Saunders NCLEX Comprehensive Review Study Questions

The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention?

1. Keep the legs aligned with the heart. 2. Elevate the legs higher than the heart.********* 3. Clean the skin with alcohol every hour. 4. Position the client onto the side during every shift.

The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective?

1. Muffled heart sounds 2. A rise in blood pressure****** 3. Jugular venous distention 4. Client expressions of dyspnea

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority?

1. Anxiety level of the client and family 2.Presence of a MedicAlert card for the client to carry 3.Knowledge of restrictions on postdischarge physical activity 4.Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver*******

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status?

1. The neurovascular status is normal because of increased blood flow through the leg.******* 2.The neurovascular status is moderately impaired, and the surgeon should be called. 3.The neurovascular status is slightly deteriorating and should be monitored for another hour. 4.The neurovascular status is adequate from an arterial approach, but venous complications are arising.

The registered nurse (RN) is orienting a new RN assigned to the care of a client with a cardiac disorder and is told that the client has an alteration in cardiac output. After educating the new RN about cardiac output, which statement made by the new RN indicates the need for further instruction?

1."A cardiac output of 2 L/min is normal." ******************** 2."A cardiac output of 4 L/min is normal." 3."A cardiac output of 6 L/min is normal." 4."A cardiac output of 7 L/min is normal."

The nurse educator asks a student to list the 5 main categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories?

1."CAM includes biologically based practices." 2."Whole medical systems are a component of CAM." 3."Mind-body medicine is part of the CAM approach." 4."Magnetic therapy and massage therapy are a focus of CAM."*********

The nurse educator is lecturing new registered nurses (RNs) about serum calcium levels. Which statement by one of the new RNs indicates that teaching has been effective?

1."Calcium has no effect on the risk for stroke." 2."Low calcium levels can lead to cardiac arrest." *************** 3."Low calcium levels cause high blood pressure." 4."Calcium has no effect on urinary stone formation."

The nurse educator is teaching the new registered nurse (RN) how to care for clients with a decrease in blood pressure. Which statement by the new RN indicates the need for further instruction?

1."Decreased contractility occurs." 2."Decreased heart rate is not a side effect." 3."Decreased myocardial blood flow is not a concern."******** 4."Increased resistance to electrical stimulation often occurs."

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching?

1."I can sit down to put on my pants and shoes." 2."I try to exercise every day and rest when I'm tired." 3."My son removed all loose rugs from my bedroom." 4."I don't need to use my walker to get to the bathroom."*************

A client is experiencing blockage of the eustachian tubes. The nurse educates the client on how the client may forcibly open the eustachian tube. Which statement by the client indicates that the teaching has been effective?

1."I should tap the side of the head lightly." 2."I should perform the Valsalva maneuver." ********* 3."I should use cotton-tipped applicators in the ears." 4."I should chew food using exaggerated mouth movements."

The nurse teaches a client about the effects of diphenhydramine, which has been prescribed as a cough suppressant. The nurse determines that the client needs further instruction if the client makes which statement?

1."I will take the medication on an empty stomach."************* 2."I won't drink alcohol while taking this medication." 3."I won't do activities that require mental alertness while taking this medication." 4."I will use sugarless gum, candy, or oral rinses to decrease dryness in my mouth."

The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions?

1."I will use a straw for drinking." 2."I will drive only during the daytime." ********** 3."I will be careful because the device alters balance." 4."I will wash the skin daily under the lamb's wool liner of the vest."

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement?

1."I will wash my face with cotton pads." 2."I'll have to start chewing on my unaffected side." 3."I should rinse my mouth if toothbrushing is painful." 4."I'll try to eat my food either very warm or very cold."************

A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed?

1."I'm not supposed to eat cold cuts." 2."I can have most fresh fruits and vegetables." 3."I'm going to weigh myself daily to be sure I don't gain too much fluid." 4."I'm going to have a ham and cheese sandwich and potato chips for lunch."********

The new registered nurse (RN) is orienting on the cardiac unit. Which statement by the new RN indicates an understanding of an early indication of fluid volume deficit due to blood loss? 1.

1."Pulse rate will increase."******* 2."Blood pressure will decrease." 3."Edema will be present in the legs." 4."Crackles in the lungs will be present."

The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20?

1."This is a normal finding." ********* 2."This is indicative of atrial flutter." 3."This is indicative of atrial fibrillation." 4."This is indicative of impending reinfarction."

A client has a prescription to have blood drawn to measure peak and trough vancomycin levels to determine the effectiveness of therapy with this medication. The nurse arranges with the laboratory to have the peak level specimen drawn at which time?

1.1 hour before administration of the scheduled dose 2.1.5 hours after completion of the scheduled infusion***** 3.Immediately after administration of the scheduled dose 4.30 minutes before administration of the scheduled dose

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period?

1.5 seconds 2.10 seconds ******* 3.30 seconds 4.60 seconds

The nurse educator is conducting an in-service education session for the nurses employed in the eye and ear surgical unit of a large trauma center. In discussing the topic of cochlear implants, the educator notes that this surgical procedure is contraindicated in which client?

1.A client with bilateral profound hearing loss 2.A client who communicates primarily by speech 3.A client who became deaf before learning to speak******** 4.A client who received no benefit from conventional hearing aids

Levothyroxine is prescribed for a client diagnosed with hypothyroidism. Upon review of the client's record, the nurse notes that the client is taking warfarin. Which modification to the plan of care should the nurse review with the client's health care provider? Rationale

1.A decreased dosage of levothyroxine 2.An increased dosage of levothyroxine 3.A decreased dosage of warfarin sodium******** 4.An increased dosage of warfarin sodium

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply.

1.A low arterial PCo2 level 2.A hyperinflated chest noted on the chest x-ray****** 3.Decreased oxygen saturation with mild exercise***** 4.A widened diaphragm noted on the chest x-ray 5.Pulmonary function tests that demonstrate increased vital capacity

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

1.A postoperative client preparing for discharge with a new medication 2.A client requiring daily dressing changes of a recent surgical incision 3.A client scheduled for a chest x-ray after insertion of a nasogastric tube 4.A client with asthma who requested a breathing treatment during the previous shift************

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer?

1.A stage 1 ulcer 2.A vascular ulcer 3.An arterial ulcer******** 4.A venous stasis ulcer

A client with hyperthyroidism has been given methimazole. Which nursing considerations are associated with this medication? Select all that apply.

1.Administer methimazole with food. ****** 2.Place the client on a low-calorie, low-protein diet. 3.Assess the client for unexplained bruising or bleeding.********* 4.Instruct the client to report side and adverse effects such as sore throat, fever, or headaches. ********** 5.Use special radioactive precautions when handling the client's urine for the first 24 hours following initial administration.

A client who had surgery 3 days earlier is receiving heparin sulfate by subcutaneous injection every 12 hours. In planning for the client's morning care, the priority nursing intervention is which action?

1.Allow the client to sit only at the bedside. 2.Assist the client to shave using an electric razor.************* 3.Monitor the prothrombin time (PT) every 4 hours. 4.Tell the client that brushing the teeth is not allowed.

A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate?

1.Allowing bathroom privileges only 2.Elevating the head of the bed to 45 degrees 3.Wearing dark glasses to read or watch television 4.Placing an eye patch over the client's affected eye*****

A caloric test is prescribed for a client suspected of having disease of the labyrinth. The nurse should obtain which essential item in preparation for this test?

1.An otoscope ******* 2.A tongue blade 3.An emesis basin 4.An ophthalmoscope

The nurse is collecting a 24-hour composite urine specimen. Besides electrolytes and glucose, what other components are measured? Select all that apply.

1.Blood 2.Protein ***** 3.Minerals ***** 4.Creatinine ****** 5.17-ketosteroids ****** 6.Catecholamines*****

The nurse is caring for a client who is receiving immunosuppressant therapy, including corticosteroids, after renal transplantation. The nurse should plan to carefully monitor results of which laboratory test for this client?

1.Blood glucose level ******* 2.Serum calcium level 3.Serum magnesium level 4.Serum albumin concentration

The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority?

1.Blood pressure 2.Status of airway******* 3.Oxygen flow rate 4.Level of consciousness

The nurse is reinforcing instructions to a hospitalized client with heart block about the fundamental concepts regarding the cardiac rhythm. The nurse explains to the client that the normal site in the heart responsible for initiating electrical impulses is which site?

1.Bundle of His 2.Purkinje fibers 3.Sinoatrial (SA) node********* 4.Atrioventricular (AV) node

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action?

1.Call a code. 2.Call the health care provider. 3.Check the client's status and lead placement.****** 4.Press the recorder button on the electrocardiogram console.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?

1.Check for an air leak. 2.Document the findings. ********** 3.Notify the health care provider. 4.Change the chest tube drainage system.

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take?

1.Check vital signs. 2.Check laboratory test results. 3.Notify the health care provider. 4.Continue to monitor for any rhythm change.********

A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedure?

1.Chest pain******* 2.Urge to cough 3.Warm, flushed feeling 4.Pressure at the insertion site

The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis?

1.Chest x-ray 2.Bronchoscopy 3.Sputum culture ***** 4.Tuberculin skin test

Which laboratory test results may be associated with peaked or tall, tented T waves on a client's electrocardiogram (ECG)?

1.Chloride level of 98 mEq/L (98 mmol/L) 2.Sodium level of 135 mEq/L (135 mmol/L) 3.Potassium level of 6.8 mEq/L 6.8 mmol/L) ******************* 4.Magnesium level of 1.6 mEq/L (0.8 mmol/L)

The nurse is listening to a cardiologist explain the results of a cardiac catheterization to a client and family. The health care provider (HCP) tells the client that a blockage is present in the large blood vessel that supplies the anterior wall of the left ventricle. The nurse determines that the blockage is located in which area?

