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A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a DNR prescription and the nurse observes that the unlicensed assistive personnel has stopped turning the client from side to side as previously scheduled. What action should the nurse take? A. Advise the UAP to resume positioning the client on schedule B. Encourage the UAP to provide comfort care measures only C. Assume total care of the client to monitor neurologic function D. Assign a practical nurse to assist the UAP in turning the client

A. Advise the UAP to resume positioning the client on schedule

A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the neurological unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? A. Altered consciousness within the first 24 hours after injury B. Cushing reflex and cerebral edema after 24 hours C. Fever, nuchal rigidity, and opisthotonos within hours D. Headache and pupillary changes 48 hours after a head injury

A. Altered consciousness within the first 24 hours after injury

The change nurse is making client care assignment on the telemetry unit. Which client is best to assign to the LPN working on the unit with the nurse? A. An immobile client receiving low molecular weight heparin q12 B. A client who is receiving a continuous infusion of heparin and hets out of bed BID C. A client who is being titrated off heparin infusion and started on PO warfarin D. An ambulatory client receiving warfarin with INR of 5 seconds

A. An immobile client receiving low molecular weight heparin q12

After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take? A. Apply light pressure over the area B. Use a sharp object to determine pain response C. Massage the area D. Apply barrier cream to the area

A. Apply light pressure over the area

The healthcare provider prescribes oxycodone/aspirin 1 tab PO every 4h as needed for pain, for a client with polycystic kidney disease. Before administering this medication, which component of the prescription should the nurse question? A. Aspirin content B. Dose C. Route D. Risk for addiction

A. Aspirin content

The nurse is teaching a client with atrial fibrillation about a newly prescribed medication, dronedarone. Which information should the nurse include in patient teaching? Select all that apply A. Avoid eating grapefruit or drinking grapefruit juice B. Report changes in the use of daily supplements C. Notify your healthcare provider if your skin becomes yellow D. Take on an empty stomach E. This medication will help with pruritus

A. Avoid grapefruit B. Report changes in the use of daily supplements C. Notify your healthcare provider if your skin becomes yellow

A male client is admitted for the removal of an internal fixation that was inserted for the fractured ankle. During the admission history, he tells the nurse he recently received vancomycin for a methicillin-resistant staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? Select all that apply A. Collect multiple site screening culture for MRSA B. Call health care provider for a prescription for linezolid C. Place the client on contact transmission precautions D. Obtain sputum specimen for culture and sensitivity E. Continue to monitor for client sign of infection

A. Collect multiple site screening culture for MRSA C. Place the client on contact transmission precautions E. Continue to monitor for client sing of infection

A female client with severe renal impairment is receiving enoxaparin 30 mg subQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider? A. Creatinine clearance 25 mL/min B. Calcium 9 mg/dl C. Hemoglobin 12 grams/dl D. Partial thromboplastin time (PTT) 30 seconds

A. Creatinine clearance 25 mL/min

An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms? A. Destruction of joint cartilage B. Result of osteoporosis C. Normal part of aging D. Co-morbidity of alcoholism

A. Destruction of joint cartilage

An unna boot is applied to a client with a venous stasis ulcer. One week later, when the unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. Which action is most appropriate for the nurse to take? A. Document the assessment B. Call the provider C. Consult with pharmacy for a new wound ointment D. Rewrap the leg

A. Document the assessment

In assessing ad adult client with a partial re-breather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths/min. What action should the nurse implement? A. Document the assessment data B. Activate the rapid response team C. Instruct the client to exhale until the bag inflates D. Call Respiratory Therapy for a breathing treatment

A. Document the assessment data

In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement. A. Document the extent of the bruising in the medical B. Immediately call the provider C. Contact physical therapy D. Prepare client for amputation

A. Document the extent of the bruising in the medical record

One day following a total knee replacement, a male client tells the nurse that he is unable to transfer because it is too painful. What action should the nurse implement? A. Encourage use of analgesics before position change B. Tell the client to suck-it-up and endure the pain C. Allow the client to remain in bed until the pain subsides D. Consult Physical Therapy

