humidified air with an increase in oral fluids
A group of nurses on a unit are discussing stoma care for clients who have had a stoma made for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown? Sigmoid colostomy Ileostomy Ileal conduit Transverse colostomy
Ileostomy
During assessment of orthostatic vital signs on a client with cardiomyopathy, the nurse finds that the systolic blood pressure (BP) decreased from 145 to 110 mm Hg between the supine and upright positions while the heart rate (HR) rose from 72 to 96 beats per minute. In addition, the client reports feeling lightheaded when standing up. The nurse should implement which of the following actions? Increase fluids that are high in protein Instruct the client to increase fluid intake for the next two days Restrict fluids for the next few hours Instruct client to increase fluid intake for several hours
Instruct client to increase fluid intake for several hours
The nurse is teaching the client with chronic renal failure (CRF) about medications. The client questions the purpose of taking aluminum hydroxide. What is the best explanation for the nurse to give the client about the therapeutic effects of this medication? It will reduce serum calcium Amphojel increases urine output The drug is taken to control gastric acid secretion It decreases serum phosphate
It decreases serum phosphate
Which statement describes the advantage of using a decision grid to make decisions? It is both a visual and a quantitative method of decision making It is the only truly objective way to make a decision in a group It allows the data to be graphed for easy interpretation It is the fastest way for group decision making
It is both a visual and a quantitative method of decision making
A nurse is providing a parenting class to individuals living in a community of older homes that were built prior to 1978. During a discussion about formula preparation, which statement is the most important by the nurse to tell the parents how to prevent lead poisoning? Boil the tap water for 10 minutes prior to preparing the formula Buy bottled water labeled "lead free" to mix with the formula Use ready-to-feed commercial infant formula Let tap water run for two minutes before adding to formula concentrate
Let tap water run for two minutes before adding to formula concentrate
A young adult seeks treatment in an outpatient mental health center. The client tells the nurse: "I am a government official being followed by spies." On further questioning, the client reveals: "My warnings must be heeded to prevent nuclear war." Which of the following actions should the nurse take? Ask for more information about the spies Listen quietly without comment Confront the client's delusion Contact the government agency
Listen quietly without comment
A community health nurse has been caring for a 16 year-old who is 22-weeks pregnant with a history of morbid obesity, asthma and hypertension. Which of these lab reports need to be communicated to the health care provider as soon as possible? Magnesium 0.8 mEq/L (0.33 mmol/L) and creatinine 3 mg/dL (265.2 μmol/L) Hemoglobin 11 g/dL (110 g/L) and calcium 6.7 mg/dL (1.68 mmol/L) Blood urea nitrogen 28 mg/dL (10 mmol/L) and glucose 225 mg/dL (12.4 mmol/L) Hematocrit 33% (0.33) and platelets 200,000 μL
Magnesium 0.8 mEq/L (0.33 mmol/L) and creatinine 3 mg/dL (265.2 μmol/L)
A community health nurse has been caring for a 16 year-old who is 22-weeks pregnant with a history of morbid obesity, asthma and hypertension. Which of these lab reports need to be communicated to the health care provider as soon as possible? Magnesium 0.8 mEq/L (0.33 mmol/L) and creatinine 3 mg/dL (265.2 μmol/L) Hemoglobin 11 g/dL (110 g/L) and calcium 6.7 mg/dL (1.68 mmol/L) Blood urea nitrogen 28 mg/dL (10 mmol/L) and glucose 225 mg/dL (12.4 mmol/L) Hematocrit 33% (0.33) and platelets 200,000 μL
Magnesium 0.8 mEq/L (0.33 mmol/L) and creatinine 3 mg/dL (265.2 μmol/L)
The parents of a 5 month-old report that the infant has "vomited nine times in the past six hours." Based on this information, the nurse should observe for which fluid and electrolyte imbalance? Metabolic alkalosis Hemoconcentration effects Metabolic acidosis Hemodilution effects
Metabolic alkalosis
A nurse listens to report on an 80 year-old client diagnosed with middle-stage Alzheimer's disease. What information suggests the nurse should do an immediate follow-up, rather than delegate any care to an unlicensed assistive person (UAP)? Minimal response to voice and touch of the peripheral areas of the body Change in the color of the fingertips from pink to pallor Increase in heart rate by 10 beats per minute A 10 mm Hg drop in systolic blood pressure
Minimal response to voice and touch of the peripheral areas of the body
The nurse is caring for a client in a violent relationship. The nurse should understand that immediately after an acute battering incident, the batterer may respond to the partner's injuries by taking which action? Minimize the episode with an underestimation of the victim's injuries Be very remorseful and assist the victim to receive medical care Seek medical help for the victim's injuries Contact a close friend and ask for help with the incident
Minimize the episode with an underestimation of the victim's injuries
A nurse is caring for a client who is diagnosed with Hodgkin's disease and is scheduled for radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience which difficulty? Night sweats High fever Face and neck edema Nausea
Nausea
A client has returned from a cardiac catheterization that was two hours ago. Which finding would indicate that the client has a potential complication from the procedure? No pulse in the affected extremity Increased blood pressure Decreased urine output Increased heart rate
