Almost Done

A young female client is receiving chemotherapeutic medications and asks about any effects the treatments will have related to her fertility. She is not wanting to have children at this time. The most appropriate statement by the nurse is "You will experience a slow menopause beginning soon." "You will continue having your menses every month right after chemotherapy ends." "You will need to practice birth control measures as we do not know if you are fertile until we assess for fertility after chemotherapy is complete" "You will be unable to have children."

"You will need to practice birth control measures as we do not know if you are fertile until we assess for fertility after chemotherapy is complete"

A 6-year-old child has been diagnosed with growth hormone deficiency. The child's mother requests more information about this condition. Which statements should be included in the nurse's response? Select all that apply. A) "The majority of children who have this condition are born of normal weight and length." B) "There are several potential causes of this condition." C) "This condition is most likely related to dwarfism in past generations of your family." D) "Most children with this condition are nutritionally deprived." E) "Your child most likely does not eat adequate amounts of protein."

A) "The majority of children who have this condition are born of normal weight and length." B) "There are several potential causes of this condition."

The nurse is gathering the necessary equipment for tracheal intubation for a child who is 2 years old. Which tracheal tube size would the nurse obtain? A) 4.5 B) 5 C) 5.5 D) 6

A) 4.5

A child weighing 51 lb (23.1 kg) requires defibrillation. How many joules would the nurse expect to give initially? A) 46 B) 92 C) 102 D) 204

A) 46

Which is the most common type of cancer in pediatric patients? A) Acute Lymphocytic Leukemia (ALL) B) Acute Myeloid Leukemia (AML) C) Chronic Lymphocytic Leukemia (CLL) D) Chronic Myeloid Leukemia (CML)

A) Acute Lymphocytic Leukemia (ALL)

The parents bring their 3-year-old son to the emergency department after he ingested some of his mother's medicine. Which assessment would be of critical importance for this child? A) Assessing mental status and skin moisture and color B) Evaluating the effectiveness of the child's breathing C) Noting the child's pulse rate and quality D) Auscultating all lung fields for signs of edema

A) Assessing mental status and skin moisture and color

A group of students are reviewing information about respiratory arrest in children. The students demonstrate understanding of this information when they identify what common causes of respiratory arrest involving the upper airway? Select all that apply. A) Croup B) Asthma C) Pertussis D) Epiglottitis E) Pneumothorax

A) Croup D) Epiglottitis

The nurse is developing a plan of care for a 7-year-old boy with diabetes insipidus. What is the priority nursing diagnosis? A) Deficient fluid volume related to dehydration B) Excess fluid volume related to edema C) Deficient knowledge related to fluid intake regimen D) Imbalanced nutrition, more than body requirements related to excess weight

A) Deficient fluid volume related to dehydration

The nurse is preparing a teaching plan for the family and their 6-year-old son who has just been diagnosed with diabetes mellitus. What would the nurse identify as the initial goal for the teaching plan? A) Developing management and decision-making skills B) Educating the parents about diabetes mellitus type 1 C) Developing a nutritionally sound, 30-day meal planD) Promoting independence with self-administration of insulin

A) Developing management and decision-making skills

The nurse is instructing the parents of a child with sickle cell anemia on safety precautions. What should the nurse emphasize during this teaching? A) Ensure a consistent and daily intake of adequate fluids to prevent dehydration. B) Remind parents that the child should avoid immunizations to prevent the introduction of bacteria into the body. C) Treat upper respiratory infections with over-the-counter medication. D) Suggest the child participate in sports activities without restriction.

A) Ensure a consistent and daily intake of adequate fluids to prevent dehydration.

You are caring for a 68-year-old man with AML who has relapsed after a stem cell transplant and subsequent salvage chemotherapy. He also has significant cardiac disease made worse by cardiotoxic chemotherapy. He and his family have decided he will go home on Hospice. While the Hospice discharge is being arranged, he has transitioned to "comfort care" on your unit. You know that the goals of comfort care are: (Select all that apply) A) Ensure that the patient's physical symptoms are well-managed B) Provide the patient with the opportunity to spend time with family and friends C) Continue chemotherapy but in lower doses to minimize side effects D) Search for a cure

A) Ensure that the patient's physical symptoms are well-managed B) Provide the patient with the opportunity to spend time with family and friends

The nurse is caring for a 9-year-old client newly diagnosed with diabetes. The client has polyuria, polydipsia, and weight loss. Which nursing diagnoses will the nurse include in the care plan? Select all that apply. A) Imbalanced nutrition: less than body requirements B) Deficient fluid volume C) Deficient knowledge regarding disease process D) Noncompliance E) Delayed growth and development

A) Imbalanced nutrition: less than body requirements B) Deficient fluid volume C) Deficient knowledge regarding disease process

A child has a tracheal tube in place and will be receiving medications via this tube. Which medications would the nurse expect to be administered in this manner? Select all that apply. A) Lidocaine B) Adenosine C) Atropine D) Dopamine E) Epinephrine F) Naloxone

A) Lidocaine C) Atropine E) Epinephrine F) Naloxone

Which of the following would most likely be included in the plan for nursing care of the hospitalized patient with multiple myeloma? Select all that apply. A) Monitor intake and output, daily weights, and creatinine B) Ensure a calcium-rich diet with calcium supplements and enforce a fluid restriction C) Patient teaching about the risk for falls D) Administer anti-emetics if the patient has nausea

A) Monitor intake and output, daily weights, and creatinine C) Patient teaching about the risk for falls D) Administer anti-emetics if the patient has nausea

One of the most painful expected effects from chemotherapy used to treat hematologic malignancies is: A) Mucositis B) Nausea C) Alopecia D) Dyspnea

A) Mucositis

What would the nurse do first for a 5-year-old girl with profound bradycardia? A) Provide oxygen at 100% B) Administer epinephrine as ordered C) Use warming blankets D) Perform gastric lavage

A) Provide oxygen at 100%

The nurse is providing care to a child experiencing shock. Which intravenous solution would the nurse expect to administer? A) Ringer lactate B) Dextrose 5% and water C) Dextrose 5% and normal saline D) Dextrose 10% and water

A) Ringer lactate

A child with diabetes insipidus is being treated with vasopressin. The nurse would assess the child closely for signs and symptoms of which condition? A) Syndrome of inappropriate antidiuretic hormone (SIADH) B) Thyroid storm C) Cushing syndrome D) Vitamin D toxicity

A) Syndrome of inappropriate antidiuretic hormone (SIADH)

A 5-year-old girl is cyanotic, dusky, and anxious when she arrives in the emergency department. Which action would be most appropriate? A) Ventilating the child with a bag-valve-mask B) Estimating the child's weight using a Broselow tape C) Providing therapy using automated external defibrillation D) Using rescue breathing and chest compressions

A) Ventilating the child with a bag-valve-mask

You are starting your night shift (1900-0730) on a hematology oncology unit. Which patient should you see first? A) Your older patient with AML who needs help to the bathroom and has her call light on B) Your young patient with HL who is day -3 of his stem cell transplant and is playing video games with his brother C) Your patient with sickle cell anemia here for pain crisis who is on a PCA and reported to be finally comfortable and watching TV D) Your patient with ALL here for neutropenic fevers and fungal sinus infection due for the next dose of antifungal at 2000

A) Your older patient with AML who needs help to the bathroom and has her call light on

A child is undergoing rapid sequence intubation and is receiving atropine. The nurse understands that this agent is used to: A) lessen the vagal effects of intubation. B) reduce intracranial pressure. C) induce amnesia. D) provide short-term paralysis.

A) lessen the vagal effects of intubation.

A client with gastritis required hospital treatment for an exacerbation of symptoms and receives a subsequent diagnosis of pernicious anemia due to malabsorption. When planning the client's continuing care in the home setting, what assessment question is most relevant? A. "Does anyone in your family have experience at giving injections?"B. "Are you going to be anywhere with strong sunlight in the next few months?" C. "Are you aware of your blood type?"D. "Do any of your family members have training in first aid?"

A. "Does anyone in your family have experience at giving injections?"

A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this client's presentation? A. "How many alcoholic drinks do you typically consume in a week?"B. "To the best of your knowledge, are your immunizations up to date?"C. "Have you ever worked in an occupation where you might have been exposed to toxins?"D. "Has anyone in your family ever experienced symptoms similar to yours?"

A. "How many alcoholic drinks do you typically consume in a week?"

A client's assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment question(s) addresses likely etiologic factors? Select all that apply. A. "How many alcoholic drinks do you typically consume in a week?" B. "Have you ever been tested for diabetes?"C. "Have you ever been diagnosed with gallstones?"D. "Would you say that you eat a particularly high-fat diet?" E. "Does anyone in your family have cystic fibrosis?"

A. "How many alcoholic drinks do you typically consume in a week?" B. "Have you ever been tested for diabetes?"C. "Have you ever been diagnosed with gallstones?"D. "Would you say that you eat a particularly high-fat diet?"

The nurse is providing care for a client whose peptic ulcer disease will be treated with a Billroth I procedure (gastroduodenostomy). Which statement(s) by the client indicates effective knowledge of the procedure? Select all that apply. A. "I will be at risk of developing diarrhea, nausea, and feeling light-headed after eating."B. "It is likely that I will need to receive nutrition directly into my veins."C. "One of my nerves, the vagus nerve, may be cut during the surgery." D. "I can eat a normal diet again after 3 to 5 weeks."E. "This surgery will remove part of my stomach and colon."

A. "I will be at risk of developing diarrhea, nausea, and feeling light-headed after eating." C. "One of my nerves, the vagus nerve, may be cut during the surgery."

A client was brought to the emergency department after a fall. The client is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize? A. "Make sure you don't bring your knees close together." B. "Try to lie as still as possible for the first few days."C. "Try to avoid bending your knees until next week."D. "Keep your legs higher than your chest whenever you can."

A. "Make sure you don't bring your knees close together."

A client comes to the clinic reporting pain in the epigastric region. What statement by the client is specific to the presence of a duodenal ulcer? A. "My pain resolves when I have something to eat."B. "The pain begins right after I eat."C. "I know that my father and my grandfather both had ulcers."D. "I seem to have bowel movements more often than I usually do."

A. "My pain resolves when I have something to eat."

The nurse is teaching the client on bed rest to perform quadriceps setting exercises. Which instruction should the nurse give the client? A. "Push the knees into the mattress." B. "Lie prone in bed."C. "Contract the buttock muscles."D. "Bend the knees."

A. "Push the knees into the mattress."

16. The clinic nurse is caring for an adult oncology client who reports extreme fatigue and weakness after the first week of radiation therapy. Which response by the nurse would best reassure this client? A. "These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory studies and test results."B. "These symptoms are part of your disease and are an unfortunately inevitable part of living with cancer."C. "Try not to be concerned about these symptoms. Every client feels this way after having radiation therapy."D. "Even though it is uncomfortable, this is a good sign. It means that only the cancer cells are dying."

A. "These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory studies and test results."

A client with a recent diagnosis of ITP has asked the nurse why the care team has not chosen to administer platelets, stating, "I have low platelets, so why not give me a transfusion of exactly what I'm missing?" How should the nurse best respond? A. "Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body."B. "A platelet transfusion often further blunts your body's own production of platelets." C. "Finding a matching donor for a platelet transfusion is exceedingly difficult." D. "A very small percentage of the platelets in a transfusion are actually functional."

A. "Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body."

Following an extensive diagnostic workup, a client has been diagnosed with myelodysplastic syndrome (MDS). Which assessment question most directly addresses the potential etiology of this client's health problem? A. "Were you ever exposed to toxic chemicals in any of the jobs that you held?" B. "When you were younger, did you tend to have recurrent infections of any kind?" C. "Have you ever smoked cigarettes or used other tobacco products?"D. "Would you say that you've had a lot of sun exposure in your lifetime?"

A. "Were you ever exposed to toxic chemicals in any of the jobs that you held?"

A client is receiving treatment for a new diagnosis of chronic lymphocytic leukemia (CLL). Based on known risk factors, age, ethnicity, and accompanying clinical conditions, which client is most likely to have this disease? A. 82-year-old Vietnam War veteran with widely disseminated shinglesB. 62-year-old client of Asian descent with a left fractured hipC. 69-year-old Gulf War veteran with deep vein thrombosis (DVT)D. 85-year-old client of Native American/First Nation descent with chest pain

A. 82-year-old Vietnam War veteran with widely disseminated shingles

6. A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What client most likely faces the highest immediate risk of oral cancer? A. A 65-year-old man with alcoholism who smokesB. A 45-year-old woman who has type 1 diabetes and who wears dentures C. A 32-year-old man who is obese and uses smokeless tobacco D. A 57-year-old man with GERD and dental caries

A. A 65-year-old man with alcoholism who smokes

A client has come to the clinic reporting pain just above her umbilicus. When assessing the client, the nurse notes Sister Mary Joseph nodules. The nurse should refer the client to the primary provider to be assessed for what health problem? A. A GI malignancyB. Dumping syndromeC. Peptic ulcer diseaseD. Esophageal/gastric obstruction

A. A GI malignancy

A man tells the nurse that their father died of prostate cancer and the client is concerned about their own risk of developing the disease, having heard that prostate cancer has a genetic link. What aspect of the pathophysiology of prostate cancer would underlie the nurse's response? A. A number of studies have identified an association of BRCA-2 mutation with an increased risk of prostate cancer.B. HNPCC is a mutation of two genes that causes prostate cancer in men and it is autosomal dominant. C. Studies have shown that the presence of the TP53 gene strongly influences the incidence of prostate cancer.D. Recent research has demonstrated that prostate cancer is the result of lifestyle factors and that genetics are unrelated.

A. A number of studies have identified an association of BRCA-2 mutation with an increased risk of prostate cancer.

The surgical nurse is admitting a client from postanesthetic recovery following the client's below-the-knee amputation. The nurse recognizes the client's high risk for postoperative hemorrhage and should keep what equipment at the bedside? A. A tourniquetB. A syringe preloaded with vitamin KC. A unit of packed red blood cells, placed on ice D. A dose of protamine sulfate

A. A tourniquet

18. An adult client with leukemia will soon begin chemotherapy. What would the nurse do to combat the most common adverse effects of chemotherapy? A. Administer an antiemetic.B. Administer an antimetabolite. C. Administer a tumor antibiotic. D. Administer an anticoagulant.

A. Administer an antiemetic.

A nurse is caring for a client who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the client? A. Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN.B. Administer a hypertonic dextrose solution for 1 to 2 hours after discontinuing the PN. C. Administer 3 ampules of dextrose 50% immediately prior to discontinuing the PN.D. Administer 3 ampules of dextrose 50% 1 hour after discontinuing the PN.

A. Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN.

The nurse is caring for a school-age child who has been having a continuous seizure for the last 40 minutes. What is the priority action by the nurse? A. Administer lorazepam IV as prescribed B. Perform a capillary blood glucose test C. Administer IV fluids D. Observe and document the length of time of the seizure and type of movement observed

A. Administer lorazepam IV as prescribed

A client with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the client's fluid volume excess? Select all that apply. A. Administering diureticsB. Administering calcium channel blockers C. Implementing fluid restrictionsD. Implementing a 1500 kcal/day restriction E. Enhancing client positioning

A. Administering diuretics C. Implementing fluid restrictions E. Enhancing client positioning

A client's health care provider has ordered a "liver panel" in response to the client's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply. A. Alanine aminotransferase (ALT) B. C-reactive protein (CRP)C. Gamma-glutamyl transferase (GGT) D. Aspartate aminotransferase (AST) E. B-type natriuretic peptide (BNP)

A. Alanine aminotransferase (ALT) C. Gamma-glutamyl transferase (GGT) D. Aspartate aminotransferase (AST)

The nurse is providing care for a client whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the client's medication regimen? A. Antidiarrheal medications 30 minutes before a meal B. Antiemetics on a PRN basis C. Vitamin B12 injections to prevent pernicious anemia D. Beta adrenergic blockers to reduce bowel motility

A. Antidiarrheal medications 30 minutes before a meal

A 10-month-old infant is brought to the emergency department by the parents after they found the infant face down in the bathtub. The parent states, "I just left the bathroom to answer the phone. When I came back, I found my infant." Which nursing action is priority?A. Assess the client's respiratory rateB. Start cardiopulmonary resusitative measuresC. Determine how long the client was face down in the waterD. Apply a heart monitor to the client

A. Assess the client's respiratory rate

A nurse has received an unconscious client with a traumatic brain injury (TBI). The nurse is concerned about the client's skin integrity and implements interventions to prevent pressure injuries. Which action should the nurse implement during the shift? A. Assessing all body surfaces and documenting skin integrity every 8 hours B. Turning and repositioning the client every 6 hoursC. Providing skin care with barrier care ointments once a dayD. Assisting the client to get out of bed to a chair four times a day.

A. Assessing all body surfaces and documenting skin integrity every 8 hours

A nurse is caring for a client with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? A. AsterixisB. Constructional apraxia C. Fetor hepaticusD. Palmar erythema

A. Asterixis

The nurse is assessing a client with a spinal cord injury that reports a severe headache with a rapid onset. The nurse knows that this could be a symptom of which complication of a spinal cord injury? A. Autonomic dysreflexia B. Spinal shockC. Retinal hemorrhage D. Myocardial infarction

A. Autonomic dysreflexia

The nurse determines that a client who has undergone skin, tissue, and muscle grafting following a modified radical neck dissection requires suctioning. What is the nurse's priority when suctioning this client? A. Avoid applying suction on or near the suture line.B. Position client on the non-operative side with the head of the bed down. C. Assess the client's ability to perform self-suctioning.D. Evaluate the client's ability to swallow saliva and clear fluids.

A. Avoid applying suction on or near the suture line.

An adult client with a history of dyspepsia has been diagnosed with chronic gastritis. The nurse's health education should include what guidelines? Select all that apply. A. Avoid drinking alcoholB. Adopt a low-residue dietC. Avoid nonsteroidal anti-inflammatories D. Take calcium gluconate as prescribed E. Prepare for the possibility of surgery

A. Avoid drinking alcohol C. Avoid nonsteroidal anti-inflammatories

A nurse is caring for an adult client diagnosed with a back strain. What health education should the nurse provide to this client? A. Avoid lifting more than one-third of body weight without assistance.B. Focus on using back muscles efficiently when lifting heavy objects.C. Lift objects while holding the object a safe distance from the body.D. Tighten the abdominal muscles and lock the knees when lifting an object.

A. Avoid lifting more than one-third of body weight without assistance.

The nurse is caring for a client whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be prescribed to control this? A. BaclofenB. Dexamethasone C. MannitolD. Phenobarbital

A. Baclofen

An older, female client with osteoporosis has been hospitalized. Prior to discharge, when teaching the client, the nurse should include information about which major complication of osteoporosis? A. Bone fractureB. Loss of estrogenC. Negative calcium balance D. Dowager hump

A. Bone fracture

The hospice nurse has just admitted a new client to the program. What principle guides hospice care? A. Care addresses the needs of the client as well as the needs of the family.B. Care is focused on the client centrally and the family peripherally.C. The focus of all aspects of care is solely on the client.D. The care team prioritizes the client's physical needs and the family is responsible for the client's emotional needs.

A. Care addresses the needs of the client as well as the needs of the family.B. Care is focused on the client centrally and the family peripherally.

A client tells the nurse that they haves pain and numbness in the thumb, first finger, and second finger of the right hand. The nurse discovers that the client is employed as an auto mechanic, and that the pain is increased while working. This may indicate that the client has what health problem? A. Carpel tunnel syndrome B. TendonitisC. Impingement syndrome D. Dupuytren contracture

A. Carpel tunnel syndrome

A nurse is teaching a client with osteomalacia about the role of diet. What would be the best choice for breakfast for a client with osteomalacia? A. Cereal with milk, a scrambled egg, and grapefruitB. Poached eggs with sausage and toastC. Waffles with fresh strawberries and powdered sugarD. A bagel topped with butter and jam with a side dish of grapes

A. Cereal with milk, a scrambled egg, and grapefruit

The nurse is planning the care of a client with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity." How can the nurse best address this risk? A. Change the client's position frequently. B. Provide a high-protein diet.C. Provide light massage at least daily. D. Teach the client deep breathing and coughing exercises.

A. Change the client's position frequently.

A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first? A. Check the client's indwelling urinary catheter for kinks to ensure patency. B. Lower the HOB to improve perfusion.C. Administer PRN analgesia as prescribed.D. Reassure the client that headaches are expected during recovery from spinal cord injuries.

A. Check the client's indwelling urinary catheter for kinks to ensure patency.

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN? A. Checking the client's capillary blood glucose levels regularlyB. Having the client frequently rate his or her hunger on a 10-point scale C. Measuring the client's heart rhythm at least every 6 hoursD. Monitoring the client's level of consciousness each shift

A. Checking the client's capillary blood glucose levels regularly

A client with leukemia has developed stomatitis and is experiencing a nutritional deficit. An oral anesthetic has consequently been prescribed. What health education should the nurse provide to the client? A. Chew with care to avoid inadvertently biting the tongue. B. Use the oral anesthetic 1 hour prior to mealtime.C. Brush teeth before and after eating D. Swallow slowly and deliberately.

A. Chew with care to avoid inadvertently biting the tongue.

A 35-year-old man is seen in the clinic because the client is experiencing recurring episodes of urinary frequency, dysuria, and fever. The nurse should recognize the possibility of what health problem? A. Chronic bacterial prostatitis B. OrchitisC. Benign prostatic hyperplasia D. Urolithiasis

A. Chronic bacterial prostatitis

A nurse is providing care for a client who has a diagnosis of irritable bowel syndrome (IBS). When planning this client's care, the nurse should collaborate with the client and prioritize what goal? A. Client will accurately identify foods that trigger symptoms.B. Client will demonstrate appropriate care of his ileostomy.C. Client will demonstrate appropriate use of standard infection control precautions.D. Client will adhere to recommended guidelines for mobility and activity.

A. Client will accurately identify foods that trigger symptoms.

A nurse is providing care for a client who has recently been admitted to the postsurgical unit from PACU following a transurethral resection of the prostate. The nurse is aware of the nursing diagnosis of Risk for Imbalanced Fluid Volume. In order to assess for this risk, the nurse should prioritize what action? A. Closely monitoring the input and output of the bladder irrigation system B. Administering parenteral nutrition and fluids as prescribedC. Monitoring the client's level of consciousness and skin turgorD. Scanning the client's bladder for retention every 2 hours

A. Closely monitoring the input and output of the bladder irrigation system

A 15-year-old adolescent is brought to the emergency department by his parents. The adolescent is febrile with chills that started suddenly. He states, "I had a sinus infection and sore throat a couple of days ago." The nurse suspects bacterial meningitis based on which findings? Select all that apply.A. Complaints of stiff neckB. PhotophobiaC. Absent headacheD. Negative Brudzinski signE. Vomiting

A. Complaints of stiff neck B. Photophobia E. Vomiting

A nurse is caring for a client who is being assessed following reports of severe and persistent low back pain. The client is scheduled for diagnostic testing in the morning. Which of the following are appropriate diagnostic tests for assessing low back pain? Select all that apply. A. Computed tomography (CT)B. AngiographyC. Magnetic resonance imaging (MRI) D. UltrasoundE. X-ray

A. Computed tomography (CT) C. Magnetic resonance imaging (MRI) D. UltrasoundE. X-ray

A client has just returned to the floor following a transurethral resection of the prostate. A triple-lumen indwelling urinary catheter has been inserted for continuous bladder irrigation. What, in addition to balloon inflation, are the functions of the three lumens? Continuous inflow and outflow of irrigation solution Intermittent inflow and continuous outflow of irrigation solution Continuous inflow and intermittent outflow of irrigation solution Intermittent flow of irrigation solution and prevention of hemorrhage

A. Continuous inflow and outflow of irrigation solution

A nurse is caring for a client with Hodgkin lymphoma at the oncology clinic. The nurse should identify what main goal of care? A. Cure of the diseaseB. Enhancing quality of life C. Controlling symptoms D. Palliation

A. Cure of the disease

A 55-year-old female client with hepatocellular carcinoma (HCC) is undergoing radiofrequency ablation. The nurse should recognize what goal of this treatment? A. Destruction of the client's liver tumor B. Restoration of portal vein patency C. Destruction of a liver abscess D. Reversal of metastasis

A. Destruction of the client's liver tumor

Phenytoin IV has been prescribed by health care provider for a child who has experienced a seizure. Before administering the drug what should the nurse do?A. Determine the IV fluid infusing is normal salineB. Assess the child's vital signs C. Monitor the electrolyte levelsD. Start another IV with a large bore needle

A. Determine the IV fluid infusing is normal saline

A client's electronic health record notes that the client has hallux valgus. What signs and symptoms should the nurse expect this client to manifest? A. Deviation of a great toe laterally B. Abnormal flexion of the great toe C. An exaggerated arch of the foot D. Fusion of the toe joints

A. Deviation of a great toe laterally

The nurse is leading a workshop on sexual health for men. The nurse should describe what organic causes of erectile dysfunction? Select all that apply. A. DiabetesB. Testosterone deficiency C. AnxietyD. Depression E. Parkinsonism

A. Diabetes B. Testosterone deficiency E. Parkinsonism

A group of nurses have attended an in-service on the prevention of occupationally acquired diseases that affect health care providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? A. Disposing of sharps appropriately and not recapping needlesB. Performing meticulous hand hygiene at the appropriate moments in careC. Adhering to the recommended schedule of immunizationsD. Wearing an N95 mask when providing care for clients on airborne precautions

A. Disposing of sharps appropriately and not recapping needles

A client with gastric cancer has been scheduled for a total gastrectomy. During the preoperative assessment, the client confides in the nurse feeling the surgery will "mutilate" the client's body. The nurse should plan interventions that address what nursing diagnosis? A. Disturbed body imageB. Deficient knowledge related to the risks of surgery C. Anxiety about the surgeryD. Low self-esteem

A. Disturbed body image

A nurse is writing the care plan of a client who has been diagnosed with myelofibrosis. What nursing diagnoses should the nurse address? Select all that apply. A. Disturbed body imageB. Impaired mobilityC. Imbalanced nutrition: Less than body requirements D. Acute confusionE. Risk for infection

A. Disturbed body image B. Impaired mobility C. Imbalanced nutrition: Less than body requirements E. Risk for infection

A 29-year-old client has just been told that they have testicular cancer and needs to have surgery. During a presurgical appointment, the client admits to feeling devastated that they require surgery, stating that it will leave them "emasculated" and "a shell of a man." The nurse should identify what nursing diagnosis when planning the client's subsequent care? A. Disturbed body image related to effects of surgery B. Spiritual distress related to effects of cancer surgery C. Social isolation related to effects of surgeryD. Risk for loneliness related to change in self-concept

A. Disturbed body image related to effects of surgery

During the physical assessment of a 2½-month-old infant, the nurse suspects the child may have hydrocephalus. Which sign or symptom was observed? A. Dramatic increase in head circumference B. Pupil of one eye dilated and reactive C. Vertical nystagmus D. Posterior fontanel is closed

A. Dramatic increase in head circumference

A nurse is caring for a client who is 12 hours' postoperative following foot surgery. The nurse assesses the presence of edema in the foot. What nursing measure should the nurse implement to control the edema? A. Elevate the foot on several pillows.B. Apply warm compresses intermittently to the surgical area. C. Administer a loop diuretic as prescribed. D. Increase circulation through frequent ambulation.