1.Circumflex coronary artery 2.Right coronary artery (RCA) 3.Posterior descending coronary artery (PDA) 4.Left anterior descending coronary artery (LAD)***********

The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma?

1.Client report of blurred vision 2.Client report of "tunnel vision" ******* 3.Client report of ocular erythema 4.Client report of halos around lights

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initial nursing action?

1.Continue to monitor. 2.Document the findings. 3.Change the chest tube drainage system. 4.Perform a focused respiratory assessment.**********

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate?

1.Continue to suction. 2.Notify the health care provider immediately. 3.Stop the procedure and reoxygenate the client.******* 4.Ensure that the suction is limited to 15 seconds.

The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action?

1.Continue with the instructions, verifying client understanding. ************* 2.Walk around the client so that the nurse constantly faces the client. 3.Give the client a dietary booklet and return later to continue with the instructions. 4.Tell the client about the importance of the instructions for the maintenance of health care.

The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention?

1.Correct the acidosis. 2.Administer 5% dextrose intravenously. 3.Apply a monitor for an electrocardiogram. 4.Administer short-duration insulin intravenously.********

A client being treated for heart failure is administered intravenous bumetanide. Which outcome indicates that the medication has achieved the expected effect?

1.Cough becomes productive of frothy pink sputum. 2.Urine output increases from 10 mL/hour to greater than 50 mL hourly. ************* 3.The serum potassium level changes from 3.8 to 3.1 mEq/L (3.8 to 3.1 mmol/L). 4.B-type natriuretic peptide (BNP) factor increases from 200 to 262 pg/mL (200 to 262 ng/L).

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery?

1.Cranial nerve I, olfactory 2.Cranial nerve IV, trochlear 3.Cranial nerve III, oculomotor 4.Cranial nerve VII, facial nerve*******

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube?

1.Deflate the cuff on the tube. *********** 2.Place the inner cannula into the tube. 3.Ensure that the client is able to speak. 4.Ensure that the client is able to swallow.

The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health care provider with this procedure, which is the initial nursing action?

1.Deflate the cuff. 2.Suction the ET tube.********** 3.Turn off the ventilator. 4.Obtain a code cart, and place it at the bedside.

A client is undergoing a series of diagnostic tests. The laboratory results indicate an increased blood urea nitrogen (BUN) to creatinine ratio. The nurse determines that which potential conditions could contribute to these results? Select all that apply.

1.Dehydration ***** 2.Catabolic state ***** 3.High-protein diet ****** 4.Fluid volume excess 5.Obstructive uropathy ******* 6.Acute renal tubular acidosis

Meperidine has been prescribed for a client to treat pain. Which side and adverse effects should the nurse monitor for? Select all that apply.

1.Diarrhea 2.Tremors ****** 3.Drowsiness ******* 4.Hypotension ******* 5.Urinary frequency 6.Increased respiratory rate

The nurse has admitted to the hospital a client with a diagnosis of an acute attack of Ménière's disease. The nurse reviews the health care provider's prescriptions for the client. Which prescription should the nurse question?

1.Diazepam 2.Nicotinic acid 3.Diphenhydramine 4.Ambulation four times daily********

The nurse in a health care clinic is preparing to conduct a nutritional session with a group of culturally diverse pregnant women. At the first session the nurse will be meeting with each client individually. The nurse prepares a list of items to be included in the session and lists which item as the priority?

1.Discuss the costs of food items. 2.Review the MyPlate food guide. 3.Identify the food preferences and methods of food preparation for each client. ******* 4.Weigh each client and ask the client to document the weight on a progress chart.

The nurse is caring for a client in the postoperative period following enucleation. The nurse notes bloody staining on the surgical eye dressing. Which nursing action is most appropriate?

1.Document the finding. 2.Reinforce the dressing. 3.Mark the site and continue to monitor. 4.Contact the health care provider (HCP).*********

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider?

1.Dry cough 2.Hematuria 3.Bronchospasm ********** 4.Blood-streaked sputum

The community health nurse is conducting an educational session with community members regarding the signs and symptoms associated with tuberculosis. The nurse informs the participants that tuberculosis is considered as a diagnosis if which signs and symptoms are present? Select all that apply.

1.Dyspnea ****** 2.Headache 3.Night sweats ****** 4.A bloody, productive cough ******** 5.A cough with the expectoration of mucoid sputum****

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding?

1.Dyspnea ********** 2.Headache 3.Weight gain 4.Hypothermia

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription?

1.Endotracheal intubation 2.100 units of NPH insulin 3.Intravenous infusion of normal saline********* 4.Intravenous infusion of sodium bicarbonate

The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition?

1.Heart failure 2.Atrial fibrillation 3.Myocardial infarction******** 4.Ventricular tachycardia

The nurse is documenting information in a client's chart when the electrocardiogram telemetry alarm sounds, and the nurse notes that the client is in ventricular tachycardia (VT). The nurse rushes to the client's bedside and should perform which assessment first?

1.Heart rate 2.Blood pressure 3.Respiratory rate 4.Check responsiveness************

The nurse is planning to administer hydrochlorothiazide to a client. The nurse should monitor for which adverse effects related to the administration of this medication?

1.Hypouricemia, hyperkalemia 2.Increased risk of osteoporosis 3.Hypokalemia, hyperglycemia, sulfa allergy********** 4.Hyperkalemia, hypoglycemia, penicillin allergy

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the first priority intervention in the event of this occurrence is which action?

1.Immobilize the affected extremity. 2.Remove jewelry and constricting clothing from the victim. 3.Place the extremity in a position so that it is below the level of the heart. 4.Move the victim to a safe area away from the snake and encourage the victim to rest.***************

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply.

1.Increase in pH 2.Comatose state***** 3.Deep, rapid breathing***** 4.Decreased urine output 5.Elevated blood glucose level*******

The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment finding, which action is most appropriate?

1.Inform the HCP. 2.Continue to monitor the client. ********** 3.Reinforce the occlusive dressing. 4.Encourage the client to deep breathe.

The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which health care provider prescriptions should the nurse anticipate receiving? Select all that apply.

1.Initiate an infusion of 3% NaCl.******** 2.Administer intravenous furosemide. 3.Restrict fluids to 800 mL over 24 hours.******** 4.Elevate the head of the bed to high Fowler's. 5.Administer a vasopressin antagonist as prescribed.*******

An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump?

1.It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals. 2.It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels. 3.It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream. 4.It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal.************

The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem?

1.Lack of knowledge 2.Inadequate fluid volume******** 3.Compromised family coping 4.Inadequate consumption of nutrients

The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles?

1.Mask ********* 2.Gown 3.Gloves 4.Eye protection

Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply.

1.Obtain an intravenous (IV) infusion pump.******* 2.Monitor urine output during administration. ******** 3.Prepare the medication for bolus administration. 4.Monitor the IV site for signs of infiltration or phlebitis. ********** 5.Ensure that the medication is diluted in the appropriate volume of fluid. *********** 6.Ensure that the bag is labeled so that it reads the volume of potassium in the solution.*********

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed?

1.Polyuria *********** 2.Diaphoresis 3.Pedal edema 4.Decreased respiratory rate

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing?

1.Restricting fluids 2.Placing a pillow under the knees 3.Encouraging active range-of-motion exercises************* 4.Applying a heating pad to the lower extremities

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving after this episode if which breath sounds are noted?

1.Rhonchi 2.Wheezes 3.Crackles in the bases********** 4.Crackles throughout the lung fields

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect?

1.Serous 2.Bloody ************ 3.Serosanguineous 4.Bloody, with frequent small clots

Prior to administering a client's daily dose of digoxin, the nurse reviews the client's laboratory data and notes the following results: serum calcium, 9.8 mg/dL (2.45 mmol/L); serum magnesium, 1.0 mEq/L (0.5 mmol/L); serum potassium, 4.1 mEq/L (4.1 mmol/L); serum creatinine, 0.9 mg/dL (79.5 mcmol/L). Which result should alert the nurse that the client is at risk for digoxin toxicity?

1.Serum calcium level 2.Serum potassium level 3.Serum creatinine level 4.Serum magnesium level*********

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?

1.Slow, deep respirations 2.Rapid, deep respirations 3.Paradoxical respirations 4.Pain, especially with inspiration*********

A client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication?

1.Sodium level of 140 mEq/L (140 mmol/L) 2.Platelet count of 400,000 mm3 (400 × 109/L) 3.Prothrombin time of 12 seconds (12 seconds) 4.Direct bilirubin level of 2 mg/dL (34 mcmol/L)*********

A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication?

1.Sodium level, 140 mEq/L (140 mmol/L) 2.Uric acid level, 4.0 mg/dL (0.24 mmol/L) 3.White blood cell count, 3000 mm3 (3.0 × 109/L) ******* 4.Blood urea nitrogen level, 10 mg/dL (3.6 mmol/L)

What action should the nurse consider when counseling a client of the Amish tradition?

1.Speak only to the husband. 2.Use complex medical terminology. 3.Avoid using scientific or medical jargon. ******* 4.Stand close to the client and speak loudly.

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action?

1.Stay very still. 2.Exhale very quickly. 3.Inhale and exhale quickly. 4.Perform the Valsalva maneuver.**********

The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain?

1.Sternal rub 2.Nail bed pressure ********** 3.Pressure on the orbital rim 4.Squeezing of the sternocleidomastoid muscle

The nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor indicates an action by the student requiring the need for further instruction?

1.Suctioning the client every hour ************ 2.Applying suction only during withdrawal of the catheter 3.Hyperventilating the client with 100% oxygen before suctioning 4.Applying suction intermittently during withdrawal of the catheter

A client is being discharged from the hospital after being treated for infective endocarditis. The nurse should provide the client with which discharge instruction?

