Review Practice Questions

The nurse is preparing to administer diphenhydramine (Benadryl) 50 mg intravenously to a patient with severe allergies. Available is diphenhydramine (Benadryl) 25 mg/1 mL. How many mL will the nurse administer? Enter the numeral only.

2 mL

The nurse is preparing to perform a vaginal cervical examination. Place the steps that the nurse will perform in the proper order from first to last. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234) 1) Insert the index and middle finger into the vagina. 2) Open the labia and observe for vaginal drainage. 3) Document findings. 4) Perform hand hygiene and provide privacy. 5) Position the woman. 6) Determine effacement, dilation, station, and presenting part.

452163

The nurse is teaching a group of nursing students how to wash their hands correctly. Place in order, from 1 to 5, the correct steps for handwashing. ___1. Rub hands together for 20 seconds. ___2. Use the paper towel to turn on the faucet. ___3. Rinse hands together with fingertips pointed downward. ___4. Dry hands with disposable paper towel. ___5. Wet hands with warm water, soap, and lather.

51342

The nurse is visited by a teenage neighbor who asks, "I have a friend who thinks she has an STI and she is afraid to ask anyone about it. Can you give me some information for her?" Which reply does the nurse make? A. "Delayed treatment can result in serious lifelong complications." B. "Tell me some of the symptoms so I can help." C. "Would it help if I approached her mother with her?" D. "Are you sure that the 'friend' isn't you?"

A. "Delayed treatment can result in serious lifelong complications."

Which question should the nurse ask when assessing spirituality? A. "Do you have any spiritual practices of which I need to be aware?" B. "What religion are you affiliated with?" C. "Is there a priest or pastor you would like for me to contact? D. "Do you believe in God?"

A. "Do you have any spiritual practices of which I need to be aware?"

Which statement regarding plotting anthropometric measurements indicates correct parental understanding? A. "Height, weight, and BMI are monitored from 3 to 18 years of age." B. "There are four charts used to monitor physical growth from birth to 18 years of age." C. "Body mass index (BMI) is monitored closely during the first year of life." D. "You will plot my baby's weight, length, and head circumference through 4 years of age."

A. "Height, weight, and BMI are monitored from 3 to 18 years of age."

The nurse is reinforcing teaching provided to a patient who has been taught ways to decrease blood pressure. Which patient statement indicates a need for further teaching? A. "I eat fried foods three times a week." B. "I don't add salt to my food anymore." C. "I walk my dog for 30 minutes every day." D. "I take high blood pressure medication daily."

A. "I eat fried foods three times a week."

The nurse is involved with a follow up visit for a female patient who contracted and had been self-treating for pubic lice. Which comment by the patient indicates that patient teaching is effective? A. "I plan to be much more discriminate about who I have sex with." B. "I plan to have a serious talk to the guy who gave me an STI." C. "I read the instructions for oral permethrin very carefully." D. "I have not seen any new red tracks in my external genital area."

A. "I plan to be much more discriminate about who I have sex with."

A nurse educates a new mother preparing for discharge on postpartum depression. Which statement indicates the need for additional explanation related to postpartum depression? A. "It's okay to cry and be sad during the first few weeks after having a baby." B. "I will take naps when the baby is sleeping." C. "It's okay to ask for help if I'm feeling overwhelmed." D. "I will ask my husband for help with the nightly feedings."

A. "It's okay to cry and be sad during the first few weeks after having a baby."

The nurse is caring for a patient who states she has been consuming therapies and herbal remedies recommended by her healer. Which statement by the nurse is most appropriate? A. "Please tell me exactly what you are taking so I can make sure they don't interact with your medications." B. "The physician knows what he is doing; I would follow his treatment instead of your healer." C. "If you would prefer, you can continue to take your herbal remedies and therapies instead of the prescribed treatment." D. "You cannot take any herbal remedies or therapies while you are receiving treatment here."

A. "Please tell me exactly what you are taking so I can make sure they don't interact with your medications."

The nurse is assisting with teaching to a woman who is having difficulty conceiving. Which instruction does the nurse provide about keeping a basal body temperature chart? A. "Starting with the first day of your period, record your temperature first thing each morning." B. "Record your temperature every 4 hours, starting the first day of each month." C. "Record your temperature in the late afternoon each day for 3 months." D. "Record your temperature three times each day of your period, then once a day thereafter."

A. "Starting with the first day of your period, record your temperature first thing each morning."

A patient asks, "What is the main purpose of these medications I take for my HIV?" Which response by the nurse is most appropriate? A. "They inhibit enzymes to interfere with viral production." B. "They encapsulate the virus-infected cells." C. "They attract macrophages to the cells making the virus." D. "They mark the virus for natural killer cells to destroy."

A. "They inhibit enzymes to interfere with viral production."

A mother expresses concern regarding her newborn's sticky black stool. What is the nurse's best response? A. "This is normal meconium stool." B. "We should be concerned." C. "We should get an x-ray." D. "This is caused by overfeeding."

A. "This is normal meconium stool." This is normal and normally expelled within 24-48 hours after birth; meconium stool is the material from mucus, vernix, lanugo, hormones, and carbohydrates that accumulated in the bowel during fetal development.

The nurse is providing care to a 4-year-old patient who is experiencing nocturnal incontinence. Which parental statement indicates the need for further education? A. "We should limit fluids after lunchtime." B. "Bed wetting can be treated with a drug that reduces urine production at night." C. "Bed wetting is typically self-limiting." D. "We should not punish our child for bed wetting."

A. "We should limit fluids after lunchtime." Fluids should be limited in the evening, and the child should be encouraged to void prior to bed; therefore, this statement indicates the need for further education.

A 50-year-old woman states, "It is such a relief not to need birth control any more. I haven't had a period in 3 months." Which response by the nurse is correct? A. "Without confirmation, you are still considered to be perimenopausal and should continue birth control." B. "Birth control is usually unnecessary after age 50, even if you are still having periods." C. "It is still possible for you to get pregnant and you should consider having a tubal ligation." D. "You should continue to use birth control for at least 6 months after cessation of your periods."

A. "Without confirmation, you are still considered to be perimenopausal and should continue birth control."

The nurse is conducting an educational program on the importance of nutrition and bone health. What is the recommended daily requirement of iron for an adolescent? A. 12 mg B. 10 mg C. 7 mg D. 8-10 mg

A. 12 mg

At which age should the nurse suggest introducing rice cereal to the infant's diet? A. 6 months B. 3 months C. 9 months D. 12 months

A. 6 months

The home-care nurse is conducting a home visit for the family of a toddler-aged patient. Which finding necessitates education related to safety? A. A bucket of water used for mopping in the hallway B. Knives stored on the counter out of reach C. Cleaning supplies stored in a locked cabinet under the sink D. Drugs kept in a medicine cabinet in the bathroom

A. A bucket of water used for mopping in the hallway

A patient with chronic pain tells the nurse she wants to learn more about body-based modalities. The nurse will teach the patient about which techniques? (Select all that apply.) A. Acupressure B. Massage C. Aquatherapy D. Guided imagery E. Chiropractic medicine

A. Acupressure B. Massage E. Chiropractic medicine

Which intervention should be included by the nurse in the plan of care for a family whose newborn is admitted to the NICU? A. Allowing the parents to participate in the baby's care B. Explaining to the parents that their baby cannot be held if intubated C. Referring to the baby using the last name D. Withholding the baby's true diagnosis until more family is present

A. Allowing the parents to participate in the baby's care The family should be allowed to provide care, as appropriate, in order to promote family-centered care.

A male nurse is receiving a new admission who is a female Muslim patient. Which action should the nurse take? A. Ask a female colleague to take the patient. B. Tell the patient the unit is short-staffed and she has no choice but to have a male nurse. C. The nurse should do nothing. Female Muslim patients may be cared for by men. D. Ask the female nurse to perform the assessment but continue to care for this patient.

A. Ask a female colleague to take the patient.

The nurse should document a baseline fetal heart rate of 105 as fetal ___________. A. Bradycardia B. Normal sinus rhythm C. Sinusoidal rhythm D. Tachycardia

A. Bradycardia Normal fetal heart rate is 110-160 bpm. Fetal heart rate under 110 is considered bradycardia.

When completing a thorough health history on a child with gastrointestinal issues the nurse knows that it is important to ask which of the following questions related to gastrointestinal health? (Select all that apply.) A. Can you tell me what you had to eat yesterday? B. Do you ever see your child eating things that are not considered food? C. How often does your child have a bowel movement? D. Are there any firearms in your home? E. Does your child have a pet?

A. Can you tell me what you had to eat yesterday? Assessing a child's diet is an important part of a gastrointestinal assessment. B. Do you ever see your child eating things that are not considered food? C. How often does your child have a bowel movement? Assessing a child's bowel movements is an important part of a gastrointestinal assessment.

Which resources are appropriate to use when providing evidence-based patient education?(Select all that apply.) A. Cochrane reviews B. PubMed C. WebMD D. Wikipedia

A. Cochrane reviews This is correct. The Cochrane Collection is a resource that the nurse can use to locate information related to best practices when providing care to patients who are from a different culture. B. PubMed This is correct. PubMed is a resource that the nurse can use to locate information related to best practices when providing care to patients who are from a different culture.

While reviewing laboratory values, the nurse sees a postpartum patient's white blood cell count is 26,699 mg/dL, and her neutrophil count is also elevated. Which is the nurse's priority action? A. Continuing to monitor laboratory findings B. Obtaining STAT vital signs C. Assessing the episiotomy for signs of infection E. Notifying the RN and/or provider

A. Continuing to monitor laboratory findings

Which immunizations should the nurse prepare the parents of an infant for during the 4-month well-child visit? (Select all that apply.) A. Diphtheria, tetanus, pertussis (DTP) B. IPV C. Rotavirus D. Hepatitis B E. MMR

A. Diphtheria, tetanus, pertussis (DTP) B. IPV C. Rotavirus

A nurse has finished bathing a newborn. What is the priority action by the nurse to maintain thermoregulation? A. Dry the newborn thoroughly. B. Place a hat on the newborn. C. Place the newborn in a clean bassinet. D. Swaddle the newborn.

A. Dry the newborn thoroughly. This is priority to maintain the baby's thermoregulation to ensure that the infant is properly dry and heat is not lost through conduction.

Which term describes assisting a family to feel supported, listened to, and competent? A. Empowerment B. Egocentric C. Enable D. Empathy

A. Empowerment

A patient develops fatigue related to radiation therapy. Which intervention is the most appropriate for this patient? A. Encourage the patient to prioritize activities around frequent rest periods. B. Encourage larger portions of foods rich with calories and protein. C. Encourage moderate exercise between radiation treatments. D. Discuss the patient's views concerning blood transfusion.

A. Encourage the patient to prioritize activities around frequent rest periods.

The nurse is caring for a patient who values time. Which demonstrates respect for this cultural phenomenon? A. Ensure 9:00 medications are administered at 9:00, not 9:20. B. Maintain eye contact with the patient. C. Include the matriarch of the family in all decisions. D. Avoid standing closely to the patient.

A. Ensure 9:00 medications are administered at 9:00, not 9:20.

The nurse is taking a medication history and the patient is reluctant to tell the nurse about a certain herb because it has been banned by the Food and Drug Administration (FDA). The nurse should suspect the patient is taking which herb? A. Ephedra B. St. John's wort C. Ginger D. Garlic

A. Ephedra

The nurse is caring for a woman who delivered her third child 2 days ago and who says, "I am having pain; it feels like labor pain. I never experienced this with my other children, and it is worse when I breastfeed." Which is the nurse's priority response? A. Explain the purpose of afterpains and reassure the patient. B. Immediately obtain vital signs and monitor vital signs every 15 minutes. C. Administer a narcotic analgesic to control pain. D. Further assess the pain's location, intensity, and frequency.

