Review

The nurse is assisting in developing a plan of care for a client preparing to breastfeed. In planning care, which factor is most significant in teaching a client to breastfeed? 1. A positive nurse-client relationship 2. A client with previous breastfeeding experience 3. A primary health care provider that encourages clients to breastfeed 4. Brief separation of the infant and mother after birth to allow the mother to rest

1. A positive nurse-client relationship

Methenamine is prescribed for a client diagnosed with a gram-positive urinary tract infection. The nurse would question the prescription if which preexisting disorder is noted in the client's record? 1. Cirrhosis 2. Hypothyroidism 3. Diabetes mellitus 4. Peripheral vascular disease

1. Cirrhosis

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. Based on this finding, the nurse would institute which interventions? Select all that apply. 1. Collect data to determine factors for fall risk. 2. Close the blinds and turn off the overhead light. 3. Instruct the client to ask for assistance when getting up to walk. 4. Teach the client to lift legs high while walking, as if walking over planks. 5. Ensure the client is upright when eating and swallows twice after each bite

1. Collect data to determine factors for fall risk. 3. Instruct the client to ask for assistance when getting up to walk.

The licensed practical nurse employed in the ambulatory clinic is assisting the registered nurse in preparing to administer a dose of intravenous immune globulin (IVIG). The licensed practical nurse would ensure that which medication is readily available before the medication is administered? 1. Epinephrine 2. Phytonadione 3. Acetylcysteine 4. Protamine sulfate

1. Epinephrine

A woman arrives at the emergency department complaining of abdominal pain of 4 on a scale of 1 to 10. She states that she thinks she is about 10 weeks pregnant. Her vital signs are pulse, 86 beats per minute; respirations, 16 breaths per minute; and blood pressure, 112/78 mm Hg. Which signs/symptoms would the nurse report to the primary health care provider immediately? Select all that apply. 1. Pulse, 112 beats per minute 2. Blood pressure, 110/76 mm Hg 3. Respirations, 17 breaths per minute 4. Pain rating of 8 on a scale of 1 to 10 5. States "I feel like I am about to faint."

1. Pulse, 112 beats per minute 4. Pain rating of 8 on a scale of 1 to 10 5. States "I feel like I am about to faint."

The nurse is reinforcing instructions to an oriented client and the client's family regarding how to use the patient-controlled analgesia (PCA) pump. The nurse would include which instructions? Select all that apply. 1. Report an inability to void or bladder discomfort. 2. Explain that the nurse will assess the pain level at frequent intervals. 3. Notify the nurse if the client begins to feel nauseated or is likely to vomit. 4. Instruct the client to push the button when the pain level begins to increase. 5. Explain that there is a lockout on the machine so the client cannot overdose. 6. Instruct a family member how to push the button every 6 minutes if the client is napping or asleep.

1. Report an inability to void or bladder discomfort. 2. Explain that the nurse will assess the pain level at frequent intervals. 3. Notify the nurse if the client begins to feel nauseated or is likely to vomit. 4. Instruct the client to push the button when the pain level begins to increase. 5. Explain that there is a lockout on the machine so the client cannot overdose.

The nurse and a mother are discussing care of her child's iron deficiency anemia. The nurse would suggest including which foods in the child's diet that are highest in iron? Select all that apply. 1. Spinach 2. Apricots 3. Raisins 4. Egg whites 5. Whole milk

1. Spinach 2. Apricots 3. Raisins

The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention would the nurse institute when providing care for the client? 1. Take daily weights and monitor trends. 2. Encourage fluids to improve hydration. 3. Elevate the legs above the level of the heart. 4. Position supine with the head of the bed at 30 degrees.

1. Take daily weights and monitor trends.

The nurse is asked to test the visual acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which procedure accurately identifies this visual acuity test? 1. The right eye is tested, followed by the left eye, and then both eyes are tested. 2. Both eyes are tested together, followed by the testing of the right and then the left eye. 3. The client is asked to stand at a distance of 40 feet from the chart and to read the largest line on the chart. 4. The client is asked to stand at a distance of 40 feet from the chart and to read the line that can be read 200 feet away by an individual with unimpaired vision.

1. The right eye is tested, followed by the left eye, and then both eyes are tested.

The nurse reinforces instructions to the client about breast self-examination (BSE). The nurse instructs the client to lie down and examine the left breast. Which is the correct area for placing a pillow when examining the left breast? 1. Under the left shoulder 2. Under the right scapula 3. Under the right shoulder 4. Under the small of the back

1. Under the left shoulder

A client with liver cancer who is receiving chemotherapy tells the nurse that some foods on the meal tray taste bitter, especially meats. The nurse would instruct the client to eat which foods instead of meat? Select all that apply. 1. Yogurt 2. Custard 3. Potatoes 4. Cantaloupe 5. Plain potato chips

1. Yogurt 2. Custard

The nurse notes documentation that a client has conductive hearing loss. The nurse plans care knowing that this kind of hearing loss can be caused by which circumstances? Select all that apply. 1. A defect in the cochlea 2. Acute otitis media with effusion 3. A defect in the 8th cranial nerve 4. A defect in the sensory fibers that lead to the cerebral cortex 5. A physical obstruction to the transmission of sound waves

2. Acute otitis media with effusion 5. A physical obstruction to the transmission of sound waves

A client with diabetes mellitus calls the clinic and tells the nurse that she has been nauseated during the night. The client asks the nurse if the morning insulin would be administered. Which is the appropriate nursing response? 1. Omit the insulin. 2. Administer the full dose as prescribed. 3. Administer half of the prescribed dose. 4. Wait until noon before making a decision.