1.Take acetaminophen if the chest pain worsens. 2.Take antibiotics until the chest pain is fully resolved. 3.Use a firm-bristle toothbrush and floss vigorously to prevent cavities. 4.Notify all health care providers (HCPs) of the history of infective endocarditis before any invasive procedures.****************

A client has a prescription to take guaifenesin. The nurse determines that the client understands the proper administration of this medication if the client states that he or she will perform which action?

1.Take an extra dose if fever develops. 2.Take the medication with meals only. 3.Take the tablet with a full glass of water.******** 4.Decrease the amount of daily fluid intake.

The nurse is assigned the care of a client who experienced a myocardial infarction and is being monitored by cardiac telemetry. The nurse notes the sudden onset of this cardiac rhythm on the monitor. The nurse should immediately take which action? Refer to Figure.

1.Take the client's blood pressure. 2.Initiate cardiopulmonary resuscitation (CPR). ******** 3.Place a nitroglycerin tablet under the client's tongue. 4.Continue to monitor the client for 1 minute and then contact the health care provider (HCP).

The nurse has assisted the health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement?

1.Tape the ET tube in place, and note the centimeter marking at the lip line. 2.Ask the radiology department to obtain a stat portable radiograph at the client's bedside. 3.Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds. *************** 4.Attach the ET tube to the ventilator and determine whether the client is able to tolerate the tidal volume prescribed.

The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage should the nurse instruct the client to select from the menu?

1.Tea 2.Cola 3.Coffee 4.Raspberry juice******

The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply.

1.The nurse who never had roseola 2.The nurse who never had mumps 3.The nurse who never had chickenpox******** 4.The nurse who never had German measles 5.The nurse who never received the varicella-zoster vaccine***********

The nurse is monitoring the function of a client's chest tube that is attached to a drainage system. The nurse notes that the fluid in the water seal chamber rises with inspiration and falls with expiration. The nurse determines that which is occurring?

1.Tidaling is present. *********** 2.There is a leak in the system. 3.The client has residual pneumothorax. 4.Suction should be added to the system.

The client arrives at the emergency department complaining of back spasms. The client states, "I have been taking 2 to 3 aspirin every 4 hours for the last week, and it hasn't helped my back." Since acetylsalicylic acid intoxication is suspected, the nurse should assess the client for which manifestation?

1.Tinnitus ********* 2.Diarrhea 3.Constipation 4.Photosensitivity

The nurse is monitoring a client who is taking digoxin for adverse effects. Which findings are characteristic of digoxin toxicity? Select all that apply.

1.Tremors 2.Diarrhea ******* 3.Irritability 4.Blurred vision ******* 5.Nausea and vomiting*******

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply.

1.Tremors 2.Weight loss 3.Feeling cold ***** 4.Loss of body hair ****** 5.Persistent lethargy ******** 6.Puffiness of the face *******

The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply.

1.Tremors ********* 2.Anorexia 3.Irritability ******** 4.Nervousness ********* 5.Hot, dry skin 6.Muscle cramps

A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to teach the client to take which action?

1.Use alcohol in small amounts only. 2.Report yellow eyes or skin immediately. ******** 3.Increase intake of Swiss or aged cheeses. 4.Avoid vitamin supplements during therapy.

The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client?

1.Use nail polish to protect the nail beds from injury. 2.Wear gloves for all activities involving the use of both hands. 3.Stop smoking because it causes cutaneous blood vessel spasm. ******** 4.Always wear warm clothing, even in warm climates, to prevent vasoconstriction.

The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person? Select all that apply.

1.Use products that contain alcohol. 2.Position the client on his or her side. ******* 3.Brush the teeth with a small, soft toothbrush.******* 4.Cleanse the mucous membranes with soft sponges.***** 5.Use lemon glycerin swabs when performing mouth care.

A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially?

1.Warm the client. 2.Maintain a patent airway. ********* 3.Administer thyroid hormone. 4.Administer fluid replacement.

A client is scheduled for a dose of ramipril. The nurse should check which measurement before administering the medication?

1.Weight 2.Apical pulse 3.Blood pressure ******* 4.Potassium level

The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions? 1.

1."Alcohol is not contraindicated while taking this medication." 2."Good oral hygiene is needed, including brushing and flossing." ************ 3."The medication dose may be self-adjusted, depending on side effects." 4."The morning dose of the medication should be taken before a serum medication level is drawn."

A client calls the nurse at the clinic and reports that ever since the vein ligation and stripping procedure was performed, she has been experiencing a sensation as though the affected leg is falling asleep. The nurse should make which response to the client?

1."Apply warm packs to the leg." 2."Keep the leg elevated as much as possible." 3."Your health care provider needs to be contacted to report this problem." ************ 4."This normally occurs after surgery and will subside when the edema goes down."

The nurse has just completed education on myocardial infarction (MI) to a group of new nurses. Which statement made by one of the nurses indicates that the teaching has been effective?

1."Chest pain is caused by tissue hypoxia in the myocardium."****** 2."Chest pain is caused by tissue hypoxia in the vessels of the heart." 3."Chest pain is caused by tissue hypoxia in the parietal pericardium." 4."Chest pain is caused by tissue hypoxia in the visceral pericardium."

The home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL (10 mmol/L). The client is taking cholestyramine and the nurse teaches the client about the medication. Which statement, by the client, indicates the need for further teaching?

1."Constipation and bloating might be a problem." 2."I'll continue to watch my diet and reduce my fats." 3."Walking a mile each day will help the whole process." 4."I'll continue my nicotinic acid from the health food store."****************

The registered nurse (RN) is educating a new nurse about aortic regurgitation. Which statement by the new nurse indicates that the teaching has been effective?

1."Failure of the aortic valve to close completely allows blood to flow retrograde through the aorta to the left ventricle." ************ 2."Failure of the aortic valve to close completely allows blood to flow retrograde through the left ventricle to the left atrium." 3."Failure of the aortic valve to close completely allows blood to flow retrograde through the right ventricle to the right atrium." 4."Failure of the aortic valve to close completely allows blood to flow retrograde through the pulmonary artery to the right ventricle."

The nurse is teaching the client about his prescribed prednisone. Which statement, if made by the client, indicates that further teaching is necessary?

1."I can take aspirin or my antihistamine if I need it." ********* 2."I need to take the medication every day at the same time." 3."I need to avoid coffee, tea, cola, and chocolate in my diet." 4."If I gain more than 5 pounds (2.25 kg) a week, I will call my health care provider (HCP)."

The nurse is preparing a plan of care for a client, and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made?

1."I cannot have surgery." 2."I cannot have any medicine." 3."I believe the soul lives on after death." 4."I cannot have any food containing or prepared with blood."**********

The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction?

1."I need to be sure not to go barefoot around the house." 2."If I cut my toenails, I need to be sure that I cut them straight across." 3."It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." 4."I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."********

The clinic nurse is providing instructions to a client with hypertension who will be taking captopril. Which statement by the client indicates a need for further instruction?

1."I need to change positions slowly." 2."I need to avoid taking hot baths or showers." 3."I need to drink at least 4 quarts (4 liters) of water daily." ************** 4."I need to sit down and rest if dizziness or lightheadedness occurs."

The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement?

1."I need to continue medication therapy for 1 month." 2."I can't shop at the mall for the next 6 months." 3."I can return to work if a sputum culture comes back negative." 4."I should not be contagious after 2 to 3 weeks of medication therapy."**********

A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the nursing unit after the procedure, and the nurse provides instructions to the client regarding home care measures. Which statement, if made by the client, indicates an understanding of the instructions?

1."I need to cut down on cigarette smoking." 2."I am so relieved that my heart is repaired." 3."I need to adhere to my dietary restrictions." ******** 4."I am so relieved that I can eat anything I want to now."

The home care nurse instructs a client on how to administer enoxaparin subcutaneously. Which statement, if made by the client, indicates an understanding of how to administer this medication?

1."I need to hold my skin flat before I put the needle into my skin." 2."I need to massage the skin with the alcohol wipe after I give the injection." 3."A syringe that has a small ⅝-inch (1.5 cm) needle is used to administer the injection." ***************** 4."I need to pull back on the syringe and aspirate before pushing the medication into my skin."

The nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage independently at home after discharge. Which statement by the client is the strongest indicator of the potential for difficulty after discharge?

1."I need to start exercising more to improve my health." 2."I will be sure to keep my appointment with the cardiologist." 3."I don't have anyone to help me with doing heavy housework at home."******** 4."I think I have a good understanding of what all my medications are for."

The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching?

1."I need to stop my insulin." ********** 2."I need to increase my fluid intake." 3."I need to monitor my blood glucose every 3 to 4 hours." 4."I need to call the health care provider (HCP) because of these symptoms."

The nurse teaches a client newly diagnosed with type 1 diabetes about storing Humulin N insulin. Which statement indicates to the nurse that the client understood the discharge teaching?

1."I should keep the insulin in the cabinet during the day only." 2."I know I have to keep my insulin in the refrigerator at all times." 3."I can store the open insulin bottle in the kitchen cabinet for 1 month."************ 4."The best place for my insulin is on the window sill, but in the cupboard is just as good."

The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching?

1."I should limit my fluids to 1 liter per day." ******** 2."I should use my treadmill or go for walks daily." 3."I should follow a moderate-calcium, high-fiber diet." 4."My alendronate helps to keep calcium from coming out of my bones.

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise?

1."I should not exercise since I am taking insulin." 2."The best time for me to exercise is after breakfast."************* 3."The best time for me to exercise is mid- to late afternoon." 4."NPH is a basal insulin, so I should exercise in the evening

A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching?