A. Encourage use of analgesics before position change

In monitoring tissue perfusion in a client following an above the knee amputation, which action should the nurse include in the plan of care? A. Evaluate closest proximal proximal pulse B. Assess skin elasticity of the stump C. Observe for swelling around the stump D. Note amount and color of wound drainage

A. Evaluate closest proximal pulse

Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? A. I have a headache that gets worse when I sit up B. I am having pain in my lower back when I move my legs C. My throat hurts when I swallow D. I feel sick to my stomach and am going to throw up

A. I have a headache that hets worse when I sit up

The nurse should teach the parents of a 6 year old recently diagnosed with asthma that the symptoms of an acute episode of asthma are due to which physiological response? A. Inflammation of the mucous membranes and bronchospasm B. Thickening of the alveoli inhibiting O2 and CO2 exchange C. Anxiety causing hyperventilation and shallow breathing D. Neurological response inhibiting breathing and respiratory rate

A. Inflammation of the mucous membranes and bronchospasm

The nurse is preparing a client who had a below the knee amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply) A. Inspect skin for redness B. Use a residual limb shrinker C. Apply alcohol to the stump after bathing D. Wash the stump with soap and water E. Avoid range of motion exercises

A. Inspect skin for redness B. Use a residual limb shrinker D. Wash the stump with soap and water

A client with acute renal failure is admitted for uncontrolled type I diabetes Mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in the client's plan of care? A. Monitor the client's cardiac activity via telemetry B. Maintain venous access with an infusion of normal saline C. Assess glucose via fingerstick q4-6 hours D. Evaluate hourly urine output for return of normal renal function

A. Monitor the client's cardiac activity via telemetry

An older male adult resident of a long term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? Select all that apply A. Move the client closer to the nurses station B. Place the client in a 5 point restraint C. Notify the healthcare provider of the client's change in mental status D. Sedate the client with morphine, benadryl and lorazepam E. Include q2 hour reorientation in the client's plan of care

A. Move the client closer to the nurses station C. Notify the healthcare provider of the client's change in mental status E. Include q2 hour reorientation in the client's plan of care

An older client is admitted to the ICU with severe abdominal pain, distention and absent bowel sounds. The client has a 100/pack per year history of smoking and is currently restless and confused. Vital signs are temp 96 F, HR 122, RR 36, MAP 64, CVP 7. Labs- hemoglobin 6.5, platelets 60,000, WBC 3,000. Based on these findings this client is at greatest risk for which conditions. A. Multiple organ dysfunction syndrome (MODS) B. Disseminated intravascular coagulation (DIC) C. Chronic obstructive pulmonary disease D. Acquired immunodeficiency syndrome (AIDS)

A. Multiple organ dysfunction syndrome (MODS)

A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider? A. No wheezing upon auscultation of the chest. B. Respiratory rate 26 breaths per minute C. S3 heart sound D. 4+ pitting edema in lower extremities

A. No wheezing upon auscultation of the chest

Following an esophagogastroduodenoscopy a male client is drowsy and difficult to arouse, and his respirations are slow and shallow. Which action should the nurse implement? Select all that apply? A. Prepare medication reversal agent B. Check oxygen saturation level C. Apply oxygen via nasal cannula D. Initiate bag-valve mask ventilation E. Begin cardiopulmonary resuscitation

A. Prepare medication reversal agent B. Check oxygen saturation level C. Apply oxygen via nasal cannula

While assessing a client's chest tube the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: BP 80/40, HR 120, RR 32, O2 sat 88%. Which interventions should the nurse implement? Select all that apply A. Provide supplemental oxygen B. Auscultate bilateral lung fields C. Administer a nebulizer treatment D. Reinforce occlusive CT dressing E. Give PRN dose of pain medication