A. Explain the purpose of afterpains and reassure the patient. The nurse should explain that these are afterpains resulting from the involution of the uterus and that they are stronger in women who are multiparous.

The nurse caring for a woman who is beginning the second trimester of pregnancy recognizes the need for further assessment when the woman reports which change in her body? A. Feeling short of breath with mild exertion B. Nasal congestion C. Constipation D. A dark line appearing on the abdomen

A. Feeling short of breath with mild exertion Shortness of breath with mild exertion during the early part of the second trimester indicates a problem requiring further assessment.

Before leaving a patient's room, the nurse says that pain medication will be provided within 15 minutes. The nurse returns in 10 minutes with the pain medication. Which ethical principle did the nurse demonstrate? A. Fidelity B. Justice C. Beneficence D. Veracity

A. Fidelity

Which vitamin helps prevent neural tube defects in the developing fetus? A. Folate B. Protein C. Iron D. Calcium

A. Folate Folate is a B vitamin that helps prevent neural tube defects in the developing fetus.

Which data would cause the licensed practical nurse (LPN) to notify the registered nurse (RN) when providing care for a newborn patient? A. Grunting with expirations B. Crying with a blood draw C. Eupnea D. Acrocyanosis

A. Grunting with expirations Grunting with expirations is a clinical manifestation associated with RDS; therefore, the LPN should notify the RN immediately.

According to Erikson, which should the nurse anticipate when assessing a preschool-aged child? A. Having highly imaginative thoughts B. Being engaged in tasks C. Wanting to participate in organized activities D. Questioning sexual identity

A. Having highly imaginative thoughts

The nurse is performing a physical assessment of a school-aged child with a history of urinary tract infection (UTI). The child's urine has been brownish lately. Based on these data, the nurse explains that a diagnostic test may be ordered to assess for which item in the urine? A. Hematuria B. Ketones C. Calcium D. Proteinuria

A. Hematuria

A child is admitted with acute glomerulonephritis. Which urinalysis result should the nurse anticipate confirming this diagnosis? A. Hematuria and proteinuria B. Elevated erythrocyte sedimentation rate (ESR) C. Elevated BUN and creatinine D. Elevated antistreptolysin-O titer (ASO)

A. Hematuria and proteinuria

A 16-year-old patient is acting indifferent when the nurse is asking questions about her pregnancy. This is consistent with what expected behavior of pregnant teens. A. Inconsistency B. Commitment C. Acceptance D. Ambivalence

A. Inconsistency Inconsistency is an expected behavior in pregnant teens, but this is not the behavior displayed in this scenario.

The nurse is teaching a nursing student about infection. Which is an example A. Insect B. Virus C. Bacteria D. Droplets

A. Insect

A female patient is scheduled for her first pelvic examination. Which action by the nurse will provide the patient with physical comfort? A. Instruct the patient to blow out a deep breath as the speculum is inserted. B. Allow the patient to remain in a sitting position until the HCP is present. C. Explain the details of the examination as the procedure is performed. D. Offer to allow the patient to squeeze the nurse's hand during the procedure.

A. Instruct the patient to blow out a deep breath as the speculum is inserted.

The nurse is caring for a patient with iron deficiency anemia, which of the following would be the most appropriate nursing intervention for this patient? A. Instruct the patient to notify the HCP of nausea or constipation. B. Take the iron supplement at the same time every day with meals. C. Take advantage of energy spurts and cluster activities at that time. D. Stop taking the iron supplement when symptoms are resolved.

A. Instruct the patient to notify the HCP of nausea or constipation

Background knowledge of a community that is needed in order to deliver quality care includes which of the following? (Select all that apply.) A. Languages spoken B. Availability of health promotion and preventive programs C. Political party affiliation D. Rates of chronic disease conditions

A. Languages spoken This is important knowledge to have about a community in order to deliver quality care. B. Availability of health promotion and preventive programs This is important knowledge to have about a community in order to deliver quality care. D. Rates of chronic disease conditions This is important knowledge to have about a community in order to deliver quality care.

The nurse is caring for a child with a complicated rib fracture. The nurse understands that this type of fracture can result in which of these conditions? A. Lung tissue damage B. Rheumatoid arthritis C. Bone growth disruption D. Osteomyelitis

A. Lung tissue damage This is a fracture in which the fractured bone impairs, damages, or complicates the function of another body part or organ, such as a rib fracture that extends into lung tissue.

The nurse is caring for a patient who reports feeling several enlarged lymph nodes. The nurse should plan to prepare the patient for which test? A. Lymphangiography B. A computerized tomography (CT) scan C. A complete blood count (CBC) D. A bone marrow biopsy

A. Lymphangiography

The nurse is caring for a patient recovering from a cardiac catheterization. Which actions for site care should the nurse take? A. Maintain pressure dressing on the site. B. Keep the site uncovered. C. Apply a gauze bandage to the puncture site. D. Apply an adhesive bandage to the site.

A. Maintain pressure dressing on the site.

The nurse is assessing abdominal girth for a pediatric client who presents with vomiting. Which nursing action is appropriate? A. Measuring the girth directly over the child's umbilicus B. Measuring the girth just below the sternum C. Measuring the girth just below the umbilicus D. Measuring the girth at the nipple line

A. Measuring the girth directly over the child's umbilicus An abdominal girth should be taken around the largest part of the abdomen, over the umbilicus.

The nurse enters the room and notices that the room feels cold. The mother says, "He has been crying and kicking and now he seems very tired." What is the nurse's priority concern? A. Metabolic acidosis B. Metabolic alkalosis C. The infant is hungry. D. The infant is overstimulated.

A. Metabolic acidosis The infant may be fatigued from the efforts of kicking and crying in an attempt to raise his body temperature, leading to cold stress. This is the priority concern.

Couvade syndrome is a sympathetic response to pregnancy experienced by spouses or partners of pregnant women. What symptoms would likely be reported? (Select all that apply.) A. Nausea B. Weight gain C. Hair loss D. Feet swelling E. Anxiety

A. Nausea Nausea is a symptom associated with Couvade syndrome. B. Weight gain Weight gain is a symptom associated with Couvade syndrome. E. Anxiety Anxiety is a symptom associated with Couvade syndrome.

The nurse is assessing a patient and notes that the nailbed angle exceeds 180 degrees and feels spongy when squeezed. Which intervention should the nurse implement? A. Notify the HCP. B. Document the normal finding in the chart. C. Encourage the patient to elevate his extremities. D. Tell the patient he has a congenital heart defect.

A. Notify the HCP.

Which of the following interventions would the nurse exclude from her plan of care for a hypoglycemic infant? A. Obtaining arterial blood gases B. Carefully managing the newborn's temperature C. Monitoring blood glucose after feedings D. Encouraging frequent feedings

A. Obtaining arterial blood gases

What does the nurse assess as part of the BUBBLE LE mnemonic? (Select all that apply.) A. Pain B. Gait C. Bonding and attachment D. Circulation in the legs E. Episiotomy or abdominal incision

A. Pain Pain should be assessed as part of the BUBBLE LE mnemonic. D. Circulation in the legs Circulation in the legs should be assessed to rule out a potential deep vein thrombosis as part of the BUBBLE LE mnemonic. E. Episiotomy or abdominal incision Assessing the episiotomy or cesarean section incision is part of the BUBBLE LE mnemonic.

The nurse is assisting the HCP in a procedure used for cytology of the surface of the cervix. Which procedure does the nurse understand is being performed? A. Papanicolaou B. Endometrial biopsy C. Lesion extraction D. Conization

A. Papanicolaou

A nurse is working on a medical unit in a hospital undergoing a Joint Commission review. The investigator asks the nurse to explain "never events." What examples should the nurse use to explain these kinds of events? (Select all that apply.) A. Paralyzed leg after falling from a bed B. Death from falling out of bed C. Having to restart an IV infusion D. Surgery on the wrong body part E. Canceling surgery because blood work is not safe

A. Paralyzed leg after falling from a bed B. Death from falling out of bed D. Surgery on the wrong body part

The nurse is assisting with the development of an educational program to reduce the incidence of infectious diseases in a community. What topics should the nurse suggest be included in this program? (Select all that apply.) A. Performance of hand hygiene B. Safe food handling techniques C. Importance of receiving immunizations D. Use of safety equipment with sports E. Use of cough etiquette

A. Performance of hand hygiene B. Safe food handling techniques C. Importance of receiving immunizations E. Use of cough etiquette

Which should the nurse monitor when assisting with the rapid assessment of body systems to assess a child's integumentary system? A. Presence of petechiae B. Retinal hemorrhage C. Abnormal heart sounds D. Paradoxical breathing

A. Presence of petechiae

The nurse working in an obstetric clinic admits a woman who is 5 months pregnant and admits to a heroin addiction. Which interventions will be effective in meeting the nurse's ethical obligation to the unborn fetus? (Select all that apply.) A. Providing referrals to community resources for drug treatment B. Reporting the patient's heroin use to the police C. Teaching the patient about the impacts to babies born to heroin addicts D. Determining whether the patient has family support during her pregnancy 5: Discussing the option of abortion because the mother will be unable to care for the child

A. Providing referrals to community resources for drug treatment C. Teaching the patient about the impacts to babies born to heroin addicts D. Determining whether the patient has family support during her pregnancy

Which action by the nurse is appropriate when using the "A" of the SBAR system? A. Providing the most recent vital signs B. Giving the patient's presenting complaint C. Identifying the reason for the phone call D. Asking if the provider will be coming to assess the patient

A. Providing the most recent vital signs

The seven Ps of labor include which of the following? (Select all that apply.) A. Psyche B. Passage C. Perfusion D. Powers E. Personnel

A. Psyche The woman's state of mind (psyche) before and during the birthing process is an important factor in labor. B. Passage The passage is the route through which the fetus must pass to be delivered vaginally. D. Powers During labor, the power of the uterine contractions and the woman's ability to push are critical factors.

The nurse is participating in planning care for a patient with mononucleosis. Which action should the nurse recommend to promote recovery? A. Rest periods B. Exercise C. Fluid restriction D. Full liquid diet

A. Rest periods

Families are entitled to protected rights within a health-care institution. Which of the following are included in the protected rights of families? (Select all that apply.) A. Right to personal dignity and privacy B. Right to refuse care provided by students C. Right to have elective procedures regardless of ability to pay D. Right to active participation in cultural beliefs and practices E. Right to visitation and family participation

A. Right to personal dignity and privacy This is correct. Families have the right to personal dignity and privacy. B. Right to refuse care provided by students This is correct. Families have the right to refuse care by students. D. Right to active participation in cultural beliefs and practices This is correct. Families have the right to active participation in cultural beliefs and practices. E. Right to visitation and family participation

Normal physiological jaundice is assessed when the nurse observes which of the following? A. Serum total bilirubin of 7.2 mg/dL on day four of life B. Serum conjugated bilirubin of 3.2 mg/dL C. Lethargy, disinterest in feeding, and decreased urine output D. Elevated unconjugated bilirubin at 12 hours of life

A. Serum total bilirubin of 7.2 mg/dL on day four of life On day four of life, a serum total bilirubin above 5.8 mg/dL and less than 11.7 mg/dL is an indication of physiological jaundice.