1."I should notify my doctor if my feet or legs start to swell." 2."My doctor told me to call his office if my pulse rate decreases below 60." 3."Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." 4."My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning."*******

The client with hyperparathyroidism is taking alendronate. Which statements by the client indicate understanding of the proper way to take this medication? Select all that apply.

1."I should take this medication with food." 2."I should take this medication at bedtime." 3."I should sit up for at least 30 minutes after taking this medication." ******** 4."I should take this medication first thing in the morning on an empty stomach." ********* 5."I can pick a time to take this medication that best fits my lifestyle as long as I take it at the same time each day."

The nurse provides discharge instructions to a client who is taking warfarin sodium. Which statement, by the client, reflects the need for further teaching?

1."I will avoid alcohol consumption." 2."I will take my pills every day at the same time." 3."I have already called my family to pick up a MedicAlert bracelet." 4."I will take coated aspirin for my headaches because it will coat my stomach."******************

The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary to control disease progression. Which statement by the client indicates a need for further teaching?

1."I will avoid using table salt with meals." 2."It is best to exercise once a week for 1 hour."******** 3."I will take nitroglycerin whenever chest discomfort begins." 4."I will use muscle relaxation to cope with stressful situations."

The nurse is educating a client on how to eliminate whistling from a hearing aid. The nurse recognizes that further teaching is needed when the client makes which statement?

1."I will cleanse my ear mold." 2."I will try reinserting the hearing aid." 3."I will raise the volume of my hearing aid."******* 4."I will make sure that my hair is not caught between the ear mold and canal."

The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided?

1."I will eat enough daily fiber to prevent straining at stool."********** 2."I will try to exercise vigorously to strengthen my heart muscle." 3."I will drink 3000 to 3500 mL of fluid daily to promote good kidney function." 4."Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels."

The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement?

1."I will stop taking my insulin if I'm too sick to eat." 2."I will decrease my insulin dose during times of illness." 3."I will adjust my insulin dose according to the level of glucose in my urine." 4."I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)."************

The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions?

1."I'll need to become a strict vegetarian." 2."I should use polyunsaturated oils in my diet."******** 3."I need to substitute eggs and whole milk for meat." 4."I should eliminate all cholesterol and fat from my diet."

The nurse is providing instructions to the client newly diagnosed with diabetes mellitus who has been prescribed pramlintide. Which instruction should the nurse include in the discharge teaching?

1."Inject the pramlintide at the same time you take your other medications." 2."Take your prescribed pills 1 hour before or 2 hours after the injection." ************ 3."Be sure to take the pramlintide with food so you don't upset your stomach." 4."Make sure you take your pramlintide immediately after you eat so you don't experience a low blood sugar."

A client with a diagnosis of varicose veins is scheduled for treatment by sclerotherapy and is receiving education about the procedure from the nurse. Which statement by the client indicates that the teaching has been effective?

1."It involves tying off the veins so that circulation is redirected in another area." 2."It involves surgically removing the varicosity, so anesthesia will be required." 3."It involves tying off the veins to prevent sluggishness of blood from occurring." 4."It involves injecting an agent into the vein to damage the vein wall and close it off."***********

A client is prescribed nicotinic acid for hyperlipidemia and the nurse provides instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions?

1."It is not necessary to avoid the use of alcohol." 2."The medication should be taken with meals to decrease flushing." 3."Clay-colored stools are a common side effect and should not be of concern." 4."Ibuprofen IB taken 30 minutes before the nicotinic acid should decrease the flushing.*************

The nurse is providing discharge teaching for a client newly diagnosed with type 2 diabetes mellitus who has been prescribed metformin. Which client statement indicates the need for further teaching?

1."It is okay if I skip meals now and then." 2."I need to constantly watch for signs of low blood sugar." *********** 3."I need to let my health care provider know if I get unusually tired." 4."I will be sure to not drink alcohol excessively while on this medication."

A client newly diagnosed with diabetes mellitus is instructed by the health care provider to obtain glucagon for emergency home use. The client asks a home care nurse about the purpose of the medication. What is the nurse's best response to the client's question?

1."It will boost the cells in your pancreas if you have insufficient insulin." 2."It will help to promote insulin absorption when your glucose levels are high." 3."It is for the times when your blood glucose is too low from too much insulin." ************** 4."It will help to prevent lipoatrophy from the multiple insulin injections over the years."

A client is scheduled to undergo cardiac catheterization for the first time, and the nurse provides instructions to the client. Which client statement indicates an understanding of the instructions?

1."It will really hurt when the catheter is first put in." 2."I will receive general anesthesia for the procedure." 3."I will have to go to the operating room for this procedure." 4."I probably will feel tired after the test from lying on a hard x-ray table for a few hours."********

The registered nurse (RN) is educating a new nurse on mitral stenosis. Which statement by the new nurse indicates that the teaching has been effective?

1."Left ventricle to aorta narrowing will impede flow of blood." 2."Left atrium to left ventricle narrowing will impede flow of blood." *************** 3."Right atrium to right ventricle narrowing will impede flow of blood." 4."Right ventricle to pulmonary artery narrowing will impede flow of blood."

The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to try to motivate the client to quit smoking?

1."None of the cardiovascular effects are reversible, but quitting might prevent lung cancer." 2."Because most of the damage has already been done, it will be all right to cut down a little at a time." 3."If you totally quit smoking right now, you can cut your cardiovascular risk to zero within a year." 4."If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."**********

The registered nurse (RN) is educating a new RN about the use of oxygen for clients with angina pectoris. Which statement by the new nurse indicates that the teaching has been effective?

1."Oxygen has a calming effect." 2."Oxygen will prevent the development of any thrombus." 3."The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells."****** 4."Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle."

The nurse has completed an educational course covering first-degree heart block. Which statement by the nurse indicates that teaching has been effective?

1."Presence of Q waves indicates first-degree heart block." 2."Tall, peaked T waves indicate first-degree heart block." 3."Widened QRS complexes indicate first-degree heart block." 4."Prolonged, equal PR intervals indicates first-degree heart block."*********

The nurse is listening to a lecture about angina. Which statement by the nurse indicates that the teaching has been effective?

1."Stable angina is chronic."******** 2."Variant angina is caused by emotional stress." 3."Unstable angina is not a life-threatening condition." 4."Intractable angina rarely limits the client's lifestyle."

A client is diagnosed with a rib fracture and asks the nurse why strapping of the ribs is not being done. Which response by the nurse is most appropriate?

1."Strapping is useful only if the ribs are fractured in several places at once." 2."That's a good idea. I'll ask the health care provider for a prescription for the needed supplies." 3."That isn't done because people often would develop pneumonia from the constricting effect on the lungs." ********************* 4."That might help you to breathe better, but this facility does not carry the necessary supplies in the stockroom. When you get home, you can purchase them at the medical supply store."

A nursing instructor asks a nursing student to describe the structure and function of the coronary arteries. Which response by the student indicates a need for further teaching on the anatomy and physiology of the heart?

1."The coronary arteries branch from the aorta." 2."The coronary arteries supply the heart muscle with blood." 3."The left coronary artery provides blood for the left atrium and the left ventricle." 4."The left coronary artery supplies the right atrium and right ventricle with blood."***********

The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include?

1."The hearing aid should not be worn if an ear infection is present."************** 2."The ear mold for the hearing aid should be washed with mild soap and water once a month." 3."The hearing aid should be removed from the ear at the end of the day and then turned off after removal." 4."The hearing aid contains a lifelong battery, so you will not need to be concerned about changing batteries."

A nursing student who is researching a medication at the nurses' station asks the registered nurse (RN) what the function of an alpha-adrenergic receptor is, and where the receptors are primarily found. The RN educates the nursing student. Which statement by the nursing student indicates that teaching has been effective?

1."The peripheral arteries and veins; when stimulated they cause vasoconstriction." **************** 2."Arterial and bronchial walls; when stimulated they cause vasodilation and bronchodilation." 3."The heart; when stimulated it causes an increase in heart rate, atrioventricular node conduction, and contractility." 4."Several tissues; when stimulated they cause contraction of smooth muscle, inhibition of lipolysis, and promotion of platelet aggregation."

A client with iron deficiency anemia complains of feeling fatigued almost all of the time. The nurse should respond with which statement?

1."The work of breathing is increased when the client is anemic." 2."Blood flows more slowly when the hemoglobin or hematocrit is low." 3."The body has to work harder to fight infection in the presence of anemia." 4."Adequate amounts of hemoglobin are needed to carry oxygen for tissue metabolism."****************

The nurse teaches the client, who is newly diagnosed with diabetes insipidus, about the prescribed intranasal desmopressin. Which statements by the client indicate understanding? Select all that apply.

1."This medication will turn my urine orange." 2."I should decrease my oral fluids when I start this medication." ********** 3."The amount of urine I make should increase if this medicine is working." 4."I need to follow a low-fat diet to avoid pancreatitis when taking this medicine." 5."I should report headache and drowsiness to my health care provider since these symptoms could be related to my desmopressin." *************

The new registered nurse (RN) is reviewing cardiac rhythms with a mentor. Which statement by the new RN indicates that teaching about ventricular fibrillation has been effective?

1."Ventricular fibrillation appears as irregular beats within a rhythm." 2."Ventricular fibrillation does not have P waves or QRS complexes."*********** 3."Ventricular fibrillation is a regular pattern of wide QRS complexes." 4."Ventricular fibrillation has recognizable P waves, QRS complexes, and T waves."

The nurse has instructed the family of a client with stroke (brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client?

1."We need to discourage him from wearing eyeglasses." 2."We need to place objects in his impaired field of vision." 3."We need to approach him from the impaired field of vision." 4."We need to remind him to turn his head to scan the lost visual field."************

The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse should immediately ask the client which question?