A. Elevate the foot on several pillows.

A nurse is caring for a client who is postoperative from a neck dissection. What would be the most appropriate nursing action to enhance the client's appetite? A. Encourage the family to bring in the client's favorite foods. B. Limit visitors at mealtimes so that the client is not distracted. C. Avoid offering food unless the client initiates.D. Provide thorough oral care immediately after the client eats.

A. Encourage the family to bring in the client's favorite foods.

A nurse is caring for a client who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. What nursing action will best achieve these goals? A. Encouraging the client to turn from side to side and to assume a prone position B. Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputationC. Minimizing movement of the flexor muscles of the hipD. Encouraging the client to sit in a chair for at least 8 hours a day

A. Encouraging the client to turn from side to side and to assume a prone positi

A nurse is caring for a client who has had surgery for oral cancer. When addressing the client's long-term needs, the nurse should prioritize interventions and referrals with what goal? A. Enhancement of verbal communication B. Enhancement of immune functionC. Maintenance of adequate social support D. Maintenance of fluid balance

A. Enhancement of verbal communication

The school nurse has been called to the football field, where a player is laying immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? A. Ensure that the player is not moved.B. Obtain the player's vital signs, if possible.C. Perform a rapid assessment of the player's range of motion. D. Assess the player's reflexes.

A. Ensure that the player is not moved.

A nurse is planning the care of an older adult client with osteomalacia. What action should the nurse recommend in order to promote vitamin D synthesis? A. Ensuring adequate exposure to sunlightB. Eating a low-purine dietC. Performing cardiovascular exercise while avoiding weight-bearing exercises D. Taking thyroid supplements as prescribed

A. Ensuring adequate exposure to sunlight

The emergency room (ER) nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding(s) are suggestive of a basilar skull fracture? Select all that apply A. EpistaxisB. Swelling of the tongue and lips C. Bruising over the mastoidD. Unilateral facial numbnessE. Severe back pain

A. Epistaxis C. Bruising over the mastoid

A client was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize? A. Esophageal or pyloric obstruction related to scarringB. Uncontrolled proliferation of H. pyloriC. Gastric hyperacidity related to excessive gastrin secretion D. Chronic referred pain in the lower abdomen

A. Esophageal or pyloric obstruction related to scarring

A client is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse caring for this client is aware that an absolute contraindication for thrombolytic therapy is what? A. Evidence of hemorrhagic strokeB. Blood pressure of 180/110 mm HgC. Evidence of stroke evolutionD. Previous thrombolytic therapy within the past 12 months

A. Evidence of hemorrhagic stroke

The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke? A. Facial droopB. DysrhythmiasC. Periorbital edema D. Projectile vomiting

A. Facial droop

During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus? A. Following proper hand-washing techniques B. Avoiding chemicals that are toxic to the liver C. Wearing a condom during sexual contactD. Limiting alcohol intake

A. Following proper hand-washing techniques

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? A. Fried chickenB. Mashed potatoes C. Dinner rollD. Tapioca pudding

A. Fried chicken

A 4-year-old boy has a history of seizures and has been started on a ketogenic diet. Which food selection would be most appropriate for his lunch?A. Fried eggs, bacon, and iced teaB. A hamburger on a bun, French fries, and milk C. Spaghetti with meatballs, garlic bread, and a cola drink D. A grilled cheese sandwich, potato chips, and a milkshake

A. Fried eggs, bacon, and iced tea

When preparing to discharge a client home, the nurse has met with the family and warned them that the client may exhibit unexpected emotional responses. The nurse should teach the family that these responses are typically a result of what cause? A. Frustration around changes in function and communication B. Unmet physiologic needsC. Changes in brain activity during sleep and wakefulnessD. Temporary changes in metabolism

A. Frustration around changes in function and communication

A client with pancreatic cancer has been scheduled for a pancreaticoduodenectomy (Whipple procedure). During health education, the client should be informed that this procedure will involve the removal of which of the following? Select all that apply. A. GallbladderB. Part of the stomachC. DuodenumD. Part of the common bile duct E. Part of the rectum ANS: A, B, C, D

A. GallbladderB. Part of the stomachC. DuodenumD. Part of the common bile duct

A client has a recent diagnosis of chronic pancreatitis and is undergoing diagnostic testing to determine pancreatic islet cell function. The nurse should anticipate what diagnostic test? A. Glucose tolerance testB. ERCPC. Pancreatic biopsyD. Abdominal ultrasonography

A. Glucose tolerance test

A nurse is teaching a 53-year-old man about prostate cancer, given the fact that the client has a family history of the disease. What information should the nurse provide to best facilitate the early identification of prostate cancer? A. Have a digital rectal examination and prostate-specific antigen (PSA) test done as recommended.B. Have a transrectal ultrasound every 5 years.C. Perform monthly testicular self-examinations, especially after age 60. D. Have a complete blood count (CBC), blood urea nitrogen (BUN), and creatinine assessment performed annually.

A. Have a digital rectal examination and prostate-specific antigen (PSA) test done as recommended.

A client has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study? A. Have the client refrain from food and fluids after midnight.B. Administer the contrast agent orally 10 to 12 hours before the study.C. Administer the radioactive agent intravenously the evening before the study. D. Encourage the intake of 64 ounces of water 8 hours before the study.

A. Have the client refrain from food and fluids after midnight.

An 82-year-old client is admitted for observation after a fall. Due to the client's age, the nurse knows that the client is at increased risk for what complication of his injury? A. Hematoma B. Skull fracture C. EmbolusD. Stroke

A. Hematoma

The results of a client's most recent blood work and physical assessment are suggestive of immune thrombocytopenic purpura (ITP). This client should undergo testing for which of the following potential causes? Select all that apply. A. HepatitisB. Acute kidney injury C. HIV D. Malignant melanoma E. Cholecystitis

A. Hepatitis, C. HIV

A nurse is presenting an educational event to a local community group. When speaking about colorectal cancer, what risk factor should the nurse cite? A. High levels of alcohol consumption B. History of bowel obstructionC. History of diverticulitisD. Longstanding psychosocial stress

A. High levels of alcohol consumption

An oncology nurse is caring for a client with multiple myeloma who is experiencing bone destruction. When reviewing the client's most recent blood tests, the nurse should anticipate which imbalance? A. HypercalcemiaB. HyperproteinemiaC. Elevated serum viscosityD. Elevated red blood count (RBC)

A. Hypercalcemia

The nurse is caring for a child with suspected increased intracranial pressure (ICP). Which assessment finding would indicate increased ICP? A. Hyperthermia B. Hypertension C. Tachypnea D. Poor handwriting

A. Hyperthermia

The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem damage? A. Hyperthermia B. Tachycardia C. Hypertension D. Bradypnea

A. Hyperthermia

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. A. ImmunizationB. Use of standard precautionsC. Consumption of a vitamin-rich diet D. Annual vitamin K injectionsE. Annual vitamin B12 injections

A. Immunization B. Use of standard precautions

6. The nurse is caring for a client who is to begin receiving external radiation for a malignant tumor of the neck. While providing client education, what potential adverse effects should the nurse discuss with the client? A. Impaired nutritional status B. Cognitive changesC. DiarrheaD. Alopecia

A. Impaired nutritional status

A nurse is providing care for a client who has a recent diagnosis of Paget disease. When planning this client's nursing care, what should interventions address? Select all that apply. A. Impaired physical mobilityB. Acute painC. Disturbed auditory sensory perception D. Risk for injuryE. Risk for unstable blood glucose

A. Impaired physical mobilityB. Acute painC. Disturbed auditory sensory perception D. Risk for injury

A nurse on a solid organ transplant unit is planning the care of a client who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority? A. Implementation of infection-control measuresB. Close monitoring of skin integrity and colorC. Frequent assessment of the client's psychosocial status D. Administration of antiretroviral medications

A. Implementation of infection-control measures

A client's abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the client's laboratory studies, what finding is most closely associated with this diagnosis? A. Increased bilirubinB. Decreased serum cholesterolC. Increased blood urea nitrogen (BUN)D. Decreased serum alkaline phosphatase level

A. Increased bilirubin

The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)? A. Increased warmth of the calfB. Decreased circumference of the calf C. Loss of sensation to the calfD. Pale-appearing calf

A. Increased warmth of the calf

A medical nurse who is caring for a client being discharged home after a radical neck dissection has collaborated with the home health nurse to develop a plan of care for this client. What is a priority psychosocial outcome for this client? A. Indicates acceptance of altered appearance and demonstrates positive self-imageB. Freely expresses needs and concerns related to postoperative pain management C. Compensates effectively for alteration in ability to communicate related to dysarthriaD. Demonstrates effective stress management techniques to promote muscle relaxation

A. Indicates acceptance of altered appearance and demonstrates positive self-image

The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of the illness. The nurse would assess the child most carefully for what finding?A. Indications of increased intracranial pressureB. An increase in the blood glucose level C. A decrease in the liver enzymes D. A presence of protein in the urine

A. Indications of increased intracranial pressure

A client is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this client's care, which of the following nursing diagnoses should the nurse prioritize? A. Ineffective tissue perfusion related to bowel ischemiaB. Imbalanced nutrition: Less than body requirements related to impaired absorptionC. Anxiety related to bowel obstruction and subsequent hospitalizationD. Impaired skin integrity related to bowel obstruction

A. Ineffective tissue perfusion related to bowel ischemia

A nurse is caring for a client who has a diagnosis of acute myelocytic leukemia (AML). Assessment of which factor most directly addresses the most common cause of death among clients with leukemia? A. Infection status B. Nutritional status C. Electrolyte levels D. Liver function

A. Infection status

A client presents to the clinic reporting vomiting and burning in the mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what? A. Infection with Helicobacter pylori B. Excessive stomach acid secretion C. An incompetent pyloric sphincter D. A metabolic acid-base imbalance

A. Infection with Helicobacter pylori

A client who is postoperative day 12 and recovering at home following a laparoscopic prostatectomy has reported that the client is experiencing occasional "dribbling" of urine. How should the nurse best respond to this client's concern? A. Inform the client that urinary control is likely to return gradually.B. Arrange for the client to be assessed by the urologist.C. Facilitate the insertion of an indwelling urinary catheter by the home care nurse. D. Teach the client to perform intermittent self-catheterization.

A. Inform the client that urinary control is likely to return gradually

A nurse is preparing to place a client's prescribed nasogastric tube. What anticipatory guidance should the nurse provide to the client? A. Insertion is likely to cause some gagging.B. Insertion will cause some short-term pain.C. A narrow-gauge tube will be inserted before being replaced with a larger-gauge tube.D. Topical anesthetics will be used to reduce discomfort during insertion.

A. Insertion is likely to cause some gagging.

A 35-year-old client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize? A. Insertion of a nasogastric tubeB. Insertion of a central venous catheterC. Administration of a mineral oil enemaD. Administration of a glycerin suppository and an oral laxative

A. Insertion of a nasogastric tube

The nurse is caring for a 6-year-old child who has a history of febrile seizures and is admitted with a temperature of 102.2 F (39C). What is the nurse's highest priority? A. Institute safety precautions B. Offer age-appropriate activities C. Encourage the child to perform self-care D. Provide family teaching

A. Institute safety precautions

A nurse is preparing to administer a client's intravenous fat emulsion simultaneously with parenteral nutrition (PN). What principle should guide the nurse's action? A. Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered.B. The nurse should prepare for placement of another intravenous line, as intravenous fat emulsions may not be infused simultaneously through the line used for PN. C. Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site after running the emulsion through a filter. D. The intravenous fat emulsions can be piggy-backed into any existing IV solution that is infusing.

A. Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered.

A client comes to the clinic reporting fatigue and the health interview is suggestive of pica. Laboratory findings reveal a low serum iron level and a low ferritin level. With what would the nurse suspect that the client will be diagnosed? A. Iron deficiency anemia B. Pernicious anemiaC. Sickle cell disease D. Hemolytic anemia

A. Iron deficiency anemia

The nurse is educating a group of nursing students about COVID-19 and risk for cerebrovascular disorders. The nurse educator notes that COVID-19 has shown to increase which condition? A. Ischemic strokeB. Decrease inflammation C. Hemorrhagic strokeD. Hypertension

A. Ischemic stroke

The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote? A. Knots in the rope should not be resting against pulleys.B. Weights should rest against the bed rails.C. The end of the limb in traction should be braced by the footboard of the bed. D. Skeletal traction may be removed for brief periods to facilitate the client's independence.

A. Knots in the rope should not be resting against pulleys.

A client with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the client will undergo what intervention? A. Laparoscopic cholecystectomyB. Methyl tertiary butyl ether (MTBE) infusion C. Intracorporeal lithotripsyD. Extracorporeal shock wave therapy (ESWL)

A. Laparoscopic cholecystectomy

A client with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure? A. Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure.B. Laparoscopic cholecystectomy can be performed in a clinic setting, while an open procedure requires an OR.C. A laparoscopic approach allows for the removal of the entire gallbladder.D. A laparoscopic approach can be performed under conscious sedation.

A. Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure.

A client with a diagnosis of prostate cancer is scheduled to have an interstitial implant for high-dose radiation (HDR). What safety measure should the nurse include in this client's plan of care? A. Limit the time that visitors spend at the client's bedside. B. Teach the client to perform all aspects of basic care independently.C. Assign male nurses to the client's care whenever possible.D. Situate the client in a shared room with other clients receiving brachytherapy.

A. Limit the time that visitors spend at the client's bedside.

A group of students are reviewing information about head injuries in children. The students demonstrate understanding of this information when they identify what as the most common type of skull fracture in children?A. Linear B. Depressed C. Diastatic D. Basilar

A. Linear

2. A nurse who works in an oncology clinic is assessing a client who has arrived for a 2-month follow-up appointment following chemotherapy. The nurse notes that the client's skin appears yellow. Which blood tests should be done to further explore this clinical sign? A. Liver function tests (LFTs)B. Complete blood count (CBC)C. Platelet countD. Blood urea nitrogen and creatinine

A. Liver function tests (LFTs)

A client is admitted to the neurologic intensive care unit (ICU) with a suspected diffuse axonal injury. Which primary neuroimaging diagnostic tool would be used on this client to evaluate the brain structure? A. Magnetic resonance imaging (MRI)B. Positron emission tomography (PET) scan C. X-ray of the headD. Ultrasound of the head

A. Magnetic resonance imaging (MRI)

A client has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurse's priority during this aspect of the client's care? A. Measure and record drainage.B. Monitor drainage for change in color.C. Titrate the suction every hour.D. Feed the client via the G tube as prescribed.

A. Measure and record drainage.

An adult client has been admitted to the medical unit for the treatment of acute pancreatitis. What nursing action should be included in this client's plan of care? A. Measure the client's abdominal girth daily. B. Limit the use of opioid analgesics.C. Monitor the client for signs of dysphagia. D. Encourage activity as tolerated.

A. Measure the client's abdominal girth daily.

A client's absolute neutrophil count (ANC) is 440/mm3 but the nurse's assessment reveals no apparent signs or symptoms of infection. What action should the nurse prioritize when providing care for this client? A. Meticulous hand hygieneB. Timely administration of antibioticsC. Provision of a nutrient-dense dietD. Maintaining a sterile care environment

A. Meticulous hand hygiene

A client with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the client may be prescribed what drug? A. MetoclopramideB. OmeprazoleC. LansoprazoleD. Calcium carbonate

A. Metoclopramide

The physician has ordered rectal diazepam for a 2-year-old boy with status epilepticus. Which instruction is essential for the nurse to teach the parents?A. Monitor their child's level of sedation.B. Watch for fever indicating infection. C. Gradually reduce the dosage as seizures stop.D. Monitor for an allergic reaction to the medication.

A. Monitor their child's level of sedation.

An oncology nurse recognizes a client's risk for fluid imbalance while the client is undergoing treatment for leukemia. What related assessments should the nurse include in the client's plan of care? Select all that apply. A. Monitoring the client's electrolyte levelsB. Monitoring the client's hepatic functionC. Measuring the client's weight on a daily basisD. Measuring and recording the client's intake and output E. Auscultating the client's lungs frequently

A. Monitoring the client's electrolyte levels C. Measuring the client's weight on a daily basisD. Measuring and recording the client's intake and output E. Auscultating the client's lungs frequently

A nurse is assessing a client who reports a throbbing, burning sensation in the right foot. The client states that the pain is worst during the day but notes that the pain is relieved with rest. The nurse should recognize the signs and symptoms of what health problem? A. Morton neuroma B. Pes cavusC. Hallux valgusD. Onychocryptosis

A. Morton neuroma

During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply. A. National Institutes of Health Stroke Scale (NIHSS) score B. Race C. LOC at time of admission D. GenderE. Age

A. National Institutes of Health Stroke Scale (NIHSS) score C. LOC at time of admission E. Age

A child with a seizure disorder will be discharged home from the hospital on the drug levetiracetam. What discharge instruction is the most important for the nurse to provide the parent?A. Notify the health care provider if child experiences poor coordination B. Notify the health care provider if the number of seizures increases after 4 weeksC. Return to the clinic in 3 weeks for laboratory test to determine therapeutic level of the drug D. Do not to take two doses together if one dose is missed

A. Notify the health care provider if child experiences poor coordination

A nurse is preparing a school-aged child for a lumbar puncture. The nurse would expect to position the child in which manner?A. On her side with the head flexed forward and knees flexed to the abdomenB. Sitting upright with the head flexed forward to the chest C. Supine with arms and legs pronated and extended D. Prone with the arms flexed under the chest

A. On her side with the head flexed forward and knees flexed to the abdomen

A client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this client? Select all that apply. A. Orthostatic hypotension B. Autonomic dysreflexia C. DVTD. Salt-wasting syndrome E. Increased ICP

A. Orthostatic hypotension B. Autonomic dysreflexia C. DVT

An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The client should undergo diagnostic testing for what health problem? A. Osteomyelitis B. Osteoporosis C. Osteomalacia D. Septic arthritis

A. Osteomyelitis

A child with a seizure diorder is being admitted to the inpatient unit. When preparing the room for the child, what should be included? Select all that apply A. Oxygen gauge and tubing B. Suction at bedside C. Tongue blade D. Padding for side rails

A. Oxygen gauge and tubing B. Suction at bedside D. Padding for side rails

A child with increased intracranial pressure is being treated with hyperventilation. The nurse understands that after this treatment:A. PaCO2 levels decrease, causing vasoconstriction.B. drainage of cerebrospinal fluid occurs. C. activity is controlled via a stimulator.D. hyperexcitability of the nerves is reduced.

A. PaCO2 levels decrease, causing vasoconstriction.

A client with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to prescribe for this client? A. Packed red blood cells (PRBCs) B. Vitamin KC. Oral anticoagulantsD. Heparin infusion

A. Packed red blood cells (PRBCs)

The nurse is caring for a client who has just been told that the client's stage IV colon cancer has recurred and metastasized to the liver. The oncologist offers the client the option of surgery to treat the progression of this disease. What type of surgery does the oncologist offer? A. PalliativeB. Reconstructive C. SalvageD. Prophylactic

A. Palliative

A client has experienced occasional urinary incontinence in the weeks since their prostatectomy. In order to promote continence, the nurse should encourage which of the following? A. Pelvic floor exercisesB. Intermittent urinary catheterization C. Reduced physical activityD. Active range of motion exercises

A. Pelvic floor exercises

A nurse is caring for a client in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristic(s) of this stage of the disease? Select all that apply. A. Perforation into the mediastinumB. Development of an esophageal lesion C. Erosion into the great vesselsD. Painful swallowingE. Obstruction of the esophagus

A. Perforation into the mediastinum C. Erosion into the great vesselsD. Painful swallowing

Diagnostic imaging and physical assessment have revealed that a client with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? A. Peritonitis B. GastritisC. Gastroesophageal reflux D. Acute pancreatitis

A. Peritonitis

A 76-year-old with a diagnosis of penile cancer has been admitted to the medical floor. Because the incidence of penile cancer is so low, the staff educator has been asked to teach about penile cancer. What risk factors should the educator cite in this presentation? Select all that apply. A. PhimosisB. PriapismC. Herpes simplex infection D. Increasing ageE. Lack of circumcision

A. Phimosis D. Increasing ageE. Lack of circumcision

A nurse is caring for a client who is postoperative day 1 following a total arthroplasty of the right hip. How should the nurse position the client? A. Place a pillow between the legs.B. Turn the client on the surgical side.C. Avoid flexion of the right hip.D. Keep the right hip adducted at all times.

A. Place a pillow between the legs.

A hospitalized child is scheduled for magnetic resonance imaging (MRI) with contrast. What nursing intervention(s) will the nurse complete to ensure safety during the examination? Select all that apply.A. Place child in clothing with no metal B. Connect the child to a heart monitor C. Assess the IV site for patencyD. Review any prescriptions for sedation E. Assess for a latex allergy

A. Place child in clothing with no metal C. Assess the IV site for patency D. Review any prescriptions for sedation

A nurse has a client with a spinal cord injury and is tailoring their care plan to prevent the major causes of death for this client. The nurse's care plan includes assisted coughing techniques, a sequential compression device, and prevention of pressure injuries. Which are the most likely possible causes of death for this client? A. Pneumonia, pulmonary embolism, and sepsisB. Cardiac tamponade, hypoxia, and malnutritionC. Oxygen toxicity in paralytic ileus and electrolyte imbalances D. Seizures, osteomyelitis, and urinary tract infections

A. Pneumonia, pulmonary embolism, and sepsis

Nursing care during the immediate recovery period from an ischemic stroke should normally prioritize which intervention? A. Positioning the client to avoid intercranial pressure (ICP) B. Maximizing partial pressure of carbon dioxide (PaCO2)C. Administering hypertonic intravenous (IV) solutionD. Initiating early mobilization

A. Positioning the client to avoid intercranial pressure (ICP)

A client is involved in a motorcycle accident and injures an arm. The health care provider diagnoses the man with an intra-articular fracture and splints the injury. The nurse implements the teaching plan developed for this client. What sequela of intra-articular fractures should the nurse describe regarding this client? A. Posttraumatic arthritisB. Fat embolism syndrome (FES) C. OsteomyelitisD. Compartment syndrome

A. Posttraumatic arthritis

A client was fitted with an arm cast after fracturing the humerus. Twelve hours after the application of the cast, the client tells the nurse that the injured arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action? A. Prepare the client for opening or bivalving of the cast. B. Obtain a prescription for a different analgesic.C. Encourage the client to wiggle and move the fingers. D. Petal the edges of the client's cast.

A. Prepare the client for opening or bivalving of the cast.

A nurse is preparing to discharge a client home on parenteral nutrition. What should an effective home care teaching program address? Select all that apply. A. Preparing the client to troubleshoot for problemsB. Teaching the client and family strict aseptic techniqueC. Teaching the client and family how to set up the infusionD. Teaching the client to flush the line with sterile waterE. Teaching the client when it is safe to leave the access site open to air

A. Preparing the client to troubleshoot for problemsB. Teaching the client and family strict aseptic techniqueC. Teaching the client and family how to set up the infusion

A client with a diagnosis of acute myeloid leukemia (AML) is being treated with induction therapy on the oncology unit. What nursing action should be prioritized in the client's care plan? A. Protective isolation and vigilant use of standard precautionsB. Provision of a high-calorie, low-texture diet and appropriate oral hygiene C. Including the family in planning the client's activities of daily livingD. Monitoring and treating the client's pain

A. Protective isolation and vigilant use of standard precautions

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? A. Provide a board of commonly used needs and phrases. B. Have the client speak to loved ones on the phone daily. C. Help the client complete his or her sentences as needed. D. Speak in a loud and deliberate voice to the client.

A. Provide a board of commonly used needs and phrases.

A 22-year-old male client is being discharged home after surgery for testicular cancer. The client is scheduled to begin chemotherapy in 2 weeks. The client tells the nurse that they do not think he can take weeks or months of chemotherapy, stating that they have researched the adverse effects online. What is the most appropriate nursing action for this client at this time? A. Provide empathy and encouragement in an effort to foster a positive outlook. B. Tell the client it is their decision whether to have chemotherapy.C. Report the client's statement to members of their support system.D. Refer the client to social work.

A. Provide empathy and encouragement in an effort to foster a positive outlook.

The nurse is caring for a client recovering from an ischemic stroke. What intervention(s) best addresses potential complications after an ischemic stroke? Select all that apply. A. Providing frequent small meals rather than three larger mealsB. Teaching the client to perform deep breathing and coughing exercises.C. Keeping a urinary catheter in place for the full duration of recovery.D. Limiting intake of insoluble fiber, carbohydrates, and simple sugars.E. Encourage the client to stay in bed and assist with turning and repositioning.

A. Providing frequent small meals rather than three larger mealsB. Teaching the client to perform deep breathing and coughing exercises.

22. The nurse is describing some of the major characteristics of cancer to a client who has recently received a diagnosis of malignant melanoma. When differentiating between benign and malignant cancer cells, the nurse should explain differences in which of the following aspects? Select all that apply. A. Rate of growthB. Ability to cause death C. Cell sizeD. Cell locationE. Ability to spread

A. Rate of growth B. Ability to cause death E. Ability to spread

An 83-year-old client has been prescribed finasteride. When performing client education with this client, the nurse should be sure to tell the client to take what action? A. Report the planned use of dietary supplements to the health care provider. B. Decrease the intake of fluids to prevent urinary retention.C. Abstain from sexual activity for 2 weeks following the initiation of treatment. D. Anticipate a temporary worsening of urinary retention before symptoms subside.

A. Report the planned use of dietary supplements to the health care provider.

17. A 16-year-old female client has post-chemotherapy alopecia. This prompts the nursing diagnoses of Disturbed Body Image and Situational Low Self-Esteem. Which response by the client would best indicate improved coping related to these diagnoses? A. Requests that her family bring her makeup and a wig B. Begins to discuss the future with her familyC. Reports less disruption from pain and discomfort D. Cries openly when discussing her disease

A. Requests that her family bring her makeup and a wig

A nurse is planning the care of client who has been diagnosed with essential thrombocythemia (ET). Which nursing diagnosis should the nurse prioritize when choosing interventions? A. Risk for ineffective tissue perfusion B. Risk for imbalanced fluid volumeC. Risk for ineffective breathing pattern D. Risk for ineffective thermoregulation

A. Risk for ineffective tissue perfusion

A nurse is writing a care plan for a client admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius? A. Risk for infectionB. Risk for ineffective role performanceC. Risk for perioperative positioning injury D. Risk for powerlessness

A. Risk for infection

A client is being discharged after a liver transplant and the nurse is performing discharge education. When planning this client's continuing care, the nurse should prioritize what risk diagnosis? A. Risk for infection related to immunosuppressant useB. Risk for injury related to decreased hemostasisC. Risk for unstable blood glucose related to impaired gluconeogenesis D. Risk for contamination related to accumulation of ammonia

A. Risk for infection related to immunosuppressant use

The nurse is educating a group of students about complications of an aneurysm. Which is a complication of aneurysm? A. SeizureB. Hypernatremia C. Airway collapse D. Pneumothorax

A. Seizure

A 37-year-old client presents at the emergency department (ED) reporting nausea and vomiting and severe abdominal pain. The client's abdomen is rigid, and there is bruising to the client's flank. The client's spouse states that the client was on a drinking binge for the past 2 days. The ED nurse should assist in assessing the client for what health problem? A. Severe pancreatitis with possible peritonitis B. Acute cholecystitisC. Chronic pancreatitisD. Acute appendicitis with possible perforation

A. Severe pancreatitis with possible peritonitis

A client presents to a clinic reporting a leg ulcer that isn't healing; subsequent diagnostic testing suggests osteomyelitis. The nurse is aware that the most common pathogen to cause osteomyelitis is: A. Staphylococcus aureus. B. Proteus.C. Pseudomonas.D. Escherichia coli.