What term describes factors such as economic stability, access to food, education, social support systems, housing, neighborhood safety and environment, access to health insurance, and access to health care? A. Social determinant of health B. Health-care quality C. Health disparity D. Environmental factor

A. Social determinant of health

What term describes factors such as economic stability, access to food, education, social support systems, housing, neighborhood safety and environment, access to health insurance, and access to health care? A. Social determinant of health B. Health disparity C. Environmental factor D. Health-care quality

A. Social determinant of health Social determinants of health are things that influence health outcomes.

Which of the following are examples of secondary characteristics of cultural diversity? (Select all that apply.) A. Socioeconomic status B. Gender C. Race D. Spirituality E. Political beliefs

A. Socioeconomic status E. Political beliefs

The nurse admits a newborn to the admission nursery and prepares to bathe the baby for the first time after assessing which of the following? A. Stable temperature for 2 hours B. Temperature 36.2°C axillary on radiant warmer C. Drying of the umbilical cord D. Two hours since last eating

A. Stable temperature for 2 hours The baby's temperature should be stable for 2 hours prior to bathing.

The nurse reviews the evidence of an herb's effectiveness and notes a rating of a grade 6. Which is an accurate description of this grade? A. Strong evidence against use B. Moderate evidence for the herb's use C. Strong evidence for the herb's use D. No literature found on this herb

A. Strong evidence against use

A patient who is pregnant for the first time tells the nurse that she has been craving ice for the past 2 weeks. The nurse understands that this practice of eating can be dangerous. What information does the nurse provide to help the patient manage this type of eating disorder? (Select all that apply.) A. Substitute chewing gum or healthy, low-calorie snacks. B. Encourage a well-balanced diet with sufficient vitamins and minerals. C. Use distraction techniques such as walking, calling a friend, or reading a book. D. Increase access to the non-nutritive substance. E. Recommend not telling anyone because this type of disorder is embarrassing.

A. Substitute chewing gum or healthy, low-calorie snacks. Substitute chewing gum or healthy, low-calorie snacks. B. Encourage a well-balanced diet with sufficient vitamins and minerals. This is correct. Encourage a well-balanced diet with sufficient vitamins and minerals. C. Use distraction techniques such as walking, calling a friend, or reading a book. Encourage distraction techniques such as walking, calling a friend, or reading a book.

Nurses caring for children with gastrointestinal conditions must be aware of the signs and symptoms of moderate dehydration. Which of the following is not a sign of moderate dehydration? A. Sunken fontanel B. 8% weight loss C. Moderate thirst D. Capillary refill of 3-4 seconds

A. Sunken fontanel

A nurse recognizes which of the following signs and symptoms of dehydration for a child who presents with diarrhea and vomiting? A. Tachycardia B. Bradycardia C. Moist pink lips D. Increased urine output

A. Tachycardia This is a correct sign of dehydration.

Which newborn is at lowest risk for elevated unconjugated bilirubin levels? A. The baby born at 41 weeks' gestation B. The premature newborn C. The newborn with significant bruising from a face presentation D. The newborn with O+ blood type, born to a mother with O- blood type

A. The baby born at 41 weeks' gestation

The nurse working in the neonatal intensive care unit (NICU) sits with the family as the provider explains that the neonate has no hope of survival and recommends discontinuation of life support. Which ethical dilemma(s) should the nurse identify in this situation? (Select all that apply.) A. The cost of providing futile care B. Euthanasia versus God's will C. Quality of life versus quantity of life D. Knowledge deficit E. Lack of support for decision-making

A. The cost of providing futile care B. Euthanasia versus God's will C. Quality of life versus quantity of life

The nurse is contributing to information for women in a fibrocystic breast disease support group. Which information does the nurse suggest including? A. The manifestations of the condition usually subside with menopause. B. The disease process frequently results in the development of cancer. C. Women between the ages of 20 and 30 years are most susceptible. D. One cause is related to the use of hormonal birth control medications.

A. The manifestations of the condition usually subside with menopause.

A patient arrives in the emergency department with pain in the scrotum. The scrotal skin is tender, red, and warm to the touch. Which information will cause the nurse to suspect the patient has epididymitis? A. The patient started a new task on his job using a jack hammer. B. The patient has not traveled out of the country before. C. The patient has not been treated for any illness for 6 months. D. The patient is single but has a monogamous sexual relationship.

A. The patient started a new task on his job using a jack hammer.

The nurse is caring for a patient from Korea who does not speak or understand English. The patient's 8-year-old son offers to interpret medical information. Which are reasons to be cautious of allowing him to interpret? (Select all that apply.) A. The son may intentionally omit information being conveyed. B. The son is readily available compared to an interpreter. C. He may be proficient in medical terminology and understand what is being said. D. He may not be mature enough to handle information being conveyed. E. Using the son to interpret violates the patient's right to privacy.

A. The son may intentionally omit information being conveyed. D. He may not be mature enough to handle information being conveyed. E. Using the son to interpret violates the patient's right to privacy.

A patient diagnosed with a pleural effusion is experiencing severe dyspnea. With which procedure does the nurse anticipate assisting? A. Thoracentesis B. Bronchoscopy C. Pericardiocentesis D. Tracheostomy

A. Thoracentesis

A female patient has not achieved pregnancy after 8 months of attempting to do so and is undergoing hormone testing. Which additional reason other than infertility does the nurse identify for hormone testing? A. To assess hormone-producing tumors B. To identify bone loss after menopause C. To confirm a patient's stage of puberty D. To verify the achievement of pregnancy

A. To assess hormone-producing tumors

Which is the nurse's priority assessment during the immediate post-delivery period? A. Vaginal bleeding and fundal firmness B. Administration of naloxone C. Assessment of the umbilical cord D. Inspection of the placenta

A. Vaginal bleeding and fundal firmness The nurse's priority assessment is bleeding and firmness of fundus.

A patient asks the nurse what is meant by the term benign. Which response by the nurse is best? A. "Benign tumors spread to other organs and lymph nodes." B. "An organ with a benign tumor will continue to function normally" C. "These types of tumors grow much quicker than cancer cells." D. "It is a cluster of cells not normal to the body and is cancerous."

B. "An organ with a benign tumor will continue to function normally"

A 17-year-old in her first trimester visits the clinic for a prenatal appointment. She is upset because her parents want her to have an abortion but she does not. What should the nurse ask to find out the emancipation status of the patient? A. "Have you graduated high school?" B. "Are you married?" C. "Do you have a job?" D. "Do you have a lawyer?"

B. "Are you married?"

The nurse is providing care for a child of Asian descent who is experiencing an exacerbation of asthma. The nurse notes bruising on the child's back in the shape of a Christmas tree. Which question exhibits therapeutic communication when conducting the health history assessment on the basis of the current data? A. "Do you require a medical translator during the interview process?" B. "Do you use spooning when caring for your child's breathing issues?" C. "Have you ever been accused of abusing or neglecting your child?" D. "Why are you subjecting your child to this treatment?"

B. "Do you use spooning when caring for your child's breathing issues?"

The nurse is educating the parents of a child diagnosed with C. diff. on proper precautions for infection control. Which statement by the parents indicated to the nurse that more education is needed? A. "C. diff. can be spread by contact with our child's fecal matter." B. "Everyone should use hand sanitizer upon entering and leaving our child's room." C. "Staff will wear gowns and gloves when caring for our child." D. "A sign will be placed on the door of our child's room to indicate that she is in isolation."

B. "Everyone should use hand sanitizer upon entering and leaving our child's room." This statement demonstrates the need for further teaching. Hand hygiene should be performed with soap and water when caring for a patient with C. diff.

The nurse is speaking with a patient at a routine prenatal visit at 12 weeks' gestation. The patient asks the nurse how much weight gain is recommended in order to maintain a healthy pregnancy. Which of the following statements made by the patient demonstrate a good understanding of maintaining a healthy weight during pregnancy? A. "I should gain 40 pounds because I am a normal weight." B. "I should gain 35 pounds because I am underweight." C. "I shouldn't gain any weight because I am underweight." D. "I shouldn't gain any weight because I am obese."

B. "I should gain 35 pounds because I am underweight." BMI of less than 18.5 is considered underweight, and she should gain 28 to 40 pounds.

The nurse is providing education to the parents of a preschool-aged child. Which statement regarding infectious disease should the nurse include in the teaching session? A. "Immunizations can increase the risk of your child developing ovarian cancer." B. "Immunizations can decrease the risk for serious complications associated with communicable diseases." C. "Immunizations are voluntary prior to entering the public school system." D. "Immunizations decrease your child's risk for developing autism spectrum disorder."

B. "Immunizations can decrease the risk for serious complications associated with communicable diseases."

The nurse is assessing the knowledge of a patient newly diagnosed with endometriosis. Which statement by the patient would the nurse need to follow up on? A. "My endometriosis is likely causing my painful menstrual cramps." B. "My endometriosis will go away in a few years." C. "I might have a hard time getting pregnant." D. "I have endometrial tissue outside of my uterus."

B. "My endometriosis will go away in a few years." This statement requires follow-up by the nurse. Endometriosis cannot be cured.

The nurse is providing preoperative care for an 80-year-old patient who is scheduled to have prostate surgery. The patient says, "I know a man who was impotent after this surgery. Will that happen to me?" Which response by the nurse is most appropriate? A. "Most men your age learn to deal with erectile dysfunction if it does occur." B. "Prostate surgery can cause erectile dysfunction. I'll ask your surgeon to explain the risks to you." C. "There are many treatments available if it does occur." D. "Impotence should not be a problem; sperm production is not affected by this surgery."

B. "Prostate surgery can cause erectile dysfunction. I'll ask your surgeon to explain the risks to you."

Which parental statement at the conclusion of a teaching session regarding environmental controls for childhood asthma indicates correct understanding of the information presented? A. "We'll use pesticides to ensure that our home is free from pests." B. "We will replace the carpet in our child's bedroom with tile." C. "We're glad the dog can continue to sleep in our child's room." D. "We'll be sure to use the fireplace often to keep the house warm in the winter."

B. "We will replace the carpet in our child's bedroom with tile."

A nurse is evaluating a newborn's laboratory results on day five. Which result is a concern to the nurse? A. 6 mg/dL B. 12 mg/dL C. 5 mg/dL D. 11.7 mg/dL

B. 12 mg/dL

To prevent rickets, which calcium requirement should the nurse include in a teaching session for the parents of a later school-aged child? A. 500 mg B. 1300 mg C. 800 mg D. 1500 mg

B. 1300 mg

A patient diagnosed with HIV asks the nurse how soon the virus can be transmitted to others. Which time frame should the nurse inform the patient? A. 10 to 12 weeks B. 2 to 4 weeks C. 14 to 16 weeks D. 6 to 8 weeks

B. 2 to 4 weeks

Which pediatric patient is at increased risk for child abuse, necessitating a focused nursing assessment? A. A 3-year-old child who is toilet-trained B. A 9-month-old child, born prematurely, who is diagnosed with reflux C. A 1-year-old child who was born at 41 weeks' gestation D. A 10-year-old child who is active in sports and recently made the honor roll

B. A 9-month-old child, born prematurely, who is diagnosed with reflux

The nurse is reviewing laboratory results for a group of patients and notes a CD4 count of 120 cells/µL. For which patient would the nurse expect to see this result? A. A patient with gastroenteritis B. A patient with HIV C. A patient with allergic rhinitis D. A patient with atrial fibrillation

B. A patient with HIV

The nurse is explaining afterpains to a postpartum patient. Which of the following statements is correct? A. Afterpains are more painful for women who have not given birth previously. B. Afterpains can be noticed while breastfeeding as a result of nipple stimulation. C. Oxytocin may be administered to resolve afterpains. D. Afterpains usually last for 3 weeks.

B. Afterpains can be noticed while breastfeeding as a result of nipple stimulation. Afterpains can be noticed while breastfeeding as a result of nipple stimulation, which causes the release of oxytocin.