1."Where is the pain located?"****** 2."Are you having any nausea?" 3."Are you allergic to any medications?" 4."Do you have your nitroglycerin with you?"

A client who is receiving digoxin daily has a serum potassium level of 3 mEq/L (3 mmol/L) and is complaining of anorexia. The health care provider prescribes a serum digoxin level to be done. The nurse checks the results and should expect to note which level that is outside of the therapeutic range?

1.0.3 ng/mL 2.0.5 ng/mL 3.0.8 ng/mL 4.1.0 ng/mL***********

A client received 20 units of Humulin N insulin subcutaneously at 08:00. At what time should the nurse plan to assess the client for a hypoglycemic reaction?

1.10:00 2.11:00 3.17:00 *********** 4.24:00

A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide?

1.3.2 mEq/L (3.2 mmol/L) ******** 2.3.8 mEq/L (3.8 mmol/L) 3.4.2 mEq/L (4.2 mmol/L) 4.4.8 mEq/L (4.8 mmol/L)

A client in ventricular fibrillation is about to be defibrillated. To convert this rhythm effectively, the monophasic defibrillator machine should be set at which energy level (in joules, J) for the first delivery?

1.50 J 2.120 J 3.200 J 4.360 J**********

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?

1.A client complaining of muscle aches, a headache, and history of seizures 2.A client who twisted her ankle when rollerblading and is requesting medication for pain 3.A client with a minor laceration on the index finger sustained while cutting an eggplant 4.A client with chest pain who states that he just ate pizza that was made with a very spicy sauce*******

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)?

1.A client requiring a colostomy irrigation 2.A client receiving continuous tube feedings 3.A client who requires urine specimen collections****** 4.A client with difficulty swallowing food and fluids

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first?

1.A client who is ambulatory demonstrating steady gait 2.A postoperative client who has just received an opioid pain medication 3.A client scheduled for physical therapy for the first crutch-walking session 4.A client with a white blood cell count of 14,000 mm3 (14.0 × 109/L) and a temperature of 101°F (38.4°C)********

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical (vocational) nurse and 3 unlicensed assistive personnel (UAPs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical (vocational) nurse?

1.A client who requires a bed bath 2.An older client requiring frequent ambulation 3.A client who requires hourly vital sign measurements 4.A client requiring abdominal wound irrigations and dressing changes every 3 hours*******************

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client?

1.A low respiratory rate 2.Diminished breath sounds ********* 3.The presence of a barrel chest 4.A sucking sound at the site of injury

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1.

1.A negative Kernig's sign 2.Absence of nuchal rigidity 3.A positive Brudzinski's sign ********* 4.A Glasgow Coma Scale score of 15

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder?

1.A urinary output of 50 mL/hour 2.A coagulation time of 5 minutes 3.A heart rate that is 90 beats/minute and irregular****** 4.A blood urea nitrogen level of 20 mg/dL (7.1 mmol/L)

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply.

1.Activities should be resumed gradually.******* 2.Avoid contact with other individuals, except family members, for at least 6 months. 3.A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. ********** 4.Respiratory isolation is not necessary because family members already have been exposed. ******** 5.Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. ********* 6.When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment.

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit. What activity level should the nurse encourage for the client immediately after transfer?

1.Ad lib activities as tolerated 2.Strict bed rest for 24 hours after transfer 3.Bathroom privileges and self-care activities*********** 4.Unsupervised hallway ambulation for distances up to 200 feet (60 meters)

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription?

1.Adding a dose of heparin sodium 2.Holding the next dose of warfarin ******** 3.Increasing the next dose of warfarin 4.Administering the next dose of warfarin

A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety?

1.Administer a sedative. 2.Convey empathy, trust, and respect toward the client.************* 3.Ignore the signs and symptoms of anxiety, anticipating that they will soon disappear. 4.Make sure that the client is familiar with the correct medical terms to promote understanding of what is happening.

The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL (4.9 mmol/L), and fasting blood glucose level of 184 mg/dL (10.2 mmol/L). The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)?

1.Age 2.Hypertension 3.Hyperlipidemia 4.Glucose intolerance**********

Glimepiride is prescribed for a client with diabetes mellitus. The nurse instructs the client that which food items are most acceptable to consume while taking this medication? Select all that apply.

1.Alcohol 2.Red meats ***** 3.Whole-grain cereals ****** 4.Low-calorie desserts 5.Carbonated beverages ******

A client has been experiencing difficulty with completion of daily activities because of underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem?

1.Ambulates 10 feet (3 meters) farther each day******* 2.Verbalizes the benefits of increasing activity 3.Chooses a healthy diet that meets caloric needs 4.Sleeps without awakening throughout the night

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication?

1.An ampule of 50% dextrose 2.NPH insulin subcutaneously 3.IV fluids containing dextrose*********** 4.Phenytoin for the prevention of seizures

The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the presence of a possible postoperative complication? Select all that apply.

1.Anxiety 2.Leukocytosis******* 3.Chvostek's sign 4.Urinary output of 800 mL/hour ******* 5.Clear drainage on nasal dripper pad ********

The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem?

1.Anxiety related to the need to make lifestyle changes 2.Boredom resulting from having already learned the material 3.An attempt to ignore or deny the need to make lifestyle changes********* 4.Lack of understanding of the material provided at the teaching session and embarrassment about asking questions

A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring for the client uses which item as the best means to monitor respiratory status on an ongoing basis?

1.Apnea monitor 2.Oxygen flowmeter 3.Telemetry cardiac monitor 4.Oxygen saturation monitor*******

Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What should be the nurse's initial action?

1.Apply normal saline drops. 2.Note the time of day the test was done. ******* 3.Contact the health care provider (HCP). 4.Instruct the client to sleep with the head of the bed flat.

The nurse should evaluate that defibrillation of a client was most successful if which observation was made?

1.Arousable, sinus rhythm, blood pressure (BP) 116/72 mm Hg ****************** 2.Nonarousable, sinus rhythm, BP 88/60 mm Hg 3.Arousable, marked bradycardia, BP 86/54 mm Hg 4.Nonarousable, supraventricular tachycardia, BP 122/60 mm Hg

The nurse is teaching cardiopulmonary resuscitation (CPR) to a group of community members. The nurse tells the group that when chest compressions are performed on infants, the sternum should be depressed how far?

1.At least 2 inches (5 cm) 2.About 1½ inches (4 cm) ********** 3.At least one half the depth of the chest 4.Deep enough to make a finger impression

A daily dose of prednisone is prescribed for a client. The nurse provides instructions to the client regarding administration of the medication and should instruct the client that which time is best to take this medication?

1.At noon 2.At bedtime 3.Early morning ********** 4.Any time, at the same time, each day

The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care?

1.Avoid overuse of the eyes. 2.Decrease the amount of salt in the diet. 3.Eye medications will need to be administered for life.********* 4.Decrease fluid intake to control the intraocular pressure.

The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item?

1.Bananas 2.Broccoli 3.Antacids******* 4.Cantaloupe

To perform defibrillation, the defibrillator pads should be placed in which areas of the client's chest?

1.Behind the right and left shoulders in the scapular area 2.1 inch (2.5 cm) below the sternum and 4 inches (10 cm) to the left of the sternum 3.1 inch (2.5 cm) below the umbilicus and 2 inches (5 cm) to the right of the left nipple 4.To the right of the sternum just below the clavicle and to the left side, just below and to the left of the pectoral muscle***********

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

1.Bilateral wheezing 2.Inspiratory crackles 3.Intercostal retractions 4.Increased respiratory rate********

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

1.Blowing the nose 2.Isometric exercises 3.Coughing vigorously 4.Exhaling during repositioning*******

A client with a clot in the right atrium is receiving a heparin sodium infusion at 1000 units/hour and warfarin sodium 7.5 mg at 5:00 p.m. daily. The morning laboratory results are as follows: activated partial thromboplastin time (aPTT), 32 seconds; international normalized ratio (INR), 1.3. The nurse should take which action based on the client's laboratory results?

1.Collaborate with the health care provider (HCP) to discontinue the heparin infusion and administer the warfarin sodium as prescribed. 2.Collaborate with the HCP to obtain a prescription to increase the heparin infusion and administer the warfarin sodium as prescribed. ******************* 3.Collaborate with the HCP to withhold the warfarin sodium since the client is receiving a heparin infusion and the aPTT is within the therapeutic range. 4.Collaborate with the HCP to continue the heparin infusion at the same rate and to discuss use of dabigatran etexilate in place of warfarin sodium.

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client?

1.Coma 2.Flushing********* 3.Dizziness 4.Tachycardia

A client with acute glomerulonephritis has had a urinalysis sample sent to the laboratory. The report reveals the presence of hematuria and proteinuria. The nurse interprets these results as which condition?

1.Consistent with glomerulonephritis ****** 2.Inconsistent with glomerulonephritis 3.Unclear; no conclusion can be drawn 4.Indicative of impending acute kidney injury

The nurse is reviewing the plan of care with an Asian American client. The client frequently nods the head during the review. Based upon this behavior, what should be the nurse's next action?

1.Contact a qualified medical interpreter.********* 2.Give corresponding written information to the client. 3.Check to see if the client has an English-speaking family member. 4.Ignore the behavior and start to review the plan of care with the client.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?

1.Cyanosis 2.Hypotension 3.Paradoxical chest movement ********** 4.Dyspnea, especially on exhalation

The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide and metformin. The nurse should provide which instructions to the client? Select all that apply.

1.Diarrhea may occur secondary to the metformin.***** 2.The repaglinide is not taken if a meal is skipped.****** 3.The repaglinide is taken 30 minutes before eating.***** 4.A simple sugar food item is carried and used to treat mild hypoglycemia episodes. ******** 5.Muscle pain is an expected effect of metformin and may be treated with acetaminophen. 6.Metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide.