2. Administer the full dose as prescribed.

The nurse is assisting in the care of a client who is being evaluated for possible myasthenia gravis. The primary health care provider gives a test dose of edrophonium. The nurse recalls that the client would have which reaction if the client has this disease? 1. Joint pain for the next 15 minutes 2. An increase in muscle strength within 1 to 3 minutes 3. A decrease in muscle strength within 1 to 3 minutes 4. Feelings of faintness or dizziness for 5 to 10 minutes

2. An increase in muscle strength within 1 to 3 minutes

A client requiring upcoming surgery is extremely anxious about the need for a possible blood transfusion and is concerned about the risk of infection from contaminated blood. The nurse suggests that the client consider which as an effective method to minimize this risk? 1. Ask a friend or family member to donate blood ahead of time. 2. Arrange an autologous blood donation before the planned surgery. 3. Take iron supplements before surgery to boost hemoglobin levels. 4. Request that any donated blood be screened twice by the blood bank.

2. Arrange an autologous blood donation before the planned surgery.

The nurse is preparing to collect client data by examining the abdomen. The nurse should begin the assessment by performing which action first? 1. Palpating the abdomen 2. Inspecting the abdomen 3. Percussing the abdomen 4. Auscultating the abdomen

2. Inspecting the abdomen

The nurse prepares the plan of care for a client with late-stage Alzheimer's disease who resides in a long-term care facility. Which would be priority concerns to include? Select all that apply. 1. Hopelessness 2. Risk for injury 3. Acute delirium 4. Risk for infection 5. Risk for aspiration 6. Impaired verbal communication

2. Risk for injury 4. Risk for infection 5. Risk for aspiration 6. Impaired verbal communication

The nurse is assisting in caring for a client in labor. Which data collection finding by the nurse places the client at risk for uterine rupture? 1. Primigravidity 2. Shoulder dystocia 3. Hypotonic contractions 4. Weak bearing-down efforts

2. Shoulder dystocia

The nurse is reinforcing the teaching to parents of a diabetic child about the signs/symptoms of hypoglycemia. Which signs/symptoms would the nurse include when reinforcing the teaching? Select all that apply. 1. Fatigue 2. Sweating 3. Headache 4. Dizziness 5. Trembling

2. Sweating 4. Dizziness 5. Trembling

The nurse is observing a nursing student preparing to suction a pediatric client through a tracheostomy. The nurse intervenes if the student verbalizes which intention? 1. To limit insertion and suctioning time to 5 seconds 2. To apply continuous suction when inserting the catheter 3. To reoxygenate the child between suction catheter passes 4. To use a twisting motion on the catheter when withdrawing the catheter

2. To apply continuous suction when inserting the catheter

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level would be noted with which condition? 1. Diarrhea 2. Traumatic burn 3. Cushing's syndrome 4. Overuse of laxatives

2. Traumatic burn

The nurse realizes that the client taking metformin needs further teaching when the client makes which statement? 1. "Metformin may cause flatulence and diarrhea." 2. "Metformin will help decrease the glucose production by my liver." 3. "I should treat hypoglycemic episodes due to metformin with glucose tablets only." 4. "I should not take my metformin for 48 hours after certain diagnostic tests that use dye."

3. "I should treat hypoglycemic episodes due to metformin with glucose tablets only."

A lethargic, pale child is brought to the primary health care provider's office with symptoms of periorbital edema and reduced quantity of urine output. The urine is cloudy and smoky in color. The nurse asks the mother if the child has had any recent infections, to which the mother responds that the child had a very sore throat a few weeks ago. The primary health care provider suspects that the child might have acute poststreptococcal glomerulonephritis. Which laboratory test would rule out a past streptococcal infection in the child? 1. Urinalysis 2. Throat culture 3. Antistreptolysin titer 4. Creatinine clearance

3. Antistreptolysin titer

The nurse is preparing to administer pentamidine isethionate to an assigned client by the intramuscular route. Which most appropriate parameter would the nurse monitor while administering this medication? 1. Capillary refill 2. Peripheral pulses 3. Blood pressure (BP) 4. Level of consciousness

3. Blood pressure (BP)

The nurse assists with admitting a child with a diagnosis of acute stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted? 1. Cracked lips 2. A normal appearance 3. Conjunctival hyperemia 4. Desquamation of the skin