Which nursing action is appropriate for the parents of a 4-month-old infant who died as a result of sudden infant death syndrome (SIDS)? A. Advising the parents that an infant autopsy is not necessary B. Allowing the parents to hold, touch, and rock the infant C. Interviewing the parents to determine the cause of the incident D. Sheltering the parents from grief by not giving them any personal items of the infant, such as footprints

B. Allowing the parents to hold, touch, and rock the infant

Which professional organization states that pregnant women without complications can continue to work throughout pregnancy? A. International Childbirth Education Association B. American College of Obstetricians and Gynecologists C. American Pregnancy Organization D. American Academy of Husband-Coached Childbirth

B. American College of Obstetricians and Gynecologists According to the American College of Obstetricians and Gynecologists, pregnant women without complications can continue to work throughout the pregnancy.

The nurse is reviewing laboratory results and becomes concerned about one patient being treated for cancer. Which patient does the nurse suspect is in need of nutritional support? A. A 56-year-old with a white cell count of 6,000/mm3 B. An 18-year-old with an albumin of 2.5 g/dL C. A 43-year-old with a platelet level of 180,000/mm3 D. A 60-year-old with a calcium level of 8 mg/dL

B. An 18-year-old with an albumin of 2.5 g/dL

The nurse is conducting an educational program for a group of new graduate nurses on postpartum depression. Which response by one of the new nurses indicates the need for further instruction? A. Advise the patient to get rest and nap when the baby sleeps. B. Antidepressants are not recommended if breastfeeding. C. Monitor for signs of suicidal thoughts or thoughts to harm the baby. D. Encourage the patient to seek counseling.

B. Antidepressants are not recommended if breastfeeding. Small amounts of these drugs do transfer to the baby through breastmilk, but medical studies show that the benefits of treating the mother's depression outweigh the small risk to the baby.

Which action by the nurse is appropriate for a child who presents in the emergency department with an ankle injury? A. Performing passive range of motion (ROM) to the extremity B. Applying ice to the extremity C. Avoiding compression of the area to allow tissue swelling as necessary D. Lowering the extremity below the level of the heart

B. Applying ice to the extremity For the first 24 hours for a sprain, rest, ice, compression, and elevation (RICE) should be followed. Therefore, the nurse should apply ice to the extremity.

The nurse is conducting a physical assessment for a preschool-aged child. When plotting the child's body mass index (BMI), the nurse notes that the child is in the 90th percentile. Which action by the nurse is most appropriate? A. Checking the child's blood glucose level B. Assessing the child's level of activity C. Conducting a developmental assessment D. Referring the child to a nutritionist

B. Assessing the child's level of activity

A patient is being prepared to receive a prescribed blood transfusion. What is the best way that the licensed practical nurse (LPN) can assist the health team to prevent a transfusion reaction? A. Monitor vital signs every 15 minutes. B. Assist the registered nurse (RN) to correctly identify the patient and the blood product. C. Administer diphenhydramine (Benadryl) before the infusion. D. Warm blood to 98.6°F (37°C) before infusion.

B. Assist the registered nurse (RN) to correctly identify the patient and the blood product.

Which parental actions indicate correct understanding of the care required for a newborn diagnosed with NAS? (Select all that apply.) A. Allowing the neonate to "cry it out" B. Avoiding strong fragrances C. Handling the neonate as often as possible D. Swaddling the neonate E. Providing a calm environment

B. Avoiding strong fragrances D. Swaddling the neonate Swaddling the neonate is an appropriate action when caring for a newborn diagnosed with NAS. E. Providing a calm environment Providing a calm environment is an appropriate action when caring for a newborn diagnosed with NAS.

Before massaging the fundus, the nurse should look for which of the following? A. Breast engorgement B. Bladder distention C. Hemorrhoids D. Amount of lochia

B. Bladder distention

Which preventive health screenings should the nurse include in the plan of care for a woman who is 30 years of age? (Select all that apply.) A. Mammogram B. Blood pressure screening C. Pap test D. Breast self-examination E. Colonoscopy

B. Blood pressure screening This is correct. A blood pressure screening should be done every 1 to 2 years (or more often depending on the patient's health). C. Pap test This is correct. A Pap test is recommended every 3 years for female patients between the ages of 21 and 30 years. Once a woman is older than 30 years, the Pap test can be performed every 5 years if the previous test result was negative. D. Breast self-examination This is correct. Monthly breast self-examination is encouraged.

The nurse is caring for a patient with chronic lung disease who is receiving oxygen via a nonrebreathing mask. Which observation indicates to the nurse that the system is functioning as expected? A. Both side vents open on expiration, reservoir bag inflated B. Both side vents closed on inspiration, reservoir bag inflated C. Both side vents closed on expiration, reservoir bag deflated D. Both side vents open on inspiration, reservoir bag deflated

B. Both side vents closed on inspiration, reservoir bag inflated

The nurse is conducting an assessment on a pregnant patient. Which symptom does the nurse recognize as abnormal for a pregnant patient? A. Urinary frequency B. Burning on urination C. Stress incontinence D. Urgency

B. Burning on urination Burning on urination is not an anticipated urinary symptom of pregnancy and indicates the potential for a urinary tract infection, requiring further testing.

An adolescent is brought to the emergency department. The patient reports decreased urine output, headaches, and abdominal swelling. Based on these data, which condition does the nurse suspect? A. Acute hematuria B. Chronic glomerulonephritis C. Vesicoureteral reflux D. Unexplained proteinuria

B. Chronic glomerulonephritis

The provider orders a hysterosalpingogram for a patient. The nurse knows that this test is used for: A. Verifying sterilization post-vasectomy B. Confirming the effectiveness of a hysterectomy C. Visualizing the vas deferens D. Visualizing vaginal atrophy

B. Confirming the effectiveness of a hysterectomy A hysterosalpingogram is an x-ray of the uterus and ovaries with injection of contrast media that is required 3 months after a hysterectomy to confirm effectiveness.

Which type of childhood injury is best described as an impact injury that causes hemorrhaging in the soft tissue? A. Dislocation B. Contusion C. Fracture D. Sprain

B. Contusion Contusions occur when there is an impact injury and the tissues tear, leading to hemorrhages in soft tissue, resulting in a significantly ecchymotic (bruised) and tender area.

The nurse is caring for the patient who recently underwent a colectomy due to a bowel perforation and peritonitis. The nurse is preparing to administer the anticoagulant heparin to prevent which of the following blood disorders? A. Thrombocytopenia B. DIC C. Pancytopenia D. PV

B. DIC

The nurse witnesses a child collapsing in the cafeteria. Which is the priority action by the nurse? A. Calling for help B. Determining unresponsiveness C. Performing chest compressions D. Giving a resuscitative breath

B. Determining unresponsiveness

The nurse instructs the patient with chronic obstructive pulmonary disease (COPD) on methods to lower the risk of lung complications. One technique is the "long huff" cough. What is the rationale for this type of coughing exercise? A. Increases oxygenation B. Helps to open and clear smaller airways C. Ensures thorough lung expansion D. Removes excess carbon dioxide

B. Helps to open and clear smaller airways

Which clinical manifestations support the diagnosis of polycythemia for a neonate? (Select all that apply.) A. Hematochezia B. Hematuria C. Ruddy skin D. Hyperglycemia E. Poor feeding

B. Hematuria C. Ruddy skin E. Poor feeding

Which of the following are examples of health disparities? (Select all that apply.) A. Flossing teeth leads to fewer cavities. B. Higher levels of education are linked to living longer. C. Lesbian women are less likely to get cancer screenings. D. Eating less meat reduces the risk of some cancers. I

B. Higher levels of education are linked to living longer. C. Lesbian women are less likely to get cancer screenings.

Which patient has the highest risk of developing postpartum psychosis? A. Illegal drug use B. History of bipolar disorder C. History of depression as a teenager D. History of depression as an adult

B. History of bipolar disorder The women with the highest risk for postpartum psychosis have a history of bipolar illness or a previous episode of PPP.

The nurse is assisting a patient to use guided imagery. Which health problem is the patient most likely experiencing? A. Hyperthyroidism B. Hypertension C. Diabetes mellitus D. Gallstones

B. Hypertension

he nurse is caring for a patient who has been on strict bedrest and subsequently developed a deep vein thrombosis (DVT). Which laboratory value should be monitored when the patient is receiving anticoagulant therapy? A. BUN B. INR C. CBC D. CRP

B. INR

A female patient is diagnosed with premenstrual dysphoric disorder (PMDD). The HCP prescribes, along with hormonal contraceptives, supplements of calcium, magnesium, and vitamins E and B6. Which information is most important for the nurse to provide to the patient? A. Side effects of hormonal contraceptives B. Instructions that vitamin increases need HCP approval C. Food sources high in calcium and magnesium D. Natural sources of vitamins E and B6

B. Instructions that vitamin increases need HCP approval

A patient with migraines tells the nurse she is using a technique to alleviate pain that involves pressure and kneading of the body. The nurse knows the patient is using which technique? A. Biofeedback B. Massage therapy C. Guided imagery D. Aquatherapy

B. Massage therapy

A woman who is 12 days postpartum presents to the clinic with fever, malaise, and a burning sensation while breastfeeding. Which diagnosis is likely responsible for the woman's symptoms? A. Thrombus B. Mastitis C. Endometritis D. Hematoma

B. Mastitis Mastitis usually occurs in one breast with a sudden onset of symptoms. Signs and symptoms include red swollen area or mass in the breast, fever of 100.4°F or higher, pain or a burning sensation while breastfeeding, skin redness, and malaise.

The nurse is caring for a patient who is prescribed cyclophosphamide (Cytoxan). Which medication should the nurse expect to administer to protect the bladder? A. Doxorubicin (Adriamycin) B. Mesna (Mesnex) C. Dexrazoxane (Zinecard) D. Filgrastim (Neupogen)

B. Mesna (Mesnex)

Which is a sign that labor is imminent? (Select all that apply.) A. Fatigue B. Nesting C. Rupture of membranes D. Bloody show E. Increase in hunger and thirst

B. Nesting Nesting is commonly reported prior to labor. C. Rupture of membranes Rupture of membranes often means labor will start soon. D. Bloody show Bloody show is a sign of cervical change and may happen in early labor.

While receiving a unit of PRBCs, the patient begins to experience hives around the neck and upper chest. What actions should the nurse perform because of this reaction? (Select all that apply.) A. Return the blood to the blood bank. B. Notify the HCP. C. Administer prescribed antihistamines. D. Restart the infusion and carefully monitor. E. Stop the transfusion.

B. Notify the HCP. C. Administer prescribed antihistamines. D. Restart the infusion and carefully monitor. E. Stop the transfusion.

22. A nurse is educating a group of adolescents about the risk factors for UTIs. Which of the following risk factors mentioned by the students indicates an appropriate understanding? (Select all that apply.) A. Unexplained proteinuria B. Obstruction C. Incomplete bladder emptying D. Reflux E. Unexplained hematuria

B. Obstruction C. Incomplete bladder emptying The most significant risk factor for UTIs is the presence of a urinary tract abnormality that causes urinary stasis, obstruction, reflux, or dysfunctional voiding. D. Reflux This is correct. The most significant risk factor for UTIs is the presence of a urinary tract abnormality that causes urinary stasis, obstruction, reflux, or dysfunctional voiding.

Which factors should the nurse consider when conducting a cultural assessment? (Select all that apply.) A. Psychological B. Physical C. Social D. Economic E. Environmental

B. Physical C. Social D. Economic E. Environmental

The nurse is transporting a patient with active tuberculosis (TB) to radiology. Which action should the nurse take? A. Instruct the patient to wear gloves to radiology. B. Place a surgical mask on the patient. C. Place a surgical mask on the nurse transporting the patient. D. Be sure the patient is wearing a protective gown.