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed?

1.Discontinuing the heparin infusion 2.Increasing the rate of the heparin infusion 3.Decreasing the rate of the heparin infusion 4.Leaving the rate of the heparin infusion as is******

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate?

1.Do nothing, because this is an expected finding. 2.Check for an air leak, because the bubbling should be intermittent. ************ 3.Increase the suction pressure so that the bubbling becomes vigorous. 4.Clamp the chest tube and notify the health care provider immediately.

The nurse is instructing the post-cardiac surgery client about activity limitations for the first 6 weeks after hospital discharge. The nurse should include which item in the instructions?

1.Driving is permitted as long as the lap and shoulder seat belts are worn. 2.Lifting should be restricted to objects that do not weigh more than 25 pounds (11.3 kg). 3.Use the arms for balance, not weight support, when getting out of bed or a chair. **************** 4.Activities that involve straining may be resumed as long as they do not cause pain.

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice?

1.Each staff member is assigned a specific task for a group of clients. 2.A staff member is assigned to determine the client's needs at home and begin discharge planning. 3.A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an unlicensed assistive personnel (UAP). 4.An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients.*********

A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. Which instruction should the nurse plan to provide to the client about this procedure?

1.Eat breakfast just before the procedure. 2.Wear firm, rigid shoes, such as work boots. 3.Wear loose clothing with a shirt that buttons in front.****** 4.Avoid cigarettes for 30 minutes before the procedure.

The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client's chest and before discharge, which intervention is a priority?

1.Ensure that the client has been intubated. 2.Set the defibrillator to the "synchronize" mode. 3.Administer an amiodarone bolus intravenously. 4.Confirm that the rhythm is actually ventricular fibrillation.*************

A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions by the nurse demonstrate cultural sensitivity and spiritual support? Select all that apply.

1.Ensures that a close relative stays with the client******* 2.Makes a referral for a Catholic priest to visit the client******* 3.Removes the crucifix from the wall in the client's room 4.Administers the sacrament of the sick to the client if death is imminent 5.Offers to provide a means for praying the rosary if the client wishes ******* 6.Reminds the dietary department that meals served on Fridays during Lent do not contain meat

The nurse is giving a report to an unlicensed assistive personnel (UAP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently?

1.Every 2 hours 2.Every 3 hours 3.Every 4 hours 4.Every 30 minutes**********

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply.

1.Excessive bubbling in the water seal chamber 2.Vigorous bubbling in the suction control chamber 3.Drainage system maintained below the client's chest******* 4.50 mL of drainage in the drainage collection chamber***** 5.Occlusive dressing in place over the chest tube insertion site ********** 6.Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation*******

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client?

1.Face tent 2.Venturi mask ******** 3.Aerosol mask 4.Tracheostomy collar

The nurse should tell the client, who is taking levothyroxine, to notify the health care provider (HCP) if which problem occurs?

1.Fatigue 2.Tremors ******** 3.Cold intolerance 4.Excessively dry skin

The nurse is monitoring the respiratory status of a client after creation of a tracheostomy. Which co-existing condition in the client may cause an inaccurate pulse oximetry reading?

1.Fever 2.Epilepsy 3.Hypotension ****** 4.Respiratory failure

The nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of exacerbation?

1.Fever 2.Fatigue 3.Weight loss 4.Shortness of breath*******

A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply.

1.Fever ******* 2.Nausea ****** 3.Lethargy 4.Tremors ***** 5.Confusion ****** 6.Bradycardia

The nurse is giving a bed bath to an assigned client when an unlicensed assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action?

1.Finish the bed bath and then administer the pain medication to the other client. 2.Ask the UAP to find out when the last pain medication was given to the client. 3.Ask the UAP to tell the client in pain that medication will be administered as soon as the bed bath is complete. 4.Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.*******************

The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication?

1.Flat neck veins 2.A pulse rate of 60 beats/minute 3.Muffled or distant heart sounds**** 4.Wheezing on auscultation of the lungs

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present?

1.Fluid is clear and tests negative for glucose. 2.Fluid is grossly bloody in appearance and has a pH of 6. 3.Fluid clumps together on the dressing and has a pH of 7. 4.Fluid separates into concentric rings and tests positive for glucose.********

The home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should tell the client to take which action?

1.Freeze the insulin. 2.Refrigerate the insulin. ******* 3.Store the insulin in a dark, dry place. 4.Keep the insulin at room temperature.

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully?

1.Gets angry with family if they interrupt a task 2.Experiences bouts of depression and irritability 3.Has difficulty with using modified feeding utensils 4.Consistently uses adaptive equipment in dressing self**********

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness?

1.Giving client full control over care decisions and restricting visitors 2.Providing positive feedback and encouraging active range of motion 3.Providing information, giving positive feedback, and encouraging relaxation ************* 4.Providing intravenously administered sedatives, reducing distractions, and limiting visitors

A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure?

1.Glipizide 2.Metformin***** 3.Repaglinide 4.Regular insulin

A client has a urine specific gravity level of 1.034. The nurse determines that which causes or conditions can be related to this level? Select all that apply.

1.Glycosuria ******* 2.Albuminuria ****** 3.Dehydration ******* 4.Diabetes insipidus 5.High creatinine level 6.Increased blood urea nitrogen (BUN)

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply.

1.Head midline********* 2.Neck in neutral position********** 3.Head of bed elevated 30 to 45 degrees********* 4.Head turned to the side when flat in bed 5.Neck and jaw flexed forward when opening the mouth

To detect the development of a chronic carrier state in a client with hepatitis, which laboratory test should the nurse assess?

1.Hepatitis B virus DNA 2.Prolonged prothrombin time 3.Hepatitis B surface antigen (HBsAg)******* 4.Antibody to surface antigen (anti-HBs)

The nurse is performing cardiopulmonary resuscitation (CPR) on a client who has had a cardiac arrest. An automatic external defibrillator (AED) is available to treat the client. Which activity will allow the nurse to assess the client's cardiac rhythm?

1.Hold the defibrillator paddles firmly against the chest. 2.Apply adhesive patch electrodes to the chest and move away from the client. *********** 3.Connect standard electrocardiographic electrodes to a transtelephonic monitoring device. 4.Apply standard electrocardiographic monitoring leads to the client, and observe the rhythm.

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported?

1.Hot, flushed feeling 2.Sudden chills and fever 3.Chest pain that occurs suddenly ******** 4.Dyspnea when deep breaths are taken

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing which problem?

1.Hypercalcemia 2.Peripheral neuritis ******** 3.Small blood vessel spasm 4.Impaired peripheral circulation

The nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. What is the initial nursing action?

1.Hyperoxygenate the client. ************* 2.Set the suction pressure range at 150 mm Hg. 3.Place the catheter into the tracheostomy tube. 4.Apply suction on the catheter, and insert it into the tracheostomy tube.

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists?

1.Hyperreflexia 2.Positive reflexes 3.Flaccid paralysis *********** 4.Reflex emptying of the bladder

The nurse is reviewing the record of a client who arrives at the health care clinic. The nurse notes that irbesartan has been prescribed for the client. The nurse should suspect that the client has which condition?

1.Hypertension ******** 2.Hypothyroidism 3.Diabetes mellitus 4.Renal transplant rejection

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client?

1.Hypoglycemia 2.Level of hoarseness 3.Respiratory distress ********* 4.Edema at the surgical site

A client is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply.

1.Hypoglycemia may be experienced before dinnertime.****** 2.The insulin dose should be decreased if illness occurs. 3.The insulin should be administered at room temperature. ******** 4.The insulin vial needs to be shaken vigorously to break up the precipitates. 5.The NPH insulin should be drawn into the syringe first, then the regular insulin.

A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL (140 mcmol/L). Which finding would be expected as a result of this laboratory result?

1.Hypotension 2.Tachycardia 3.Slurred speech *********** 4.No abnormal finding

A client with a diagnosis of Addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional health care team focus on? Select all that apply.

1.Hypotension ******** 2.Leukocytosis 3.Hyperkalemia ******* 4.Hypercalcemia 5.Hypernatremia

The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the client for which finding?

1.Hypotension******** 2.Flat neck veins 3.Complaints of nausea 4.Complaints of headache

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem?

1.Hypovolemia 2.Acute kidney injury******* 3.Glomerulonephritis 4.Urinary tract infection

To perform cardiopulmonary resuscitation (CPR), the nurse should use the method pictured to open the airway in which situation? Refer to figure.

1.If neck trauma is suspected ***************** 2.In all situations requiring CPR 3.If the client has a history of seizures 4.If the client has a history of headaches

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states that he or she will immediately report which finding?

1.Impaired sense of hearing 2.Gastrointestinal side effects 3.Orange-red discoloration of body secretions 4.Difficulty in discriminating the color red from green********

A new registered nurse (RN) is assigned to the care of a client hospitalized with a diagnosis of hypothermia. After consulting with an experienced RN, which statement by the new RN indicates understanding of likely assessment findings for this client?

1.Increased heart rate and increased blood pressure 2.Increased heart rate and decreased blood pressure 3.Decreased heart rate and increased blood pressure 4.Decreased heart rate and decreased blood pressure*******

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising?

1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure********** 3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate?

1.Insert nasal packing. 2.Document the findings. 3.Contact the health care provider (HCP).********* 4.Monitor the client's blood pressure and check for signs of increased intracranial pressure.

A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the adverse effects of this medication and should tell the client that which undesirable effect is associated with this medication?

1.Insomnia 2.Constipation 3.Hypotension 4.Bronchospasm********

The nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply.

1.Insomnia ****** 2.Weight loss ****** 3.Bradycardia 4.Constipation 5.Mild heat intolerance ******

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit?