No pulse in the affected extremity
The nurse is assessing a 4 year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and reports having severe pain. The right foot is pale and there is no palpable pulse. What action should the nurse take first? Administer the ordered PRN medication Reassess the extremity in 15 minutes Readjust the traction for comfort Notify the health care provider
Notify the health care provider
The nurse witnesses a client who is exhibiting seizure activity. Which observation is the priority and will be used to help determine treatment? Identify the pattern of breathing Note the time from beginning to end Observe the sequence and types of movement Determine if loss of bowel or bladder control occurs
Observe the sequence and types of movement
A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should take which action? Focus on reality orientation to time, place and person Document the statement on the client's chart with a report to the manager Obtain more details of the client's claim of abuse by a nurse Assist with the report of the client's complaint to the police
Obtain more details of the client's claim of abuse by a nurse
A newborn who is delivered at home and without a birth attendant is admitted to the hospital for observation. The initial temperature is 95 F (35 C) axillary. The nurse should recognize that cold stress may lead to what complication? Hyperglycemia Metabolic alkalosis Lowered basal metabolic rate Reduced partial pressure of oxygen in arterial blood (PaO2)
Reduced partial pressure of oxygen in arterial blood (PaO2)
The nurse is reviewing the laboratory results for several clients. Which of the laboratory result indicates a client with partly compensated metabolic acidosis? Chloride 100 mEq/L (100 mmol/L) Sodium 130 mEq/L (130 mmol/L) Hemoglobin 15 g/dL (150 g//L) PaCO2 30 mm Hg
PaCO2 30 mm Hg
A nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which approach demonstrates appropriate teaching by the nurse? Chewable aspirin is the preferred analgesic Recommend an antiviral medication to relieve itching The illness is only contagious when the lesions are present Papules, vesicles and crusts will be present at one time
Papules, vesicles and crusts will be present at one time
The nurse is assigned to a client newly diagnosed with active tuberculosis (TB) and a productive cough. Which of these interventions would be a priority for the nurse to implement? Place the client in a negative pressure private room and have disposable particulate respirators available for hospital employees Have the client cough into a tissue and dispose of the tissue in a separate bag Reinforce that everyone should wash their hands before and after entering the room Place client in a private room and implement droplet precautions
Place the client in a negative pressure private room and have disposable particulate respirators available for hospital employees
The client is admitted to an ambulatory surgery center and undergoes a right inguinal orchiectomy. Which option is the priority before the client can be discharged to home? Able to ambulate in the hallway with assistance Post-operative pain is managed Able to tolerate a regular diet Psychological counseling is scheduled
Post-operative pain is managed
The client, who is receiving chemotherapy through a central venous access device (CVAD) at home, is admitted to the intensive care unity (ICU) with a diagnosis of sepsis. Which of the following nursing interventions is the priority? Change the dressing over the site of the existing CVAD Insert an indwelling catheter Prepare the client for insertion of a new CVAD Restrict contact with persons having known, or recent, infections
Prepare the client for insertion of a new CVAD
The nurse is evaluating a developmentally challenged 2 year-old child. During the evaluation, what goal should the nurse stress when talking to the child's mother? Prepare for independent toileting Teach the child self-care skills Promote the child's optimal development Help the family decide on long-term care
Promote the child's optimal development
Today's prothrombin time for a client receiving warfarin 20 seconds. The normal range listed by the lab is 10 to 14 seconds. What is an appropriate nursing action? Notify the health care provider immediately Assess for bleeding gums or IV sites Recognize that this is a therapeutic level Observe the client for hematoma development
Recognize that this is a therapeutic level
A nurse, during an assessment of a day-old newborn, notices that the breasts are enlarged bilaterally with a white, thin discharge. What action should the nurse perform next? Ask about medications taken during pregnancy Record the findings while thinking that they are "normal" Obtain fluid to check for glucose by Dextrostix Notify the health care provider within that shift
Record the findings while thinking that they are "normal"
The nurse observes a client with a diagnosis of obsessive-compulsive disorder on an inpatient unit. Which behavior is consistent with this medical diagnosis? Repetitive, involuntary movements Verbalized suspicions about thefts on the unit Preference for consistent caregivers Repeatedly checking that a door is locked
Repeatedly checking that a door is locked
A nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which evaluation data would be the best measure of learning? Performance on written tests Reported behavioral changes Responses to verbal questions Completion of a mailed survey
Reported behavioral changes
A mother asks about expected motor skill development for her 3 year-old child. Which activity is considered a typical motor skill for the 3 year-old? Tying shoelaces Playing hopscotch Riding a tricycle Jumping rope