A. Staphylococcus aureus.

7. While a client is receiving intravenous (IV) doxorubicin hydrochloride for the treatment of cancer, the nurse observes swelling and pain at the IV site. The nurse should prioritize which action? A. Stopping the administration of the drug immediately B. Notifying the client's health care providerC. Continuing the infusion but decreasing the rate D. Applying a warm compress to the infusion site

A. Stopping the administration of the drug immediately

A nurse is preparing a presentation for a local health fair about meningitis and has developed a display that lists the following causes:Streptococcus group BHaemophilus influenzae type B Streptococcus pneumoniaeNeisseria meningitidisWhat would the nurse highlight as the most common cause of meningitis in newborns? A. Streptococcus group BB. Haemophilus influenzae type BC. Streptococcus pneumoniaeD. Neisseria meningitidis

A. Streptococcus group B

A nurse is collaborating with the physical therapist to plan the care of a client with osteomyelitis. What principle should guide the management of activity and mobility in this client? A. Stress on the weakened bone must be avoided.B. Increased heart rate enhances perfusion and bone healing.C. Bed rest results in improved outcomes in clients with osteomyelitis. D. Maintenance of baseline ADLs is the primary goal during osteomyelitis treatment.

A. Stress on the weakened bone must be avoided.

A 32-year-old client comes to the clinic reporting shoulder tenderness, pain, and limited movement. Upon assessment the nurse finds edema. An MRI shows hemorrhage of the rotator cuff tendons and the client is diagnosed with impingement syndrome. What action should the nurse recommend in order to promote healing? A. Support the affected arm on pillows at night.B. Take prescribed corticosteroids as prescribed.C. Put the shoulder through its full range of motion three times daily. D. Keep the affected arm in a sling for 2 to 4 weeks.

A. Support the affected arm on pillows at night.

A client who experienced a large upper gastrointestinal (GI) bleed due to gastritis has had the bleeding controlled and is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence? A. Tachycardia, hypotension, and tachypneaB. Tarry, foul-smelling stoolsC. Diaphoresis and sudden onset of abdominal painD. Sudden thirst, unrelieved by oral fluid administration

A. Tachycardia, hypotension, and tachypnea

THe nurse is interviewing the caregivers of a child brought to the emergency unit. The caregiver states, "She has a history of seizures but this time it lasted more than 30 minutes and she just keeps having them."The most accurate description of this child's condition would be: A. The child is in status epilepticus B. The child is having generalized seizures C. This child's history indicates she has infantile seizures D. The child may begin to have absence seizures every day

A. The child is in status epilepticus

A child is in the emergency department with a head injury obtained in a motor vehicle crash. The glascow coma scale assessment is rated at 10 (3 eye opening, 3 motor, 4 verbal). How should the nurse interpret these findings?A. The child's eyes open to verbal stimuli, is confused and flexes with painful stimuli B. The child's eyes open spontaneously, able to localize pain and uses inappropriate words C. The child's eyes open to speech, is able to obey commands but is confusedD. The child's eyes open to pain, opens to extension and says incomprehensible words

A. The child's eyes open to verbal stimuli, is confused and flexes with painful stimuli

A client who suffered an ischemic stroke now has disturbed sensory perception. What principle should guide the nurse's care of this client? A. The client should be approached on the side where visual perception is intact. B. Attention to the affected side should be minimized in order to decrease anxiety. C. The client should avoid turning in the direction of the defective visual field to minimize shoulder subluxation. D. The client should be approached on the opposite side of where the visual perception is intact to promote recovery.

A. The client should be approached on the side where visual perception is intact.

A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that the client remain on bed rest to hasten recovery and to conserve energy. What principle of care should inform the nurse's response to the family? A. The client should mobilize as soon as physically able.B. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks.C. The client should remain on bed rest until the client expresses a desire to mobilize.D. Lack of mobility will greatly increase the client's risk of stroke recurrence.

A. The client should mobilize as soon as physically able.

A client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with minor cell changes. What principle should be integrated into the client's subsequent care? A. The client will be monitored closely to detect malignant changes. B. Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage.C. Small amounts of blood are likely to be present in the stools and are not cause for concern. D. Antacids may be discontinued when symptoms of heartburn subside.

A. The client will be monitored closely to detect malignant changes.

A nurse is caring for a 78-year-old client with a history of osteoarthritis (OA). When planning the client's care, what goal should the nurse prioritize? A. The client will express satisfaction with the ability to perform ADLs. B. The client will recover from OA within 6 months.C. The client will adhere to the prescribed plan of care.D. The client will deny signs or symptoms of OA.

A. The client will express satisfaction with the ability to perform ADLs.

A client's neck dissection surgery resulted in damage to the client's superior laryngeal nerve. What area of assessment should the nurse consequently prioritize? A. The client's swallowing abilityB. The client's ability to speakC. The client's management of secretions D. The client's airway patency

A. The client's swallowing ability

An oncology nurse is providing health education for a client who has recently been diagnosed with leukemia. What should the nurse explain about commonalities between all of the different subtypes of leukemia? A. The different leukemias all involve unregulated proliferation of white blood cells. B. The different leukemias all have unregulated proliferation of red blood cells and decreased bone marrow function.C. The different leukemias all result in a decrease in the production of white blood cells. D. The different leukemias all involve the development of cancer in the lymphatic system.

A. The different leukemias all involve unregulated proliferation of white blood cells.

A 60-year-old client with chronic myeloid leukemia (CML) will be treated in the home setting, and the nurse is preparing appropriate health education. Which topic should the nurse emphasize? A. The importance of adhering to the prescribed drug regimen B. The need to ensure that vaccinations are up to dateC. The importance of daily physical activityD. The need to avoid shellfish and raw foods

A. The importance of adhering to the prescribed drug regimen

Diagnostic testing of a client with a history of dyspepsia and abdominal pain has resulted in a diagnosis of gastric cancer. The nurse's anticipatory guidance should include what information? A. The possibility of surgery, chemotherapy and radiotherapyB. The possibility of needing a short-term or long-term colostomyC. The benefits of weight loss and exercise as tolerated during recovery D. The good prognosis for clients who are treated for gastric cancer

A. The possibility of surgery, chemotherapy and radiotherapy

The home health nurse is performing a home visit for an oncology client discharged three days ago after completing chemotherapy treatment for non-Hodgkin lymphoma. The nurse's priority assessment should include examination for the signs and symptoms of which complication? A. Tumor lysis syndrome (TLS)B. Syndrome of inappropriate antidiuretic hormone (SIADH) C. Disseminated intravascular coagulation (DIC)D. Hypercalcemia

A. Tumor lysis syndrome (TLS)

A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A. Two to three soft bowel movements dailyB. Significant increase in appetite and food intake C. Absence of nausea and vomitingD. Absence of blood or mucus in stool

A. Two to three soft bowel movements daily

A male client who is being treated in the hospital for a spinal cord injury (SCI) is advocating for the removal of the urinary catheter, stating that they want to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? A. Urinary catheter use often leads to urinary tract infections (UTIs). B. Urinary function is permanently lost following an SCI.C. Urinary catheters should not remain in place for more than 7 days. D. Overuse of urinary catheters can exacerbate nerve damage.

A. Urinary catheter use often leads to urinary tract infections (UTIs).

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply. A. Young ageB. Frequent travelC. African American race D. Male genderE. Alcohol or drug use

A. Young age D. Male genderE. Alcohol or drug use

The nurse's review of a client's most recent laboratory results indicates a bilirubin level of 3.0 mg/dL (51 mmol/L). The nurse assesses the client for: A. jaundice.B. bleeding.C. malnutrition. D. hypokalemia.

A. jaundice.

The nurse is admitting a client whose medication regimen includes regular injections of vitamin B12. The nurse should question the client about a history of: A. total gastrectomy.B. bariatric surgery.C. diverticulitis.D. gastroesophageal reflux disease (GERD)

A. total gastrectomy.

14. While on spring break, a 22-year-old client was taken to the hospital for heat stroke and alcohol poisoning. The client is worried and states that a biopsy was taken and showed "some kind of benign condition." Which response by the nurse would be best? A. "I understand that you are worried. Benign conditions are noncancerous, but let's look at your chart to see your results."B. "You have every right to be upset; a benign condition means you may have cancerous cells. Let me call your health care provider to talk to you." C. "Are you sure a biopsy was done? Your admitting diagnosis would not prompt that kind of procedure."D. "Do not worry; if something was wrong, your primary health care provider would have told you and started treatment."

ANS: A

A child presents with congenital adrenal hyperplasia and is in adrenal crisis. Out of the following orders, which should the nurse complete first? Administer IV hydrocortisone Administer IV fluids and monitor I and O Prepare for intubation and administer oxygen Correct electrolyte imbalances with oral supplements

Administer IV hydrocortisone

A nurse is teaching a group of middle-aged clients about peptic ulcers. When discussing risk factors for peptic ulcers, the nurse should mention: A sedentary lifestyle Hemorrhoids and smoking Acute renal failure Alcohol use disorder and smoking

Alcohol use disorder and smoking

A nurse educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. What is an important education topic regarding the effects of medications in a patient with a liver disorder? Altered metabolism of medications Need for increased drug dosages Need for more frequently divided dosages Medications becoming completely ineffective

Altered metabolism of medications

In a patient with lymphedema, the nurse will teach the patient to (select all that apply): Avoid venipuncture and BP in the affected limb. Avoid restrictive clothing on the affected limb. Watch for cellulitis and seek care early if infection is suspected in the limb. Consider wearing compression sleeves when recommended by PT (such as when flying)

Avoid venipuncture and BP in the affected limb. Avoid restrictive clothing on the affected limb. Watch for cellulitis and seek care early if infection is suspected in the limb. Consider wearing compression sleeves when recommended by PT (such as when flying)

A nurse is caring for a client who has just had a rigid fixation of a mandibular fracture. When planning the discharge teaching for this client, what would the nurse be sure to include? Increasing calcium intake to promote bone healing Avoiding chewing food for the specified number of weeks after surgery Techniques for managing parenteral nutrition in the home setting Techniques for managing a gastrostomy

Avoiding chewing food for the specified number of weeks after surgery

The nurse is teaching a CPR course for a group of nursing students. Which responses indicate an understanding of the content provided regarding the AED? Select all that apply. A) "When considering the use of the AED, the child must weigh at least 30 lb (13.6 kg)." B) "An AED must only be employed if the collapse is witnessed." C) "To use the device the child must be at least 1 year of age." D) "The AED can be used only if the victim demonstrates no heart rate." E) "The AED is safe for use prehospital."

B) "An AED must only be employed if the collapse is witnessed." C) "To use the device the child must be at least 1 year of age." D) "The AED can be used only if the victim demonstrates no heart rate." E) "The AED is safe for use prehospital."

Two nurses are driving to work and have just come upon the scene of a motor vehicle accident (MVA) involving a child being hit by a car. The nurses decide to stop and find that only the child was injured. One of the nurses begins providing care. What is the first question the other nurse should ask the witnesses of the accident? A) "Can I get your name and numbers in case someone needs to contact you later?" B) "How did the accident happen?" C) "Do you know if the children have any health history I should know about?" D) "How long ago did someone activate the EMS?"

B) "How did the accident happen?"

After teaching the parents of a daughter with central precocious puberty about medication therapy, which statement by the parents indicates successful teaching? A) "She needs to use the nasal spray once every day." B) "She will start puberty again when the medication stops." C) "This medication will slow down the changes but not reverse them." D) "Once therapy is done, she'll need surgery."

B) "She will start puberty again when the medication stops."

A 5-year-old child with type 1 diabetes is brought to the clinic by his mother for a follow-up visit after having his hemoglobin A1C level drawn. Which result would indicate to the nurse that the child is achieving long-term glucose control? A) 9.0% B) 8.2% C) 7.3% D) 6.9%

B) 8.2%

The nurse is providing care to a child who is intubated, and the child's condition is deteriorating. What would the nurse do first? A) Check if the tracheal tube is obstructed B) Assess for displacement of the tracheal tube C) Look for signs of a possible pneumothorax D) Check the equipment for malfunction

B) Assess for displacement of the tracheal tube

The nurse is caring for a 7-year-old boy experiencing respiratory distress who is scheduled to have a chest radiograph. What would be most important for the nurse to include in the child's plan of care? A) Administering a sedative to help calm the child B) Assisting the child to lie still during the chest radiograph C) Accompanying the child to continue observation D) Informing the child that he might hear a loud banging noise

B) Assisting the child to lie still during the chest radiograph

What would lead the nurse to suspect that a 5-year-old child is experiencing supraventricular tachycardia? A) Heart rate 160 beats per minute B) Flattened P waves C) Normal QRS complex D) History of fever

B) Flattened P waves

A child with diabetes reports that he is feeling a little shaky. Further assessment reveals that the child is coherent but with some slight tremors and sweating. A fingerstick blood glucose level is 70 mg/dL. What would the nurse do next? A) Administer a sliding-scale dose of insulin. B) Give 10 to 15 g of a simple carbohydrate. C) Offer a complex carbohydrate snack. D) Administer glucagon intramuscularly.

B) Give 10 to 15 g of a simple carbohydrate.

A client diagnosed with acute myeloid leukemia has just been admitted to the oncology unit. When planning care, which potential complication should the nurse address first? A) Pancreatitis B) Hemorrhage C) Arteritis D) Liver dysfunction

B) Hemorrhage

A group of nursing students are reviewing the components of the endocrine system. The students demonstrate understanding of the review when they identify what as the primary function of this system? A) Regulation of water balance B) Hormonal secretion C) Cellular metabolism D) Growth stimulation

B) Hormonal secretion

The nurse is reviewing the laboratory test results of a child with Addison disease. What would the nurse expect to find? A) Hypernatremia B) Hyperkalemia C) Hyperglycemia D) Hypercalcemia

B) Hyperkalemia

The nurse is caring for an 8-year-old girl with hyperpituitarism. What ordered treatment will the nurse expect to perform? A) Give desmopressin acetate intranasally B) Inject octreotide acetate C) Give 1 mg/kg/day of methimazole D) Administer glipizide orally

B) Inject octreotide acetate

A child is diagnosed with hyperthyroidism. Which agent would the nurse expect the healthcare provider to prescribe? A) Mineralocorticoid B) Methimazole C) Levothyroxine D) Dexamethasone

B) Methimazole

A 9-year-old girl who has fallen from a second-story window is brought to the emergency department. Which assessment would be the priority? A) Evaluating pupils for equality and reactivity B) Monitoring oxygen saturation levels C) Asking the child if she knows where she is D) Using the appropriate pain assessment scale

B) Monitoring oxygen saturation levels

Understanding the normal values on a CBC with differential, and knowing the expectedalterations in different disease states and with cancer treatments will help the nurse: A) Provide a medical diagnosis to the patient B) Plan priorities for patient care and education C) Understand the patient's kidney function D) Gauge the effectiveness of anti-emetic medications

B) Plan priorities for patient care and education

A nurse has just transferred from an adult medical-surgical unit to a pediatric unit. When reviewing CPR skills, what it is important for the nurse to realize? A) The pediatric chain of survival and the adult chain of survival are the same. B) Prevention of cardiac arrest and injuries is the first step in the chain of survival for children. C) Integrated post-cardiac arrest care is not part of the chain of survival for children. D) Early CPR should occur before any steps of the chain of survival are considered.

B) Prevention of cardiac arrest and injuries is the first step in the chain of survival for children.

A child is brought to the emergency department with a suspected poisoning. What treatment would the nurse least likely expect to be used? A) Gastric lavage B) Syrup of ipecac C) Activated charcoal D) Whole bowel irrigation

B) Syrup of ipecac

The nurse is caring for an 8-year-old girl with an endocrine disorder involving the posterior pituitary gland. What care would the nurse expect to implement? A) Instructing the parents to report adverse reactions to the growth hormone treatment B) Teaching the parents how to administer the desmopressin acetate C) Informing the parents that treatment stops when puberty begins D) Educating the parents to report signs of acute adrenal crisis

B) Teaching the parents how to administer the desmopressin acetate

The nurse is providing care to a 4-year-old boy with a broken arm and an infected laceration from a fall. The nurse notes a significant elevation in the child's heart rate. Which intervention would be least appropriate? A) Administering antipyretics as ordered for fever B) Using a defibrillator to reduce the heart rate C) Administering analgesics to reduce pain D) Allowing the parents to comfort the child

B) Using a defibrillator to reduce the heart rate

A client is admitted to the hospital with new neurological changes and a beefy, red tongue. After the provider diagnoses a vitamin deficiency, the nurse should prepare to administer which of the following medications? A) Folic acid B) Vitamin B12 C) Lactulose D) Magnesium sulfate

B) Vitamin B12

There are four kinds of leukemia which are categorized based on: A) How aggressive they are AND whether they mostly affect adults or children B) What cell line is involved AND whether they are slow or fast-growing C) Whether they are managed inpatient or outpatient AND whether they are curable or not D) What cell line is involved AND whether they are curable or not

B) What cell line is involved AND whether they are slow or fast-growing

The nurse is collecting data from the caregivers of a child admitted with seizures. Which statement indicates the child most likely had an absence seizure? A. "His arms had jerking movements in his legs and face." B. "He was just staring into space and was totally unaware." C. "He kept smacking his lips and rubbing his hands." D. "He usually is very coordinated, but he couldn't even walk without falling."

B. "He was just staring into space and was totally unaware."

A client with gallstones has been prescribed ursodeoxycholic acid (UDCA). The nurse understands that additional teaching is needed regarding this medication when the client states: A. "It is important that I see my health care provider for scheduled follow-up appointments while taking this medication."B. "I will take this medication for 2 weeks and then gradually stop taking it." C. "If I lose weight, the dose of the medication may need to be changed." D. "This medication will help dissolve small gallstones made of cholesterol."

B. "I will take this medication for 2 weeks and then gradually stop taking it."

A client with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the client's cast care? A. "Cover the cast with a blanket until the cast dries."B. "Keep your right leg elevated above heart level."C. "Use a clean object to scratch itches inside the cast."D. "A foul smell from the cast is normal after the first few days."

B. "Keep your right leg elevated above heart level."

A client with chronic pancreatitis had a pancreaticojejunostomy created 3 months ago for relief of pain and to restore drainage of pancreatic secretions. The client has come to the office for a routine postsurgical appointment. The client is frustrated that the pain has not decreased. What is the most appropriate initial response by the nurse? A. "The majority of clients who have a pancreaticojejunostomy have their normal digestion restored but do not achieve pain relief."B. "Pain relief occurs by 6 months in most clients who undergo this procedure, but some people experience a recurrence of their pain." C. "Your health care provider will likely want to discuss the removal of your gallbladder to achieve pain relief."D. "You are probably not appropriately taking the medications for your pancreatitis and pain, so we will need to discuss your medication regimen in detail."

B. "Pain relief occurs by 6 months in most clients who undergo this procedure, but some people experience a recurrence of their pain."

A rehabilitation nurse caring for a client who has had a stroke is approached by the client's family and asked why the client has to do so much for self-care while obviously struggling to do so. What would be the nurse's best answer? A. "We are trying to help the client be as useful as possible."B. "The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible."C. "We aren't here to care for the client the way the hospital staff did; we are here to help the client get better and return home."D. "Rehabilitation means helping clients do exactly what they did before their stroke."

B. "The focus on care in a rehabilitation facility is to help the client to resume as much self-care as possible."

A child is brought to the emergency department after sustaining a concussion. The child is to be discharged home with his parents. What would the nurse include in the child's discharge instructions?A. "Expect his headache to get worse initially and then disappear." B. "Wake him every 2 hours to check his movement and responses." C. "Call your medical provider if he vomits more than five times." D. "Any watery fluid draining from his ears is normal."

B. "Wake him every 2 hours to check his movement and responses."

A client with a documented history of glucose-6-phosphate dehydrogenase deficiency has presented to the emergency department with signs and symptoms including pallor, jaundice, and malaise. Which of the nurse's assessment questions relates most directly to this client's hematologic disorder? A. "When did you last have a blood transfusion?" B. "What medications have you taken recently?" C. "Have you been under significant stress lately?" "Have you suffered any recent injuries?"

B. "What medications have you taken recently?"

28. A client has been admitted to the critical care unit with a diagnosis of toxic hepatitis. When planning the client's care, the nurse should be aware of what potential clinical course of this health problem? Place the following events in the correct sequence.1. Fever rises. 2. Hematemesis.3. Clotting abnormalities. 4. Vascular collapse.5. Coma. A. 1, 2, 5, 4, 3 B. 1, 2, 3, 4, 5 C. 2, 3, 1, 4, 5 D. 3, 1, 2, 5, 4

B. 1, 2, 3, 4, 5

A client returns to the unit after a neck dissection. The surgeon placed a Jackson-Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours the nurse would notify the health care provider immediately for what finding? A. Presence of small blood clots in the drainageB. 60 mL of milky or cloudy drainageC. Spots of drainage on the dressings surrounding the drain D. 120 mL of serosanguinous drainage

B. 60 mL of milky or cloudy drainage

A client with acute kidney injury has decreased erythropoietin production. Upon analysis of the client's complete blood count, the nurse will expect which of the following results? A. An increased hemoglobin and decreased hematocritB. A decreased hemoglobin and hematocritC. A decreased mean corpuscular volume (MCV) and red cell distribution width (RDW)D. An increased mean corpuscular volume (MCV) and red cell distribution width (RDW)

B. A decreased hemoglobin and hematocrit

A nurse is conducting health screening with a diverse group of clients. Which client likely has the most risk factors for developing hemorrhoids? A. A 45-year-old teacher who stands for 6 hours per dayB. A pregnant woman at 28 weeks' gestationC. A 37-year-old construction worker who does heavy lifting D. A 60-year-old professional who is under stress

B. A pregnant woman at 28 weeks' gestation

A client with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this client's treatment, the nurse should anticipate what intervention? A. Administration of immune globulinsB. A regimen of antiviral medicationsC. Rest and watchful waitingD. Administration of fresh-frozen plasma (FFP)

B. A regimen of antiviral medications

A nurse's assessment of a client's knee reveals edema, tenderness, muscle spasms, and ecchymosis. The client states that 2 days ago the client ran in a long-distance race and now it "really hurts to stand up." The nurse should plan care based on the belief that the client has experienced what injury? A. A first-degree strainB. A second-degree strain C. A first-degree sprainD. A second-degree sprain

B. A second-degree strain

A client has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the client may have developed liver metastases? A. Persistent fever and cognitive changesB. Abdominal pain and hepatomegalyC. Peripheral edema unresponsive to diuresis D. Spontaneous bleeding and jaundice

B. Abdominal pain and hepatomegaly

What health promotion teaching should the nurse prioritize to prevent drug-induced hepatitis? A. Finish all prescribed courses of antibiotics, regardless of symptom resolution. B. Adhere to dosing recommendations of over-the-counter analgesics.C. Ensure that expired medications are disposed of safely.D. Ensure that pharmacists regularly review drug regimens for potential interactions.

B. Adhere to dosing recommendations of over-the-counter analgesics.

A client who is scheduled for an open prostatectomy is concerned about the potential effects of the surgery on sexual function. What aspect of prostate surgery should inform the nurse's response? A. Erectile dysfunction is common after prostatectomy as a result of hormonal changes. B. All prostatectomies carry a risk of nerve damage and consequent erectile dysfunction.C. Erectile dysfunction after prostatectomy is expected, but normally resolves within several months. D. Modern surgical techniques have eliminated the risk of erectile dysfunction following prostatectomy.

B. All prostatectomies carry a risk of nerve damage and consequent erectile dysfunction.

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? A. Generalized painB. Alteration in level of consciousness (LOC) C. Tonic-clonic seizuresD. Shortness of breath

B. Alteration in level of consciousness (LOC)

A group of nurses are learning about the high incidence and prevalence of anemia among different populations. Which individual is most likely to have anemia? A. A 50-year-old black woman who is going through menopauseB. An 81-year-old woman who has chronic heart failureC. A 48-year-old man who travels extensively and has a high-stress job D. A 13-year-old girl who has just experienced menarche

B. An 81-year-old woman who has chronic heart failure

A nurse is reviewing the trend of a client's scores on the Glasgow Coma Scale (GCS). This provides what potential information to the nurse about the client's status? A. The client's level of knowledge about preceding eventsB. An assessment of the client's current level of consciousnessC. An assessment of the client's lowest verbal and physical response to stimuli D. An in-depth and real-time neurological assessment of the client's condition

B. An assessment of the client's current level of consciousness

Which of the following clients should the nurse recognize as being at the highest risk for the development of osteomyelitis? A. A middle-aged adult who takes ibuprofen daily for rheumatoid arthritis B. An older adult client with an infected pressure ulcer in the sacral area C. A 17-year-old football player who had orthopedic surgery 6 weeks prior D. An infant diagnosed with jaundice

B. An older adult client with an infected pressure ulcer in the sacral area

The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal sign(s) of brain death? Select all that apply. A. Absence of pain responseB. ApneaC. ComaD. Absence of brain stem reflexes E. Absence of deep tendon reflexes

B. ApneaC. ComaD. Absence of brain stem reflexes

A client has had a laparoscopic cholecystectomy. The client is now reporting right shoulder pain. What should the nurse suggest to relieve the pain? A. Aspirin every 4 to 6 hours as prescribedB. Application of heat 15 to 20 minutes each hourC. Application of an ice pack for no more than 15 minutes D. Application of liniment rub to affected area

B. Application of heat 15 to 20 minutes each hour

A client has suffered a muscle strain and is reporting pain at 6 on a 10-point scale. The nurse should recommend what action? A. Taking an opioid analgesic as prescribedB. Applying a cold pack to the injured siteC. Performing passive ROM exercisesD. Applying a heating pad to the affected muscle

B. Applying a cold pack to the injured site

A nurse in a busy emergency department provides care for many clients who present with contusions, strains, or sprains. What are treatment modalities that are common to all of these musculoskeletal injuries? Select all that apply. A. MassageB. Applying iceC. Compression dressingsD. Resting the affected extremity E. CorticosteroidsF. Elevating the injured limb

B. Applying iceC. Compression dressingsD. Resting the affected extremity F. Elevating the injured limb

A group of nursing students are reviewing cerebral vascular disorders and risk factors in children. The students demonstrate understanding of the material when they identify which as a risk factor for hemorrhagic stroke? A. Congenital heart defect B. Arteriovenous malformations (AVMs) C. Sickle cell disease D. Meningitis

B. Arteriovenous malformations (AVMs)

What information is most correct regarding the nervous system of the child? A. The child's nervous system is fully developed at birth. B. As the child grows, the gross and fine motor skills increase from head to toe. C. The child has underdeveloped fine motor skills and well-developed gross motor skills. D. The child has underdeveloped gross motor skills and well-developed fine motor skills.