1.Is disoriented to person, place, and time 2.Affect is flat, with periods of emotional lability******* 3.Cannot recall what was eaten for breakfast today 4.Demonstrates inability to add and subtract; does not know who is the president of the United States

The ambulatory care nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. What should the nurse plan to teach the client about this type of angina?

1.It is most effectively managed by beta-blocking agents. 2.It has the same risk factors as stable and unstable angina. 3.It can be controlled with a low-sodium, high-potassium diet. 4.Generally it is treated with calcium channel-blocking agents.***********

A client who has been exercising in a gymnasium stops to measure his pulse and places his fingers over both carotid arteries simultaneously. The nurse exercising nearby is correct when cautioning the client to check the pulse on only one side, primarily for which reason?

1.It is unnecessary to use both hands. 2.The client could occlude the trachea. 3.The heart rate and blood pressure could drop. *********** 4.Feeling dual pulsations may lead to an incorrect measurement.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply.

1.Keeping the linens wrinkle-free under the client******** 2.Preventing unnecessary pressure on the lower limbs***** 3.Limiting bladder catheterization to once every 12 hours 4.Turning and repositioning the client at least every 2 hours ********** 5.Ensuring that the client has a bowel movement at least once a week

Which clients have a high risk of obesity and diabetes mellitus? Select all that apply.

1.Latino American man **** 2.Native American man ****** 3.Asian American woman 4.Hispanic American man ***** 5.African American woman*****

A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms?

1.Left atrium 2.Right atrium 3.Left ventricle********* 4.Right ventricle

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function?

1.Listening to lung sounds******* 2.Palpating for organomegaly 3.Assessing for jugular vein distention 4.Assessing for peripheral and sacral edema

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? Select all that apply.

1.Loosening restrictive clothing ******** 2.Restraining the client's limbs 3.Removing the pillow and raising padded side rails***** 4.Positioning the client to the side, if possible, with the head flexed forward ********* 5.Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist

The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action?

1.Lower the head of the bed. 2.Test the drainage for glucose.********** 3.Obtain a culture of the drainage. 4.Continue to observe the drainage.

The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider (HCP) will most likely prescribe which option?

1.Maintain activity level as prescribed.******** 2.Maintain the affected leg in a dependent position. 3.Administer an opioid analgesic every 4 hours around the clock. 4.Apply cool packs to the affected leg for 20 minutes every 4 hours.

A client is being treated with procainamide for a cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. What intervention should the nurse take first?

1.Measure the heart rate on the rhythm strip. 2.Administer prescribed nitroglycerin tablets. 3.Obtain a 12-lead electrocardiogram immediately. 4.Auscultate the client's apical pulse and obtain a blood pressure.****************

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease?

1.Meningitis or encephalitis during the last 5 years 2.Seizures or trauma to the brain within the last year 3.Back injury or trauma to the spinal cord during the last 2 years 4.Respiratory or gastrointestinal infection during the previous month************

A client is diagnosed with an ST segment elevation myocardial infarction (STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention?

1.Monitor for kidney failure. 2.Monitor psychosocial status. 3.Monitor for signs of bleeding. *********** 4.Have heparin sodium available.

The nurse is caring for a client with chronic back pain. Codeine has been prescribed for the client. Specific to this medication, which intervention should the nurse include in the plan of care while the client is taking this medication?

1.Monitor radial pulse. 2.Monitor bowel activity. *********** 3.Monitor apical heart rate. 4.Monitor peripheral pulses.

The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up?

1.Muscle weakness in the arms and legs 2.A temperature of 98.6°F (37°C), decreased from 99.0°F (37.2°C) 3.A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg *************** 4.A heart rate of 80 beats/minute, decreased from 85 beats/minute

The nurse is preparing to administer a dose of naloxone intravenously to a client with an opioid overdose. Which supportive medical equipment should the nurse plan to have at the client's bedside if needed?

1.Nasogastric tube 2.Paracentesis tray 3.Resuscitation equipment******* 4.Central line insertion tray

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room?

1.Nebulizer and pulse oximeter 2.Blood pressure cuff and flashlight 3.Flashlight and incentive spirometer 4.Electrocardiographic monitoring electrodes and intubation tray***********

A client with myasthenia gravis has become increasingly weaker. The health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis?

1.No change in the condition 2.Complaints of muscle spasms 3.An improvement of the weakness 4.A temporary worsening of the condition******

The nurse who is auscultating a 56-year-old client's apical heart rate before administering digoxin notes that the heart rate is 52 beats/min. The nurse should make which interpretation of this information?

1.Normal, because of the client's age 2.Abnormal, requiring further assessment **************** 3.Normal, as a result of the effects of digoxin 4.Normal, because this is the reason the client is receiving digoxin

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply.

1.Open doors to client rooms. 2.Move beds away from windows.********* 3.Close window shades and curtains.********** 4.Place blankets over clients who are confined to bed.************ 5.Relocate ambulatory clients from the hallways back into their rooms.

Terbutaline is prescribed for a client with bronchitis. The nurse checks the client's medical history for which disorder in which the medication should be used with caution?

1.Osteoarthritis 2.Hypothyroidism 3.Diabetes mellitus ********** 4.Polycystic disease

A client recovering from an exacerbation of left-sided heart failure is experiencing activity intolerance. Which change in vital signs during activity would be the best indicator that the client is tolerating mild exercise?

1.Oxygen saturation decreased from 96% to 91%. 2.Pulse rate increased from 80 to 104 beats per minute. 3.Blood pressure decreased from 140/86 to 112/72 mm Hg. 4.Respiratory rate increased from 16 to 19 breaths per minute.********

A client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. The nurse should assess for which finding as the best indicator of adequate ongoing respiratory status?

1.Oxygen saturation of 89% 2.Respiratory rate of 16 breaths/minute************* 3.Moderate amounts of tracheobronchial secretions 4.Small to moderate amounts of frank blood suctioned from the tube

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply.

1.Padding the side rails of the bed ********* 2.Placing an airway at the bedside ********* 3.Placing the bed in the high position 4.Putting a padded tongue blade at the head of the bed 5.Placing oxygen and suction equipment at the bedside************ 6.Flushing the intravenous catheter to ensure that the site is patent************

The nurse is caring for a postoperative pneumonectomy client. Which finding on assessment of the client is an adverse sign or symptom indicating pulmonary edema?

1.Pain with deep breathing 2.Increased chest tube drainage 3.Lung crackles in the remaining lung ********** 4.Respiratory rate of 20 breaths/minute

The nurse is caring for a client in the emergency department who has been diagnosed with Bell's palsy. The client has been taking acetaminophen, and acetaminophen overdose is suspected. Which antidote should the nurse prepare for administration if prescribed?

1.Pentostatin 2.Auranofin 3.Fludarabine 4.Acetylcysteine*********

The nurse is conducting a basic life support (BLS) recertification class and is discussing chest compressions in a pregnant woman. The nurse should tell the class that which action should be taken in an advanced pregnancy client whose fundal height is at or above the umbilicus?

1.Perform the chest compressions directly over the umbilicus. 2.Turn the pregnant client on her side and perform back thrusts. 3.Maintain manual left uterine displacement during compressions. *********** 4.Perform chest thrusts midway between the umbilicus and the pubic bone.

Zafirlukast is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication?

1.Platelet count 2.Neutrophil count 3.Liver function tests ******* 4.Complete blood count

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply.

1.Platelets 35,000 mm3 (35 × 109/L) ****** 2.Sodium 150 mEq/L (150 mmol/L) ***** 3.Potassium 5.0 mEq/L (5.0 mmol/L) 4.Segmented neutrophils 40% (0.40) ******* 5.Serum creatinine, 1 mg/dL (88.3 mmol/L) 6.White blood cells, 3000 mm3 (3.0 × 109/L)*******

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply.

1.Polyuria 2.Shakiness****** 3.Palpitations****** 4.Blurred vision 5.Lightheadedness******* 6.Fruity breath odor

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply.

1.Polyuria ******* 2.Headache 3.Bone pain ********* 4.Nervousness 5.Weight gain

A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding?

1.Positive ******** 2.Negative 3.Inconclusive 4.Need for repeat testing

A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL (10.2 to 11.4 mmol/L). Which medication, if added to the client's regimen, may have contributed to the hyperglycemia?

1.Prednisone*******8 2.Atenolol 3.Phenelzine 4.Allopurinol

The home health nurse visits a client who is taking phenytoin for control of seizures. During the assessment, the nurse notes that the client is taking birth control pills. Which information should the nurse include in the teaching plan?

1.Pregnancy must be avoided while taking phenytoin. 2.The client may stop the medication if it is causing severe gastrointestinal effects. 3.There is the potential of decreased effectiveness of birth control pills while taking phenytoin. ************ 4.There is the increased risk of thrombophlebitis while taking phenytoin and birth control pills together.

The nurse is caring for a client who is pulseless and experiencing this dysrhythmia. Which interventions should the nurse anticipate implementing in collaboration with the health care provider (HCP)? Select all that apply. Refer to Figure.

1.Prepare for cardioversion. 2.Prepare to administer digoxin 3.Prepare to administer amiodarone.******* 4.Prepare to administer epinephrine.*********** 5.Provide cardiopulmonary resuscitation (CPR).******

The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome?

1.Promote oxygen intake. 2.Strengthen the diaphragm. 3.Strengthen the intercostal muscles. 4.Promote carbon dioxide elimination.*******

A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hour. The nurse determines that the client is receiving the therapeutic effect based on which results?

1.Prothrombin time of 12.5 seconds 2.Activated partial thromboplastin time of 60 seconds********** 3.Activated partial thromboplastin time of 28 seconds 4.Activated partial thromboplastin time longer than 120 seconds

Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect?