A. Provide supplemental oxygen B. Auscultate bilateral lung fields D. Reinforce occlusive CT dressing

Which interventions should the nurse include in a long term plan of care for a client with COPD? A. Reduce risk factors for infection B. Limit fluid intake to reduce secretions C. Use diaphragmatic breathing to achieve better exhalation D. Administer high flow oxygen during sleep

A. Reduce risk factors for infection

A client with diabetic peripheral neuropathy has been taking pregabalin (lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective? A. Reduced level of pain B. Full volume of pedal pulses C. Granulating tissue in foot ulcer D. Edema 1+ in all extremities

A. Reduced level of pain

A client who had a below the knee amputation is experiencing severe phantom limb pain and asks the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful? A. Research indicates that mirror therapy is effective in reducing phantom limb pain B. You can try mirror therapy, but do not expect to complete elimination of the pain C. Transcutaneous electrical nerve stimulators (TENS) have been found to be more effective D. Where did you learn about the use of mirror therapy in treating phantom limb pain

A. Research indicates that mirror therapy is effective in reducing phantom limb pain

The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow Coma Scale score is 9. What information is most important for the nurse to determine? A. The client's previous GCS score B. When the client's stoke symptoms started C. In the client is oriented to time D. The client's blood pressure and respiration rate

A. The client's previous GCS score

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? A. To reduce abdominal pressure on the diaphragm B. To promote retraction of the intercostal accessory muscle of respiration C. To promote bronchodilation and effective airway clearance D. To decrease pressure on the medullary center which stimulates breathing

A. To reduce abdominal pressure on the diaphragm

A client with history of bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? A. Ventricular arrhythmias B. Blood pressure of 110/70 C. Temp of 37.9 C D. Potassium of 5.0

A. Ventricular arrhythmias

The practical nurse is assigned to work with three registered nurses who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN? A. Viral meningitis whose temperature changed from 101-102 F B. Head injury with a rapidly decreasing GCS score C. Tibial fracture complaining of 10/10 pain after receiving pain medication 45 minutes ago D. Burn client who has become unresponsive to painful stimuli

A. Viral meningitis whose temperature changed from 101-102 F

The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply A. White blood cell count B. BUN/creatinine C. Sputum culture and sensitivity D. Platelet count E. Potassium level

A. White blood cell count C. Sputum culture and sensitivity

After teaching a male client with chronic kidney disease about therapeutic diet. Which items indicate that the teaching was effective? Select all that apply A. A slice of whole grain toast B. A bowl of cream of wheat C. 2 fried eggs D. 3 slices of bacon E. 16 oz Dr. Pepper

A. a slice of whole grain toast B. A bowl of cream of wheat

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (armphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? A. allopurinol B. aspirin, low dose C. furosemide (lasix) D. enalapril (vasote)

A. allopurinol

The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell count and erythrocyte sedimentation rate are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain? A. Degree of skin elasticity B. Appearance of wound C. Bilateral pedal pulse force D. Onset of any bleeding

B. Appearance of wound

The home care nurse provides self-care instruction for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply A. Cross legs at knee but not at ankle B. Avoid prolonged standing or sitting C. Use recliner for long period of sitting D. Maintain the bed flat while sleeping E. Continue wearing elastic stockings

B. Avoid prolonged sitting or standing C. Use recliner for long periods of sitting E. Continue wearing elastic stockings

A Female client with acute respiratory distress syndrome is chemically paralyzed and sedated while she is on assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse? A. Glasgow coma scale of 9 B. Diminished left lower lobe sounds C. Hypoactive bowel sounds D. Blood pressure 150/92 mmHg

B. Diminished left lower lobe sounds

Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity? A. Range of motion B. Distal pulse intensity C. Extremity sensation D. presence of exudate

B. Distal pulse intensity

A vacuum-assistive closure device is being used to provide wound care for a client who has a stage III pressure ulcer on a below-the-knee residual limb. Which intervention should the nurse implement to ensure maximum effectiveness of the device? A. Never change the VAC dressing B. Ensure the transparent dressing has no tears C. Monitor the client for nausea D. Ensure the transparent dressing has holes for aeration