B. As the child grows, the gross and fine motor skills increase from head to toe.

A client has recently been admitted to the orthopedic unit following total hip arthroplasty. The nurse assesses that the indwelling urinary catheter was removed one hour ago in the post-anesthesia care unit and that the client has not yet voided. Which action should the nurse take? A. Inform the primary provider promptly.B. Ask if the client needs to void.C. Perform intermittent catheterization.D. Obtain an order to reinsert the indwelling urinary catheter.

B. Ask if the client needs to void.

The nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. What are these nursing actions attempting to prevent? A. Gastric ulcersB. AspirationC. Abdominal distention D. Diarrhea

B. Aspiration

A client with a new diagnosis of leukemia is about to start treatment and expresses fear and anxiety with the prognosis. Which action is the nurse's most appropriate? A. Communicate to the health care provider the need to provide more information to the client and family. B. Assess how much information is desired from the client in terms of illness, treatment, and complications.C. Offer to call pastoral services and review hospice and/or palliative care so the client can have a quiet, dignified death.D. Encourage the client to call their family and discuss immediate role restructuring in both their family and professional life.

B. Assess how much information is desired from the client in terms of illness, treatment, and complications.

An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform? A. Encourage the client to take stool softener daily. B. Assess the client's food and fluid intake.C. Assess the client's surgical history.D. Encourage the client to take fiber supplements.

B. Assess the client's food and fluid intake.

A nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this client's plan of care? A. Measurement of abdominal girth and body weight B. Assessment for variceal bleedingC. Assessment for signs and symptoms of jaundice D. Monitoring of results of liver function testing

B. Assessment for variceal bleeding

A nurse is taking care of a client with swallowing difficulties after a stroke. What are some interventions the nurse can accomplish to prevent the client from aspirating while eating? Select all that apply. A. Encourage the client to increase his/her intake of water and juice.B. Assist the client out of bed and into the chair for meals.C. Instruct the client to tuck his/her chin towards their chest when swallowing. D. Request a swallowing assessment by a speech therapist before the client's dischargeE. Recommend the insertion of a percutaneous endoscopic gastrostomy (PEG) tube.

B. Assist the client out of bed and into the chair for meals.C. Instruct the client to tuck his/her chin towards their chest when swallowing.

A client who is undergoing consolidation therapy for the treatment of leukemia has been experiencing debilitating fatigue. How can the nurse best meet this client's needs for physical activity? A. Teach the client about the risks of immobility and the benefits of exercise. B. Assist the client to a chair during awake times, as tolerated.C. Collaborate with the physical therapist to arrange for stair exercises.D. Teach the client to perform deep breathing and coughing exercises.

B. Assist the client to a chair during awake times, as tolerated.

The nurse is caring for a client who is known to be at risk for cardiogenic embolic strokes. What arrhythmia does this client most likely have? A. Ventricular tachycardia B. Atrial fibrillation C. Supraventricular tachycardia D. Bundle branch block

B. Atrial fibrillation

A client's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next? A. Withdraw the NG tube 2 inches (5 cm) and reattempt aspiration.B. Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.C. Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers.D. Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider.

B. Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating.

An older adult client has fallen in the home and is brought to the emergency department by ambulance with a suspected fractured hip. X-rays confirm a fracture of the left femoral neck. When planning assessments during the client's presurgical care, the nurse should be aware of the client's heightened risk of what complication? A. OsteomyelitisB. Avascular necrosis C. Phantom painD. Septicemia

B. Avascular necrosis

A nurse is providing discharge education to a client who has recently been diagnosed with a bleeding disorder. Which topic should the nurse prioritize when teaching this client? A. Avoiding buses, subways, and other crowded, public sites B. Avoiding activities that carry a risk for injuryC. Keeping immunizations currentD. Avoiding foods high in vitamin K

B. Avoiding activities that carry a risk for injury

The nurse is providing care for a client who has recently been diagnosed with chronic gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease? A. Performing 15 minutes of physical activity at least three times per weekB. Avoiding taking aspirin to treat pain or feverC. Taking multivitamins as prescribed and eating organic foods whenever possible D. Maintaining a healthy body weight

B. Avoiding taking aspirin to treat pain or fever

A client recently had a stroke. Now the client has spasms in his/her hands, which is preventing a favorite hobby of knitting. The client is looking for a permanent solution to this problem. Which therapies would the nurse recommend? A. Botulinum toxin type A and heat B. Baclofen and stretchingC. Amitriptyline and splintingD. Corticosteroids and acupuncture

B. Baclofen and stretching

A health care provider has explained to the client that they have an inflammation of the Cowper glands. Where are the Cowper glands located? A. Within the epididymis B. Below the prostate, within the posterior aspect of the urethra C. On the inner epithelium lining the scrotum, lateral to the testes D. Medial to the vas deferens

B. Below the prostate, within the posterior aspect of the urethra

The nurse is caring for a client who has just returned from the ERCP removal of gallstones. The nurse should monitor the client for signs of what complications? A. Pain and peritonitisB. Bleeding and perforationC. Acidosis and hypoglycemiaD. Gangrene of the gallbladder and hyperglycemia

B. Bleeding and perforation

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client? A. Respiratory distress and projectile vomiting B. Bradycardia and hypertensionC. Tachycardia and agitationD. Third-spacing and hyperthermia

B. Bradycardia and hypertension

A client with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the client's prioritization for receiving a donor liver be determined? A. By considering the client's age and prognosisB. By objectively determining the client's medical needC. By objectively assessing the client's willingness to adhere to post-transplantation careD. By systematically ruling out alternative treatment options

B. By objectively determining the client's medical need

To detect complications as early as possible in a child with meningitis who's receiving IV fluids, monitoring for which condition should be the nurse;s priority? A. Renal failure B. Cerebral edema C. Left- sided heart failure D. Cardiogenic shock

B. Cerebral edema

A 35-year-old client is being admitted to the intensive care unit (ICU) for increased observation with a brain injury and is awake, alert, and disoriented to time and situation. The client sustained a fall from a roof, and x-rays are pending. The nurse would anticipate which supportive priority measures for this client? A. Seizure prophylaxis and prevention B. Cervical and spinal immobilizationC. Fluid and electrolyte maintenance,D. Intubation and mechanical ventilation

B. Cervical and spinal immobilization

A nurse is aware of the high incidence of catheter-related bloodstream infections in clients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections? A. Use clean technique and wear a mask during dressing changes.B. Change the dressing no more than weekly.C. Apply antibiotic ointment around the site with each dressing change.D. Irrigate the insertion site with sterile water during each dressing change.

B. Change the dressing no more than weekly.

A nurse is caring for a client who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoses on the client's sacral area and petechiae on the forearms. In addition to informing the client's primary care provider, the nurse should perform what action? A. Initiate measures to prevent venous thromboembolism (VTE). B. Check the client's most recent platelet level.C. Place the client on protective isolation.D. Ambulate the client to promote circulatory function.

B. Check the client's most recent platelet level.

A client presents to the emergency department with paraphimosis. The health care provider is able to compress the glans and manually reduce the edema. Once the inflammation and edema subside, the nurse should prepare the client for what intervention? A. Needle aspiration of the corpus cavernosum B. CircumcisionC. Abstinence from sexual activity for 6 weeks D. Administration of vardenafil

B. Circumcision

A nurse is caring for an older adult client who is preparing for discharge following recovery from a total hip replacement. What outcome must be met prior to discharge? A. Client is able to perform ADLs independently.B. Client is able to perform transfers safely.C. Client is able to weight-bear equally on both legs.D. Client is able to demonstrate full ROM of the affected hip.

B. Client is able to perform transfers safely.

A client has a diagnosis of multiple myeloma and the nurse is preparing health education in preparation for discharge from the hospital. Which action should the nurse promote? A. Daily performance of weight-bearing exercise to prevent muscle atrophy B. Close monitoring of urine output and kidney function C. Daily administration of warfarin, as prescribedD. Safe use of supplementary oxygen in the home setting

B. Close monitoring of urine output and kidney function

A nurse is creating a care plan for a client who is receiving parenteral nutrition. The client's care plan should include nursing action(s) relevant to what potential complications? Select all that apply. A. Dumping syndromeB. Clotted or displaced catheter C. PneumothoraxD. Hyperglycemia

B. Clotted or displaced catheter C. PneumothoraxD. Hyperglycemia E. Line sepsis

Radiographs of a client's upper arm shows three fragments of the humeral bone. This diagnostic result suggests what type of fracture? A. OpenB. Comminuted C. Intra-articular D. Greenstick

B. Comminuted

A nurse admits a client who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. The orthopedic nurse should plan to care for what type of fracture? A. Compression B. Compound C. ImpactedD. Transverse

B. Compound

A client has been admitted to the hospital with a spontaneous vertebral fracture related to osteoporosis. Which of the following nursing diagnoses must be addressed in the plan of care? A. Risk for aspiration related to vertebral fractureB. Constipation related to vertebral fractureC. Impaired swallowing related to vertebral fractureD. Decreased cardiac output related to vertebral fracture

B. Constipation related to vertebral fracture

A night nurse is reviewing the next day's medication administration record (MAR) of a hospital client who has hemophilia. The nurse notes that the MAR specifies both oral and subcutaneous options for the administration of a PRN antiemetic. What is the nurse's best action? A. Ensure that the day nurse knows not to give the antiemetic.B. Contact the prescriber to have the subcutaneous option discontinued. C. Reassess the client's need for antiemetics.D. Remove the subcutaneous route from the client's MAR.

B. Contact the prescriber to have the subcutaneous option discontinued.

A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response? A. Administer a Fleet enema as prescribed and remain with the client.B. Contact the primary care provider promptly and report these signs of perforation.C. Position the client supine and insert an NG tube.D. Page the primary provider and report that the client may be obstructed.

B. Contact the primary care provider promptly and report these signs of perforation.

A client newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the client asks the nurse to explain the condition. The nurse explains to this client that this condition occurs due to which factor? A. An attack on the platelets by antibodiesB. Decreased production of plateletsC. Impaired communication between plateletsD. An autoimmune process causing platelet malfunction

B. Decreased production of platelets

A client has returned to the unit after undergoing limb-sparing surgery to remove a metastatic bone tumor. The nurse providing postoperative care in the days following surgery assesses for what complication from surgery? A. Deficient fluid volume B. Delayed wound healing C. HypocalcemiaD. Pathologic fractures

B. Delayed wound healing

23. When discussing with a client factors that distinguish malignant cells from benign cells of the same tissue type, which characteristic should the nurse mention? A. Slow rate of mitosis of cancer cellsB. Different proteins in the cell membrane C. Differing size of the cellsD. Different molecular structure in the cells

B. Different proteins in the cell membrane

The nurse is assessing a client who had an ileostomy created three days ago for the treatment of irritable bowel disease. The nurse observes that the client's stoma is bright red and there are scant amounts of blood on the stoma. What is the nurse's best action? A. Contact the care provider to have the client's hemoglobin and hematocrit measured.B. Document these expected assessment findings.C. Apply barrier ointment to the stoma as prescribed. D. Cleanse the stoma with alcohol or chlorhexidine.

B. Document these expected assessment findings.

A client has been prescribed cimetidine for the treatment of peptic ulcer disease. When providing relevant health education for this client, the nurse should ensure the client is aware of what potential outcome? A. Bowel incontinenceB. Drug-drug interactions C. Abdominal painD. Heat intolerance

B. Drug-drug interactions

When caring for a client who has had a stroke, a priority is reduction of ICP. What client position is most consistent with this goal? A. Head turned slightly to the right sideB. Elevation of the head of the bedC. Position changes every 15 minutes while awake D. Extension of the neck

B. Elevation of the head of the bed

A nurse is preparing health education for a client who has received a diagnosis of myelodysplastic syndrome (MDS). Which of the following topics should the nurse prioritize? A. Techniques for energy conservation and activity managementB. Emergency management of bleeding episodesC. Technique for the administration of bronchodilators by metered-dose inhaler D. Techniques for self-palpation of the lymph nodes

B. Emergency management of bleeding episodes

A client with sickle cell disease is taking narcotic analgesics for pain control. Which intervention by the nurse would decrease the risk for narcotic substance abuse? A. Encourage the client to rely on complementary and alternative therapies.B. Encourage the client to seek care from a single provider for pain relief.C. Teach the client to accept chronic pain as an inevitable aspect of the disease. D. Limit the reporting of emergency department visits to the primary health care provider.

B. Encourage the client to seek care from a single provider for pain relief.

A client with a simple arm fracture is receiving discharge education from the nurse. What would the nurse instruct the client to do? A. Elevate the affected extremity to shoulder level when at rest. B. Engage in exercises that strengthen the unaffected muscles.C. Apply topical anesthetics to accessible skin surfaces as needed. D. Avoid using analgesics so that further damage is not masked.

B. Engage in exercises that strengthen the unaffected muscles.

A nurse is providing care for a client whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis? A. Encourage the client to conduct online research into colostomies.B. Engage the client in dialogue about the implications of having the colostomy. C. Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem.D. Emphasize the fact that the colostomy is temporary measure and is not permanent.

B. Engage the client in dialogue about the implications of having the colostomy.

A nurse is caring for a client who just has been diagnosed with a peptic ulcer. When teaching the client about his new diagnosis, how should the nurse best describe it? A. Inflammation of the lining of the stomachB. Erosion of the lining of the stomach or intestine C. Bleeding from the mucosa in the stomachD. Viral invasion of the stomach wall

B. Erosion of the lining of the stomach or intestine

A client's electronic health record notes that the client has previously undergone treatment for secondary polycythemia. The nurse should assess for which factor? A. Recent blood donationB. Evidence of lung diseaseC. A history of venous thromboembolism D. Impaired renal function

B. Evidence of lung disease

The nurse is providing care for a client who has had a below-the-knee amputation. The nurse enters the client's room and finds the client resting in bed with the residual limb supported on a pillow. What is the nurse's most appropriate action? A. Inform the surgeon of this finding.B. Explain the risks of flexion contracture to the client.C. Transfer the client to a sitting position.D. Encourage the client to perform active ROM exercises with the residual limb.

B. Explain the risks of flexion contracture to the client.

A client has just begun been receiving skeletal traction and the nurse is aware that muscles in the client's affected limb are spastic. How does this change in muscle tone affect the client's traction prescription? A. Traction must temporarily be aligned in a slightly different direction. B. Extra weight is needed initially to keep the limb in proper alignment. C. A lighter weight should be initially used.D. Weight will temporarily alternate between heavier and lighter weights.

B. Extra weight is needed initially to keep the limb in proper alignment.

The nurse is caring for a client who is undergoing diagnostic testing for suspected malabsorption. When taking this client's health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis? A. Recurrent constipation coupled with weight lossB. Foul-smelling diarrhea that contains fatC. Fever accompanied by a rigid, tender abdomenD. Bloody bowel movements accompanied by fecal incontinence

B. Foul-smelling diarrhea that contains fat

A client with a diagnosis of colon cancer is 2 days' postoperative following bowel resection and anastomosis. The nurse has planned the client's care in the knowledge of potential complications. What assessment should the nurse prioritize? A. Close monitoring of temperatureB. Frequent abdominal auscultationC. Assessment of hemoglobin, hematocrit, and red blood cell levels D. Palpation of peripheral pulses and leg girth

B. Frequent abdominal auscultation

A client presents at a clinic reports heel pain that impairs walking ability. The client is subsequently diagnosed with plantar fasciitis. This client's plan of care should include what intervention? A. Wrapping the affected area in lamb's wool or gauze to relieve pressure B. Gently stretching the foot and the Achilles tendonC. Wearing open-toed shoes at all timesD. Applying topical analgesic ointment to plantar surface each morning

B. Gently stretching the foot and the Achilles tendon

A client has recently begun mobilizing during the recovery from an ischemic stroke. To protect the client's safety during mobilization, the nurse should perform what action? A. Support the client's full body weight with a waist belt during ambulation. B. Have a colleague follow the client closely with a wheelchair.C. Avoid mobilizing the client in the early morning or late evening.D. Ensure that the client's family members do not participate in mobilization.

B. Have a colleague follow the client closely with a wheelchair.

The nurse knows that children have larger heads in relation to the body and a higher center of gravity. When developing a teaching plan for parents, the nurse includes information about an increased risk for which problem?A. Febrile seizures B. Head traumaC. Caput succedaneumD. Posterior plagiocephaly

B. Head trauma

A client diagnosed with acute myeloid leukemia has just been admitted to the oncology unit. When writing this client's care plan, which potential complication should the nurse address? A. Pancreatitis B. HemorrhageC. ArteritisD. Liver dysfunction

B. Hemorrhage

The orthopedic nurse should assess for signs and symptoms of Volkmann contracture if a client has fractured which of the following bones? A. FemurB. Humerus C. Radial head D. Clavicle

B. Humerus

A client has been diagnosed with acute pancreatitis. The nurse is addressing the diagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention is most likely to be ordered for this client? A. Oral oxycodoneB. IV hydromorphone C. IM meperidineD. Oral naproxen

B. IV hydromorphone

A nurse is preparing a plan of care for a client with pancreatic cysts that have necessitated drainage through the abdominal wall. What nursing diagnosis should the nurse prioritize? A. Disturbed body imageB. Impaired skin integrityC. NauseaD. Risk for deficient fluid volume

B. Impaired skin integrity

The nurse is admitting an oncology client to the unit prior to surgery. The nurse reads in the electronic health record that the client has just finished radiation therapy. With knowledge of the consequent health risks, the nurse should prioritize assessments related to what health problem? A. Cognitive deficitsB. Impaired wound healing C. Cardiac tamponadeD. Tumor lysis syndrome

B. Impaired wound healing

A client is hospitalized because a large abdominal tumor was seen on the computed tomography scan. A biopsy is ordered, and the client wants to know if "this will cause a big scar." Which type of biopsy will this client likely experience? A. Excisional B. Incisional C. NeedleD. Fine needle

B. Incisional

An adult client has been diagnosed with diverticular disease after ongoing challenges with constipation. The client will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply. A. Anticholinergic medications B. Increased fiber intakeC. Enemas on alternating days D. Reduced fat intake E. Fluid reduction

B. Increased fiber intake D. Reduced fat intake

During a client's scheduled home visit, an older adult client has stated to the community health nurse that the client has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following? A. Regular application of an OTC antibiotic ointment B. Increased fluid and fiber intakeC. Daily use of OTC glycerin suppositoriesD. Use of an NSAID to reduce inflammation

B. Increased fluid and fiber intake

A client is undergoing diagnostic testing for chronic lymphocytic leukemia (CLL). Which assessment finding is certain to be present if the client has CLL? A. Increased numbers of blast cellsB. Increased lymphocyte levelsC. Intractable bone painD. Thrombocytopenia with no evidence of bleeding

B. Increased lymphocyte levels

A nurse is caring for a client who is receiving parenteral nutrition. When writing this client's plan of care, which of the following nursing diagnoses should be included? A. Risk for peripheral neurovascular dysfunction related to catheter placement B. Ineffective role performance related to parenteral nutritionC. Bowel incontinence related to parenteral nutritionD. Chronic pain related to catheter placement

B. Ineffective role performance related to parenteral nutrition

A nurse practitioner is assessing a client who has a fever, malaise, and a white blood cell count that is elevated. What principle should guide the nurse's management of the client's care? A. There is a need for the client to be assessed for lymphoma.B. Infection is the most likely cause of the client's change in health status. C. The client is exhibiting signs and symptoms of leukemia.D. The client should undergo diagnostic testing for multiple myeloma.

B. Infection is the most likely cause of the client's change in health status.

A nurse is assessing a client who has peptic ulcer disease. The client requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the client? A. Most affected clients acquired the infection during international travel.B. Infection typically occurs due to ingestion of contaminated food and water. C. Many people possess genetic factors causing a predisposition to H. pylori infection.D. The H. pylori microorganism is endemic in warm, moist climates.

B. Infection typically occurs due to ingestion of contaminated food and water.

A client has returned to the medical-surgical floor from the post-anesthesia care unit (PACU). Upon inspection, the nurse notes leakage around the suprapubic tube. Which action by the nurse is most appropriate? A. Cleanse the skin surrounding the suprapubic tube.B. Inform the urologist of this finding as it is abnormal.C. Remove the suprapubic tube and apply a wet to dry dressing. D. Administer antispasmodic drugs as prescribed.

B. Inform the urologist of this finding as it is abnormal.

A nurse is initiating parenteral nutrition (PN) to a postoperative client who has developed complications. The nurse should initiate therapy by performing which of the following actions? A. Starting with a rapid infusion rate to meet the client's nutritional needs as quickly as possibleB. Initiating the infusion slowly and monitoring the client's fluid and glucose tolerance C. Changing the rate of administration every 2 hours based on serum electrolyte valuesD. Increasing the rate of infusion at mealtimes to mimic the circadian rhythm of the body

B. Initiating the infusion slowly and monitoring the client's fluid and glucose tolerance

A client has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention? A. Administration of antiemeticsB. Insertion of an NG tube for decompressionC. Infusion of hypotonic IV solutionD. Administration of proton pump inhibitors as prescribed

B. Insertion of an NG tube for decompression

A nurse is caring for a client who is being treated in the hospital for a spontaneous vertebral fracture related to osteoporosis. The nurse should address the nursing diagnosis of Acute Pain Related to Fracture by implementing what intervention? A. Maintenance of high Fowler positioning whenever possible B. Intermittent application of heat to the client's backC. Use of a pressure-reducing mattressD. Passive range of motion exercises

B. Intermittent application of heat to the client's back

A nurse is caring for a client with gallstones who has been prescribed ursodeoxycholic acid (UDCA). The client asks how this medicine is going to help his symptoms. The nurse should be aware of what aspect of this drug's pharmacodynamics? A. It inhibits the synthesis of bile.B. It inhibits the synthesis and secretion of cholesterol. C. It inhibits the secretion of bile.D. It inhibits the synthesis and secretion of amylase.

B. It inhibits the synthesis and secretion of cholesterol.

A client with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform? A. Keep client NPO until the results of test are known.B. Keep client NPO until the client's gag reflex returns.C. Administer analgesia until post-procedure tenderness is relieved. D. Give the client a cold beverage to promote swallowing ability.

B. Keep client NPO until the client's gag reflex returns.

21. A client's most recent diagnostic imaging has revealed that lung cancer has metastasized to the bones and liver. What is the most likely mechanism by which the client's cancer cells spread? A. ApoptosisB. Lymphatic circulation C. InvasionD. Angiogenesis

B. Lymphatic circulation

A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? A. Prevent complications of immobility.B. Maintain and improve cerebral tissue perfusion. C. Relieve anxiety and pain.D. Relieve sensory deprivation.

B. Maintain and improve cerebral tissue perfusion.

A nurse is caring for a client who has suffered an unstable thoracolumbar fracture. What goal should the nurse prioritize during nursing care? A. Preventing skin breakdownB. Maintaining spinal alignmentC. Maximizing functionD. Preventing increased intracranial pressure

B. Maintaining spinal alignment

20. An oncology nurse educator is providing health education to a client who has been diagnosed with skin cancer. The client's wife has asked about the differences between normal cells and cancer cells. What characteristic of a cancer cell should the educator cite? A. Malignant cells possess greater mobility than normal body cells.B. Malignant cells contain proteins called tumor-associated antigens.C. Chromosomes contained in cancer cells are more durable and stable than those of normal cells. D. The nuclei of cancer cells are unusually large, but regularly shaped.

B. Malignant cells contain proteins called tumor-associated antigens.

A client with diabetes is attending a class on the prevention of associated diseases. What action should the nurse teach the client to reduce the risk of osteomyelitis? A. Increase calcium and vitamin intake.B. Monitor and control blood glucose levels.C. Exercise 3 to 4 times weekly for at least 30 minutes. D. Take corticosteroids as prescribed.

B. Monitor and control blood glucose levels.

8. A client newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what should the nurse describe? A. Pruritis (itching)B. Nausea and vomitingC. Altered glucose metabolism D. Confusion

B. Nausea and vomiting

Following a spinal cord injury, a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? A. Complete the pin site care to decrease risk of infection. B. Notify the neurosurgeon of the occurrence.C. Stabilize the head in a lateral position.D. Reattach the pin to prevent further head trauma.

B. Notify the neurosurgeon of the occurrence.

The nurse assesses a child's level of consciousness, noting that the child falls asleep unless he is stimulated. What is the child's level of consciousness?A. ConfusionB. Obtunded C. Stupor D. Coma

B. Obtunded

A nurse is caring for a client with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? A. Watery, blood-streaked diarrhea B. Orange and foamy urineC. Increased abdominal girthD. Decreased cognition

B. Orange and foamy urine

A client with diabetes has been diagnosed with osteomyelitis. The nurse observes that the client's right foot is pale and mottled, cool to touch, with a capillary refill of greater than 3 seconds. The nurse should suspect what type of osteomyelitis? A. Hematogenous osteomyelitisB. Osteomyelitis with vascular insufficiency C. Contiguous focus osteomyelitisD. Osteomyelitis with muscular deterioration

B. Osteomyelitis with vascular insufficiency

A 20-year-old client with no medical history arrives at a walk-in/urgent care clinic reporting swelling on the left side of the neck. On palpation, the lymph nodes on the neck are painless, firm but not hard. What is the next appropriate intervention for this client? A. Recommend immediate and urgent transfer to the nearest trauma center.B. Perform diagnostic studies to rule out any infectious origin at a hospital.C. Refer the client to a primary health care provider for a nonurgent appointment. D. Complete a computed tomography scan because the client has Hodgkin lymphoma.

B. Perform diagnostic studies to rule out any infectious origin at a hospital.

A client's blood work reveals a platelet level of 17,000/mm3. When inspecting the client's integumentary system, what finding would be most consistent with this platelet level? A. Dermatitis B. Petechiae C. Urticaria D. Alopecia

B. Petechiae

What nursing intervention should the nurse prioritize to facilitate healing in a client who has suffered a hip fracture? A. Administer analgesics as required.B. Place a pillow between the client's legs when turning.C. Maintain prone positioning at all times.D. Encourage internal and external rotation of the affected leg.

B. Place a pillow between the client's legs when turning.

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action? A. Prepare to transfuse packed red blood cells.B. Prepare for interventions to increase the client's BP. C. Place the client in the Trendelenburg position.D. Prepare an ice bath to lower core body temperature.

B. Prepare for interventions to increase the client's BP.

A nurse is caring for a client who has undergone neck resection with a radial forearm free flap. The nurse's most recent assessment of the graft reveals that it has a bluish color and that mottling is visible. What is the nurse's most appropriate action? A. Document the findings as being consistent with a viable graft. B. Promptly report these indications of venous congestion.C. Closely monitor the client and reassess in 30 minutes.D. Reposition the client to promote peripheral circulation.

B. Promptly report these indications of venous congestion.

An adult client's abnormal complete blood count (FBC) and physical assessment have prompted the primary care provider to order a diagnostic workup for Hodgkin lymphoma. The presence of what assessment finding is considered diagnostic of the disease? A. Schwann cellsB. Reed-Sternberg cells C. Lewy bodiesD. Loops of Henle

B. Reed-Sternberg cells

A client was diagnosed with cancer several weeks ago and family members describe the client as "utterly distraught." The client has fully withdrawn from social and family contact. What is the nurse's best action? A. Reassure the client and the family that these types of responses to cancer are common.B. Refer the client to the appropriate mental health provider.C. Educate the client about the mental health benefits of exercise. D. Reassure the family that the client is grieving and will eventually come to terms with the diagnosis.