B. Place a surgical mask on the patient.

A patient in labor is diagnosed with MPC. For which health problems does the nurse anticipate providing care to the newborn? (Select all that apply.) A. Irregular heart rate B. Pneumonia C. Cyanotic extremities D. Flaccid extremities E. Conjunctivitis

B. Pneumonia E. Conjunctivitis

A patient is scheduled for a surgical biopsy for removal of a lesion suspected to be breast cancer. Which care by the nurse is most important? A. Sharing that most breast biopsies are benign B. Presenting a calm and understanding attitude C. Explaining the reasons for the surgical biopsy D. Providing the patient with antianxiety medication

B. Presenting a calm and understanding attitude

Which nursing intervention is appropriate when caring for the child suffering from an inflammatory bowel disease? A. Educate parents on the need for the child to drink a gallon of fluid daily to avoid dehydration. B. Provide heating pads for relief of abdominal pain. C. Educate on first-line treatment with chemotherapeutic drugs. D. Provide high-fat snacks to help combat weight loss.

B. Provide heating pads for relief of abdominal pain.

What should the nurse consider when preparing a birth plan for a patient during the second stage of labor? A. Cord cutting B. Pushing positions C. Induction preferences D. Placenta delivery

B. Pushing positions

A patient is admitted to the labor and delivery unit, and a plan of care based on that patient's needs is developed by which member of the health-care team? A. Nurse practitioner B. Registered nurse (RN) C. Certified nurse midwife D. Licensed practical nurse (LPN)/Licensed vocational nurse (LVN)

B. Registered nurse (RN)

A 30-year-old male patient has just received a diagnosis of testicular cancer. He appears sad and states, "I always wanted to have children. Now it will be impossible." Which information does the nurse provide to assist the patient? A. Validate the impossibility of the patient fathering a child. B. Share that it is possible to bank sperm before treatment. C. Contact information for a support group. D. Provide the patient with literature about adoption.

B. Share that it is possible to bank sperm before treatment.

The nurse is caring for a patient with lung cancer who reports chest pain, dyspnea, facial redness, and swollen neck veins. Which oncological emergency does the nurse suspect this patient is experiencing? A. Hypercalcemia B. Superior vena cava syndrome (SVCS) C. Spinal cord compression D. Thrombocytopenia

B. Superior vena cava syndrome (SVCS)

A male child presents with acute pain in the testicle area, nausea, vomiting, and a lump in the scrotal sac. What acute condition does the nurse suspect? A. Hypospadias B. Testicular torsion C. Exstrophy of the bladder D. Epispadias

B. Testicular torsion Acute condition of the spermatic cord becoming twisted, which required a surgical procedure

When reviewing a laboring patient's medical record, the nurse sees that a longitudinal lie has been documented. How is the fetus positioned? A. The fetus is lying at an angle to the mother's body between parallel and perpendicular. B. The fetus is lying parallel with the mother's body. C. The fetus is in the head-down position. D. The fetus is lying perpendicular to the mother's body.

B. The fetus is lying parallel with the mother's body.

The nurse suspects a patient is a victim of human trafficking. Which characteristic supports this suspicion? A. The patient tells the nurse she is stressed because she owns a chain of restaurants. B. The individual has a man with her who answers all questions for her and will not leave the room. C. The patient is talkative and makes eye contact. D. The patient is calm and answers questions.

B. The individual has a man with her who answers all questions for her and will not leave the room.

Which statement reflects an appropriate understanding of the anatomy and physiology of the musculoskeletal system? A. The other components of the musculoskeletal system include bone marrow and muscles but not joints. B. The musculoskeletal system develops in utero and is structurally intact at birth. C. Most of the bones are present at birth but consist more of cartilage than of bone material. D. The musculoskeletal system's functions include body structure and protection but not blood cell production.

B. The musculoskeletal system develops in utero and is structurally intact at birth.

The nurse is caring for a Chinese patient who refuses antibiotics for pneumonia. Which can the nurse infer as the reason? A. The patient cannot afford antibiotics. B. The patient believes the illness is caused by an imbalance of Yin. C. Western medicine is prohibited among the Chinese culture. D. The patient has many allergies and is afraid to have a reaction.

B. The patient believes the illness is caused by an imbalance of Yin.

The IV line of a patient receiving a vesicant chemotherapy agent has disconnected and is lying on the floor. The medication is dripping all over the floor. Which action should the nurse take first? A. Wipe it up as quickly as possible with disposable cloths. B. Use gloves and a protective gown to clean the spill according to agency policy. C. Reconnect the IV tubing immediately. D. No special precautions are needed for vesicant drug cleanups.

B. Use gloves and a protective gown to clean the spill according to agency policy.

During a patient care conference, the health care providers (HCPs) are reviewing potential outcomes based on individual interventions. Which bioethical theory is being demonstrated during this care conference? A. Theological B. Utilitarianism C. Religion D. Deontology

B. Utilitarianism

An infant who is diagnosed with a mild heart defect will not have surgical correction for at least 2 years. Which information should the nurse include in the discharge teaching regarding management in the home environment? A: "Your child is not at risk for congestive heart failure." B: "It is important for your child to maintain normal activity." C: "Your child will have a low-grade fever until the defect is repaired." D: "It is important to avoid antipyretics for the treatment of fever."

B: "It is important for your child to maintain normal activity."

A patient who is 6 weeks postpartum asks the nurse when she will start her menstrual cycle. How should the nurse respond? A. "You should begin your period the month after delivery." B. "You should start your cycle in 2 weeks." C. "Are you breastfeeding?" D. "How much sleep are you getting?"

C. "Are you breastfeeding?" The first menstrual period for a postpartum woman can occur anytime from 6 to 12 weeks after childbirth or even longer if the patient is breastfeeding, so the nurse should ask the patient if she is breastfeeding.

Which question is used to assess economic factors that may influence a patient's worldview and health status? A. "How many people live in your home?" B. "Are you exposed to high levels of noise?" C. "Do you have health insurance?" D. "Do you have access to clean drinking water?"

C. "Do you have health insurance?"

The nurse is collecting data on a patient in a HCP's office. The patient tells the nurse he or she has the flu. The nurse notices a skin rash on the palms of the hands and soles of the feet, mouth sores, and lymphadenopathy. Which question is most important for the nurse to ask? A. "Is your activity hindered by joint pain?" B. "Do you ever have unprotected sex?" C. "Have you had any painless sores lately?" D. "Does your hair appear to be thinning?"

C. "Have you had any painless sores lately?"

The nurse learns that a patient plans to try St. John's wort for depression. How should the nurse respond to the patient about this herbal remedy? A. "Herbs can be dangerous. You should avoid taking them while you are on other medications because interactions could occur." B. "Some people believe it can be helpful for depression. Because it is an herb, it would be safe to try it." C. "Herbs are medicines. You should not try anything without first consulting your primary care provider." D. "St. John's wort has been shown in research to be safe and effective for treating depression. Be sure to follow the package instructions."

C. "Herbs are medicines. You should not try anything without first consulting your primary care provider."

The nurse is caring for a patient with herpes simplex. Which statement related to disease transmission should the nurse include in the patient's discharge teaching? A. "Vehicle transmission means that particles float through the air." B. "Herpes simplex is an airborne disease." C. "Herpes simplex is transmitted through direct transmission." D. "HEPA filtration is necessary with herpes simplex."

C. "Herpes simplex is transmitted through direct transmission."

The nurse is teaching a patient about the practice of chiropractic medicine. Which statement indicates an understanding of the teaching? A. "The practitioner will insert needles along meridians of qi flows." B. "The practitioner will lead me through a visualization exercise." C. "The chiropractor will perform manipulation of the vertebral column." D. "The chiropractor can prescribe me some medication for my neck pain."

C. "The chiropractor will perform manipulation of the vertebral column."

Which statement should the nurse include in the teaching session for depot medroxyprogesterone acetate, a hormonal contraceptive? A. "This medication is administered by a patch every week." B. "This medication is taken daily at the same time." C. "This medication is administered by injection every 3 months." D. "This medication is inserted into the vagina and is used with a cervical cap."

C. "This medication is administered by injection every 3 months."

The nurse is collecting information from a female patient who is 55 years of age. The patient is postmenopausal for 8 years. The patient is also small boned, Caucasian, and has never been pregnant. Which type of bone testing does the nurse suggest to the patient? A. A laboratory test to determine estrogen levels B. A heel scan that is performed at the local pharmacy C. A dual energy x-ray absorptiometry (DEXA) scan D. A blood test to determine circulating calcium levels

C. A dual energy x-ray absorptiometry (DEXA) scan

The staff development instructor is preparing a presentation on the different types of medicine being used by the patients cared for in the organization. Which definition should the instructor use to describe the allopathic system or philosophy of health care? A. A system that holds that disease is a result of nerve dysfunction B. A system that uses tiny doses of a substance that create the symptoms of disease in a healthy person to relieve those symptoms in a sick person C. A method of treating disease with remedies that produce effects different from those caused by the disease D. A system that maintains that illness is the result of falling out of balance with nature

C. A method of treating disease with remedies that produce effects different from those caused by the disease

The nurse is caring for a group of patients. Which patient should the nurse see first? A. A patient with a blood pressure of 140/70 mm Hg who is asymptomatic B. A patient with a blood pressure of 150/60 mm Hg who is anxious C. A patient with a blood pressure of 180/120 mm Hg reporting a nosebleed D. A patient with a blood pressure of 170/80 mm Hg with a headache

C. A patient with a blood pressure of 180/120 mm Hg reporting a nosebleed

The nurse is providing discharge teaching to a patient who does not speak English. Which action by the nurse is appropriate when providing reference materials to the patient? A. Telling the patient to Google the information after discharge B. Having the interpreter write the information in a notebook for the patient to take home C. Accessing brochures and pamphlets that are written in the patient's native language D. Asking the patient's family to take notes during the teaching session

C. Accessing brochures and pamphlets that are written in the patient's native language The nurse should provide the patient and family with discharge information written in their native language, if available.

The nurse is caring for a patient with serum sickness. Which intervention should the nurse implement? A. Prepare the patient for a blood transfusion. B. Restrict the patient's fluid intake. C. Administer acetaminophen (Tylenol) as ordered. D. Teach the patient about immunosuppressive drugs.

C. Administer acetaminophen (Tylenol) as ordered.

The nurse is reviewing the medications prescribed by the health care provider (HCP) for a patient with COPD. Which prescription will cause the nurse to verify the ordered medication? A. Theophylline bronchodilator B. Corticosteroid inhaler C. Antitussive D. Short-term antibiotic therapy

C. Antitussive

The nurse is caring for a patient who is immunocompromised. Which action should the nurse take to ensure that the patient does not develop a hospital-acquired infection? A. Massage back with a skin-drying agent. B. Restrict oral fluids. C. Apply lotion to dry skin. D. Provide alcohol-based mouthwash.

C. Apply lotion to dry skin.

A woman develops a vaginal hematoma after a prolonged delivery resulting in the use of forceps. Which of the following statements would reflect the appropriate medical management of a hematoma? (Select all that apply.) A. Massage as needed B. Antibiotics as prescribed C. Applying an ice pack for 20 minutes every 2 hours for 12 hours D. Pain medication as prescribed E. Warm sitz baths as needed

C. Applying an ice pack for 20 minutes every 2 hours for 12 hours D. Pain medication as prescribed E. Warm sitz baths as needed Correct. A sitz bath will provide comfort and assist with reabsorption of the clot.

The nurse is caring for a patient with liver failure who is unconscious. The patient's girlfriend of 12 years has been making health care decisions. The patient is still legally married, and his wife whom he has not seen in 20 years shows up and wants to take over in making medical decisions. Which action should the nurse take? A. Ignore both parties and provide care based on the nurse's own values. B. Provide care according to the girlfriend's wishes. C. Ask for an ethics committee consult. D. Ask the charge nurse to assign another nurse to care for the patient.