3. Conjunctival hyperemia

The nurse discusses the risk factors associated with gastric cancer as part of a health promotion program. The nurse determines that there is a need for further teaching if a member attending the program states that which factor is a risk? 1. History of gastric polyps 2. History of pernicious anemia 3. High meat and carbohydrate consumption 4. A diet of smoked, highly salted, and spicy food

3. High meat and carbohydrate consumption

A client with moderate depression who was admitted to the mental health unit 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by taking which action? 1. Suggesting a reduction of medication 2. Allowing increased "in-room" activities 3. Increasing the level of suicide precautions 4. Allowing the client off-unit privileges as needed (PRN)

3. Increasing the level of suicide precautions

The nurse caring for a client who has been diagnosed with stage 3 Alzheimer's disease would expect to observe which behaviors in this client? Select all that apply. 1. Incontinence of stool 2. Confusion as to day and time 3. Misplacing a valuable object 4. Forgetfulness of recent events 5. Difficulty coming up with the right word

3. Misplacing a valuable object 5. Difficulty coming up with the right word

A 1-year-old child has been prescribed digoxin to treat heart failure (HF). When would the nurse plan on withholding the prescribed dose of the medication? 1. A dose is missed by more than 1 hour. 2. The child has a fever greater than 101°F. 3. The child's pulse is less than 80 beats per minute. 4. The child's pulse is more than 100 beats per minute.

3. The child's pulse is less than 80 beats per minute.

The nurse is assisting with caring for a client with abruptio placentae. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse would take which action first? 1. Monitor the urinary output. 2. Monitor the maternal pulse. 3. Turn the client onto her side. 4. Monitor the maternal blood pressure.

3. Turn the client onto her side.

The nurse prepares to take a blood pressure (BP) on a school-age child. Where would the nurse place the blood pressure cuff to obtain an accurate measurement? 1. One-half the distance between the antecubital fossa and the shoulder 2. One-third the distance between the antecubital fossa and the shoulder 3. Two-thirds the distance between the antecubital fossa and the shoulder 4. One-quarter the distance between the antecubital fossa and the shoulder

3. Two-thirds the distance between the antecubital fossa and the shoulder

Mycophenolate mofetil is prescribed for the client as prophylaxis for organ rejection following an allogeneic renal transplant. Which instruction would the nurse most reinforce regarding administration of this medication? 1. Administer medication after meals. 2. Take the medication with a magnesium-type antacid. 3. Open the capsule and mix with food for administration. 4. Contact the primary health care provider (PHCP) if a sore throat occurs.

4. Contact the primary health care provider (PHCP) if a sore throat occurs.

The nurse is assisting with developing a teaching plan for the client with glaucoma. Which instruction would the nurse suggest to include in the plan of care? 1. Decrease the amount of salt in the diet. 2. Decrease fluid intake to control the intraocular pressure. 3. Avoid reading the newspaper and watching television. 4. Eye medications may need to be administered for the rest of your life.

4. Eye medications may need to be administered for the rest of your life. Submit

The nurse is assisting in preparing a plan of care for a client who just delivered a dead fetus. Which initial intervention in meeting the emotional needs of the client and her spouse is appropriate? 1. Allow family members to name the baby. 2. Allow the client and the spouse to hold the baby. 3. Encourage the client to talk about the dead fetus. 4. Gather data from the client and spouse about the perception of the event.

4. Gather data from the client and spouse about the perception of the event.

These are signs and symptoms of glaucoma. Which sign or symptom is found only in narrow-angle glaucoma? 1. Blurred or hazy vision 2. Colored rings around lights 3. Tonometry reading 30 mm Hg 4. Severe pain in and around eye

4. Severe pain in and around eye

The nurse has received a client assignment for the day. In which priority order would the nurse see the clients? Arrange the clients in the order that they should be seen. All options must be used. 1. The 2-year-old client receiving digoxin with a heart rate of 70 beats per minute 2. The 9-year-old client with rheumatic fever complaining of increased pain at a level of 8/10 3. The 15-year-old client scheduled for surgery in 2 hours who still needs preoperative teaching 4. The 4-year-old client with heart failure (HF) who needed an increase in the elevation of the head of the bed to sleep because of dyspnea

4. The 4-year-old client with heart failure (HF) who needed an increase in the elevation of the head of the bed to sleep because of dyspnea 1. The 2-year-old client receiving digoxin with a heart rate of 70 beats per minute 2. The 9-year-old client with rheumatic fever complaining of increased pain at a level of 8/10 3. The 15-year-old client scheduled for surgery in 2 hours who still needs preoperative teaching

A client with carcinoma is admitted to the hospital for a chemotherapy treatment with intravenous bleomycin sulfate. The plan of care mentions observing for interstitial pneumonitis as the priority of care. Which finding most closely correlates to symptoms of interstitial pneumonitis and requires reporting? 1. Barking cough upon exertion 2. Lung wheezing and shortness of breath 3. Productive cough with thick, yellow sputum 4. Distended neck veins with pink, frothy sputum

Lung wheezing and shortness of breath