B. Refer the client to the appropriate mental health provider.

A client has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the client to describe what sign or symptom? A. Burning pain on swallowingB. Regurgitation of undigested foodC. Symptoms mimicking a myocardial infarction D. Chronic parotid abscesses

B. Regurgitation of undigested food

A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has not had ostomy output for the past 12 hours. The client also reports worsening nausea. What is the nurse's priority action? A. Facilitate a referral to the wound-ostomy-continence (WOC) nurse.B. Report signs and symptoms of obstruction to the health care provider.C. Encourage the client to mobilize in order to enhance motility.D. Contact the health care provider and obtain a swab of the stoma for culture.

B. Report signs and symptoms of obstruction to the health care provider.

A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response? A. Ensure that the client's sodium intake does not exceed recommended levels. B. Report this finding to the primary provider due to the possibility of hepatic encephalopathy.C. Inform the primary provider that the client should be assessed for alcoholic hepatitis. D. Implement interventions aimed at ensuring a calm and therapeutic care environment.

B. Report this finding to the primary provider due to the possibility of hepatic encephalopathy.

A 55-year-old client with a history of type 1 diabetes presents at the clinic reporting erectile dysfunction. The health care provider prescribes tadalafil to be taken 1 hour before sexual intercourse. The nurse reviews the client's history prior to instructing the client on the use of this medication. What disorder will contraindicate the use of tadalafil? A. CataractsB. RetinopathyC. Diabetic neuropathy D. Diabetic nephropathy

B. Retinopathy

A client with a recent stroke history is admitted to a rehabilitation unit and placed on high fall risk precautions. The client is impulsive, easily distracted, frequently forgets his/her cane when walking, and the location of his/her room. What stroke conditions do these signs best indicate? A. Ischemic strokeB. Right hemispheric stroke C. Hemorrhagic strokeD. Left hemispheric stroke

B. Right hemispheric stroke

A nurse is caring for a client with acute myeloid leukemia who is preparing to undergo induction therapy. In preparing a plan of care for this client, the nurse should assign the highest priority to which nursing diagnosis? A. Activity intoleranceB. Risk for infectionC. Acute confusionD. Risk for spiritual distress

B. Risk for infection

A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis? A. Imbalanced nutrition: Less than body requirements related to decreased oral intakeB. Risk for infection related to possible rupture of appendixC. Constipation related to decreased bowel motility and decreased fluid intake D. Chronic pain related to appendicitis

B. Risk for infection related to possible rupture of appendix

A nurse is caring for a client with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this client, what nursing diagnosis should the nurse prioritize? A. Risk for activity intolerance related to the presence of a subclavian catheterB. Risk for infection related to the presence of a subclavian catheterC. Risk for functional urinary incontinence related to the presence of a subclavian catheterD. Risk for sleep deprivation related to the presence of a subclavian catheter

B. Risk for infection related to the presence of a subclavian catheter

A client is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 11/2 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure? A. Risk for impaired skin integrity B. Risk for injuryC. Risk for autonomic dysreflexia D. Risk for suffocation

B. Risk for injury

The public health nurse is presenting a health promotion class to a group at a local community center. Which intervention most directly addresses the leading cause of cancer deaths in North America? A. Monthly self-breast exams B. Smoking cessationC. Annual colonoscopiesD. Monthly testicular exams

B. Smoking cessation

The nurse is caring for a client with an advanced stage of breast cancer and the client has recently learned that the cancer has metastasized. The nurse enters the room and finds the client struggling to breathe, and the nurse's rapid assessment reveals that the client's jugular veins are distended. The nurse should suspect the development of what oncologic emergency? A. Increased intracranial pressureB. Superior vena cava syndrome (SVCS) C. Spinal cord compressionD. Metastatic tumor of the neck

B. Superior vena cava syndrome (SVCS)

A rapid response and stroke alert/code has been called for a client with deep vein thrombosis (DVT) of the left leg being treated with intravenous heparin. The client's international normalized ratio (INR) is 2.1 and vital signs are: Temperature 100.1°F (37.8°C), heart rate 102, blood pressure 190/100, respirations 14, and saturation 89% on room air. What are priority interventions for a client who is currently on anticoagulant therapy and having an ischemic stroke? A. Immediate intubation and urinary catheter placementB. Supplemental oxygen and monitoring blood glucose levelsC. Antipyretics in order to keep the client in a state of hypothermia D. Antihypertensive medications and vital signs every two hours

B. Supplemental oxygen and monitoring blood glucose levels

A client is admitted to the unit with acute cholecystitis. The health care provider has stated that surgery will be scheduled in 4 days. The client asks why the surgery is being put off for a week when he has a "sick gallbladder." What rationale would underlie the nurse's response? A. Surgery is delayed until the client can eat a regular diet without vomiting. B. Surgery is delayed until the acute symptoms subside.C. The client requires aggressive nutritional support prior to surgery.D. Time is needed to determine whether a laparoscopic procedure can be used.

B. Surgery is delayed until the acute symptoms subside.

A nurse is caring for a client receiving skeletal traction. Due to the client's severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications? A. Perform chest physiotherapy once per shift and as needed.B. Teach the client to perform deep breathing and coughing exercises.C. Administer prophylactic antibiotics as prescribed.D. Administer nebulized bronchodilators and corticosteroids as prescribed.

B. Teach the client to perform deep breathing and coughing exercises.

A 75-year-old male client is being treated for phimosis. When planning this client's care, what health promotion activity is most directly related to the etiology of the client's health problem? A. Teaching the client about safer sexual practicesB. Teaching the client about the importance of hygieneC. Teaching the client about the safe use of PDE-5 inhibitors D. Teaching the client to perform testicular self-examination

B. Teaching the client about the importance of hygiene

A man comes to the clinic reporting difficulty obtaining an erection. When reviewing the client's history, what might the nurse note that contributes to erectile dysfunction? Select all that apply. A. The client has been treated for a UTI twice in the past year. B. The client has a history of hypertension.C. The client is 66 years old.D. The client leads a sedentary lifestyle. E. The client drinks five to six alcoholic drinks per day.

B. The client has a history of hypertension. E. The client drinks five to six alcoholic drinks per day.

A client with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the client has a perforated ulcer? A. The client has abdominal bloating that developed rapidly.B. The client has a rigid, "board-like" abdomen that is tender.C. The client is experiencing intense lower right quadrant pain.D. The client is experiencing dizziness and confusion with no apparent hemodynamic changes.

B. The client has a rigid, "board-like" abdomen that is tender.

A client has recently received a diagnosis of gastric cancer; the nurse is aware of the importance of assessing the client's level of anxiety. Which of the following actions is most likely to accomplish this? A. The nurse gauges the client's response to hypothetical outcomes.B. The client is encouraged to express fears openly.C. The nurse provides detailed and accurate information about the disease. D. The nurse closely observes the client's body language.

B. The client is encouraged to express fears openly.

A nurse is assessing a client for risk factors known to contribute to osteoarthritis. What assessment finding should the nurse interpret as a risk factor? A. The client has a 30 pack-year smoking history. B. The client's body mass index is 34 (obese).C. The client has primary hypertension.D. The client is 58 years old.

B. The client's body mass index is 34 (obese).

A nurse is assessing a client who is receiving traction. The nurse's assessment confirms that the client is able to perform plantar flexion. What conclusion can the nurse draw from this finding? A. The leg that was assessed is free from DVT.B. The client's tibial nerve is functional.C. Circulation to the distal extremity is adequate.D. The client does not have peripheral neurovascular dysfunction.

B. The client's tibial nerve is functional.

A nurse at an outpatient surgery center is caring for a client who had a hemorrhoidectomy. What discharge education topics should the nurse address with this client? A. The appropriate use of antibiotics to prevent postoperative infectionB. The correct procedure for taking a sitz bathC. The need to eat a low-residue, low-fat diet for the next 2 weeksD. The correct technique for keeping the perianal region clean without the use of water

B. The correct procedure for taking a sitz bath

A client has been prescribed sildenafil (Viagra). What should the nurse teach the client about this medication? A. Sexual stimulation is not needed to obtain an erection.B. The drug should be taken 1 hour prior to intercourse.C. Facial flushing or headache should be reported to the health care provider. D. The drug has the potential to cause permanent visual changes.

B. The drug should be taken 1 hour prior to intercourse.

A nurse is caring for a client who has been scheduled for endoscopic retrograde cholangiopancreatography (ERCP) the following day. When providing anticipatory guidance for this client, the nurse should describe what aspect of this diagnostic procedure? A. The need to protect the incision postprocedureB. The use of moderate sedationC. The need to infuse 50% dextrose during the procedure D. The use of general anesthesia

B. The use of moderate sedation

A 35-year-old father of three tells the nurse that they want information on a vasectomy. What would the nurse tell the client about ejaculate after a vasectomy? A. There will be no ejaculate after a vasectomy, though the client's potential for orgasm is unaffected.B. There is no noticeable decrease in the amount of ejaculate even though it contains no sperm. C. There is a marked decrease in the amount of ejaculate after vasectomy, though this does not affect sexual satisfaction.D. There is no change in the quantity of ejaculate after vasectomy, but the viscosity is somewhat increased.

B. There is no noticeable decrease in the amount of ejaculate even though it contains no sperm.

During a well-child visit, the nurse assesses an infant's ability to suck on a pacifier. The nurse is assessing which cranial nerve?A. OlfactoryB. Trigeminal C. FacialD. Accessory

B. Trigeminal

A nurse in an oral surgery practice is working with a client scheduled for removal of an abscessed tooth. When providing discharge education, the nurse should recommend what action? A. Rinse the mouth with alcohol before bedtime for the next 7 days.B. Use warm saline to rinse the mouth as needed.C. Brush around the area with a firm toothbrush to prevent infection.D. Use a toothpick to dislodge any debris that gets lodged in the socket.

B. Use warm saline to rinse the mouth as needed.

A client is admitted to the hospital with pernicious anemia. The nurse should prepare to administer which of the following medications? A. Folic acidB. Vitamin B12C. LactuloseD. Magnesium sulfate

B. Vitamin B12

A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? A. Preparation for emergency craniotomy B. Watchful waiting and close monitoring C. Administration of inotropic drugsD. Fluid resuscitation

B. Watchful waiting and close monitoring

A clinic nurse is providing preprocedure education for a man who will undergo a vasectomy. Which of the following measures will enhance healing and comfort? Select all that apply. A. Abstaining from sexual intercourse for at least 14 days' postprocedure B. Wearing a scrotal support garmentC. Using sitz bathsD. Applying a heating pad intermittently E. Staying on bed rest for 48 to 72 hours' postprocedure

B. Wearing a scrotal support garment C. Using sitz baths

A client has come to the clinic for a routine annual physical. The nurse practitioner notes a palpable, painless projection of bone at the client's shoulder. The projection appears to be at the distal end of the humerus. The nurse should suspect the presence of: A. osteomyelitis.B. osteochondroma. C. osteomalacia.D. Paget disease.

B. osteochondroma.

A teenage girl diagnosed with polycystic ovary syndrome tells the nurse, "I refuse to take oral contraceptives since I am not sexually active." What is the best response to the girl? A) "It's important for you to take the pills even if you're not sexually active in order to prevent unwanted symptoms of the disease." B) "The healthcare provider has prescribed these for you because it is an effective treatment method for the disease." C) "I know it's hard remembering to take those pills every day. Tell me more about what is making you not want to take the oral contraceptives." D) "Do your parents know that you are not taking the treatment medication your healthcare provider prescribed?"

C) "I know it's hard remembering to take those pills every day. Tell me more about what is making you not want to take the oral contraceptives."

A child has been prescribed growth hormone. When collecting data from this client, which report is of the greatest concern? A) "I sometimes have headaches." B) "I feel tired." C) "My hips often hurt." D) "I take this medication with food."

C) "My hips often hurt."

The nurse is administering 10 units of NPH insulin to a child at 8 AM. The nurse would expect this insulin to begin acting at which time? A) By 8:15 AM B) Between 8:30 and 9 AM C) Between 9 and 11 AM D) Around 12 noon

C) Between 9 and 11 AM

In ALL, we will commonly provide extra treatment directly to the CNS and testes. The rationale for this is: A) Testicular relapse of ALL is the most common form of relapse B) Extra therapy to these areas will decrease the side effects of chemotherapy, which damages healthy cells that are rapidly dividing C) Conventional chemotherapy does not reach ALL in these areas, called "sanctuary sites" because these are areas where leukemic cells can hide D) Direct treatment to the CNS and testes can prepare patients better for hematopoietic stem cell transplantation (HSCT) by priming these sites for stem cell infusion

C) Conventional chemotherapy does not reach ALL in these areas, called "sanctuary sites" because these are areas where leukemic cells can hide

A nurse is preparing a presentation for a group of parents of adolescents diagnosed with type 1 diabetes. What issues would the nurse need to address? Select all that apply. A) Self-monitoring of blood glucose levels B) Feelings of being different C) Deficient decision-making skills D) Body image conflicts E) Struggle for independence

C) Deficient decision-making skills D) Body image conflicts E) Struggle for independence

The nurse suspects that a 4 year old with type 1 diabetes is experiencing hypoglycemia based on what findings? Select all that apply. A) Blurred vision B) Dry, flushed skin C) Diaphoresis D) Slurred speech E) Fruity breath odor F) Tachycardia

C) Diaphoresis D) Slurred speech F) Tachycardia

The nurse is preparing a teaching plan for a 10-year-old girl with hyperthyroidism. What information would the nurse include in the plan? A) Describing surgery to remove an anterior pituitary tumor B) Teaching her parents to give injections of growth hormone C) Explaining about the radioactive iodine procedure D) Showing her parents how to give DDAVP intranasally

C) Explaining about the radioactive iodine procedure

A group of students are working on a presentation for a local health fair about safety for children. When developing this presentation, the students would address what cause as the most common in pediatric injury? A) Sports B) Firearm use C) Falls D) Automobile accidents

C) Falls

As part of their orientation to their pediatric clinical rotation, an instructor is teaching a group of students how to perform cardiopulmonary resuscitation (CPR) on a child. Two students return demonstrate the skill using an infant manikin. What action indicates the proper technique? A) Compressing 30 times for every 2 breaths B) Placing the heel of the hand on the midsternum C) Giving 2 breaths followed by 15 compressions D) Using two hands to perform chest compressions

C) Giving 2 breaths followed by 15 compressions

The best way to explain the difference between HL and NHL is: A) HL only affects young people whereas NHL generally affects people over age 60 B) HL is curable with stem cell transplant C) HL is a certain kind of lymphoma arising from a B-cell mutation that results in a hallmark Reed-Sternberg cell D) HL is a more heterogenous disease, with many presentations based on the lymph nodes affected whereas NHL is a more homogenous disease with classic features

C) HL is a certain kind of lymphoma arising from a B-cell mutation that results in a hallmark Reed-Sternberg cell

A child with growth hormone deficiency is receiving growth hormone. What result would the nurse interpret as indicating effectiveness of this therapy? A) Rapid weight gain B) Complaints of headaches C) Height increase of 4 in D) Growth plate closure

C) Height increase of 4 in

The nurse is assessing a 9-year-old girl with a history of tuberculosis at age 6 years. She has been losing weight and has no appetite. The nurse suspects Addison disease based on which assessment findings? A) Arrested height and increased weight B) Thin, fragile skin and multiple bruises C) Hyperpigmentation and hypotension D) Blurred vision and enuresis

C) Hyperpigmentation and hypotension

After teaching a group of nursing students about shock in children, the instructor determines that the teaching was successful when the students identify which type of shock as most common? A) Septic B) Cardiogenic C) Hypovolemic D) Distributive

C) Hypovolemic

A group of nursing students are reviewing information about the endocrine system in infants and children. The students demonstrate understanding of the information when they state: A) Endocrine glands begin developing in the third trimester of gestation. B) At birth, the endocrine glands are completely functional. C) Infants have difficulty balancing glucose and electrolytes. D) A child's endocrine system has little effect on growth and development.

C) Infants have difficulty balancing glucose and electrolytes.

When caring for an 8-year-old boy injured in an automobile accident, the nurse demonstrates understanding of the principles of Pediatric Advanced Life Support (PALS) by which action? A) Assisting ventilation with a bag-valve-mask (BVM) device B) Treating ventricular fibrillation using a defibrillator C) Managing compensated shock to prevent decompensated shock D) Treating supraventricular tachycardia using cardioversion

C) Managing compensated shock to prevent decompensated shock

The rationale for watchful waiting for a slow-growing hematologic malignancy is based on: A) The expense of targeted therapies which causes a burden for many patients B) The need for people to adjust emotionally over time to their cancer before they can fully invest in the treatment regimen C) The low risk of the disease causing morbidity and mortality and the risk of toxicities from the available treatments D) The need to allocate scarce medical resources to more aggressive malignancies

C) The low risk of the disease causing morbidity and mortality and the risk of toxicities from the available treatments

The nurse is assessing a 13-year-old boy with type 2 diabetes mellitus. What would the nurse correlate with disorder? A) The parents report that their child had "a cold or flu" recently. B) Blood pressure is decreased when checking vital signs. C) The parents report that their son "can't drink enough water." D) Auscultation reveals Kussmaul breathing.

C) The parents report that their son "can't drink enough water."

A nurse determines that a child is exhibiting compensated supraventricular tachycardia (SVT). What action would be attempted first? A) Adenosine B) Synchronized cardioversion C) Vagal maneuvers D) Amiodarone

C) Vagal maneuvers

Which measure would be most appropriate for the nurse to do to ensure that a child's endotracheal (ET) tube is correctly positioned? A) Auscultate for abdominal breath sounds B) Mark the tracheal tube at the child's lip C) Watch for a yellow display on a CO2 monitor D) Inspect for water vapor in the tracheal tube

C) Watch for a yellow display on a CO2 monitor

You are starting your day shift (0700-1930) on a hematology oncology unit. Which patient should you see first? A) Your patient with AML here for consolidation chemotherapy, who is stable and sleeping, and is not due for another dose until 1000 B) Your patient with HL admitted 2 days ago for neutropenic fever who is on IV antibiotics, next due at 0900 and has his mom in the room with him overnight C) Your patient with new ALL who is having a CVAD placed this morning with a procedure time of 0800 D) Your patient with MM who is day 22 of a stem cell transplant and will be discharging home early this afternoon

C) Your patient with new ALL who is having a CVAD placed this morning with a procedure time of 0800

A 1-month-old infant admitted to the emergency department in respiratory distress exhibits a regular pattern of breathing followed by brief periods of apnea, then tachypnea for a short time, eventually returning to a normal respiratory rate. This type of breathing is: A) hypoventilation. B) hyperventilation. C) periodic breathing D) stridor.

C) periodic breathing

A client has just been diagnosed with chronic pancreatitis. The client is underweight and in severe pain and diagnostic testing indicates that over 80% of the client's pancreas has been destroyed. The client asks the nurse why the diagnosis was not made earlier in the disease process. What would be the nurse's best response? A. "The symptoms of pancreatitis mimic those of much less serious illnesses."B. "Your body doesn't require pancreatic function until it is under great stress, so it is easy to go unnoticed." C. "Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost."D. "It's likely that your other organs were compensating for your decreased pancreatic function."

C. "Chronic pancreatitis often goes undetected until a large majority of pancreatic function is lost."

A nurse is providing teaching to the parents of a child who has had a shunt inserted as treatment for hydrocephalus. The parents demonstrate understanding of the teaching when they make what statement?A. "Having the shunt put in decreases his risk for developmental problems."B. "If he doesn't get an infection in the first week, the risk is greatly reduced."C. "He will need more surgeries to replace the shunt as he grows."D. "The shunt will help to prevent any further complications from his disease."

C. "He will need more surgeries to replace the shunt as he grows."

The management of the client's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the client is managing the tube correctly? A. "I clean my stoma twice a day with alcohol."B. "The only time I flush my tube is when I'm putting in medications."C. "I flush my tube with water before and after each of my medications." D. "I try to stay still most of the time to avoid dislodging my tube."

C. "I flush my tube with water before and after each of my medications."

A client who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The client has since become comatose and the client's family asks the nurse why the health care provider is recommending the removal of the client's NG tube and the insertion of a gastrostomy tube. What is the nurse's best response? A. "It eliminates the risk for infection."B. "Feeds can be infused at a faster rate."C. "Regurgitation and aspiration are less likely."D. "It allows caregivers to provide personal hygiene more easily."

C. "Regurgitation and aspiration are less likely."

A client is admitted to the orthopedic unit in skeletal traction for a fractured proximal femur. Which explanation should the nurse give the client about skeletal traction? A. "Skeletal traction temporarily stabilizes the fracture before surgery." B. "Weights are attached to the leg using a boot."C. "Traction involves passing a pin through the bone."D. "Light weights must be used with skeletal traction."

C. "Traction involves passing a pin through the bone."

19. A client has been hospitalized for a wedge resection of the left lower lung lobe after a routine chest x-ray showed carcinoma. The client reports feeling anxious and asks to smoke. Which statement by the nurse would be most therapeutic? A. "Smoking is the reason you are here."B. "The doctor left orders for you not to smoke."C. "You are anxious about the surgery. Do you see smoking as helping?" D. "Smoking is OK right now, but after your surgery it is contraindicated."

C. "You are anxious about the surgery. Do you see smoking as helping?"

The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following steps. Place the steps in the order in which they occur. All options must be used. 1. Change in pH2. Blood flow decreases3. A switch to anaerobic respiration 4. Membrane pumps fail5. Cells cease to function6. Lactic acid is generated A. 635241 B. 352416 C. 236145 D. 162534

C. 236145

A nurse who provides care in a community clinic assesses a wide range of individuals. The nurse should identify which client as having the highest risk for chronic pancreatitis? A. A 45-year-old obese woman with a high-fat diet B. An 18-year-old man who is a weekend binge drinkerC. A 39-year-old man with chronic alcoholismD. A 51-year-old woman who smokes one-and-a-half packs of cigarettes per day

C. A 39-year-old man with chronic alcoholism

22. A client's colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the client has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurse's most appropriate response to this observation? A. Ensure that the client knows that he or she will be responsible for care after discharge.B. Reassure the client that many people are fearful after the creation of an ostomy. C. Acknowledge the client's reluctance and initiate discussion of the factors underlying it. D. Arrange for the client to be seen by a social worker or spiritual advisor.

C. Acknowledge the client's reluctance and initiate discussion of the factors underlying it.

Paramedics have brought an intubated client to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following? A. Keep the head of the bed (HOB) flat at all times. B. Teach the client to perform the Valsalva maneuver. C. Administer benzodiazepines on a PRN basis.D. Perform endotracheal suctioning every hour.

C. Administer benzodiazepines on a PRN basis.

The nurse is administering medications to a client through a feeding tube. Which action should the nurse take? A. Flush the tube with 5 mL of water before administering medication.B. Turn the tube feeding off for 1 hour before administering the medication. C. Administer each medication separately. D. Flush with 50 mL of water between each medication.

C. Administer each medication separately.

A nurse is assisting a client who had a recent stroke with getting dressed for physical therapy. The client looks at each piece of clothing before putting it on the body. The client states, "This is how I know what item I am holding." What impairment is this client likely experiencing? A. Homonymous hemianopsia B. Receptive aphasiaC. AgnosiaD. Hemiplegia

C. Agnosia

A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms? A. A pattern of distinct exacerbations and remissions B. Severe diarrheaC. An absence of blood in stoolD. Involvement of the rectal mucosa

C. An absence of blood in stool

A nurse is caring for a client with Paget disease and is reviewing the client's most recent laboratory values. Which of the following values are most characteristic of Paget disease? A. An elevated level of parathyroid hormone and low calcitonin levelsB. A low serum alkaline phosphatase level and a low serum calcium level C. An elevated serum alkaline phosphatase level and a normal serum calcium level D. An elevated calcitonin level and low levels of parathyroid hormone

C. An elevated serum alkaline phosphatase level and a normal serum calcium level

A client with myelodysplastic syndrome (MDS) is being treated on a medical unit. Which priority finding should prompt the nurse to contact the client's primary care provider? A. Reports of a frontal lobe headacheB. An episode of urinary incontinenceC. An oral temperature of 37.5°C (99.5°F)D. An oxygen saturation (SpO2) of 91% on room air

C. An oral temperature of 37.5°C (99.5°F)

A community health nurse is caring for a client whose multiple health problems include chronic pancreatitis. During the most recent home visit, the nurse learns that the client is experiencing severe abdominal pain and has vomited 3 times in the past several hours. What is the nurse's most appropriate action? A. Administer a PRN dose of pancreatic enzymes as prescribed.B. Teach the client about the importance of abstaining from alcohol. C. Arrange for the client to be transported to the hospital.D. Insert an NG tube, if available, and stay with the client.

C. Arrange for the client to be transported to the hospital.

A nursing student is learning how to perform sexual assessments using the PLISSIT model. According to this model, the student should begin an assessment by doing which of the following? A. Briefly teaching the client about normal sexual physiologyB. Assuring the client that what they say will be confidentialC. Asking the client if the client is willing to discuss sexual functioning D. Ensuring client privacy

C. Asking the client if the client is willing to discuss sexual functioning

A client with several chronic health problems has been newly diagnosed with a qualitative platelet defect. What component of the client's previous medication regimen may have contributed to the development of this disorder? A. Calcium carbonate B. Vitamin B12C. AspirinD. Vitamin D

C. Aspirin

The nurse is reviewing the medication administration record of a client who possesses numerous risk factors for stroke. Which of the client's medications carries the greatest potential for reducing her risk of stroke? A. Naproxen 250 PO b.i.d.B. Calcium carbonate 1,000 mg PO b.i.d. C. Aspirin 81 mg PO o.d.D. Lorazepam 1 mg SL b.i.d. PRN

C. Aspirin 81 mg PO o.d.

A nurse is assessing a client who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize? A. Assess ability to clear oral secretions. B. Assess for signs of infection.C. Assess for a patent airway.D. Assess for ability to communicate.

C. Assess for a patent airway.

After receiving a diagnosis of acute lymphocytic leukemia, a client is visibly distraught, stating, "I have no idea where to go from here." How should the nurse prepare to meet this client's psychosocial needs? A. Assess the client's previous experience with the health care system. B. Reassure the client that treatment will be challenging but successful. C. Assess the client's specific needs for education and support.D. Identify the client's plan of medical care.

C. Assess the client's specific needs for education and support.

The clinical nurse educator is presenting health promotion education to a client who will be treated for non-Hodgkin lymphoma on an outpatient basis. The nurse should recommend which of the following actions? A. Avoiding direct sun exposure in excess of 15 minutes daily B. Avoiding grapefruit juice and fresh grapefruitC. Avoiding highly crowded public placesD. Using an electric shaver rather than a razor

C. Avoiding highly crowded public places

A client has presented to the emergency department with an injury to the wrist. The client is diagnosed with a third-degree strain. Why would the health care provider prescribe an x-ray of the wrist? A. Nerve damage is associated with third-degree strains.B. Compartment syndrome is associated with third-degree strains. C. Avulsion fractures are associated with third-degree strains.D. Greenstick fractures are associated with third-degree strains.