C. Ask for an ethics committee consult.

A pediatric nurse is performing a respiratory assessment on an 18-month-old child. The nurse most likely uses which recommended techniques? A. Assess for normal breath sounds using palpation B. Assess the resonance of the lungs and underlying organs by using auscultation C. Assess breath sounds by listening to all lung fields and alternating sides for comparison D. Assess the child's respiratory status when fully awake and active

C. Assess breath sounds by listening to all lung fields and alternating sides for comparison

The nurse is caring for a patient who has been diagnosed with respiratory acidosis. Which of the following medical condition would be the contributing factor? A. Acute hypoxemia due to high altitudes B. Acetaminophen overdose C. Chronic obstructive pulmonary disease D. End-stage renal disease

C. Chronic obstructive pulmonary disease

Which type of urine specimen is collected when the nurse places a cotton ball in the diaper of a newborn or infant? A. Sterile B. Midstream sample C. Clean catch D. Uro bag

C. Clean catch A cotton ball can be placed in the diaper of a newborn or infant to collect a clean-catch urine specimen.

The nurse is talking with a pregnant patient at her 36-week appointment about preparations for the baby's arrival. The patient says that she has prepared the nursery, gone to childbirth classes, read several books, and has accumulated all of the care items and clothing she will need. Which Reva Rubin maternal task is this woman demonstrating? A. Seeking safe passage for herself and her fetus B. Securing acceptance for herself as a mother and for her fetus C. Committing herself to the child as she progresses through pregnancy D. Learning to give of herself and to accept herself as a mother to the infant

C. Committing herself to the child as she progresses through pregnancy

Which of the following must be reported to the state board of nursing? (Select all that apply.) A. Student loan debt B. Number of individuals in household C. Conviction occurring in any state D. Location of employment E. Address changes

C. Conviction occurring in any state E. Address changes

The nurse is contributing to the teaching plan for a patient who is allergic to dust. Which environmental modification should the nurse recommend be included in the teaching plan to help control symptoms? A. Installing wall-to-wall carpeting B. Using heavy draperies on sunny windows C. Covering heating ducts with filters D. Installing a hot air heater

C. Covering heating ducts with filters

Which term should the nurse use to describe the display of culturally appropriate behaviors? A. Diversity B. Worldview C. Cultural sensitivity D. Cultural awareness

C. Cultural sensitivity

Nurses from diverse community groups being included in hospital committees addressing safety and education will assist hospitals in providing what kind of care? A. Worldview B. Endemic C. Culturally competent D. Health literacy

C. Culturally competent The knowledge and expertise of these nurses will assist the hospital in the delivery of culturally competent care. Culturally competent means able to function effectively within the cultural context of beliefs, behaviors, and needs of the person or community being served.

The nurse is caring for a patient who has CLL when the patient suddenly develops petechiae, nausea, and severe back pain. The nurse recognizes this life-threatening event as which of the following? A. Pancytopenia B. Thrombocytopenia C. DIC D. Sickle cell crisis

C. DIC

A patient of northern European descent recovering from surgery denies postoperative pain; however, vital signs indicate an elevated pulse and blood pressure. The patient refuses to move in bed. Which nursing action would best ensure comfort and timely discharge? A. Give the pain medicine as prescribed. B. Respect the patient's denial of pain and do not encourage the pain medicine. C. Explain that the pain medicine will help prevent complications. D. Ask the physician to prescribe the analgesics around the clock.

C. Explain that the pain medicine will help prevent complications.

The nurse is providing care to a female patient who just received a diagnosis of agenesis of the ovaries. Which nursing care is most appropriate for the patient? A. Provide for privacy so the patient can consider options. B. Monitor for physical pain related to testing. C. Express a willingness to listen if the patient wishes. D. Check surgical dressings for signs of bleeding.

C. Express a willingness to listen if the patient wishes.

The nurse is collecting health history on a female client who is considered a high-risk pregnancy. Which information will the nurse record if the patient has had four pregnancies, a miscarriage at 16 weeks, one 22-week stillborn delivery, and delivery at term to a set of twins and a single birth? A. G4P4A1 B. G4P3A2 C. G4P2A1 D. G4P2A2

C. G4P2A1

An inflammatory process that occurs in the stomach, small intestine, or large intestine is known as which of the following? A. Gastroesophageal reflux B. Viral infection C. Gastroenteritis D. Abdominal distention

C. Gastroenteritis Gastroenteritis is the correct term used to describe an inflammatory process that occurs in the stomach, small intestine, or large intestine.

Which test does the Centers for Disease Control and Prevention (CDC) recommend all pregnant women be screened for at 35 to 37 weeks' gestation? A. Amniocentesis B. Biophysical profile (BPP) C. Group B streptococcus (GBS) D. Amniotic fluid index

C. Group B streptococcus (GBS) All pregnant women should be screened for group B streptococcus (GBS) at 35 to 37 weeks' gestation. Group B streptococcus can be dangerous to the fetus.

Which of the following is not a risk factor for developing postpartum depression? A. A recent breakup with the father of the newborn B. History of depression C. History of bipolar disorder D. An unintended pregnancy

C. History of bipolar disorder Women with the highest risk for postpartum psychosis have a history of bipolar illness or a previous episode of PPP.

A nurse is treating a school-aged child for nephrotic syndrome. Which of the following orders should the nurse question? A. Corticosteroids B. Diuretics C. IV fluids D. Antibiotics

C. IV fluids

A patient is discharged from the emergency department after treatment for epistaxis. The physician orders that all home medications be continued. Which medication will the nurse question? A. Amlodipine B. Montelukast sodium C. Ibuprofen D. Furosemide

C. Ibuprofen

A nurse is explaining child development to expectant parents. How should the nurse explain the proximal-distal aspect of development? A. Infants can crawl before they can walk. B. Infants can grasp objects before they can move their arms. C. Infants can move their arms before they can grasp objects. D. Infants have head control before they can walk.

C. Infants can move their arms before they can grasp objects.

A female patient who is experiencing symptoms related to menopause is denied hormone replacement therapy by the HCP because of a family history of breast cancer and heart disease. Which suggestion does the nurse make for management of symptoms that is likely to be ineffective? A. Increase weight-bearing exercise and activity. B. Discuss the benefit of including dietary phytoestrogens. C. Initiate a calcium and vitamin regimen. D. Dress in layers to promote comfort during hot flashes.

C. Initiate a calcium and vitamin regimen.

A patient comes to the HCP's office reporting a serious sore throat that "has lasted for 2 weeks." A rapid streptococcal antigen test is positive for strep throat. Which is the most important diagnostic test the nurse expects the HCP to order? A. Identifying the exudate in the throat B. Antibiotic allergy testing C. Laboratory tests for renal function D. Culture and sensitivity testing

C. Laboratory tests for renal function

The nurse is providing teaching to a pregnant patient. Which recommendation will help the patient avoid vena caval syndrome? A. Drink 2 L of water per day. B. Walk for 30 minutes per day. C. Lie on your left side. D. Wear low-heeled shoes.

C. Lie on your left side. Vena caval syndrome can occur when a pregnant woman lies on her back and can cause feelings of light-headedness and decrease in blood pressure. The side-lying position provides for better brain and placental perfusion.

Which assessment finding indicates adequate peripheral perfusion for a child after a cardiac catheterization? A. Dorsalis pedis pulse is palpable, but posterior tibial pulse is weak. B. Sensation is decreased, with a weakened dorsalis pedis pulse. C. Lower extremities are warm, with a capillary refill of less than 3 seconds. D. Capillary refill is greater than 3 seconds.

C. Lower extremities are warm, with a capillary refill of less than 3 seconds.

Which physical characteristics should the nurse expect to find when assessing a post-term newborn? (Select all that apply.) A. Decrease in alertness after birth B. Excess vernix and lanugo C. Meconium staining on the umbilical cord D. Dry and peeling skin E. Loose skin

C. Meconium staining on the umbilical cord Meconium staining on the umbilical cord is often noted in the post-term infant because the infant is more likely to have meconium in the amniotic fluid. D. Dry and peeling skin Dry and peeling skin is a common finding in the post-term infant. E. Loose skin

The pediatric nurse is interpreting laboratory values for a patient suspected of having ulcerative colitis. Which finding does the nurse anticipate based on the diagnosis? A. Decreased white blood cell count B. Protein in the urine C. Microcytic anemia D. Decreased sedimentation rate

C. Microcytic anemia

The nurse is assessing a blood pressure of a patient and obtains a reading of 110/60 mm Hg. The nurse knows the patient falls under which category? A. Stage 1 hypertension B. Stage 2 hypertension C. Normal blood pressure D. Elevated blood pressure

C. Normal blood pressure

The LPN/LVN is contemplating whether delegation is appropriate. Which would help the LPN/LVN make this decision? A. Facility policy and procedure manual B. Joint Commission guidelines C. Nurse practice act D. Patient's bill of rights

C. Nurse practice act

The nurse reviews the medical record of a woman admitted in labor and sees that she has a narrow pelvis. Which of the seven Ps of labor does this impact? A. Power B. Presentation C. Passage D. Passenger

C. Passage The passage is impacted by a narrow pelvis and may impede the fetus's ability to move through the passage to be delivered vaginally.

It is time for a newborn to have blood collected for the newborn screening. How does the nurse turn this into a bonding opportunity for the mother? A. Take the baby to the nursery for the test to avoid upsetting the mother. B. Perform the test without mentioning it to the mother to reduce anxiety. C. Perform the test in the mother's room and encourage her to comfort the newborn afterward. D. Explain the bandage on the baby's foot when returning the baby to the mother's room.

C. Perform the test in the mother's room and encourage her to comfort the newborn afterward. When the test is performed in the mother's room, the new mother can comfort the baby during and after the procedure.

Which method of family planning requires the woman to track her menstrual periods and estimate the time of ovulation? A. Diaphragm B. Lactational amenorrhea C. Periodic abstinence D. Coitus interruptus

C. Periodic abstinence Periodic abstinence is a natural family planning method in which abstinence from sexual intercourse is practiced around the time of ovulation; this is also known as the calendar method or rhythm method because the woman must keep careful track of her menstrual periods.

The nurse is told during a physical examination that a male patient has a curved penis during erection. Which term does the nurse use to document this observation? A. Phimosis B. Priapism C. Peyronie disease D. Paraphimosis

C. Peyronie disease

After finding a mass in the scrotum of a male patient, the nurse provides the HCP with a flashlight and turns off the lights. For which reason did the nurse perform these actions? A. Preparation for identifying a varicocele B. Preparation for a PSA to be drawn C. Preparation for transillumination of the testes D. Preparation for a digital rectal examination

C. Preparation for transillumination of the testes

The nurse is reviewing orders for a patient with systemic lupus erythematosus (SLE). For which medication should the nurse request clarification? A. Phenytoin (Dilantin) B. Levothyroxine (Synthroid) C. Promethazine (Phenergan) D. Pantoprazole (Protonix)

C. Promethazine (Phenergan)

The nurse performs a focal postpartum assessment using the BUBBLE LE mnemonic. Which assessment finding is incorrect to document as part of this examination? A. Lochia pink, small amount of drainage B. Breasts firm and tender; patient reports sore nipples C. Pulse strong and regular at rate of 84 beats per minute D. Fundus 2 cm below umbilicus, firm

C. Pulse strong and regular at rate of 84 beats per minute Pulse rate is not a part of the BUBBLE LE mnemonic and should not be included in this assessment.