B. Ensure the transparent dressing has no tears

The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history? A. Daily diet and fluid intake B. Frequency of laxative use for chronic constipation C. Daily activity level and endurance D. Adherence to prescribed medication regimen

B. Frequency of laxative use for chronic constipation

A young adult female with chronic kidney disease due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent PVCs. Her blood pressure is 200/110 and her temperature is 101 F which PRN medication should the nurse administers first? A. Enalapril B. Furosemide C. Acetaminophen D. Promethazine

B. Furosemide

An elderly male client is admitted to the urology unit with acute renal failure due to a post-renal obstruction. Which questions best assists the nurse in obtaining relevant historical data? A. Have you had a heart attack in the last 6 months? B. Have you had any difficulty in starting your urinary stream? C. Have you taken any antibiotics recently? D. Have you received any blood products in the last year?

B. Have you had any difficulty in starting your urinary stream?

A 75-year old female client is admitted to the orthopedic unit following an open reduction and internal fixation of a hip fracture. On the second postoperative day, the client becomes confused and repeatedly asks the nurse where she is. What information is important for the nurse to obtain? A. Use of sleeping medications B. History of alcohol use C. Use of anti-anxiety medications D. History of this behavior

B. History of alcohol use

The nurse caring for a client with acute renal failure has noted that the client has voided 800 mL of urine in the last 4 hours. Based on this assessment, what should the nurse anticipate the client will need? A. Fluid restriction of 1000 mL/day B. Large amounts of fluid and electrolyte replacement C. Furosemide 40 mg IV push D. Ibuprofen 800 mg po for mild pain

B. Large amounts of fluid and electrolyte replacement

The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care? A. Conduct regular eye checks B. Monitor blood pressure frequently C. Check distal pulses every 24 hours D. Change resuscitation status to DNR

B. Monitor blood pressure frequently

The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. What expected outcome has the highest priority for this client? A. Identifies 2 treatments for constipation due to immobility B. Names 3 home safety hazards to be resolved immediately C. State 4 risk factors for the development of osteoporosis D. Lists 5 calcium rich foods to be added to her daily diet

B. Names three home safety hazards to be resolved immediately

An older adult client with heart failure develops cardiac tamponade. The client has muffled, distant, heart sounds and is anxious and restless, After initiating oxygen therapy and IV hydration which intervention is most important for the nurse to implement? A. Observe neck for jugular vein distension B. Notify healthcare provider to prepare for pericardiocentesis C. Assess for paradoxical blood pressure D. Monitor oxygen saturation via continuous pulse oximetry

B. Notify healthcare provider to prepare for pericardiocentesis

A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 F. He is drooling and becoming increasingly more restless. What action should the nurse take first? A. Document the assessment data B. Notify the healthcare provider and obtain a tracheostomy trach C. Give mom a washcloth to wipe the drooling D. Administer 0.01 mg/kg of lorazepam

B. Notify the healthcare provider and obtain a tracheostomy tray

A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client's plan of care? A. Determine client's level current blood alcohol level B. Observe for changes in level of consciousness C. Involve the client's family in healthcare decisions D. Provide grief counseling for client and his family

B. Observe for changes in level of consciousness

A client who was admitted yesterday with severe dehydration is complaining of pain at site of 24 gauge IV with normal saline infusing at 150 ml/hr. Which intervention should the nurse implement first? A. Reassure the client that this is a normal finding B. Stop the normal saline infusion C. Call the provider D. Increase the saline infusion rate

B. Stop the normal saline infusion

A client with unstable angina receives routine applications of nitroglycerin ointment. The nurse should delay the next dose if the client has: A. Atrial fibriliation B. Systolic blood pressure below 90 C. Headache D. Skin redness at the current site

B. Systolic blood pressure below 90

The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement? A. Inquire about food allergies and food likes and dislikes B. Talk directly to the client while providing care C. Initiate open communication with the teen's parents D. Monitor vital signs and neuro status every 2 hours