C. Avulsion fractures are associated with third-degree strains.

3. The nurse is conducting a health education about cancer prevention to a group of adults. What menu best demonstrates dietary choices for potentially reducing the risks of cancer? A. Smoked salmon and green beansB. Pork chops and fried green tomatoesC. Baked apricot chicken and steamed broccoli D. Liver, onions, and steamed peas

C. Baked apricot chicken and steamed broccoli

A nurse is creating a care plan for a client with acute pancreatitis. The care plan includes reduced activity. What rationale for this intervention should be cited in the care plan? A. Bed rest reduces the client's metabolism and reduces the risk of metabolic acidosis.B. Reduced activity protects the physical integrity of pancreatic cells.C. Bed rest lowers the metabolic rate and reduces enzyme production. D. Inactivity reduces caloric need and gastrointestinal motility.

C. Bed rest lowers the metabolic rate and reduces enzyme production.

A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron-deficiency anemia in recent weeks. When providing the client with nutritional guidelines and meal suggestions, what foods would be most likely to increase the woman's iron stores? A. Salmon accompanied by whole milkB. Mixed vegetables and brown riceC. Beef liver accompanied by orange juice D. Yogurt, almonds, and whole grain oats

C. Beef liver accompanied by orange juice

A nurse is providing an educational event to a local men's group about prostate cancer. The nurse should cite an increased risk of prostate cancer in what ethnic group? A. Native Americans/First Nations B. WhiteC. BlackD. Asian

C. Black

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? A. Acute pain B. Septicemia C. Bleeding D. Seizures

C. Bleeding

A student nurse is caring for a client who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments? A. Fluid outputB. Oral intakeC. Blood glucose levelsD. BUN and creatinine levels

C. Blood glucose levels

The nurse is performing an initial assessment of a 75-year-old client who has just relocated to the long-term care facility. During the nurse's interview with the client, the client admits drinking around 600 mL (20 oz) of vodka every evening. What types of cancer does this put the client at risk for? Select all that apply. A. Malignant melanoma B. Brain cancerC. Breast cancerD. Esophageal cancer E. Liver cancer

C. Breast cancerD. Esophageal cancer E. Liver cancer

The nurse is caring for a client who had a low-profile gastrostomy device placed. Which instruction should the nurse give the client and family? A. Wear the tubing outside of clothing.B. Use tape to secure the device.C. Bring the connection tubing if going to the hospital. D. Change the wet-to-dry dressing daily.

C. Bring the connection tubing if going to the hospital.

A nurse is reviewing the pathophysiology that may underlie a client's decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation? A. EstrogenB. Parathyroid hormone (PTH) C. CalcitoninD. Progesterone

C. Calcitonin

A nurse is caring for a client with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL (408 mmol/L). For what complication is this client at risk? A. Chronic jaundiceB. Pigment stones in portal circulation C. Central nervous system damage D. Hepatomegaly

C. Central nervous system damage

The nurse planning the care of a client with head injuries is addressing the client's nursing diagnosis of "sleep deprivation." What action should the nurse implement? A. Administer a benzodiazepine at bedtime each night.B. Do not disturb the client between 2200 and 0600.C. Cluster overnight nursing activities to minimize disturbances. D. Ensure that the client does not sleep during the day.

C. Cluster overnight nursing activities to minimize disturbances.

Which intervention should the nurse teach a client who is at risk for hypercalcemia? A. Avoid the use of stool softeners.B. Take laxatives daily.C. Consume 2 to 4 L of fluid daily. D. Restrict calcium intake.

C. Consume 2 to 4 L of fluid daily.

A nurse is working with a client who has chronic constipation. What should be included in client teaching to promote normal bowel function? A. Use glycerin suppositories on a regular basis.B. Limit physical activity in order to promote bowel peristalsis. C. Consume high-residue, high-fiber foods.D. Resist the urge to defecate until the urge becomes intense.

C. Consume high-residue, high-fiber foods.

A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments? A. Assessment of blood pressure and assessment for headaches and visual changesB. Assessments for signs and symptoms of venous thromboembolismC. Daily weights and abdominal girth measurement D. Blood glucose monitoring q4h

C. Daily weights and abdominal girth measurement

A client with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the client's treatment? A. Decisional conflictB. Deficient knowledgeC. Death anxietyD. Disturbed thought processes

C. Death anxiety

A nurse is planning the care of a client who has been admitted to the medical unit with a diagnosis of multiple myeloma. In the client's care plan, the nurse has identified a diagnosis of Risk for Injury, which should be attributed to which factor? A. LabyrinthitisB. Left ventricular hypertrophy C. Decreased bone densityD. Hypercoagulation

C. Decreased bone density

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until the femur can be rodded in surgery. For what early complication(s) should the nurse monitor this client? Select all that apply. A. Systemic infectionB. Complex regional pain syndrome C. Deep vein thrombosisD. Compartment syndromeE. Fat embolism

C. Deep vein thrombosisD. Compartment syndromeE. Fat embolism

The nurse is discharging home a client who had a stroke. The client has a flaccid right arm and leg and is experiencing urinary incontinence. The nurse makes a referral to a home health nurse because of an awareness of what common client response to a change in body image? A. ConfusionB. Uncertainty C. DepressionD. Disassociation

C. Depression

A nurse is assessing a client's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding? A. Irrigate the ostomy to clear a possible obstruction.B. Contact the primary care provider to report this finding.C. Document that the stoma appears healthy and well perfused. D. Document a nursing diagnosis of Impaired Skin Integrity.

C. Document that the stoma appears healthy and well perfused.

A nurse is providing care to a client with multiple myeloma with reports of nausea, diarrhea, alopecia, and red urine. The client's recent interventions include electrocardiogram (ECG), multigated acquisition scan (MUGA), and a central line venous access placed on the right chest wall. Which medication is the client most likely receiving? A. Dexamethasone B. LenalidomideC. DoxorubicinD. Etoposide

C. Doxorubicin

A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action should the nurse recommend as having the greatest potential to prevent esophageal cancer? A. Promotion of a nutrient-dense, low-fat dietB. Annual screening endoscopy for clients over 50 with a family history of esophageal cancerC. Early diagnosis and treatment of gastroesophageal reflux diseaseD. Adequate fluid intake and avoidance of spicy foods

C. Early diagnosis and treatment of gastroesophageal reflux disease

A client has been admitted to the hospital for the treatment of chronic pancreatitis. The client has been stabilized and the nurse is now planning health promotion and educational interventions. Which of the following should the nurse prioritize? A. Educating the client about expectations and care following surgeryB. Educating the client about the management of blood glucose after discharge C. Educating the client about postdischarge lifestyle modificationsD. Educating the client about the potential benefits of pancreatic transplantation

C. Educating the client about postdischarge lifestyle modifications

A client with a total hip replacement has developed decreased breath sounds What is the nurse's best action? A. Place the client on bed rest.B. Request an antitussive medication from the health care provider. C. Encourage use of the incentive spirometer.D. Assess for signs and symptoms of systemic infection.

C. Encourage use of the incentive spirometer.

9. A client on the oncology unit is receiving carmustine, a chemotherapy agent, and the nurse is aware that a significant side effect of this medication is thrombocytopenia. Which symptom should the nurse assess for in clients at risk for thrombocytopenia? A. Interrupted sleep pattern B. Hot flashesC. EpistaxisD. Increased weight

C. Epistaxis

Splints have been prescribed for a client who is at risk of developing foot drop following a spinal cord injury. When should the nurse remove and reapply the splints? A. At the client's requestB. Each morning and eveningC. Every 2 hoursD. One hour prior to mobility exercises

C. Every 2 hours

A nurse is caring for a 33-year-old male client who has come to the clinic for a physical examination. The client states not having a routine physical in 5 years. The health care provider's digital rectal examination (DRE) reveals "stony" hardening in the posterior lobe of the prostate gland that is not mobile. The nurse recognizes that the observation typically indicates what? A. A normal findingB. A sign of early prostate cancerC. Evidence of a more advanced lesion D. Metastatic disease

C. Evidence of a more advanced lesion

A nurse is providing anticipatory guidance to a client who is preparing for a total gastrectomy. The nurse learns that the client is anxious about numerous aspects of the surgery. What intervention is most appropriate to alleviate the client's anxiety? A. Emphasize the fact that gastric surgery has a low risk of complications. B. Encourage the client to focus on the benefits of the surgery.C. Facilitate the client's contact with support services.D. Obtain an order for a PRN benzodiazepine.

C. Facilitate the client's contact with support services.

A client is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication? A. Sudden increase in random blood glucose readingsB. Increased abdominal girth accompanied by decreased level of consciousness C. Fever, increased heart rate and decreased blood pressureD. Abdominal pain unresponsive to analgesics

C. Fever, increased heart rate and decreased blood pressure

A nurse is preparing a presentation for a group of expectant parents about neural tube defects and prevention. Which information will the nurse emphasize? A. Smoking cessation B. Increased calcium intake C. Folic acid supplementation D. Aerobic exercise

C. Folic acid supplementation

A nurse has entered the room of a client with cirrhosis and found the client on the floor. The client reports falling when transferring to the commode. The client's vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurse's most appropriate action? A. Remove the client's commode and supply a bedpan.B. Complete an incident report and submit it to the unit supervisor.C. Have the client assessed by the primary provider due to the risk of internal bleeding.D. Perform a focused abdominal assessment in order to rule out injury.

C. Have the client assessed by the primary provider due to the risk of internal bleeding.

As a result of seizure activity, a computed tomography (CT) scan was performed and showed that an 18-month-old child has intracranial arteriovenous malformation. When developing the child's plan of care, what would the nurse expect to implement actions to prevent?A. Drug interactions B. Developmental disabilities C. Hemorrhagic strokeD. Respiratory paralysis

C. Hemorrhagic stroke

A client is scheduled for the creation of a continent ileostomy. What dietary guidelines should the nurse encourage during the weeks following surgery? A. A minimum of 30 g of soluble fiber dailyB. Increased intake of free water and clear juices C. High intake of strained fruits and vegetables D. A high-calorie, high-residue diet

C. High intake of strained fruits and vegetables

A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? A. How to differentiate between hemorrhagic and ischemic strokeB. Risk factors for ischemic strokeC. How to correctly modify the home environmentD. Techniques for adjusting the client's medication dosages at home

C. How to correctly modify the home environment

An adolescent is identified as having a collection of fluid in the tunica vaginalis of their testes. The nurse knows that this adolescent will receive what medical diagnosis? A. Cryptorchidism B. OrchitisC. HydroceleD. Prostatism

C. Hydrocele

A nurse at a long-term care facility is amending the care plan of a resident who has just been diagnosed with essential thrombocythemia (ET). The nurse should anticipate the administration of which medication? A. Dalteparin B. Allopurinol C. Hydroxyurea D. Hydrochlorothiazide

C. Hydroxyurea

A nurse in a long-term care facility is admitting a new resident who has a bleeding disorder. When planning this resident's care, the nurse should include which action? A. Housing the resident in a private roomB. Implementing a passive ROM programC. Implementing of a plan for fall prevention D. Providing the client with a high-fiber diet

C. Implementing of a plan for fall prevention

A critical care nurse is caring for a client diagnosed with acute pancreatitis. The nurse knows this client should be started on parenteral nutrition (PN) after what indications? A. 5% deficit in body weight compared to pre-illness weight and increased caloric needB. Calorie deficit and muscle wasting combined with low electrolyte levelsC. Inability to take in adequate oral food or fluids within 7 days D. Significant risk of aspiration coupled with decreased level of consciousness

C. Inability to take in adequate oral food or fluids within 7 days

The nurse caring for a client with a spinal cord injury notes that the client is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? A. Limit the amount of assistance provided with ADLs.B. Collaborate with the physical therapist and immobilize the client's extremities temporarily.C. Increase the frequency of ROM exercises.D. Educate the client about the importance of frequent position changes.

C. Increase the frequency of ROM exercises.

A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client? A. Risk for impaired skin integrity related to immobility and sensory lossB. Impaired physical mobility related to loss of motor functionC. Ineffective breathing patterns related to weakness of the intercostal muscles D. Urinary retention related to inability to void spontaneously

C. Ineffective breathing patterns related to weakness of the intercostal muscles

The nurse on the pediatric unit is caring for a 10-year-old child with a diagnosis of hemophilia. The nurse should assess carefully for indication of what nursing diagnosis? A. HypothermiaB. DiarrheaC. Ineffective copingD. Imbalanced nutrition: Less than body requirements

C. Ineffective coping

A nurse is planning the care of a client with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. Which nursing diagnosis should the nurse prioritize in the client's plan of care? A. Risk for disuse syndrome related to ineffective peripheral circulation B. Functional urinary incontinence related to urethral occlusionC. Ineffective tissue perfusion related to thrombosisD. Ineffective thermoregulation related to hypothalamic dysfunction

C. Ineffective tissue perfusion related to thrombosis

A nurse is discussing conservative management of tendonitis with a client. What is the nurse's best recommendation? A. Weight reductionB. Use of oral opioid analgesicsC. Intermittent application of ice and heat D. Passive range of motion exercises

C. Intermittent application of ice and heat

A client is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the client to first seek care? A. Hematemesis and persistent sensation of fullness B. Abdominal bloating and recurrent constipationC. Intermittent pain and bloody stoolD. Unexplained bowel incontinence and fatty stools

C. Intermittent pain and bloody stool

When providing care to a newborn infant who was born at 29 weeks' gestation, the nurse integrates knowledge of potential complications, being alert for signs and symptoms of what condition?A. Neonatal conjunctivitis B. Facial deformitiesC. Intracranial hemorrhage D. Incomplete myelinization

C. Intracranial hemorrhage

A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education? A. Take the iron with dairy products to enhance absorption. B. Increase the intake of vitamin E to enhance absorption. C. Iron will cause the stools to darken in color.D. Limit foods high in fiber due to the risk for diarrhea.

C. Iron will cause the stools to darken in color.

The nurse is observing an infant who may have acute bacterial meningitis. WHich finding might the nurse look for? A. Flat fontanelle ( fontanelle) B. Jaundice, drowsiness, and refusal to eat C. Irritability, fever, and vomiting D. Negative Kernig sign

C. Irritability, fever, and vomiting

A nurse is providing client education for a client with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The client has recently been prescribed misoprostol. What would the nurse be most accurate in informing the client about the drug? A. It reduces the stomach's volume of hydrochloric acid B. It increases the speed of gastric emptyingC. It protects the stomach's liningD. It increases lower esophageal sphincter pressure

C. It protects the stomach's lining

Diagnostic testing has revealed that a client's hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this client's plan of care will focus on what intervention? A. CryosurgeryB. Liver transplantation C. LobectomyD. Laser hyperthermia

C. Lobectomy

A nurse is providing discharge education to a client who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods? A. High-fiber foodsB. Low-purine, nutrient-dense foodsC. Low-fat foods high in proteins and carbohydrates D. Foods that are low-residue and low in fat

C. Low-fat foods high in proteins and carbohydrates

Hydrocephalus is suspected in a 4-month-old infant. Which would the nurse expect to assess? A. Sunken fontanelsB. Diminished reflexesC. Lower extremity spasticity D. Skull symmetry

C. Lower extremity spasticity

12. During a routine mammogram, a client asks the nurse whether breast cancer causes the most deaths. Which type of cancer is the leading cause of death in the United States? A. Colorectal B. Prostate C. LungD. Breast

C. Lung

A nurse is providing care for a client who has osteomalacia. What major goal should guide the choice of medical and nursing interventions? A. Maintenance of skin integrityB. Prevention of bone metastasisC. Maintenance of adequate levels of activated vitamin D D. Maintenance of adequate parathyroid hormone function

C. Maintenance of adequate levels of activated vitamin D

A client is brought to the ED by family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to anticipate for which priority intervention? A. Insertion of an intracranial monitoring device B. Treatment with antihypertensivesC. Making openings in the skullD. Administration of anticoagulant therapy

C. Making openings in the skull

The nurse is assessing a new client with reports of acute fatigue and a sore tongue that is visibly smooth and beefy red. This client is demonstrating signs and symptoms associated with what form of hematologic disorder? A. Sickle cell diseaseB. HemophiliaC. Megaloblastic anemia D. Thrombocytopenia

C. Megaloblastic anemia

A client who underwent a gastric resection 3 weeks ago is having their diet progressed on a daily basis. Following the latest meal, the client reports dizziness and palpitations. Inspection reveals that the client is diaphoretic. What is the nurse's best action? A. Insert a nasogastric tube promptly.B. Reposition the client supine.C. Monitor the client closely for further signs of dumping syndrome. D. Assess the client for signs and symptoms of aspiration.

C. Monitor the client closely for further signs of dumping syndrome.

A client with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the client's risk for orthostatic hypotension? A. Administer an IV bolus of normal saline prior to repositioning. B. Maintain bed rest until normal BP regulation returns.C. Monitor the client's BP before and during position changes. D. Allow the client to initiate repositioning.

C. Monitor the client's BP before and during position changes.

An emergency department nurse is triaging a 77-year-old client who presents with uncharacteristic fatigue as well as back and rib pain. The client denies any recent injuries. The nurse should recognize the need for this client to be assessed for which health problem? A. Hodgkin diseaseB. Non-Hodgkin lymphoma C. Multiple myelomaD. Acute thrombocythemia

C. Multiple myeloma

The nurse recognizes that a client with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? A. Position the client in a high-Fowler position when in bed. B. Support the knees with a pillow when the client is in bed. C. Perform passive ROM exercises as prescribed.D. Administer NSAIDs as prescribed.

C. Perform passive ROM exercises as prescribed.

A nurse is assessing a client who presented to the ED with priapism. The student nurse is aware that this condition is classified as a urologic emergency because of the potential for what issue? A. Urinary tract infectionB. Chronic painC. Permanent vascular damage D. Future erectile dysfunction

C. Permanent vascular damage

An uncircumcised 78-year-old male client has presented at the clinic reporting that they cannot retract the foreskin over the glans. On examination, it is noted that the foreskin is very constricted. The nurse should recognize the presence of what health problem? A. Bowen disease B. Peyronie disease C. PhimosisD. Priapism

C. Phimosis

A nurse is performing an admission assessment of a client with a diagnosis of cirrhosis. What technique should the nurse use to palpate the client's liver? A. Place hand under the right lower abdominal quadrant and press down lightly with the other hand.B. Place the left hand over the abdomen and behind the left side at the 11th rib. C. Place hand under right lower rib cage and press down lightly with the other hand. D. Hold hand 90 degrees to right side of the abdomen and push down firmly.

C. Place hand under right lower rib cage and press down lightly with the other hand.

A client has undergone surgery for oral cancer and has just been extubated in postanesthetic recovery. What nursing action best promotes comfort and facilitates spontaneous breathing for this client? A. Placing the client in a left lateral positionB. Administering opioids as prescribedC. Placing the client in Fowler positionD. Teaching the client to use the client-controlled analgesia (PCA) system

C. Placing the client in Fowler position

A client who underwent surgery for esophageal cancer is admitted to the critical care unit following postanesthetic recovery. What should the nurse include in the client's immediate postoperative plan of care? A. Teaching the client to self-suctionB. Performing chest physiotherapy to promote oxygenation C. Positioning the client to prevent gastric refluxD. Providing a regular diet as tolerated

C. Positioning the client to prevent gastric reflux

A young man with a diagnosis of hemophilia A has been brought to emergency department after suffering a workplace accident resulting in bleeding. Rapid assessment has revealed the source of the client's bleeding and established that his vital signs are stable. What should be the nurse's next action? A. Position the client in a prone position to minimize bleeding.B. Establish IV access for the administration of vitamin K.C. Prepare for the administration of factor VIII.D. Administer a normal saline bolus to increase circulatory volume.

C. Prepare for the administration of factor VIII.

4. Which nursing action best demonstrates primary cancer prevention? A. Encouraging yearly Pap testsB. Teaching testicular self-examinationC. Promoting and providing vaccines D. Facilitating screening mammograms

C. Promoting and providing vaccines

A client who has had a radical neck dissection is being prepared for discharge. The discharge plan includes referral to an outpatient rehabilitation center for physical therapy. What should the goals of physical therapy for this client include? A. Muscle training to relieve dysphagiaB. Relieving nerve paralysis in the cervical plexusC. Promoting maximum shoulder functionD. Alleviating achalasia by decreasing esophageal peristalsis

C. Promoting maximum shoulder function

A client has undergone rigid fixation for the correction of a mandibular fracture suffered in a fight. What area of care should the nurse prioritize when planning this client's discharge education? A. Resumption of activities of daily living B. Pain controlC. Promotion of adequate nutritionD. Strategies for promoting communication

C. Promotion of adequate nutrition

5. A woman with a family history of breast cancer received a positive result on a breast tumor marking test and is requesting a bilateral mastectomy. This surgery is an example of which type of oncologic surgery? A. Salvage surgeryB. Palliative surgeryC. Prophylactic surgery D. Reconstructive surgery

C. Prophylactic surgery

The nurse in the intensive care unit (ICU) is using the neurological assessment flow chart to evaluate a calm client with traumatic brain injury (TBI) that has several medications infusing. Which medication would best allow an accurate assessment of the client's neurological status? A. LorazepamB. Benzodiazepines C. PropofolD. Midazolam

C. Propofol

A nurse is caring for a client who has a leg cast. The nurse observes the client using a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? A. Allow the client to gently scratch inside the cast with a pencil.B. Give the client a sterile tongue depressor to use for scratching instead of the pencil.C. Provide a fan to blow cool air into the cast to relieve itching,D. Obtain a prescription for a sedative, such as lorazepam, to prevent the client from scratching.

C. Provide a fan to blow cool air into the cast to relieve itching,

A nurse is caring for a client who is being treated for leukemia in the hospital. The client was able to maintain nutritional status for the first few weeks following the diagnosis but is now exhibiting early signs and symptoms of malnutrition. In collaboration with the dietitian, the nurse should implement what intervention? A. Arrange for total parenteral nutrition (TPN).B. Facilitate placement of a percutaneous endoscopic gastrostomy (PEG) tube. C. Provide the client with several small, soft-textured meals each day.D. Assign responsibility for the client's nutrition to the client's friends and family.

C. Provide the client with several small, soft-textured meals each day.

A client with liver disease has developed ascites; the nurse is collaborating with the client to develop a nutritional plan. The nurse should prioritize which of the following in the client's plan? A. Increased potassium intake B. Fluid restriction to 2 L per day C. Reduction in sodium intakeD. High-protein, low-fat diet

C. Reduction in sodium intake

A client who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this client knows to immediately report what assessment finding to the health care provider? A. Decreased breath soundsB. Drainage of bile-colored fluid onto the abdominal dressing C. Rigidity of the abdomenD. Acute pain with movement

C. Rigidity of the abdomen

13. The nurse on a bone marrow transplant unit is caring for a client with cancer who has just begun hematopoietic stem cell transplantation (HSCT). What is the priority nursing diagnosis for this client? A. Fatigue related to altered metabolic processesB. Altered nutrition: less than body requirements related to anorexia C. Risk for infection related to altered immunologic responseD. Body image disturbance related to weight loss and anorexia

C. Risk for infection related to altered immunologic response

A client presents at a clinic reporting back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain? A. BursitisB. Radiculopathy C. SciaticaD. Tendonitis

C. Sciatica

A client has received the news that the client's treatment for Hodgkin lymphoma has been deemed successful and that no further treatment is necessary at this time. The care team should ensure that the client receives regular health assessments in the future due to the risk of which complication? A. Iron-deficiency anemia B. HemophiliaC. Secondary malignancy D. Lymphedema

C. Secondary malignancy

A public health nurse has formed an interdisciplinary team that is developing an educational program entitled Cancer: The Risks and What You Can Do About Them. Participants will receive information, but the major focus will be screening for relevant cancers. This program is an example of what type of health promotion activity? A. Disease prophylaxis B. Risk reductionC. Secondary prevention D. Tertiary prevention

C. Secondary prevention

A client has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize what topic? A. Management of fluid balance in the home settingB. The need for blood glucose monitoring for the next week C. Signs and symptoms of intra-abdominal complications D. Appropriate use of prescribed pancreatic enzymes

C. Signs and symptoms of intra-abdominal complications

A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates. What of the following risk factors should the educator describe? A. Recurrent infections and prolonged use of NSAIDs B. High alcohol intake and low body mass indexC. Small frame and female sexD. Male sex, diabetes, and high protein intake

C. Small frame and female sex

A nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem? A. Consumes one or more protein drinks daily.B. Takes over-the-counter antacids frequently throughout the day. C. Smokes one pack of cigarettes daily.D. Reports a history of social drinking on a weekly basis.

C. Smokes one pack of cigarettes daily.

A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A. Epidural hemorrhageB. Hypertensive emergency C. Spinal shockD. Hypovolemia

C. Spinal shock

A nurse is caring for a client with hepatic encephalopathy. The nurse's assessment reveals that the client exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

C. Stage 3

11. A nurse is admitting a client with immune thrombocytopenic purpura to the unit. In completing the admission assessment, the nurse must be alert for what medications that potentially alter platelet function? Select all that apply. A. AntihypertensivesB. PenicillinsC. Sulfa-containing medications D. Aspirin-based drugsE. NSAIDs

C. Sulfa-containing medications D. Aspirin-based drugsE. NSAIDs

The nurse is caring for an 8-year-old boy who has chronic epilepsy. What would be most important to address when teaching the child and parents about living with this condition? A. Multiple corrective surgeries to slowly remove diseased parts of his brainB. Physical, occupational, and speech therapy to maximize his potential C. Support for maintaining self-esteem because of his altered lifestyleD. Hyperventilation therapy to counteract the periods of decreased oxygenation

C. Support for maintaining self-esteem because of his altered lifestyle

A nurse is caring for a client with a bone tumor. The nurse is providing education to help the client reduce the risk for pathologic fractures. What should the nurse teach the client? A. Strive to achieve maximum weight-bearing capabilities.B. Gradually strengthen the affected muscles through weight training. C. Support the affected extremity with external supports such as splints. D. Limit reliance on assistive devices in order to build strength.

C. Support the affected extremity with external supports such as splints

The nurse is preparing health education for a client who is being discharged after hospitalization for a hemorrhagic stroke. What content should the nurse include in this education? A. Mild, intermittent seizures can be expected. B. Take ibuprofen for a serious headache. C. Take antihypertensive medication as prescribed.D. Drowsiness is normal for the first week after discharge.

C. Take antihypertensive medication as prescribed.

The nurse is caring for a client diagnosed with an ischemic stroke and knows that effective positioning of the client is important. Which of the following should be integrated into the client's plan of care? A. The client's hip joint should be maintained in a flexed position.B. The client should be in a supine position unless ambulating.C. The client should be placed in a prone position for 15 to 30 minutes several times a day.D. The client should be placed in a Trendelenburg position two to three times daily to promote cerebral perfusion.

C. The client should be placed in a prone position for 15 to 30 minutes several times a day.

A nurse is performing an admission assessment on a 40-year-old man who has been admitted for outpatient surgery on the right knee. While taking the client's family history, the client states, "My father died of prostate cancer at age 48." The nurse should instruct the client on which of the following health promotion activities? A. The client will need PSA levels drawn starting at age 55.B. The client should have testing for presence of the CDH1 and STK11 genes. C. The client should have PSA levels drawn regularly.D. The client should limit alcohol use due to the risk of malignancy.