The nurse is caring for a patient who underwent a liver transplant and is taking cyclosporine (Sandimmune) and azathioprine (Imuran). Which important information should the nurse teach the patient regarding the medication? A. Urine will turn orange. B. Take on an empty stomach. C. Report signs of infection immediately. D. Monitor for signs of abnormal bleeding.

C. Report signs of infection immediately.

The home care nurse is providing teaching to the family of a patient with multiple myeloma. Which nursing diagnosis should guide the nurse for this teaching? A. Ineffective airway clearance related to swelling of the lymph nodes B. Ineffective tissue perfusion related to vascular occlusion C. Risk for injury related to compromised bone integrity D. Risk for deficit fluid volume related to a bleeding disorder

C. Risk for injury related to compromised bone integrity

The nurse is assisting in the assessment process for a school-aged patient who reports hip pain all week. When assessing the right hip, the nurse finds that the hip does not fully rotate internally, abduction is limited, and the child is limping while ambulating. Based on these data, which condition might the nurse suspect? A. Legg-Calvé-Perthes disease B. Osgood-Schlatter disease C. Slipped capital femoral epiphysis D. Left hip and femur fracture

C. Slipped capital femoral epiphysis Hip pain and limping are common complaints with a slipped capital femoral epiphysis. A slipped capital femoral epiphysis is confirmed via radiography and ruling out endocrine, hormonal, and renal dysfunction or disorders.

A patient is receiving a transfusion of packed RBCs. Ten minutes after the infusion begins, the patient reports low back pain and a headache. Which action should the nurse take first? A. Start a normal saline infusion. B. Notify the physician STAT. C. Stop the blood infusion. D. Check vital signs.

C. Stop the blood infusion.

The nurse is providing care for a patient who had a mastectomy for breast cancer 2 days ago and is now developing pulmonary congestion. For which reason is a mastectomy patient at risk for pulmonary complications? A. Pathogens may have been introduced during the surgical procedure. B. Mastectomy patients are on bedrest for the first 48 to 72 hours postoperatively. C. The chest incision makes the patient hesitant to deep-breathe and cough. D. Breast cancer often metastasizes to the lungs prior to diagnosis.

C. The chest incision makes the patient hesitant to deep-breathe and cough.

The nurse is participating in the care of a male patient in the emergency department for a severe episode of hypotension. The patient takes sildenafil for erectile dysfunction. Medical history indicates management of hypertension and diabetes. Which information does the nurse provide related to meeting this patient's needs? A. Testing to validate an adequate testosterone level B. Testing to determine compromised penile circulation C. The effectiveness of herbs for erectile dysfunction D. The need to have antihypertensive medication adjusted

C. The effectiveness of herbs for erectile dysfunction

The nurse reviews laboratory values for a male patient with an elevated PSA level and notes that the alkaline phosphatase and serum calcium levels are also elevated. Which condition do these findings suggest to the nurse? A. The patient has a fulminating bladder infection. B. The patient has an obstruction of the spermatic cord. C. The patient has cancer that has metastasized to the bone. D. The patient has a sexually transmitted infection.

C. The patient has cancer that has metastasized to the bone.

The licensed practical nurse/licensed vocational nurse (LPN/LVN) is watching a nursing student administer medications to a patient with HIV. Which action by the student requires correction by the nurse? A. The student washes her hands before and after administering the medication. B. The student uses a needleless system to administer the medication. C. The student recaps the needle and places it in the sharps container. D. The student wears gloves when administering the medication.

C. The student recaps the needle and places it in the sharps container.

Which guideline should the nurse include in the education provided to the parents of pediatric patients regarding the implementation of the rapid response team? A. The team can be activated only by the family, but the nurse can assist with this process. B. The team should be activated for customer service issues. C. The team can be activated for signs and symptoms indicating the child is deteriorating, such as trouble breathing. D. The team should be activated when an immediate care conference is required.

C. The team can be activated for signs and symptoms indicating the child is deteriorating, such as trouble breathing.

he nurse is administering a pneumococcal vaccine to an older patient. What is the rationale for this vaccine? A. Many older adults are exposed to more pathogens as they age. B. Many older adults become residents in extended-care facilities (ECFs). C. There is a decline in effectiveness of lung defense mechanisms. D. Many older adults develop immunity to viral pneumonia, not bacterial.

C. There is a decline in effectiveness of lung defense mechanisms.

Which topic is the priority for the nurse who is teaching the family of an infant diagnosed with osteogenesis imperfecta? A. Traction care B. Cast care C. Trunk and extremity support during everyday care D. Postoperative spinal surgery care

C. Trunk and extremity support during everyday care

An adolescent client reports recurrent abdominal pain with diarrhea and bloody stools. Which type of inflammatory bowel disease does the nurse suspect based on these data? A. Crohn's disease B. Appendicitis C. Ulcerative colitis (UC) D. Necrotizing enterocolitis (NEC)

C. Ulcerative colitis (UC)

The nurse notes that a patient's lower legs are brown and the feet are blue when they are in the dependent position. For which health problem should the nurse collect additional data? A. Decreased arterial blood flow B. Anemia C. Venous blood flow problems D. Insufficient oxygenation

C. Venous blood flow problems

The nurse is reviewing orders for a patient taking digoxin (Lanoxin). Which additional medication should the nurse question? A. Clonidine (Catapres) B. Carvedilol (Coreg) C. Verapamil (Calan SR) D. Ramipril (Altace)

C. Verapamil (Calan SR)

The nurse is preparing an oral chemotherapeutic medication for a patient's cancer treatment. What should the nurse do to ensure personal safety when preparing this medication? A. Apply a lead apron when providing. B. Crush the medication before providing. C. Wear gloves while preparing. D. Wash hands before administering.

C. Wear gloves while preparing.

3. Which intervention should the nurse include in the plan of care for a patient who is diagnosed with PMS? A: Hormone therapy, such as prescribed drospirenone and estrogen B: Light therapy C: Moderate physical activity for 2.5 hours each week D: Increased intake of sugary foods

C: Moderate physical activity for 2.5 hours each week

16. A mother who is holding her 2-hour-old newborn says, "I don't think she likes breastfeeding, but last time, when we were in the delivery room, she did really well." Which is the nurse's best response? A. "Your milk isn't in yet. That is why she acts disinterested in eating." B. "You just need to wake her up so she'll be alert and ready to eat." C. "Let me help you get her to latch on. Once she takes hold, she'll be fine." D. "After birth, babies go into a deep sleep, but when she wakes up, she'll be hungry."

D. "After birth, babies go into a deep sleep, but when she wakes up, she'll be hungry."

Which description regarding the pathophysiology of persistent pulmonary hypertension should the nurse include in the teaching session with a newborn's parents? A. "Oxygen is picked up, and carbon dioxide is released." B. "Blood flows from the right ventricle into the pulmonary artery." C. "Gas exchange occurs in the alveoli." D. "Blood is shunted away from the lungs, affecting oxygenation."

D. "Blood is shunted away from the lungs, affecting oxygenation."

A patient with dysfunctional uterine bleeding is asking the nurse about her plan of care. How should the nurse respond? A. "If your test results are normal, the problem will likely go away on its own." B. "If your test results are normal, the provider will likely perform a colposcopy." C. "If your test results are normal, the provider will likely perform an endometrial ablation." D. "If your test results are normal, the provider will likely prescribe hormone therapy."

D. "If your test results are normal, the provider will likely prescribe hormone therapy."

The nurse is gathering information from a male patient who is presenting with difficult, painful, and frequent urination and a clear penile discharge. Which additional information supports urethritis? A. "I don't have tenderness anywhere else in my genitals." B. "I drank cranberry juice in case it was my bladder." C. "I could have gotten something from swimming in a river." D. "My partner also has some of the same symptoms."

D. "My partner also has some of the same symptoms."

When obtaining consent to give an infant a vitamin K injection, what information should the nurse give regarding the need for the injection? A. "It prevents eye infections and preserves eyesight." B. "Immunizations are part of normal newborn care." C. "It is a routine procedure for all infants immediately after birth." D. "Newborns are deficient in vitamin K, which is necessary to help blood clot.

D. "Newborns are deficient in vitamin K, which is necessary to help blood clot. We give them vitamin K to help reduce the risk of bleeding." This is the correct information for the parents.

A patient has just returned from a transurethral resection of the prostate (TURP). Which explanation does the nurse provide if the patient asks why he needs a urinary catheter? A. "The catheter is being used to irrigate your bladder with antibiotics." B. "We can take the catheter out when you are able to urinate on your own." C. "The catheter keeps your bladder empty to reduce risk for infection" D. "The catheter is keeping pressure on the surgery area to prevent bleeding."

D. "The catheter is keeping pressure on the surgery area to prevent bleeding."

A patient who has unsuccessfully implemented lifestyle modifications for high blood pressure asks what else can be done. What should the nurse respond to this patient? A. "You should get more rest." B. "You should decrease your exercise plan." C. "You should consider more strenuous exercise." D. "Your doctor may discuss medication with you."

D. "Your doctor may discuss medication with you."

The nurse works in the office of an HCP specializing in female health. Which patient does the nurse identify as being at greatest risk due to prescribed oral contraceptives? A. A 30-year-old patient with a history of thrombophlebitis and high cholesterol B. A 20-year-old patient with a family history of cardiovascular disease C. A 38-year-old patient with a high-stress job who is being treated for anxiety D. A 45-year-old patient who smokes and is treated for diabetes and hypertension

D. A 45-year-old patient who smokes and is treated for diabetes and hypertension

The nurse is caring for a group of patients. Which patient does the nurse identify at highest risk for developing an infection? A. A 12-year-old child who plays sports and lives with his parents B. A 24-year-old who works at a bank and lives at home C. A 45-year-old stay-at-home parent who lives with a friend D. A 60-year-old who lives in a long-term care facility

D. A 60-year-old who lives in a long-term care facility

Which should the nurse monitor when assisting with the rapid assessment of body systems to assess a child's cardiovascular system? A. Paradoxical breathing B. Presence of petechiae C. Retinal hemorrhage D. Abnormal heart sounds

D. Abnormal heart sounds

The nurse is planning care for patients with hypertension. Which ethnic group should the nurse understand is most sensitive to the effects of the beta blocker propranolol (Inderal)? A. Chinese B. Koreans C. Japanese Americans D. African Americans

D. African Americans

When planning community health promotion activities, which should the nurse consider when catering an educational session to the adolescent? A. Marijuana is not an issue until college. B. There is no risk of texting and driving during adolescence. C. More females smoke cigarettes than males. D. Alcohol and drug use often goes hand-in-hand with sexual intercourse.

D. Alcohol and drug use often goes hand-in-hand with sexual intercourse.

Which finding indicates the need for further testing before a diagnosis of pregnancy can be confirmed? A. Audible fetal heart tones B. Fetal movement felt by the nurse C. Fetal ultrasound showing a growing fetus D. Amenorrhea

D. Amenorrhea Although amenorrhea is considered a presumptive sign of pregnancy, it can be caused by other factors; thus, further testing is needed before making a diagnosis of pregnancy.

The nurse is assessing a group of patients. Which patient does the nurse identify at highest risk for stroke? A. A European American female B. A Hispanic female C. An Asian American male D. An African American male

D. An African American male

The nurse is providing information on breast self-examination to a female patient. Which palpation pattern does the nurse instruct the patient to use when performing this examination? A. Parallel lines B. Wheel-spoke pattern C. Spiral pattern D. Any pattern that is consistent and thorough

D. Any pattern that is consistent and thorough

While assisting the physician with a physical examination, the nurse notes which sign or symptom as most definitive of a diagnosis of pregnancy? A. Breast enlargement and tenderness B. Positive Goodell's sign C. Quickening felt by mother D. Auscultation of fetal heart sounds

D. Auscultation of fetal heart sounds When the health-care provider auscultates fetal heart sounds, it is considered a positive and definitive indication of pregnancy.