B. Talk directly to the client while providing care

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply A. A bedside commode is positioned near the bed B. A saline lock is present in the right forearm C. A full pitcher of water is on the bedside table D. The client is lying in a supine position in bed E. A low sodium diet tray was brought to the room

C. A full pitcher of water is on the bedside table D. The client is lying in a supine position in bed

A male client is admitted with a severe asthma attack. For the last 3 hours he has experienced increased shortness of breath. His arterial blood gas results are: pH 7.22, PaCO2 55 mmHg, HCO3 25. Which intervention should the nurse implement? A. Space care to provide periods of rest B. Instruct client to purse lip breathe C. Administer PRN dose of albuterol D. Position client for maximum comfort

C. Administer PRN dose of albuterol

A postoperative female client has a prescription for mophine sulfate 10 mg IV q3 for pain. One dose of morphine was administered when the client was admitted to the post anesthesia care unit (PACU) and 3 hours later, the client is again complaining of pain. Her current respiratory rate is 8 breaths/min. What action should the nurse take? A. Document the assessment data B. Prepare the client to be transferred to the med/surg unit C. Administer naloxone IV D. Check the client's lab levels

C. Administer naloxone IV

Which class of drugs is a first line of defense for septic shock? A. Anti-virals B. Corticosteroids C. Anti-infectives D. beta-blockers

C. Anti-infectives

A client who had a percutaneous transluminal coronary angioplasty two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction of 30%. Today the client's assessment includes clear lung sounds, 1+ pedal edema, and a 5 pound weight gain. Which intervention should the nurse implement? A. Arrange transport for admission to the hospital B. Insert saline lock for IV diuretic therapy C. Assess compliance with routine prescriptions D. Instruct the client to monitor daily caloric intake

C. Assess compliance with routine prescriptions

A client's telemetry monitor indicates ventricular fibrillation. After delivering one counter shock, the nurse resumes chest compression, after another minute of compression, the client's rhythm converts to supraventricular tachycardia on the monitor, at this point, what is the priority intervention for the nurse? A. Prepare for transcutaneous pacing B. Administer IV epinephrine per ACLS protocol C. Give IV dose of adenosine rapidly over 1-2 seconds D. Deliver another defibrillator shock

C. Give IV dose of adenosine rapidly over 1-2 seconds

When caring for a client with traumatic brain injury who had a craniotomy for increased intracranial pressure, the nurse assess the client using the Glasgow Coma Scale every two hours, For the past 8 hours the client' GCS score has been 14. What does the GCS finding indicate about the client? A. The client is experiencing a steady increase of ICP B. The client is experiencing a steady decrease of ICP C. Neurologically stable without indications of an increased ICP D. The client is dead

C. Neurologically stable without indications of an increase ICP

One day following an open reduction, internal fixation of a compound fracture of the leg, a male client complains of a tingling sensation in his left foot. The nurse determines the client's left pedal pulses are diminished. Based on these findings, what is the client's greatest risk? A. Psychosocial integrity related to decreased motor function B. Pain related to compound fracture C. Neurovascular and circulation compromise related to compartment syndrome D. Risk for falls related to immobility

C. Neurovascular and circulation compromise related to compartment syndrome

A client with possible acute kidney injury is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? A. Collect a clean catch urine specimen B. Instruct the client to empty the bladder C. Obtain vital signs and breath sounds D. No specific nursing action is required

C. Obtain vital signs and breath sounds

A client experiences acute myocardial ischemia. The nurse administers oxygen and sublingual nitroglycerin. When assessing an electrocardiogram for evidence that blood flow to the myocardium has improved, the nurse should focus on the: A. Widening of the QRS complex B. Frequency of ectopic beats C. Return of the ST segment to baseline D. Presence of a significant Q wave

C. Return of the ST segment to baseline

The nurse is caring for a client with acute kidney injury secondary to gentamycin therapy the client's serum blood potassium is elevated, which finding requires immediate action by the nurse? A. Tall peaked T waves B. Peripheral pitting edema at 2 + C. Serum creatinine above 0.5 mg/dl D. Anuria for the last 12 hours