C. The client should have PSA levels drawn regularly.

A client with a left hemispheric stroke is having difficulty with their normal speech patterns. The nurse is not sure whether the client has expressive aphasia or apraxia. Which statement would most likely be reflective of apraxia? A. The nurse gives direction to get out of bed but the client does not understand. B. The client points and gestures to an object needed on the overhead table. C. The client starts by saying "good morning" but finishes with saying "good day" to the nurse.D. The client sits up and turns to one side to see the object and states what is needed.

C. The client starts by saying "good morning" but finishes with saying "good day" to the nurse.

A client who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? A. The client will obtain measurement of drainage from the T-tube. B. The client will exercise three times a week.C. The client will take immunosuppressive agents as required.D. The client will monitor for signs of liver dysfunction.

C. The client will take immunosuppressive agents as required.

A client's screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this client's health problem? A. Adherence to a high-fiber diet will help the polyps resolve.B. The client should be assured that this is a normal, age-related physiologic change. C. The client's polyps constitute a risk factor for cancer.D. The presence of polyps is associated with an increased risk of bowel obstruction.

C. The client's polyps constitute a risk factor for cancer.

A nurse is planning discharge teaching for a 21-year-old client with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the client's coping after discharge? A. The family's ability to take care of the client's special diet needs B. The family's ability to monitor the client's changing health status C. The family's ability to provide emotional supportD. The family's ability to manage the client's medication regimen

C. The family's ability to provide emotional support

A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for which purpose? A. To decrease cerebral edemaB. To prevent seizure activity that is common following a TIA C. To remove atherosclerotic plaques blocking cerebral flow D. To determine the cause of the TIA

C. To remove atherosclerotic plaques blocking cerebral flow

An older adult has a diagnosis of Alzheimer disease and has recently been experiencing fecal incontinence. However, the nurse has observed no recent change in the character of the client's stools. What is the nurse's most appropriate intervention? A. Keep a food diary to determine the foods that exacerbate the client's symptoms. B. Provide the client with a bland, low-residue diet.C. Toilet the client on a frequent, scheduled basis.D. Liaise with the primary provider to obtain an order for loperamide.

C. Toilet the client on a frequent, scheduled basis.

A client is admitted to the ICU with acute pancreatitis. The client's family asks what causes acute pancreatitis. The critical care nurse knows that a majority of clients with acute pancreatitis have what health issue? A. Type 1 diabetesB. An impaired immune systemC. Undiagnosed chronic pancreatitis D. An amylase deficiency

C. Undiagnosed chronic pancreatitis

A 91-year-old client is slated for orthopedic surgery and the nurse is integrating gerontologic considerations into the client's plan of care. What intervention is most justified in the care of this client? A. Administration of prophylactic antibiotics B. Total parenteral nutrition (TPN)C. Use of a pressure-relieving mattressD. Use of a Foley catheter until discharge

C. Use of a pressure-relieving mattress

The nurse cares for a 7-year-old child with new-onset seizure disorder. Which prescription will the nurse anticipate for this client first? A. Vagus nerve stimulation B. Frequent temperature assessment C. Use of anticonvulsant medication D. Ketogenic diet

C. Use of anticonvulsant medication

A client with a history of atrial fibrillation has contacted the clinic reporting an accidental overdose on prescribed warfarin. The nurse should recognize the possible need for which antidote? A. Intravenous immunoglobulins (IVIG) B. Factor IXC. Vitamin KD. Factor VIII

C. Vitamin K

A nurse is preparing to discharge a client after recovery from gastric surgery. What is an appropriate discharge outcome for this client? A. Bowel movements maintain a loose consistency. B. Three large meals per day are tolerated.C. Weight is maintained or gained.D. High calcium diet is consumed.

C. Weight is maintained or gained.

A school nurse is assessing a student who was kicked in the shin during a soccer game. The area of the injury has become swollen and discolored. The triage nurse should organize care for a: A. sprain.B. strain.C. contusion. D. dislocation.

C. contusion.

A nurse practitioner is assessing a 55-year-old male client who reports perineal discomfort, burning, urgency, and frequency with urination. The client states that he has pain with ejaculation. The nurse knows that the client is exhibiting symptoms of: A. varicocele. B. epididymitis. C. prostatitis. D. hydrocele.

C. prostatitis.

Which nursing assessment finding would be indicative of compartment syndrome in the client with a cast applied to the left forearm 3 hours earlier? Fingers pink, warm, and move freely Capillary refill of left fingers greater than 3 seconds Radial pulses 2+ bilaterally Intact sensation

Capillary refill of left fingers greater than 3 seconds

The nurse is caring for a 6-year-old girl who was injured in a bicycle accident. Which question would be most important for the nurse to ask during the health history? A) "Has she been diagnosed with any chronic disorders?" B) "Is your daughter currently taking any medications?" C) "Is she allergic to any medications or drugs?" D) "Tell me how the bicycle accident happened."

D) "Tell me how the bicycle accident happened."

A child who weighs 53 lb is receiving fluid volume replacement as part of the treatment for shock. The nurse is evaluating the child's hourly urinary output to determine if the child's condition is improving. Which output would the nurse interpret as most indicative of improvement? A) 12 mL B) 15 mL C) 22 mL D) 30 mL

D) 30 mL

Which of the following is NOT the role of the registered nurse in managing central venous access devices (CVADs)? A) Monitoring CVAD sites for s/sx infection B) Troubleshooting lines that will not draw blood C) Teaching patients how to flush their lines at home D) All of these are the role of the RN in managing CVADs

D) All of these are the role of the RN in managing CVADs

The nurse is caring for a 13-year-old girl with delayed puberty. Based on the nurse's knowledge of this condition, the nurse would include which nursing diagnosis in the child's plan of care? A) Disabled family coping related to the child's disorder B) Imbalanced nutrition, less than body requirements related to the child's short stature C) Noncompliance related to the need for lifelong hormone therapy D) Deficient knowledge related to the administration of estradiol

D) Deficient knowledge related to the administration of estradiol

Which intervention would be most helpful in preventing barotrauma when ventilating a 3-year-old girl with a bag-valve-mask? A) Choosing the correct size bag and face mask B) Setting the flow rate at exactly 10 L/minute C) Maintaining the airway in the open position D) Delivering one breath every 3 to 5 seconds

D) Delivering one breath every 3 to 5 second

A group of students are reviewing information about the various types of insulin used to treat type 1 diabetes. The students demonstrate understanding of the information when they identify which of these insulins as having the longest duration? A) Lispro B) Regular C) NPH D) Glargine

D) Glargine

The parents of a child with congenital adrenal hyperplasia bring the child to the emergency department for evaluation because the child has had persistent vomiting. What finding would lead the nurse to suspect that the child is experiencing an acute adrenal crisis? A) Hypernatremia B) Bradycardia C) Hypertension D) Hyperkalemia

D) Hyperkalemia

Which best explains induction and consolidation chemotherapy? A) Induction chemotherapy is given over months to years to ensure long-term remission and consolidation chemotherapy is given before stem cell transplant to prepare the body for the stem cell infusion B) Induction chemotherapy is given outpatient and consolidation chemotherapy is given inpatient C) Induction chemotherapy is given for leukemias, and consolidation chemotherapy is given for lymphomas and multiple myeloma D) Induction chemotherapy is given at diagnosis to attempt to induce remission and consolidation chemotherapy is given in planned cycles to ensure that the remission is durable

D) Induction chemotherapy is given at diagnosis to attempt to induce remission and consolidation chemotherapy is given in planned cycles to ensure that the remission is durable

The nurse is caring for a child who has been admitted for a sickle cell crisis. What would the nurse do first to provide adequate pain management? A) Administer a nonsteroidal anti-inflammatory drug (NSAID) as ordered. B) Use guided imagery and therapeutic touch. C) Administer meperidine as ordered. D) Initiate pain assessment with a standardized pain scale.

D) Initiate pain assessment with a standardized pain scale.

The nurse is obtaining a health history from parents whose 4-month-old boy has congenital hypothyroidism. What would the nurse most likely assess? A) The child has above-normal growth for his age. B) The child is active and playful. C) The skin is pink and healthy looking. D) It is difficult to keep the child awake.

D) It is difficult to keep the child awake.

The nurse is preparing the plan of care for a child experiencing respiratory distress. What action would be the top priority? A) Providing supplemental oxygen B) Monitoring for changes in status C) Assisting ventilation D) Maintaining a patent airway

D) Maintaining a patent airway

A nurse is teaching the parents of an infant with congenital adrenal hyperplasia about the signs and symptoms of adrenal crisis. The nurse determines that the teaching was successful when the parents correctly identify what sign of adrenal crisis? A) Bradycardia B) Constipation C) Fluid overload D) Persistent vomiting

D) Persistent vomiting

What would be most appropriate to use to help maintain a patent airway in an infant experiencing a respiratory emergency? A) Neck hyperextension B) Head tilt-chin lift technique C) Jaw-thrust maneuver D) Small towel under shoulders

D) Small towel under shoulders

The parents of a 7-year-old girl with type 1 diabetes has been recording her blood glucose measurements before meals and at bedtime for the past 4 days; they are as follows: Monday Tuesday Wednesday ThursdayB: 120 mg/dL 135 mg/dL 124 mg/dL 200 mg/dL L: 110 mg/dL 120 mg/dL 140 mg/dL 220 mg/dL D: 90 mg/dL140 mg/dL 130 mg/dL 200 mg/dLBed: 110 mg/dL 110 mg/dL 160 mg/dL 240 mg/dL The parents bring the child in for a follow-up visit and show the nurse the results. Based on the results, the nurse would need to obtain additional information from the parents and child about which day? A) Monday B) Tuesday C) Wednesday D) Thursday

D) Thursday

What finding would the nurse expect to assess in a child with hypothyroidism? A) Nervousness B) Heat intolerance C) Smooth velvety skin D) Weight gain

D) Weight gain

11. A nurse provides care on a bone marrow transplant unit and is preparing a client for a hematopoietic stem cell transplantation (HSCT) the following day. Which information should the nurse emphasize to the client's family and friends? A. "Your family should likely gather at the bedside in case there is a negative outcome."B. "Make sure the client doesn't eat any food in the 24 hours before the procedure." C. "Wear a hospital gown when you go into the client's room."D. "Do not visit if you've had a recent infection."

D. "Do not visit if you've had a recent infection."

A nurse is caring for a client who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the client's statements would indicate to the nurse that the client requires further teaching? A. "I'll need to keep several pillows between my legs at night."B. "I need to remember not to cross my legs. It's such a habit."C. "The occupational therapist is showing me how to use a 'sock puller' to help me get dressed."D. "I will need my husband to assist me in getting off the low toilet seat at home."

D. "I will need my husband to assist me in getting off the low toilet seat at home."

A client seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education? A. "Drinking beverages after your meal, rather than with your meal, may bring some relief."B. "It's best to avoid dry foods, such as rice and chicken, because they're harder to swallow." C. "Many clients obtain relief by taking over-the-counter antacids 30 minutes before eating."D. "Instead of eating three meals a day, try eating smaller amounts more often."

D. "Instead of eating three meals a day, try eating smaller amounts more often."

A client with Hodgkin lymphoma is receiving information from the oncology nurse. The client asks the nurse why it is necessary to stop drinking and smoking and stay out of the sun. Which response by the nurse would be best? A. "Avoiding these factors can reduce the risk of Reed-Sternberg cells developing." B. "These behaviors can reduce the effectiveness of your chemotherapy."C. "Engaging in these activities increases your risk of hemorrhage."D. "It's important to reduce other factors that increase the risk of second cancers."

D. "It's important to reduce other factors that increase the risk of second cancers."

A client has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse explain the pathophysiology of this client's health problem? A. "Toxins have accumulated and inflamed your pancreas."B. "Bacteria likely migrated from your intestines and became lodged in your pancreas."C. "A virus that was likely already present in your body has begun to attack your pancreatic cells."D. "The enzymes that your pancreas produces have damaged the pancreas itself."

D. "The enzymes that your pancreas produces have damaged the pancreas itself."

A child who has been having seizures is admitted to the hospital for diagnostic testing. The child has had laboratory testing and an EEG, and is scheduled for a lumbar puncture. The parents voice concern to the nurse stating, "I don't understand why our child had to have a lumbar puncture since the EEG was negative." What is the best response by the nurse? A. "A lumbar puncture is a routine test that is performed anytime someone has a seizure disorder." B. "I know it must be frustrating not having a diagnosis yet, but you have to be patient. Seizure disorders are difficult to diagnose.' C. "Since the EEG was negative there must be some other cause for the seizures. The lumbar puncture is necessary to determine what the cause is." D. "The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures."

D. "The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures."

An intensive care nurse is aware of the need to identify clients who may be at risk of developing disseminated intravascular coagulation (DIC). Which ICU client most likely faces the highest risk of DIC? A. A client with extensive burns B. A client who has a diagnosis of acute respiratory distress syndrome C. A client who suffered multiple trauma in a workplace accidentD. A client who is being treated for septic shock

D. A client who is being treated for septic shock

A client comes into the clinic reporting fatigue. Blood work shows an increased bilirubin concentration and an increased reticulocyte count. Which condition should the nurse most suspect the client has? A. A hypoproliferative anemia B. A leukemiaC. ThrombocytopeniaD. A hemolytic anemia

D. A hemolytic anemia

A nurse is performing an admission assessment for an 81-year-old client who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding? A. Similar liver size and texture as in younger adults B. A nonpalpable liverC. A slightly enlarged liver with palpably hard edges D. A slightly decreased size of the liver

D. A slightly decreased size of the liver

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? A. Passive range-of-motion exercises to prevent contractures B. Supine positioningC. Early initiation of physical therapyD. Absolute bed rest in a quiet, non stimulating environment

D. Absolute bed rest in a quiet, non stimulating environment

A 35-year-old client is admitted to the hospital reporting severe headaches, vomiting, and testicular pain. The client's blood work shows reduced numbers of platelets, leukocytes, and erythrocytes, with a high proportion of immature cells. The nurse caring for this client suspects which diagnosis? A. Acute myeloid leukemia (AML)B. Chronic myeloid leukemia (CML) C. Myelodysplastic syndromes (MDS) D. Acute lymphocytic leukemia (ALL)

D. Acute lymphocytic leukemia (ALL)

A client has returned to the floor after undergoing a transurethral resection of the prostate (TURP). The client has a continuous bladder irrigation system in place. The client reports bladder spasms. What is the most appropriate nursing action to relieve the discomfort of the client? A. Apply a cold compress to the pubic area.B. Notify the urologist promptly.C. Irrigate the catheter with 30 to 50 mL of normal saline as ordered. D. Administer a smooth-muscle relaxant as ordered.

D. Administer a smooth-muscle relaxant as ordered.

A client is being treated for acute pain from an episode of pancreatitis. The nurse has identified a nursing diagnosis of Ineffective Breathing Pattern related to pain secondary to effects of surgery. Which intervention should the nurse perform in order to best address this diagnosis? A. Position the client supine to facilitate diaphragm movement. B. Administer corticosteroids by nebulizer as prescribed.C. Perform oral suctioning as needed to remove secretions.D. Administer analgesic per orders.

D. Administer analgesic per orders.

A client with esophageal varices is being cared for in the ICU. The varices have begun to bleed. The client has Ringer lactate at 150 cc/hr infusing. The nurse should also anticipate what intervention? A. Positioning the client supineB. Administering diureticsC. Oxygen by nasal cannulaD. Administering volume expanders

D. Administering volume expanders

A nurse is amending a client's plan of care in light of the fact that the client has recently developed ascites. What should the nurse include in this client's care plan? A. Mobilization with assistance at least 4 times dailyB. Administration of beta-adrenergic blockers as prescribed C. Vitamin B12 injections as prescribedD. Administration of diuretics as prescribed

D. Administration of diuretics as prescribed

A community health nurse is preparing for an initial home visit to a client discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include? A. Enteral feeding via gastrostomy tube (G tube)B. Gastrointestinal decompression by nasogastric tube C. Periodic assessment for esophageal distensionD. Administration of injections of vitamin B12

D. Administration of injections of vitamin B12

A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine? A. The hepatitis A vaccineB. Albumin infusionC. The hepatitis A and B vaccines D. An immune globulin injection

D. An immune globulin injection

A client sustained a head injury as a result of trauma. The health care provider has instituted seizure prophylactic measures. The nurse anticipates which specific measures being initiated for this client? A. Antiemetic medications on day three of injuryB. Aspiration precautions on day four of injuryC. Intubation and ventilator support on day one of injury D. Anticonvulsant medications on day two of injury

D. Anticonvulsant medications on day two of injury

A client with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the client's family how to safely perform which of the following actions? A. Aspirating bile from the catheter using a syringeB. Removing the catheter when output is 15 mL in 24 hours C. Instilling antibiotics into the catheterD. Assessing the patency of the drainage catheter

D. Assessing the patency of the drainage catheter

The nurse has implemented interventions aimed at facilitating family coping in the care of a client with a traumatic brain injury. How can the nurse best facilitate family coping? A. Help the family understand that the client could have died.B. Emphasize the importance of accepting the client's new limitations. C. Have the members of the family plan the client's inclient care.D. Assist the family in setting appropriate short-term goals.

D. Assist the family in setting appropriate short-term goals.

A client with a peptic ulcer disease has had metronidazole added to their current medication regimen. What health education related to this medication should the nurse provide? A. Take the medication on an empty stomach. B. Take up to one extra dose per day if stomach pain persists. C. Take at bedtime to mitigate the effects of drowsiness. D. Avoid drinking alcohol while taking the drug.

D. Avoid drinking alcohol while taking the drug.

When teaching a client with sickle cell disease about strategies to prevent crises, what measures should the nurse recommend? A. Using prophylactic antibiotics and performing meticulous hygiene B. Maximizing physical activity and taking OTC iron supplementsC. Limiting psychosocial stress and eating a high-protein dietD. Avoiding cold temperatures and ensuring sufficient hydration

D. Avoiding cold temperatures and ensuring sufficient hydration

A client is being treated for polycythemia vera, and the nurse is providing health education. Which practice should the nurse recommend to prevent the complications of this health problem? A. Avoiding natural sources of vitamin KB. Avoiding altitudes of 1500 feet (457 meters)C. Performing active range of motion exercises daily D. Avoiding tight and restrictive clothing on the legs

D. Avoiding tight and restrictive clothing on the legs

14. A client returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the client for signs and symptoms of what serious potential complication of this surgery? A. Diabetic comaB. Decubitus ulcerC. Wound evisceration D. Bile duct injury

D. Bile duct injury

What finding is consistent with increased intracranial pressure (ICP) in an infant? A. Emotional lability B. Increased appetite C. Narcolepsy D. Bulging fontanels

D. Bulging fontanels

A nurse is teaching an educational class to a group of older adults at a community center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended intake of what nutrients? Select all that apply. A. Vitamin B12 B. Potassium C. Calcitonin D. Calcium E. Vitamin D

D. Calcium E. Vitamin D

A client diagnosed with a cerebral aneurysm reports a severe headache to the nurse. What action is a priority for the nurse? A. Sit with the client for a few minutes.B. Administer an analgesic.C. Inform the nurse manager.D. Call the health care provider immediately.

D. Call the health care provider immediately.

A nurse is educating a group of nursing students about signs and symptoms of a hemorrhagic stroke. Which is true of hemorrhagic stroke? A. Occurs with vascular occlusion.B. Is also known as thrombotic stroke. C. Can be known as lacunar strokes.D. Can occur in the subarachnoid space.

D. Can occur in the subarachnoid space.

A nurse is reviewing the care of a client who has a long history of lower back pain that has not responded to conservative treatment measures. The nurse should anticipate the administration of what drug? A. CalcitoninB. PrednisoneC. AspirinD. Cyclobenzaprine

D. Cyclobenzaprine

A client with liver cancer is being discharged home with a hepatic artery catheter in place. The nurse should be aware that this catheter will facilitate which of the following? A. Continuous monitoring for portal hypertensionB. Administration of immunosuppressive drugs during the first weeks after transplantationC. Real-time monitoring of vascular changes in the hepatic systemD. Delivery of a continuous chemotherapeutic dose

D. Delivery of a continuous chemotherapeutic dose

15. A client with terminal small-cell lung cancer has been given a six-month prognosis and wants to die at home. The health care team believes the condition warrants inpatient care. The nurse might suggest which compromise? A. Discuss a referral for rehabilitation hospital. B. Panel the client for a personal care home. C. Discuss a referral for acute care.D. Discuss a referral for hospice care.

D. Discuss a referral for hospice care

10. The nurse manager is orienting a new nurse to the oncology unit. When reviewing the safe administration of antineoplastic agents, which action should the nurse manager emphasize? A. Adjust the dose to the client's present symptoms.B. Wash hands with an alcohol-based cleanser following administration.C. Use gloves and a lab coat when preparing the medication.D. Dispose of the antineoplastic wastes in the hazardous waste receptacle.

D. Dispose of the antineoplastic wastes in the hazardous waste receptacle.

A nursing student is writing a care plan for a newly admitted client who has been diagnosed with a stroke. What major nursing diagnosis should most likely be included in the client's plan of care? A. Adult failure to thriveB. Post-trauma syndromeC. HyperthermiaD. Disturbed sensory perception

D. Disturbed sensory perception

A client presents at the clinic with a report of morning numbness, cramping, and stiffness in the fourth and fifth fingers of the right hand. What disease process should the nurse suspect? A. TendonitisB. A ganglionC. Carpal tunnel syndrome D. Dupuytren disease

D. Dupuytren disease

A The client is experiencing painful oral lesions following radiation for oropharyngeal cancer. Which instruction should the nurse give this client? A. Spicy foods stimulate salivation and are soothing. B. Eat food while it is hot to enhance flavor.C. Avoid brushing teeth while lesions are present. D. Eat soft or liquid foods.

D. Eat soft or liquid foods.

A client has been treated in the hospital for an episode of acute pancreatitis. The client has acknowledged the role that his alcohol use played in the development of his health problem, but has not expressed specific plans for lifestyle changes. What is the nurse's most appropriate response? A. Educate the client about the link between alcohol use and pancreatitis. B. Ensure that the client knows the importance of attending follow-up appointments.C. Refer the client to social work or spiritual care. D. Encourage the client to connect with a community-based support group.

D. Encourage the client to connect with a community-based support group.

What should be included in the client's care plan when establishing an exercise program for a client affected by a stroke? A. Schedule passive range of motion every other day.B. Keep activity limited, as the client may be overstimulated.C. Have the client perform active range-of-motion (ROM) exercises once a day. D. Exercise the affected extremities passively four or five times a day.

D. Exercise the affected extremities passively four or five times a day.

An adult client has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely to apply to this client's health status? A. Risk for deficient fluid volume related to impaired erythropoiesis B. Risk for infection related to tissue hypoxiaC. Acute pain related to uncontrolled hemolysisD. Fatigue related to decreased oxygen-carrying capacity

D. Fatigue related to decreased oxygen-carrying capacityv

A nurse is talking with the parents of a child who has had a febrile seizure. The nurse would integrate an understanding of what information into the discussion?A. The child's risk for cognitive problems is greatly increased.B. Structural damage occurs with febrile seizure. C. The child's risk for epilepsy is now increased. D. Febrile seizures are benign in nature.

D. Febrile seizures are benign in nature.

A clinic nurse is working with a client who has a long-standing diagnosis of polycythemia vera. How can the nurse best gauge the course of the client's disease? A. Document the color of the client's palms and face during each visit. B. Follow the client's erythrocyte sedimentation rate over time.C. Document the client's response to erythropoietin injections.D. Follow the trends of the client's hematocrit.

D. Follow the trends of the client's hematocrit.

A client has been experiencing disconcerting GI symptoms that have been worsening in severity. Following medical assessment, the client has been diagnosed with lactose intolerance. The nurse should recognize an increased need for what form of health promotion? A. Annual screening colonoscopiesB. Adherence to recommended immunization schedules C. Regular blood pressure monitoringD. Frequent screening for osteoporosis

D. Frequent screening for osteoporosis

An emergency department nurse is admitting a 3-year-old brought in after swallowing a piece from a wooden puzzle. The nurse should anticipate the administration of what medication in order to relax the esophagus to facilitate removal of the foreign body? A. Haloperidol B. Prostigmine C. Epinephrine D. Glucagon

D. Glucagon

A home health nurse is caring for a client with multiple myeloma. What intervention should the nurse prioritize when addressing the client's severe bone pain? A. Implementing distraction techniquesB. Educating the client about the effective use of hot and cold packs C. Teaching the client to use NSAIDs effectivelyD. Helping the client manage the opioid analgesic regimen

D. Helping the client manage the opioid analgesic regimen

A 25-year-old client comes to the emergency department with excessive bleeding from a cut sustained when cleaning a knife. Blood work shows a prolonged prothrombin time (PT), but a vitamin K deficiency is ruled out. When assessing the client, areas of ecchymosis are noted on other areas of the body. Which of the following is the most plausible cause of the client's signs and symptoms? A. Lymphoma B. Leukemia C. Hemophilia D. Hepatic dysfunction

D. Hepatic dysfunction

A client has been diagnosed with pancreatic cancer and has been admitted for care. Following initial treatment, the nurse should be aware that the client is most likely to require which of the following situations? A. Inpatient rehabilitationB. Rehabilitation in the home setting C. Intensive physical therapyD. Hospice care

D. Hospice care

A nurse is participating in the emergency care of a client who has just developed variceal bleeding. What intervention should the nurse anticipate? A. Infusion of intravenous heparinB. IV administration of albuminC. STAT administration of vitamin K by the intramuscular route D. IV administration of octreotide

D. IV administration of octreotide

A nurse is caring for a client with liver failure and is performing an assessment of the client's increased risk of bleeding. The nurse recognizes that this risk is related to the client's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A. Alterations in glucose metabolismB. Retention of bile saltsC. Inadequate production of albumin by hepatocytes D. Inability of the liver to use vitamin K

D. Inability of the liver to use vitamin K

A nurse is caring for a client who is acutely ill and has included vigilant oral care in the client's plan of care. What factor increases this client's risk for dental caries? A. Hormonal changes brought on by the stress response cause an acidic oral environmentB. Systemic infections frequently migrate to the teethC. Hydration that is received intravenously lacks fluoride D. Inadequate nutrition and decreased saliva production can cause cavities

D. Inadequate nutrition and decreased saliva production can cause cavities

A client has presented at the clinic with symptoms of benign prostatic hyperplasia. What diagnostic findings would suggest that this client has chronic urinary retention? A. HypertensionB. Peripheral edemaC. Tachycardia and other dysrhythmias D. Increased blood urea nitrogen (BUN)

D. Increased blood urea nitrogen (BUN)

Which of the following is the most plausible nursing diagnosis for a client whose treatment for colon cancer has necessitated a colostomy? A. Risk for unstable blood glucose due to changes in digestion and absorption B. Unilateral neglect related to decreased physical mobilityC. Risk for excess fluid volume related to dietary changes and changes in absorption D. Ineffective sexuality patterns related to changes in self-concept

D. Ineffective sexuality patterns related to changes in self-concept

A nurse is providing care for a client whose neck dissection surgery involved the use of a graft. When assessing the graft, the nurse should prioritize data related to what nursing diagnosis? A. Risk for disuse syndrome B. Unilateral neglectC. Risk for traumaD. Ineffective tissue perfusion

D. Ineffective tissue perfusion

A client has experienced symptoms of dumping syndrome following gastric surgery. To what physiologic phenomenon does the nurse attribute this syndrome? A. Irritation of the phrenic nerve due to diaphragmatic pressure B. Chronic malabsorption of iron and vitamins A and CC. Reflux of bile into the distal esophagusD. Influx of extracellular fluid into the small intestine

D. Influx of extracellular fluid into the small intestine

A client is being treated on the medical unit for a sickle cell crisis. The nurse's most recent assessment reveals a fever and a new onset of fine crackles on lung auscultation. Which action by the nurse would be the most appropriate? A. Apply supplementary oxygen by nasal cannula.B. Administer bronchodilators by nebulizer.C. Liaise with the respiratory therapist and consider high-flow oxygen. D. Inform the health care provider that the client may have an infection.

