Archer 12
A, B
The nurse is caring for a client receiving a continuous infusion of regular insulin. The nurse should plan to monitor which clinical data? Select all that apply. A. Hourly blood glucose B. Potassium C. BUN and creatinine D. Gastric pH E. Fasting blood glucose
C
The nurse is caring for a client receiving prescribed sumatriptan. Which client report would indicate that the client is experiencing an adverse response? A. Nervousness B. Warm sensation C. Angina D. Tingling sensation
50 mL/hr
The primary healthcare provider (PHCP) prescribes magnesium sulfate at 2 grams/hour. The medication label reads magnesium sulfate 20 grams in 500 mL of 0.9% saline. How many mL per hour will administer the prescribed dose? Fill in the blank.
D
The primary objective in identifying similarities and differences among cultural beliefs of a patient is to: A. Communicate with the family B. Make sure the proper diet is ordered C. Perform a spiritual consult D. Avoid making assumptions
C
The nurse is assessing a client suspected of having the early stages of dementia. Which defense mechanism would the nurse expect? A. Identification B. Projection C. Denial D. Conversion
B
The nurse is caring for a client with a tracheostomy. Which of the following items is essential to have at the bedside? A. Air humidifier B. Inner cannula C. Nasal cannula oxygen D. Tracheostomy brush
D
The nurse overhears another nurse state to a client "If you do not behave, I will restrain you." This statement demonstrates an example A. battery. B. libel. C. slander. D. assault.
C
A 12-year-old child is scheduled for an appendectomy. The child's mother has already signed the consent form and the child is about to be wheeled by the nurse to the operating room when her father arrives. It is made known to the nurse that the child's parents are divorced and have joint legal custody. Which action by the nurse is most appropriate? A. Have the father sign a new consent form. B. Cancel the operation. C. Proceed with the child's operation. D. Notify the physician.
A, C, D
A 3-year-old child presents to the ED with a sore throat, large red, edematous epiglottis, drooling, and moderate subcostal retractions. On exam, heart rate is 188/min, respiratory rate is 72/min, blood pressure is 88/56 mmHg, and temperature is 39 degrees Celsius. The nurse suspects epiglottitis. She should avoid which of the following actions to maintain the child's airway? Select all that apply. A. Taking an oral temperature B. Obtaining a blood culture C. Visualizing the posterior pharynx D. Obtaining a throat culture
B
A G1P0 client in the first trimester of pregnancy informs the clinic nurse that she has replaced coffee with hot tea at breakfast. Her hemoglobin level was 10 g/dL today. She tells the nurse that she is taking her iron supplements twice daily. Which response by the nurse would be most appropriate? A. "You're off to a great start! Tea has much less caffeine than coffee." B. "A great addition to your cup of tea would be a little lemon. It's going to help you absorb your iron pill better." C. "Right now your iron levels are low. Please eliminate all caffeine." D. "That's alright. Drinking coffee or tea won't affect the fetus."
A, B, F
A cast is applied to a thirteen-month-old girl for the treatment of talipes equinovarus (clubfoot). Which of the following instructions should the nurse give the child's mother regarding the child's care while in the cast? Select all that apply. A. "It is important to do frequent skin checks around the edges of the cast." B. "Pay attention if your child expresses discomfort that may suggest numbness or tingling in her toes." C. "Reassure your child that this type of cast will be removed in a week for good." D. "Check the temperature and color of the skin on your child's feet." E. "Ask the child once per day if she feels that the cast is too tight." F. "Call the doctor if the child has pain unrelieved by medication."
B
A client admitted to the medical ward for convulsions is receiving intravenous magnesium sulfate. Which of the following signs indicate an expected side effect of the drug? A. Less frequency of urination B. Frequent sleepiness C. Absence of a knee jerk reflex D. Decreased respirations
D
A client arrives to the emergency department (ED) with complaints of vomiting for three days. The client's spouse reports the client has been getting progressively weaker with increasing dyspnea. The nurse notes that the client's respiratory rate is ten (10) breaths/min. An electrocardiogram (ECG) indicates tachycardia with a heart rate of 120 beats/min. Arterial blood gases (ABG) are subsequently ordered and drawn. When reviewing the ABG results, the nurse should anticipate which of the following? A. A decreased pH and an elevated CO2 B. An elevated pH and a decreased CO2 C. A decreased pH and a decreased HCO3- D. An increased pH with an increased HCO3-
B
A client in the medical ward developed a sudden drop in blood pressure, difficulty of breathing, and cyanosis after receiving intravenous penicillin. With the nurses' understanding of anaphylactic reactions, what can the nurse conclude is the cause of this reaction? A. Potent antibodies were formed when the antibiotic was being infused into the patient. B. The client was previously exposed to penicillin which enabled his body to produce antibodies. C. Passive immunity to penicillin was developed by the client. D. Atopic sensitization occurred.