1.Pruritus 2.Tachycardia 3.Hypertension 4.Impaired voluntary movements***********

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101°F (38.3°C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse?

1.Pulse 2.Respiration 3.Temperature ******** 4.Blood pressure

The client who is beginning an exercise program asks the nurse why his heart "feels like it's pounding" when he is exercising vigorously. The nurse provides education to the client about increased cardiac response based on which physiological concept?

1.Pulse rate is not a reflection of cardiac response. 2.Cardiac index is the mechanism that allows blood to flow better. 3.Cardiac output is the body's attempt to meet metabolic demands. ******************** 4.Stroke volume is an artificial number used to determine the adequacy of cardiac output.

The health care provider (HCP) has written a prescription for a client to have an echocardiogram. Which action should the nurse take to prepare the client for the procedure?

1.Questions the client about allergies to iodine or shellfish 2.Has the client sign an informed consent form for an invasive procedure 3.Tells the client that the procedure is painless and takes 30 to 60 minutes********* 4.Keeps the client on nothing by mouth (NPO) status for 2 hours before the procedure

The nursing instructor teaches a group of students about cardiopulmonary resuscitation. The instructor asks a student to identify the most appropriate location at which to assess the pulse of an infant younger than 1 year of age. Which response would indicate that the student understands the appropriate assessment procedure?

1.Radial artery 2.Carotid artery 3.Brachial artery ************ 4.Popliteal artery

The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior?

1.Reflecting a cultural value ********* 2.An acceptance of the treatment 3.Client agreement to the required procedures 4.Client understanding of the preoperative procedures

The clinic nurse has obtained a throat culture specimen from a client in whom a throat infection is suspected. The nurse calls the laboratory to have the specimen picked up and is told that the laboratory is short staffed and the laboratory assistant will pick up the specimen in 2 hours. Which is the appropriate nursing action?

1.Refrigerate the specimen.******** 2.Tell the client to return in 1 hour for a repeat throat culture. 3.Contact the health care provider (HCP) who prescribed the specimen. 4.Tell the laboratory that someone needs to pick up the specimen immediately.

A client has been started on long-term therapy with rifampin. The nurse should provide which information to the client about the medication?

1.Should always be taken with food or antacids 2.Should be double-dosed if 1 dose is forgotten 3.Causes orange discoloration of sweat, tears, urine, and feces ********** 4.May be discontinued independently if symptoms are gone in 3 months

The nurse is assessing an electrocardiogram (ECG) rhythm strip for a client. The PP and RR intervals are regular. The PR interval is 0.14 second, and the QRS complexes measure 0.08 second. The overall heart rate is 82 beats/min. The nurse should report the cardiac rhythm to be which rhythm?

1.Sinus bradycardia 2.Sick sinus syndrome 3.Normal sinus rhythm ********* 4.First-degree heart block

A client's electrocardiogram (ECG) strip shows atrial and ventricular rates of 70 complexes/minute. The PR interval is 0.16 second, the QRS complex measures 0.06 second, and the PP interval is slightly irregular. How should the nurse report this rhythm?

1.Sinus tachycardia 2.Sinus bradycardia 3.Sinus dysrhythmia ********** 4.Normal sinus rhythm

A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm?

1.Sinus tachycardia****** 2.Sinus bradycardia 3.Sinus dysrhythmia 4.Normal sinus rhythm

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply.

1.Sitting up and leaning on a table ******** 2.Standing and leaning against a wall ******** 3.Lying supine with the feet elevated 4.Sitting up with the elbows resting on knees ******* 5.Lying on the back in a low Fowler's position

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume?

1.Sitting up in bed 2.Side-lying in bed 3.Sitting in a recliner chair 4.Sitting up and leaning on an overbed table********

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective?

1.Taking medications as scheduled ********** 2.Eating large, well-balanced meals 3.Doing muscle-strengthening exercises 4.Doing all chores early in the day while less fatigued

A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator. What assessment finding should the nurse identify as an indicator that the client is experiencing complications of this therapy?

1.Tarry stools********* 2.Nausea and vomiting 3.Orange-colored urine 4.Decreased urine output

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply.

1.The acuity level of the clients****** 2.Specific requests from the staff 3.The clustering of the rooms on the unit 4.The number of anticipated client discharges 5.Client needs and workers' needs and abilities*********

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply.

1.The client is aphasic. ******* 2.The client has weakness on the right side of the body.******* 3.The client has complete bilateral paralysis of the arms and legs. 4.The client has weakness on the right side of the face and tongue. *********** 5.The client has lost the ability to move the right arm but is able to walk independently. 6.The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance.

The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse should interpret that the pain is most likely caused by myocardial infarction (MI) on the basis of what assessment finding?

1.The client is not experiencing dyspnea. 2.The client is not experiencing nausea or vomiting. 3.The pain has not been relieved by rest and nitroglycerin tablets.********* 4.The client says the pain began while she was trying to open a stuck dresser drawer.

The nurse is monitoring a client who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication?

1.The development of complaints of insomnia 2.The development of audible expiratory wheezes******* 3.A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after 2 doses of the medication 4.A baseline resting heart rate of 88 beats/minute followed by a resting heart rate of 72 beats/minute after 2 doses of the medication

An adult client has been unsuccessfully defibrillated for ventricular fibrillation, and cardiopulmonary resuscitation (CPR) is resumed. The nurse confirms that CPR is being administered effectively by noting which action?

1.The ratio of compressions to ventilations is 30:2. 2.The carotid pulse is palpable with each compression.******* 3.Respirations are given at a rate of 10 breaths per minute. 4.The chest compressions are given at a depth of 1.5 to 2 inches (2.5 to 5 cm).

The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is tolerating the procedure if which observation is made?

1.The skin color becomes cyanotic. 2.Secretions are becoming bloody. 3.Coughing occurs with suctioning. ********** 4.Heart rate decreases from 78 to 54 beats/minute.

The nurse is changing the tracheostomy ties on a client with a tracheostomy and is assessing the security of the ties. Which method is used to ensure that the ties are not too tightly placed?

1.The ties leave no marks on the neck. 2.The tracheotomy can be pulled slightly away from the neck. 3.The nurse places 1 finger loosely between the tie and the neck. ***************** 4.The nurse uses a 12-inch tie that is tightly affixed with hook-and-loop closures.

A client is brought into the emergency department in ventricular fibrillation (VF). The nurse prepares to defibrillate by placing defibrillation pads on which part of the chest?

1.The upper and lower halves of the sternum 2.Parallel between the umbilicus and the right nipple 3.The right shoulder and the back of the left shoulder 4.To the right of the sternum and to the left of the precordium************

A thrombolytic is administered in the hospital emergency department to a client who has had a myocardial infarction. The client's spouse asks the nurse about the purpose of the medication. The nurse bases the response on which fact regarding this medication?

1.Thrombolytics suppress the production of fibrin. 2.Thrombolytics act to prevent thrombus formation. 3.Thrombolytics act to dissolve thrombi that have already formed. *************** 4.Thrombolytics have been proved to reverse all detrimental effects of heart attacks.

The nurse is concerned about the adequacy of peripheral tissue perfusion in the post-cardiac surgery client. Which action should the nurse include within the plan of care for this client?

1.Use the knee gatch on the bed. 2.Cover the legs lightly when sitting in a chair. ************** 3.Encourage the client to cross the legs when sitting in a chair. 4.Provide pillows for the client to place under the knees as desired.

A client who has had a myocardial infarction asks the nurse why she should not bear down or strain to ensure having a bowel movement. The nurse provides education to the client based on which physiological concept?

1.Vagus nerve stimulation causes a decrease in heart rate and cardiac contractility. ************** 2.Vagus nerve stimulation causes an increase in heart rate and cardiac contractility. 3.Sympathetic nerve stimulation causes a decrease in heart rate and cardiac contractility. 4.Sympathetic nerve stimulation causes an increase in heart rate and cardiac contractility.

Intravenous heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit?

1.Vitamin K 2.Protamine sulfate ******** 3.Potassium chloride 4.Aminocaproic acid

A client has a difficulty with the ability to flex the hips. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item?

1.Walker 2.Slider board 3.Raised toilet seat ********** 4.Adaptive eating utensils

The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply

1.Water or a kink in the tubing ********** 2.Biting on the endotracheal tube *********** 3.Increased secretions in the airway ********** 4.Disconnection or leak in the system 5.The client ceasing spontaneous breathing

A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge?

1.Weigh self on a daily basis.********** 2.Sleep with the head of the bed flat. 3.Take a double dose of the diuretic if peripheral edema is noted. 4.Withhold prescribed digoxin if slight respiratory distress occurs.

The nurse provides instructions to a client who is taking levothyroxine. The nurse should tell the client to take the medication in which way?

1.With food 2.At lunchtime 3.On an empty stomach ******** 4.At bedtime with a snack

The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching?

1.Withdraws the NPH insulin first ******** 2.Withdraws the regular insulin first 3.Injects air into NPH insulin vial first 4.Injects an amount of air equal to the desired dose of insulin into each vial

The health care provider (HCP) prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. The nurse should plan to take which most appropriate intervention?

1.Withhold the medication and call the HCP, questioning the prescription for the client. ******** 2.Administer the medication within 60 minutes before the morning and evening meal. 3.Monitor the client for gastrointestinal side effects after administering the medication. 4.Withdraw the insulin from the prefilled pen into an insulin syringe to prepare for administration.

A client with a history of ear problems is going on vacation by aircraft. The nurse advises the client to include which activities to prevent barotrauma during ascent and descent of the airplane? Select all that apply.

1.Yawning ****** 2.Humming 3.Swallowing ******* 4.Chewing gum ****** 5.Sucking on hard candy*******