Riding a tricycle
The nurse is caring for a client diagnosed with anemia and confusion. Which task could the nurse delegate to the unlicensed assistive personnel (UAP)? Assess and document skin turgor and skin color changes Suggest foods that are high in iron and prepare a list of likes and dislikes Test stool for occult blood and urine for pH with a report of the results Report mental status changes and level of mental clarity
Test stool for occult blood and urine for pH with a report of the results
A client diagnosed with testicular cancer has undergone a unilateral orchiectomy. The client expresses fears about his prognosis prior to discharge. What information would the nurse want to include when helping the client better understand this type of cancer? This surgery causes impotence and infertility Intensive chemotherapy is the treatment of choice following surgery Testicular cancer has a five-year survival rate of 95% with early diagnosis and treatment With early intervention, the cure rate for teticular cancer is about 50%
Testicular cancer has a five-year survival rate of 95% with early diagnosis and treatment
Nursing students are reviewing the various types of oxygen delivery systems. Which oxygen delivery system is the most accurate? The Venturi mask A partial nonrebreather mask The simple face mask A nasal cannula
The Venturi mask
The charge nurse has a health care team that consists of one licensed practical nurse (LPN), one unlicensed assistive personnel (UAP) and one LPN student. The charge nurse has made these assignments. Which assignment should be questioned by the nurse manager? Measuring vital signs and assisting with activities of daily living (ADLs) for the client admitted with myocardial infarction 4 days ago - UAP A client who was diagnosed with a major stroke 6 days ago - LPN student The admission at the change of shifts of a client diagnosed with atrial fibrillation and acute heart failure - LPN A child diagnosed with second-degree burns over 20% of the body, has IV packed red cells running and an order for IV albumin - charge nurse
The admission at the change of shifts of a client diagnosed with atrial fibrillation and acute heart failure - LPN
A nurse uses the New Ballard Scale to assess gestational age of a newborn. The assessment score total is very high. What is a reasonable interpretation of this result? The baby experienced distress during labor The baby is large for gestational age The baby is premature The baby is post-term
The baby is post-term
The nurse receives a report on a client being admitted with the diagnosis of cirrhosis of the liver and ascites. What should the nurse emphasize to the nursing assistant about providing care for this client? The client may ambulate and sit in a chair as tolerated The client should remain on bed rest in a semi-Fowler's position The client is to ambulate as tolerated and be positioned in semi-Fowler's position when in bed The client should ambulate as tolerated, resting in bed with legs elevated between walks
The client should ambulate as tolerated, resting in bed with legs elevated between walks
During a situation of pain management, which statement is a priority to consider for the ethical guidance of a nurse? Clients have the right to have their pain relieved Cultural sensitivity is fundamental to pain management The client's self-report is the most important consideration Nurses should not prejudge a client's pain using their own values
The client's self-report is the most important consideration
The parents of a 7 year-old tell the nurse that their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents? Insecurity and attention getting are common motives The ethical sense and feelings of justice are developing Attempts to control the family using new coping styles Complex thought processes help to resolve conflicts
The ethical sense and feelings of justice are developing
An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When a nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. What should the nurse understand about the child's situation and administration of the immunization? Live vaccines are withheld in children with renal chronic illness The risk of the vaccine side effects precludes the administration of the vaccine An inactivated form of the vaccine can be given at any time The measles, mumps and rubella (MMR) vaccine should be given now, before the transplant
The measles, mumps and rubella (MMR) vaccine should be given now, before the transplant
The nurse is providing discharge teaching to the parents of a 15 month-old child diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome or infantile polyarteritis). The child has received immunoglobulin therapy. Which instruction point would be appropriate to include during the discussion? Complete recovery is expected within several days The measles, mumps and rubella vaccine should be delayed High doses of aspirin will be continued for some time Active range of motion exercises should be done frequently
The measles, mumps and rubella vaccine should be delayed
A woman in labor calls a nurse to assist her in the bathroom. The nurse notices a large amount of clear fluid on the bed linens. The nurse should act based on knowledge that fetal monitoring must now assess for what complication? Variable decelerations Early decelerations Late accelerations Periodic accelerations
Variable decelerations
A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest at what period of time? When the client's mood improves with an increase in energy level During the night shift when staffing is limited After a visit from the client's estranged partner At the time of the client's greatest despair
When the client's mood improves with an increase in energy level