C
A client is admitted to the ward for exacerbation of his rheumatoid arthritis. The nurse would expect the physician to prescribe which medication to combat the client's inflammation and produce immunosuppression? A. Allopurinol B. Azathioprine C. Prednisone D. Naproxen sodium
C
A client presents to the emergency department (ED) with a suspected ectopic pregnancy. The nurse anticipates which diagnostic test will confirm this finding? A. Nonstress testing B. Abdominal radiograph (x-ray) C. Transvaginal ultrasound D. Doppler transducer
A
A client tells the nurse that they know their baby is in the "Trust vs. Mistrust" stage and want to learn more about it. An accurate explanation from the nurse would be: A. "Trust vs. Mistrust" is the first stage of development in Erikson's theory that describes the eight developmental tasks everyone must face. B. It is a theory based on how an individual derives pleasure from different parts of the body. C. It is a theory that outlines the development of logical thinking. D. It is parallel to Selye's adaptation theory.
A
A client was recently transferred back to their room following a below-knee amputation (BKA). While monitoring the client, which of the following would prompt the nurse to assess the client further for a developing complication? A. Increasing restlessness of the client B. Blood pressure of 140/78 mmHg C. Pulse rate of 89 bpm D. Hypoactive bowel sounds in all four quadrants
105 mg
A client with a stroke is prescribed alteplase. The prescription is for 0.9 mg/kg. The client weighs 257 pounds. How many milligrams will this equal? Round your answer to the nearest whole number. Fill in the blank.
D
A mother brings her toddler to the pediatrician. Her child is on digoxin for congestive heart failure. The nurse tells the mother about signs of digoxin toxicity. Which statement by the mother would indicate an understanding of the topic? A. "I will have my son checked if his respirations are less than 20." B. "I will stop digoxin if my son does not gain any weight after 6 months." C. "I will avoid feeding him potassium rich food." D. "I will have the doctor see my son if he vomits."
B
A nurse cares for a client in the first trimester of pregnancy and notes that the client's serum potassium level is 2.9 mEq/L. Which of the following assessment findings is likely related to this lab finding? A. Alcohol consumption during pregnancy B. Hyperemesis gravidarum C. Lack of weight gain since the onset of pregnancy D. Food aversions
D
A nurse in a gynecology clinic is assessing a first-time client (G1P0) who is eight weeks pregnant. Which assessment finding would alert the nurse of a high-risk pregnancy? A. The client reports nausea and vomiting four to five mornings per week. B. The client expresses her ambivalence toward the pregnancy to the nurse. C. The client reports intermittent constipation since learning she was pregnant. D. The client reports intermittent vaginal spotting and abdominal cramping.
D
A nurse is caring for a client receiving total parenteral nutrition (TPN). Strict surgical asepsis is required when changing TPN dressings and tubing because: A. The TPN requires refrigeration, and once the TPN is opened and is no longer refrigerated, it presents a risk for infection. B. The presence of manganese and zinc in TPN increases the risk of infection. C. The magnesium and cobalt often present in TPN increases the risk of infection. D. The high concentration of dextrose in TPN increases the risk of infection.
B
A nurse is caring for a client taking sildenafil. While reviewing the client's other medications, which medication requires follow-up? A. Furosemide B. Isosorbide C. Atorvastatin D. Losartan
C
A nurse is conducting pre-operative teaching to a client who will undergo surgery in 1 week. Which response by the client would prompt the nurse to give additional teaching? A. "Aspirin can possibly cause bleeding even after surgery." B. "Aspirin can adversely affect my clotting ability" C. "I should stop aspirin one day prior to my surgery." D. "It is important that I talk to my physician about the possibility of stopping aspirin before the surgery."
A, E
A nurse is educating a student nurse about blood transfusions. Which of the following statements by the student nurse indicates the need for additional teaching? Select all that apply. A. "If a client should develop a fever, it is a sign of a hemolytic reaction." B. "Transfusion-related graft versus host disease most commonly occurs in immuno-suppressed individuals." C. "Transfusion-associated circulatory overload (TACO) is more common in clients with renal failure." D. "It is important to ask the client about history of previous blood transfusions." E. "Pre-medication with diphenhydramine and acetaminophen is always needed before transfusion."
44 mg
A nurse is preparing to administer gentamycin to a child. The order is for 3 mg/kg IV daily in three divided doses. The client weighs 97 lbs. How many milligrams should the nurse administer per dose? Fill in the blank. Round your answer to the nearest whole number.
B
A patient being treated for hypertension is assessed by the nurse and found to have poor gait and impaired balance. What would the nurse's appropriate action be? A. Do nothing as this has nothing to do with why the patient was hospitalized. B. Speak with the attending physician about his concerns and request a referral to physical therapy. C. Speak with the attending physician about his concerns and request a referral for the patient to go to the hospital gym. D. Add this issue to the nursing care plan and have daily gait/balance training as an intervention.