D. Anuria for the last 12 hours

The nurse identifies an electrolyte imbalance, an elevated pulse rate, and elevated BP for a client with chronic kidney disease. Which is the most important action for the nurse to take? A. Monitor daily sodium intake B. Record usual eating patterns C. Measure ankle circumference D. Auscultate for irregular heart rate

D. Auscultate for irregular heart rate

A 13 year old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects home aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. What action should the nurse implement next? A. Administer antiemetic agents B. Bivalve the cast for distal compromise C. Provide high calorie, high protein diet D. Begin parenteral antibiotic therapy

D. Begin parenteral antibiotic therapy

During a clinic visit a client with a kidney transplant asks, 'What will happen if chronic rejection develops?' Which response is best for the nurse to provide? A. You'll die B. There is nothing you can do to prevent chronic rejection of your kidney C. Ensure that you are taking at least 800 mg of ibuprofen daily to prevent rejection D. Dialysis would need to be resumed if chronic rejection becomes a reality

D. Dialysis would need to be resumed if chronic rejection become a reality

An infant who is admitted for surgical repair of a ventricular septal defect is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first? A. Metropolol B. Sucrose pacifier C. Amoxicillin D. Digoxin

D. Digoxin

An adult woman who is seen in the clinic with possible neuropathic pain of the right leg rates her pain as 7/10. What action should the nurse take? A. Determine her Glasgow Coma Scale B. Take the client's vitals C. Talk to client about possible right below the knee amputation D. Encourage the client to describe the pain

D. Encourage the client to describe the pain

A client comes to the emergency department with a dissecting aortic aneurysm. The client is at greatest risk for: A. Septic schock B. Anaphylactic shock C. Cardiogenic shock D. Hypovolemic shock

D. Hypovolemic shock

An adult female client with chronic kidney disease asks the nurse if she can continue her over the counter medications, Which medication provides the greatest threat to this client? A. Acetaminophen B. Vitamin C C. Vitamin D D. Magnesium hydroxide (maalox)

D. Magnesium Hydroxide (maalox)

While assisting a client who recently had a hip replacement into a bed pan, the nurse notices that there is a small amount of blood drainage on the surgical dressing, the client's skin is warm to the touch and there is a strong odor from the urine. Which action should the nurse take? A. Obtain a urine sample from the bed pan B. Remove dressing and assess surgical site C. Insert an indwelling urinary catheter D. Measure the client's oral temperature

D. Measure the client's oral temperature

The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. His pulse is weak and thready. The client has a bilateral below the knee amputation. What action should the nurse take? A. Document that an accurate oxygen saturation reading cannot be obtained B. Elevate the client's hands for five minutes prior to obtaining a reading from the finger C. Increase the oxygen based on the clients breathing patterns and lung sounds D. Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading

D. Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading

An older adult male is admitted with complications related to chronic obstructive pulmonary disease. He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? A. Limit the intake of high calorie foods B. Eat meals at the same time daily C. Maintain a low protein diet D. Restrict daily fluid intake

D. Restrict daily fluid intake

A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complains of difficulty breathing. The nurse determines that the client is tachypneic with absent breath sounds in the right lung fields. Which additional finding indicates that the client has developed a tension pneumothorax? A. Continuous bubbling in the water seal chamber B. Decrease bright red blood drainage C. Tachypnea and difficulty breathing D. Tracheal deviation toward the left lung.

D. Tracheal deviation toward the left lung

An adult male who fell from a roof and fractures his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse? A. Onset of mild confusion B. Pain score 8/10 C. Pale, diaphoretic skin D. Weak palpable distal pulses

D. Weak palpable distal pulses

Several months after a foot injury, an adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will 'finally go away'? How should the nurse respond? A. Your pain will never go away B. Cannabis helps with my pain, Maybe you should try it. C. Avoid opioids at all costs D. Lets develop a goal to manage the pain

D. lets develop a goal to manage the pain