D. Inform the health care provider that the client may have an infection.

An older adult client sought care for the treatment of a swollen, painful knee joint. Diagnostic imaging and culturing of synovial fluid resulted in a diagnosis of septic arthritis. The nurse should prioritize what aspect of care? A. Administration of oral and IV corticosteroids as prescribed B. Prevention of falls and pathologic fracturesC. Maintenance of adequate serum levels of vitamin DD. Intravenous administration of antibiotics

D. Intravenous administration of antibiotics

During class, a student states, "I didn't think children could have strokes. I thought this only occurred in older adults." When responding to the student, what would be most important for the instructor to integrate into the response?A. Strokes in children often have an identifiable cause. B. The signs and symptoms in children are different from an adult. C. Research has identified specific treatments for children.D. Ischemic strokes are more common than hemorrhagic strokes.

D. Ischemic strokes are more common than hemorrhagic strokes.

A public health nurse has been asked to provide a health promotion session for men at a wellness center. What should the nurse inform the participants about testicular cancer? A. It is most common among men over 55. B. It is one of the least curable solid tumors. C. It typically does not metastasize.D. It is highly responsive to treatment.

D. It is highly responsive to treatment.

The nurse is assessing urinary output 24 hours after a prostatectomy for a client with continuous bladder irrigation. What color of output should the nurse expect to find in the drainage bag? A. Red wine colored B. Tea coloredC. AmberD. Light pink

D. Light pink

A nurse is planning the postoperative care of a client who is scheduled for radical prostatectomy. What intraoperative position will place the client at particular risk for the development of deep vein thrombosis postoperatively? A. Fowler positionB. Prone positionC. Supine positionD. Lithotomy position

D. Lithotomy position

A client is undergoing diagnostic testing for osteomalacia. Which of the following laboratory results are most suggestive of this diagnosis? A. High chloride, calcium, and magnesium levels B. High parathyroid and calcitonin levelsC. Low serum calcium and magnesium levelsD. Low serum calcium and low phosphorus level

D. Low serum calcium and low phosphorus level

A nurse is talking with a client who is scheduled to have a hemicolectomy with the creation of a colostomy. The client admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. What nursing action is most appropriate? A. Reassure the client that the procedure is relatively low risk and that clients are usually successful in adjusting to an ostomy.B. Provide the client with educational materials that match the client's learning style. C. Encourage the client to write down these concerns and questions to bring forward to the surgeon.D. Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse.

D. Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse.

A client has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes? A. Preventing infectionB. Maintaining skin and tissue integrityC. Preventing nausea and vomitingD. Maintaining fluid and electrolyte balance

D. Maintaining fluid and electrolyte balance

A client is recovering in the hospital following gastrectomy. The nurse notes that the client has become increasingly difficult to engage and has had several angry outbursts at staff members in recent days. The nurse's attempts at therapeutic dialogue have been rebuffed. What is the nurse's most appropriate action? A. Ask the client's primary provider to liaise between the nurse and the client. B. Delegate care of the client to a colleague.C. Limit contact with the client in order to provide privacy.D. Make appropriate referrals to services that provide psychosocial support.

D. Make appropriate referrals to services that provide psychosocial support.

A home health nurse is caring for a client discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the potential complications that may occur after surgery. What are the most likely complications for the client who has had pancreatic surgery? A. Proteinuria and hyperkalemiaB. Hemorrhage and hypercalcemia C. Weight loss and hypoglycemiaD. Malabsorption and hyperglycemia

D. Malabsorption and hyperglycemia

A client has been diagnosed with a malignancy of the oral cavity and is undergoing oncologic treatment. The oncologic nurse is aware that the prognosis for recovery from head and neck cancers is often poor because of what characteristic of these malignancies? A. Radiation therapy often results in secondary brain tumors. B. Surgical complications are exceedingly common.C. Diagnosis rarely occurs until the cancer is end stage.D. Metastases are common and respond poorly to treatment.

D. Metastases are common and respond poorly to treatment.

An ED nurse has just received a call from EMS that they are transporting a 17-year-old client who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what event? A. Syncope (fainting)B. Suicide attemptsC. Workplace injuriesD. Motor vehicle accidents

D. Motor vehicle accidents

A group of nursing students are reviewing information related to seizures that occur in infants and children. The students demonstrate a need for additional review when they identify which type as common in neonates?A. TonicB. Focal clonicC. Multifocal clonicD. Myoclonic

D. Myoclonic

A nurse is planning the care of a client who has a diagnosis of hemophilia A. When addressing the nursing diagnosis of Acute Pain Related to Joint Hemorrhage, what principle should guide the nurse's choice of interventions? A. Gabapentin (Neurontin) is effective because of the neuropathic nature of the client's pain.B. Opioids partially inhibit the client's synthesis of clotting factors.C. Opioids may cause vasodilation and exacerbate bleeding. D. NSAIDs are contraindicated due to the risk for bleeding.

D. NSAIDs are contraindicated due to the risk for bleeding.

A client confides to the nurse that he cannot engage in sexual activity. The client is 27 years old and has no apparent history of chronic illness that would contribute to erectile dysfunction. What does the nurse know will be ordered for this client to assess sexual functioning? A. Sperm countB. Ejaculation capacity testsC. Engorgement testsD. Nocturnal penile tumescence tests

D. Nocturnal penile tumescence tests

A client who had a total hip replacement two days ago reports new onset calf tenderness to the nurse. Which action should the nurse take? A. Administer pain medication. B. Massage the client's calf.C. Apply antiembolic stockings. D. Notify the health care provider.

D. Notify the health care provider.

A nurse is caring for a client who has a diagnosis of GI bleed. During shift assessment, the nurse finds the client to be tachycardic and hypotensive, and the client has an episode of hematemesis while the nurse is in the room. In addition to monitoring the client's vital signs and level of conscious, what would be a priority nursing action for this client? A. Place the client in a prone position.B. Provide the client with ice water to slow any GI bleeding. C. Prepare for the insertion of an NG tube.D. Notify the health care provider.

D. Notify the health care provider.

16. The nurse is performing a neurologic assessment on a child. The previous examination noted the child to be alert but answering questions inappropriately. In this examination, the child only responds to vigours stimuli. Which action should the nurse take first? A. Reassess in one hour B. Document the findings in the hourly assessment tool C. Have another nurse verify the results D. Notify the healthcare provider immediately

D. Notify the healthcare provider immediately

A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury? A. Restrain the client as ordered.B. Administer opioids PRN as prescribed.C. Arrange for friends and family members to sit with the client. D. Pad the side rails of the client's bed.

D. Pad the side rails of the client's bed.

A client with an ischemic stroke has been brought to the emergency room. The health care provider institutes measures to restore cerebral blood flow. What area of the brain would most likely benefit from this immediate intervention? A. Cerebral cortex B. Temporal lobeC. Central sulcusD. Penumbra region

D. Penumbra region

A nurse is caring for a client whose diagnosis of multiple myeloma is being treated with bortezomib. The nurse should assess for what adverse effect of this treatment? A. StomatitisB. NephropathyC. Cognitive changesD. Peripheral neuropathy

D. Peripheral neuropathy

A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage the potential sensory and perceptional difficulties? A. Keep the lighting in the client's room low.B. Place the client's clock on the affected side.C. Approach the client on the side where vision is impaired.D. Place the client's extremities where the client can see them.

D. Place the client's extremities where the client can see them.

A nurse is caring for an older adult who has been experiencing severe Clostridium difficile-related diarrhea. When reviewing the client's most recent laboratory tests, the nurse should prioritize what finding? A. White blood cell level B. Creatinine levelC. Hemoglobin levelD. Potassium level

D. Potassium level

The ED is notified that a 6-year-old child is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy? A. Promoting adequate circulation B. Treating the child's increased ICP C. Assessing secondary brain injury D. Preserving brain homeostasis

D. Preserving brain homeostasis

What finding would lead the nurse to suspect that a child is beginning to develop increased intracranial pressure?A. BradycardiaB. Cheyne-Stokes respirations C. Fixed, dilated pupils D. Projectile vomiting

D. Projectile vomiting

A client who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team? A. Maximize the efficiency of care. B. Ensure that the client's health care is holistic.C. Facilitate the client's adjustment to a new body image. D. Promote the client's highest possible level of function.

D. Promote the client's highest possible level of function.

A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse is unable to palpate the client's dorsalis pedis or posterior tibial pulse and the client's foot is pale. What is the nurse's most appropriate action? A. Warm the client's foot and determine whether circulation improves. B. Reposition the client with the affected foot dependent.C. Reassess the client's neurovascular status in 15 minutes.D. Promptly inform the primary care provider.

D. Promptly inform the primary care provider.

A 4-year-old boy has a febrile seizure during a well-child visit. What action would be a priority?A. Hyperextending the child's head while placing him on his sideB. Using a tongue blade to pry open the child's jaw C. Loosening the child's clothing to ensure a patent airway D. Protecting the child from harm during the seizure

D. Protecting the child from harm during the seizure

A client has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. What would be the nursing care most needed by the client at this time? A. Teaching the client about necessary nutritional modification B. Helping the client weigh treatment optionsC. Teaching the client about the etiology of gastritisD. Providing the client with physical and emotional support

D. Providing the client with physical and emotional support

A client has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. Which of the following actions should the nurse prioritize? A. Teaching the client about necessary nutritional modification B. Helping the client weigh treatment optionsC. Teaching the client about the etiology of gastritisD. Providing the client with physical and emotional support

D. Providing the client with physical and emotional support

A client has been diagnosed with erectile dysfunction; the cause has been determined to be psychogenic. The client's interdisciplinary plan of care should prioritize which of the following interventions? A. Penile implant B. PDE-5 inhibitors C. Physical therapy D. Psychotherapy

D. Psychotherapy

A nurse is caring for a client who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the client and notes the presence of high-pitched adventitious sounds over the client's trachea on auscultation. The client's oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurse's most appropriate action? A. Encourage the client to perform deep breathing and coughing exercises hourly. B. Reposition the client into a prone or semi-Fowler position and apply supplementary oxygen by nasal cannula.C. Activate the emergency response system. D. Report this finding promptly to the health care provider and remain with the client.

D. Report this finding promptly to the health care provider and remain with the client.

A nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider? A. Inability to use a wheelchairB. Unable to swallow liquid and solid food C. Incontinent in bowel movementsD. Requires full assistance for elimination

D. Requires full assistance for elimination

A nurse is assessing a client who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the client's pain, the nurse should anticipate that it may radiate to what region? A. Left upper chest B. Inguinal region C. Neck or jawD. Right shoulder

D. Right shoulder

A 62-year-old woman diagnosed with breast cancer is scheduled for a partial mastectomy. The oncology nurse explained that the surgeon will want to take tissue samples to ensure the disease has not spread to adjacent axillary lymph nodes. The client has asked if they will have her lymph nodes dissected, like her mother did several years ago. What alternative to lymph node dissection will this client most likely undergo? A. Lymphadenectomy B. Needle biopsyC. Open biopsyD. Sentinel node biopsy

D. Sentinel node biopsy

A child is brought to the emergency department after experiencing a series of continuous seizures. The nurse is reviewing the orders for care and treatment. Which order would be of the highest priority? A. Urinalysis B. White blood cell count C. Hemoglobin level D. Serum glucose level

D. Serum glucose level

A client has been living with a diagnosis of anemia for several years and has experienced recent declines in hemoglobin levels despite active treatment. Which assessment finding would signal complications of anemia? A. Venous ulcers and visual disturbances B. Fever and signs of hyperkalemiaC. Epistaxis and gastroesophageal reflux D. Shortness of breath and peripheral edema

D. Shortness of breath and peripheral edema

A nurse is assessing an older adult client with gallstones. The nurse is aware that the client may not exhibit typical symptoms, and that particular symptoms that may be exhibited in the elderly client may include what examples? A. Fever and painB. Chills and jaundiceC. Nausea and vomitingD. Signs and symptoms of septic shock

D. Signs and symptoms of septic shock

A critical care nurse is caring for a client with immune hemolytic anemia. The client is not responding to conservative treatments, and the client's condition is now becoming life-threatening. The nurse is aware that a treatment option in this case may include which intervention? A. HepatectomyB. Vitamin K administration C. Platelet transfusionD. Splenectomy

D. Splenectomy

The nurse has developed a teaching plan for the family of a 2-year-old boy who holds his breath when he gets frustrated. What will be most important to include in this plan?A. Provide cuddle time whenever the child begins to act out.B. Explain the child's behavior to the parents. C. Encourage the parents to interact more with the child. D. Stay close to prevent injury when he gets frustrated.

D. Stay close to prevent injury when he gets frustrated.

A nurse is caring for a client hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize? A. Strategies for maintaining an alkaline gastric environmentB. Safe technique for self-suctioningC. Techniques for positioning correctly to promote gastric healing D. Strategies for avoiding irritating foods and beverages

D. Strategies for avoiding irritating foods and beverages

A 16-year-old boy reports to the school nurse with headaches and a stiff neck. Which sign or symptom would alert the nurse that the child may have bacterial meningitis?A. Fixed and dilated pupilsB. Frequent urination C. Sunset eyesD. Sunlight is "too bright"

D. Sunlight is "too bright"

The nurse inspects the eyes of a child and observes that the sclera is showing over the top of the iris. The nurse documents this finding as:A. Decorticate posturingB. Nystagmus C. Doll's eye D. Sunsetting

D. Sunsetting

A 57-year-old male client reports that when having an erection the penis curves and becomes painful. The client's diagnosis is identified as severe Peyronie disease. The nurse should prepare the client for what likely treatment modality? A. Physical therapyB. Treatment with PDE-5 inhibitorsC. Intracapsular hydrocortisone injections D. Surgery

D. Surgery

A nurse is caring for a client who has had a plaster arm cast applied. Immediately after application, the nurse should provide what teaching to the client? A. The cast will feel cool to touch for the first 30 minutes.B. The cast should be wrapped snuggly with a towel until the client gets home. C. The cast should be supported on a board while drying.D. The cast will only have full strength when dry.

D. The cast will only have full strength when dry.

A client has just been diagnosed with prostate cancer and is scheduled for brachytherapy the following week. The client and spouse are unsure of having the procedure because their child is 3 months' pregnant. What is the most appropriate teaching the nurse should provide to this family? A. The client should not be in contact with the baby after delivery. B. The client's treatment poses no risk to the child or the infant. C. The client's brachytherapy may be contraindicated for safety reasons. D. The client should avoid close contact with the child for 2 months.

D. The client should avoid close contact with the child for 2 months.

A client with von Willebrand disease (vWD) has experienced recent changes in bowel function that suggest the need for a screening colonoscopy. What intervention should be performed in anticipation of this procedure? A. The client should not undergo the normal bowel cleansing protocol prior to the procedure.B. The client should receive a unit of fresh-frozen plasma 48 hours before the procedure. C. The client should be admitted to the surgical unit on the day before the procedure.D. The client should be given necessary clotting factors before the procedure.

D. The client should be given necessary clotting factors before the procedure.

A client recovering from a stroke has severe shoulder pain from subluxation of the shoulder. To prevent further injury and pain, the nurse caring for this client is aware of what principle of care? A. The client should be fitted with a cast because use of a sling should be avoided due to adduction of the affected shoulder.B. Elevation of the arm and hand can lead to further complications associated with edema. C. Passively exercising the affected extremity is avoided in order to minimize pain. D. The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

D. The client should be taught to interlace fingers, place palms together, and slowly bring scapulae forward to avoid excessive force to shoulder.

A 13-year-old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. Which assessment finding would rule out discharging the client? A. The client reports a headache.B. The client reports pain at the site where the ball hits his head. C. The client is visibly fatigued.D. The client's speech is slightly slurred.

D. The client's speech is slightly slurred.

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event? A. The client received a blood transfusion.B. The client's analgesia regimen was recently changed. C. The client was not repositioned during the night shift. D. The client's urinary catheter became occluded.

D. The client's urinary catheter became occluded.

A nurse is admitting a client diagnosed with late-stage gastric cancer. The client's family is distraught and angry that the client was not diagnosed earlier in the course of her disease. What factor most likely contributed to the client's late diagnosis? A. Gastric cancer does not cause signs or symptoms until metastasis has occurred. B. Adherence to screening recommendations for gastric cancer is exceptionally low.C. Early symptoms of gastric cancer are usually attributed to constipation. D. The early symptoms of gastric cancer are usually not alarming or highly unusual.

D. The early symptoms of gastric cancer are usually not alarming or highly unusual.

An orthopedic nurse is caring for a client who is postoperative day 1 following foot surgery. What nursing intervention should be included in the client's subsequent care? A. Dressing changes should not be performed unless there are clear signs of infection.B. The surgical site can be soaked in warm bath water for up to 5 minutes. C. The surgical site should be cleansed with hydrogen peroxide once daily. D. The foot should be elevated in order to prevent edema.

D. The foot should be elevated in order to prevent edema.

A client has been experiencing occasional episodes of constipation and has been unable to achieve consistent relief by increasing physical activity and improving the client's diet. When introducing the client to the use of laxatives, what teaching should the nurse emphasize? A. The effect of laxatives on electrolyte levels B. The underlying causes of constipationC. The risk of fecal incontinenceD. The risk of becoming laxative-dependent

D. The risk of becoming laxative-dependent

A nurse is providing a class on osteoporosis at the local center for older adults. Which statement related to osteoporosis is most accurate? A. High levels of vitamin D can cause osteoporosis.B. A nonmodifiable risk factor for osteoporosis is a person's level of activity. C. Secondary osteoporosis occurs in women after menopause.D. The use of corticosteroids increases the risk of osteoporosis.

D. The use of corticosteroids increases the risk of osteoporosis.

A client is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing the client the nurse notes that the client's right leg is shorter than the left leg; the right hip is noticeably deformed and the client is in acute pain. Imaging does not reveal a fracture. What is the most plausible explanation for this client's signs and symptoms? A. Subluxated right hipB. Right hip contusionC. Hip strainD. Traumatic hip dislocation

D. Traumatic hip dislocation

A nurse is creating a care plan for a client receiving nasogastric tube feedings. Which intervention should the nurse include? A. Check the gastric residual volume every 4 hours.B. Hold the tube feeding if the gastric residual volume is greater than 200 mL. C. Position client flat in bed during feedings.D. Use client assessment findings to determine tolerance of feedings.

D. Use client assessment findings to determine tolerance of feedings.

A nasogastric tube is being inserted in a client with the COVID virus. Which action should the nurse take? A. Place the client in a prone position. B. Administer bolus feedings.C. Place a mask over the client's nose. D. Wear personal protective equipment.

D. Wear personal protective equipment.

Diagnostic testing has resulted in a diagnosis of acute myeloid leukemia (AML) in an adult client who is otherwise healthy. The client and the care team have collaborated and the client will soon begin induction therapy. The nurse should prepare the client for: A. daily treatment with targeted therapy medications. B. radiation therapy on a daily basis.C. hematopoietic stem cell transplantation.D. an aggressive course of chemotherapy.

D. an aggressive course of chemotherapy.

he nurse suspects that a 4 year old with type 1 diabetes is experiencing hypoglycemia based on what findings? Select all that apply. Blurred vision Dry, flushed skin Diaphoresis Slurred speech Fruity breath odor Tachycardia

Diaphoresis Slurred speech Tachycardia

An adolescent is having an annual physical. The adolescent has a documented weight loss of 9 lb (4.08 kg). The parent states, "He eats constantly." Exam findings are normal overall, except that the child reports having trouble sleeping, and the child's eyeballs are noted to bulge slightly. Which interventions would the nurse perform based on these findings? Prepare the parent for a neurology consult. Explain why the child might need to schedule an eye exam Discuss preparing for a thyroid function test. Explain the preparation for an 8-hour fasting blood glucose test.

Discuss preparing for a thyroid function test.

The nurse is conducting discharge teaching for a client with diverticulosis. Which instruction should the nurse include in the teaching? Avoid whole grains Drink 8 to 10 glasses of water per day Use laxatives daily Avoid daily exercise

Drink 8 to 10 glasses of water per day

True or False: Viral meningitis is known for causing more serious symptoms than bacterial meningitis

False

True or false: Cancer cells adhere to the rules of the origin tissue's "boundaries," and grow more slowly than native cells. True False

False

A client sustained an open fracture of the femur 24 hours ago. While assessing the client, the nurse observes the client is having difficulty breathing, and oxygen saturation decreases to 88% from a previous 99%. What does the nurse understand might be occurring with this client? Spontaneous pneumothorax Cardiac tamponade Pneumonia Fat embolism

Fat embolism

Which potential condition in a client with pancreatitis makes it necessary for the nurse to check fluid intake and output, check hourly urine output, and monitor electrolyte levels? Dry mouth, which makes the client thirsty Frequent vomiting, and NPO status, leading to loss of fluid volume Acetone in the urine High glucose concentration in the blood

Frequent vomiting, and NPO status, leading to loss of fluid volume

What are the nurse's initial priorities for a patient who has a history of congenital adrenal hyperplasia and presents in an adrenal crisis? Select all that apply. High dose glucocorticoids (hydrocortisone) per orders IV fluids per orders Encouraging nutrition per orders Administering thyroid replacement hormone per orders

High dose glucocorticoids (hydrocortisone) per orders IV fluids per orders

A 35-year-old client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize? Insertion of a nasogastric tube Insertion of a central venous catheter Administration of a mineral oil enema Administration of a glycerin suppository and an oral laxative

Insertion of a nasogastric tube

A client has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. While all of the following may be important to the plan of care, the nurse's care should prioritize which of the following outcomes? Preventing infection Maintaining skin and tissue integrity Preventing nausea and vomiting Maintaining fluid and electrolyte balance

Maintaining fluid and electrolyte balance

According to the TNM classification system, T0 means there is No evidence of primary tumor No distant metastasis Distant metastasis No regional lymph node involvement

No evidence of primary tumor

What initial measure can the nurse implement to reduce risk of injury for a client with liver disease who is experiencing alcohol withdrawal Raise all four side rails on the bed Prevent visitiors so as not to agitate the client Pad the side rails of the bed Apply soft wrist restraints

Pad the side rails of the bed

A nurse is caring for a client who just arrived from the OR after having foot surgery. Which nursing intervention is most important for the nurse to include in the nursing care plan this shift? Examine the surgical dressing every four hours per orders Administer pain medication per orders Monitor vital signs every four hours per orders Perform neurovascular assessment every hour per orders

Perform neurovascular assessment every hour per orders

The nurse working in an outpatient infusion center suspects what complication in a patient with breast cancer who has been receiving chemotherapy over the past 6 months and complains that it is getting difficult to button her shirt, hold her fork in the usual way, and that the bottom of her feet feel "prickly." Chemo brain Peripheral neuropathy Depression Spinal cord compression

Peripheral neuropathy

What is the priorty nursing intervention for a child presenting with hyperthyroidism? Administering levothyroxine Ensuring adequate hydration Reducing environmental stimuli to minimize stress Initiating seizure precautions

Reducing environmental stimuli to minimize stress

A nurse is caring for a client with a nasogastric tube for feeding. During shift assessment, the nurse auscultates a new onset of bilateral lung crackles and notes a respiratory rate of 30 breaths per minute. The client's oxygen saturation is 89% by pulse oximetry. After ensuring the client's immediate safety, what is the nurse's most appropriate action? Perform chest physiotherapy Reduce the height of the client's bed and remove the NG tube Liase with the dietitian to obtain a feeding solution with lower osmolality Report possible signs of aspiration pneumonia to the health care provider

Report possible signs of aspiration

A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals changes in the client's cognition and behavior. What is the nurse's most appropriate response? Ensure that the client's sodium intake does not exceed recommended levels. Report this finding to the primary provider due to the possibility of hepatic encephalopathy. Inform the primary provider that the client should be assessed for alcoholic hepatitis. Implement interventions aimed at ensuring a calm and therapeutic care environment.

Report this finding to the primary provider due to the possibility of hepatic encephalopathy.

The nurse is providing care to a client with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this client? Respiratory assessment related to increased thoracic pressure Urinary output related to increased sodium retention Peripheral vascular assessment related to immobility Skin assessment related to increase in bile salts

Respiratory assessment related to increased thoracic pressure

A client received chemotherapy 24 hours ago. They are feeling slight nausea and near-complete loss of appetite. As the nurse, you will need to plan nutritional interventions based on your knowledge that: It is better to fast after chemotherapy to "starve" the tumor of glucose during chemotherapy administration Chemotherapy related nausea and vomiting can never really be controlled Small, frequent meals and snacks with pre-meal anti-emetics are indicated to support caloric needs There are no nutritional supplements that are dairy-free

Small, frequent meals and snacks with pre-meal anti-emetics are indicated to support caloric needs

A client with pancreatic cancer underwent surgery to remove a malignant tumor in the pancreas. Despite the tumor being removed, the healthcare provider informs the client that chemotherapy is indicated. Why might the healthcare provider opt for chemotherapy? To prevent metastasis To encourage angiogenesis To prevent stomatitis To prevent fatigue

To prevent metastasis

True or False: Crohn's disease may be more severe than ulcerative colitis since it can happen anywhere in the GI tract and affects all layers of the GI tract. True False

True

True or False: Drowning is the #1 cause of injury from seizures

True

True/False: The pathophysiology of an ischemic stroke involves the ischemic cascade, which includes the following chronological steps: ◦ Blood flow decreases ◦ A switch to anaerobic respiration ◦ Lactic acid is generated ◦ Change in pH ◦ Membrane pumps fail ◦ Cells cease to function

True

The nurse is caring for a client with chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency? Vitamin C Vitamin A Vitamin B12 Vitamin E

Vitamin B12

A client with severe, chronic liver dysfunction comes to the clinic with bleeding of the gums and blood in the stool. What vitamin deficiency does the nurse suspect the client may be experiencing? Vitamin D deficiency Vitamin A deficiency Vitamin C deficiency Vitamin K deficiency

Vitamin K deficiency

A client is admitted to the emergency department with reports right lower quadrant pain. Blood specimens are drawn and sent to the laboratory. Which laboratory finding should be reported to the health care provider immediately? Hematocrit 42% (normal 36-54%) WBC 22.8/mm3 (normal 4-11) Serum potassium 4.2 mEq/L (normal 3.5-4.5) Serum sodium 135 (normal 135-145)

WBC 22.8/mm3 (normal 4-11)

A client with cholelithiasis has a gallstone lodged in the common bile duct. When assessing this client, the nurse expects to note: Yellow sclerae Light amber urine Circumoral pallor Black, tarry stools

Yellow sclerae

An older adult woman's current medication regimen includes alendronate. What outcome would indicate successful therapy? A. Increased bone massB. Resolution of infectionC. Relief of bone painD. Absence of tumor spread

ful therapy?