The parent of a toddler states, "My child wants to do everything by herself." Which term should the nurse use to describe this behavior in the medical record? A. Egocentric B. Negativism C. Temperament D. Autonomy

D. Autonomy

The nurse is providing education to a patient taking tamoxifen (Nolvadex). Which topic should the nurse include in the teaching? A. Watch for changes in neurologic status. B. Take with mesna (Mesnex) to protect the bladder. C. Monitor daily weights. D. Avoid antacids within 2 hours of tamoxifen.

D. Avoid antacids within 2 hours of tamoxifen.

What is the FIRST action in the sequence of events including internal and external stimuli that must happen in order for the infant to breathe upon a vaginal delivery? A. First breaths B. Increased blood flow to the lungs C. Surfactant secretion D. Chest squeeze

D. Chest squeeze

The nurse is caring for a patient with thrombocytopenia. Which of the following products would the nurse anticipate being prescribed? A. Packed RBCs B. Albumin C. Lactated Ringer's D. Cryoprecipitate

D. Cryoprecipitate

Which is a child factor that may increase the risk for abuse? A. History of divorce B. Substance abuse C. Lack of respite care D. Developmental delay

D. Developmental delay

How does an infant acquire the intestinal bacteria needed for digestion and elimination? A. A vitamin K injection at birth B. Formula C. Breastmilk D. Environmental exposure

D. Environmental exposure

The nurse is providing teaching to a group of teenage girls about menstrual cramp pain relief. What non-pharmacological suggestion should the nurse include? A. Drink 2 L of water per day. B. Place an ice pack on the lower abdomen. C. Take ibuprofen. D. Exercise regularly.

D. Exercise regularly.

The nurse is caring for an obese pregnant woman in preterm labor with intact amniotic membranes who is receiving medications to stop labor. Which type of monitoring is best for this patient? A. Internal fetal and external contraction monitoring B. Internal fetal and contraction monitoring C. External fetal and internal contraction monitoring D. External fetal and contraction monitoring

D. External fetal and contraction monitoring

Which task is most appropriate for the licensed practical nurse/licensed vocational nurse (LPN/LVN) to delegate to the unlicensed assistive personnel (UAP)? A. Assessment of a newly admitted patient B. Changing the dressing of a patient who had abdominal surgery C. Ambulating a patient who just underwent knee surgery D. Feeding a patient who needs assistance with eating

D. Feeding a patient who needs assistance with eating

Which statement about fetal circulation is true? A. Fetal circulation continues until adulthood. B. Fetal circulation continues until after the stress of labor. C. Fetal circulation continues until red blood cells are broken down. D. Fetal circulation is no longer effective at birth.

D. Fetal circulation is no longer effective at birth. This is correct; as the newborn starts breathing and the umbilical cord is cut, changes occur in the blood flow, pressure, and volume within the heart. Fetal circulation is no longer effective and the blood flows a new route.

A patient with hepatitis B virus (HBV) delivers a 6-pound, 2-ounce baby. Which action does the nurse anticipate will be needed for the infant? A. There is no treatment that is safe and effective for infants. B. IV antibiotics for 12 hours C. Antiviral eye medication less than 2 hours after birth D. HBV-immune globulin before 12 hours and HBV vaccine series

D. HBV-immune globulin before 12 hours and HBV vaccine series

The postpartum nurse is caring for a patient 24 hours post-vaginal delivery who complains of constant pain and pressure in the vaginal and rectal area. Which condition does the nurse suspect based on the patient's complaint? A. Infection B. Constipation C. Hemorrhage D. Hematoma

D. Hematoma

A child is admitted with acute glomerulonephritis. Which urinalysis result should the nurse anticipate confirming this diagnosis? A. Elevated erythrocyte sedimentation rate (ESR) B. Elevated antistreptolysin-O titer (ASO) C. Elevated BUN and creatinine D. Hematuria and proteinuria

D. Hematuria and proteinuria The nurse anticipates to see the results of hematuria and proteinuria in the urinalysis. Glomerulonephritis is an inflammation of the glomeruli of the kidneys.

The nurse is providing care for a patient who presents with redness, itching, pain, and burning of the vulva and vagina. Which additional manifestation will support the nurse's suspicion of vulvovaginitis? A. Presence of Bartholin gland abscesses B. A thin watery vaginal discharge C. Nausea, vomiting, and loss of appetite D. History of treatment for multiple sexually transmitted infections (STIs)

D. History of treatment for multiple sexually transmitted infections (STIs)

Which term should the nurse use to document decreased fetal growth due to impaired perfusion of the placenta? A. Low birth weight B. Premature neonate C. Small-for-gestational age (SGA) D. Intrauterine growth restriction (IUGR)

D. Intrauterine growth restriction (IUGR)

Which anatomical difference between adults and children places a pediatric patient at risk for insensible losses? A. Disproportionate head size B. Obligatory nose breathing C. Poorly developed intercostal chest muscles D. Large body surface area

D. Large body surface area

A new adolescent mother asks the nurse how to bathe her baby. Which is the nurse's best approach to teach her this procedure? A. Explain the procedure using pictures and diagrams. B. Have the new mother bathe the baby while the nurse talks her through the process. C. Give the new mother a brochure and tell her to ask if she has any questions. D. Let the new mother watch the nurse bathe the baby and then give a return demonstration tomorrow.

D. Let the new mother watch the nurse bathe the baby and then give a return demonstration tomorrow.

The nurse is teaching a patient the importance of completing treatment for gonorrhea. On which information is the nurse basing this teaching? A. Gonorrhea is not treatable. B. Only men experience symptoms; women are usually asymptomatic. C. Treatment is associated with many serious side effects, so compliance is low. D. Men and women may be asymptomatic and still transmit the infection.

D. Men and women may be asymptomatic and still transmit the infection.

9. The nurse caring for the infant with brachial plexus injury demonstrates proper care of the newborn by ___________. A. Allowing the affected arm to move freely B. Ordering an x-ray of the infant's clavicle C. Lifting the infant equally under both axillae D. Monitoring the infant for signs of pain

D. Monitoring the infant for signs of pain Monitoring for signs of pain and reporting to the health-care provider is an appropriate nursing intervention.

The nurse notices a colleague place a hydrocodone tablet in their pocket prior to leaving the hospital. Which action should the nurse take? A. Ask an RN what to do. B. Call the police and report the incident. C. Confront the coworker about what the nurse saw. D. Notify the nurse manager of the unit.

D. Notify the nurse manager of the unit.

The nurse is providing care to a patient who has been receiving high oxygen concentration therapy for 36 hours. Which of the following symptoms, if exhibited by the patient, should the nurse contact the HCP for suspected lung damage from this therapy? (Select all that apply.) A. Dry cough, and chest pain B. Crepitus in the scapular area C. Hypoactive bowel sounds D. Numbness in the extremities E. PaO2 greater than 100 mm Hg

D. Numbness in the extremities E. PaO2 greater than 100 mm Hg

A male patient is unable to achieve or maintain a penile erection long enough for ejaculation. The erectile dysfunction is considered the reason for the patient's infertility. Which treatment does the nurse expect the HCP to prescribe initially? A. Dehydroepiandrosterone B. Penile injections C. Testosterone replacemen D. Oral doses of tadalafil

D. Oral doses of tadalafil

Which data collected by the nurse during the health history support the suspected diagnosis of an ovarian cyst? A. Insomnia B. Pelvic pressure C. Vasomotor episodes D. Pain during intercourse

D. Pain during intercourse

The nurse is taking a health history for a patient who is ill. The patient states that no one in his family is sick nor has he been around any sick individuals. The nurse suspects the patient likely contracted the illness by indirect transmission. Which is an example of this type of transmission? A. Standing next to a person who sneezes B. Talking to a sick individual C. Walking past a person with a cough D. Picking up a toy a sick child has played with

D. Picking up a toy a sick child has played with

Which pediatric anatomical factor increases the risk for respiratory failure when care is provided to a child? A. Obligatory nose breathing B. Smaller airway C. Large posterior head bone occiput D. Poorly developed intercostal chest muscles

D. Poorly developed intercostal chest muscles

The nurse is collecting data on a patient with Chlamydia. Which assessment finding should be reported immediately to the registered nurse (RN) or physician? A. Vaginal discharge B. Red conjunctivae C. Painful urination D. Sharp pain at the base of the ribs

D. Sharp pain at the base of the ribs

A patient develops a hospital-acquired surgical wound infection. Which organism should the nurse recognize as being the most likely cause of this infection? A. Campylobacter B. Shigella C. Salmonella D. Staphylococcus aureus

D. Staphylococcus aureus

Which clinical manifestation does the nurse anticipate for a pediatric patient who is admitted with CHF? A. Bradycardia B. Weight loss C. Hypertension D. Tachycardia

D. Tachycardia

The nurse is caring for a woman who has lost over 2,000 mL of blood during cesarean delivery. Which of the following are late signs of a patient with significant blood loss? A. Bradycardia and pink, dry skin B. Tachycardia and pink, dry skin C. Tachycardia and elevated blood pressure D. Tachycardia and low blood pressure

D. Tachycardia and low blood pressure Tachycardia and low blood pressure are late signs of significant blood loss.

The nurse is reviewing the report on fertility testing for a male patient who is 28 years of age. The report designates the cause of infertility as a low sperm count with no other identified physiological disorders. Which type of infertility does the nurse recognize? A. Pretesticular B. Hormonal C. Posttesticular D. Testicular

D. Testicular

The nurse prepares a child to receive oxygen via a tent delivery system by allowing the child to place a teddy bear in and out of the tent and then rewarding the child with a sticker. Which practice is the nurse using? A. Therapeutic interventions B. Therapeutic rewards C. Therapeutic communication D. Therapeutic play

D. Therapeutic play

Which clinical manifestation noted during a physical examination causes the nurse to suspect physical abuse? A. Unilateral ecchymosis of the eye B. Extremity fractures C. Weight below the 10th percentile D. Traumatic alopecia

D. Traumatic alopecia

The nurse understands that normal adolescent development can have implications on the way in which a teen experiences pregnancy and prenatal care. Which nursing intervention is MOST appropriate when preparing the adolescent for prenatal care and pregnancy? A. Use abstract concepts. B. Discuss the adolescent's future. C. Discuss the adolescent's financial stability. D. Use direct, concrete communication.

D. Use direct, concrete communication. The nurse should use direct, concrete communication with the adolescent and provide information about the positive effects of healthy behaviors and fetal health.

Which topics are appropriate for the nurse to include in a teaching session for an adolescent patient who is experiencing acne? (Select all that apply.) A. Scrubbing the face with a washcloth B. Discouraging the consumption of greasy foods C. Recommending products that contain oil D. Washing the face twice per day E. Using a mild soap on the face

D. Washing the face twice per day E. Using a mild soap on the face

Which data collected during the health history of a laboring patient may increase the risk of delivering an SGA newborn? A. Pulse rate of 90 beats per minute B. Serum glucose level of 85 mg/dL C. Blood pressure level of 110/60 mm Hg D. Weight gain of 12 lb (5.5 kg)

D. Weight gain of 12 lb (5.5 kg)

A 26-year-old patient comes to the clinic for her 36-week checkup. The nurse explains the procedure to the patient and places a monitor on the woman's abdomen. Which test is the nurse performing? A: Fetal kick counts B: Amniocentesis C: Fundal height measurement D: Nonstress test (NST)

D: Nonstress test (NST) This test is performed after 28 weeks to monitor fetal distress. A fetal monitor is attached to the mother's abdomen, and the fetus is monitored for several minutes.