B
A patient has recently been diagnosed with leukemia. Which of the following symptoms would a healthcare professional expect? A. Dyspnea, malaise, and hypotension. B. Bruising, fatigue, and bone pain. C. Bradycardia, hypotension, and palpitations. D. Paresthesia, facial rash, and abdominal pain.
B
A patient is about to get a Salem sump NG tube inserted. Which position should the nurse place the patient in? A. Supine, with the head of the bed elevated at 30° - 45° B. Supine, with the head of the bed elevated at 60° - 90° C. Knee-chest position D. Prone position
C
A patient is scheduled for an IV pyelogram. He asks the nurse what he needs to do to prepare for the test. The correct response is: A. "You need to have a full bladder for the test to be successful." B. "You need to alert the technician if you feel any burning after the dye is injected." C. "You will receive a bowel preparation before the test can be performed." D. "You must lie on your back for four hours after the test is performed."
B
A patient with bladder cancer is being evaluated for metastasis. Which of the following locations is not a common site for metastasis? A. Lung B. Brain C. Liver D. Bone
D
A pregnant client is brought into an emergency department by her husband. The client reports she is currently at 37 weeks gestation and began experiencing severe abdominal pain and bright red vaginal bleeding which "runs down my legs" thirty minutes prior to arrival. She currently rates her abdominal pain 10/10. Based on this information, which assessment method should the emergency room nurse refrain from performing? A. External fetal heart rate monitoring B. Abdominal palpation C. Measurement of vital signs D. Internal vaginal examination
C
After a patient experiences a motor vehicle accident (MVA) and suffers a complete spinal cord injury to L3, the nurses would assess for loss of motor function in the: A. Abdomen B. Arms C. Legs D. Chest
A
An emergency room nurse is assigned to triage. Four people check-in at the same time. Which patient should receive immediate priority care? A. A 29-year-old female two-day post-cesarean section that complains of a headache and leg swelling. B. A 15-year-old female with LLQ pain for three days. C. A 55-year-old male with dull RUQ pain & history of pancreatitis. D. A 2-year-old female child with pain upon urination.
B
As you are taking the "staff only" elevator, you encounter a nurse who is now caring for a client, Mr. B, whom you provided care for the week before. You ask the nurse how Mr. B is doing, and the nurse tells you how significantly his condition has deteriorated over the past week. You have now: A. Asked an appropriate question since you are in a private, staff-only elevator. B. Violated Mr. B's right to healthcare information privacy. C. Demonstrated your compassion for Mr. B. D. Asked an appropriate question since you anticipate Mr. B will return to you as a client shortly.
A
At her first visit, a prenatal client is found to be suffering from mildly high blood pressure. The nurse should have her client reduce which dietary component? A. Salt B. Magnesium C. Potassium D. Calcium
D
At the initial prenatal visit, and often the subsequent visits, the health care provider will obtain a clean catch urine specimen to look for all of the following, except: A. Ketones B. Sexually transmitted infections C. Glucose D. Testosterone levels
D
Based on the following choices and accompanying rationales, which of the following clients would be the highest priority? A. The need to develop trust versus mistrust since this is the most basic of all needs. B. The need to be free of fear and anxiety, as these feelings inhibit coping. C. The need for adequate cardiovascular functioning because without this, life is unsustainable. D. The need for a patent airway as life cannot be sustained without this.
Position the patient with the head slightly elevated Aspirate gastric contents Measure the aspirate Return the aspirate Begin the prescribed nasogastric feeding
Before administering a nasogastric feeding to a preterm infant, the nurse prepares to aspirate the residual fluid from the stomach. Please place the following nursing actions in sequential order.
B
Following surgery for a prolapsed bladder, a 74-year-old female client is two days postoperative with an indwelling urinary catheter. While the nurse is making morning rounds, the client states, "I feel like peeing again!" The most appropriate response for the nurse is: A. "It's just bladder spasms. Nothing to worry about." B. "Let me look at your urine bag to ensure it's draining properly." C. "You should do Kegel exercises regularly to stop this urge to void." D. "Is this the first time this has happened?"
D
In which age group is child abuse most likely to occur? A. Ten-years-old or older B. 6-10 years old C. 4-6 years old D. Birth-3 years old
D
Increased levels of which of the following hormones is related to hyperemesis gravidarum? A. Testosterone B. Progesterone C. Aldosterone D. Estrogen
A, C
Malignant hyperthermia is a serious adverse reaction that can occur after the administration of which of the following medications? Select all that apply. A. Halothane B. Vancomycin C. Succinylcholine D. Omeprazole
D
Minimizing and challenging the client's report of pain and pain intensity is: A. Often necessary if the client has a history of substance abuse. B. Often necessary if the client has a history of drug seeking behavior. C. Contrary to and in violation of the Nightingale oath. D. Contrary to and in violation of the American Nurses Association's standard of care.
A
Risk factors for preeclampsia include all of the following, except: A. Chronic hypotension B. Age C. Race D. Family history of preeclampsia
C
Select the developmental age group that is accurately paired with the normal number of hours of sleep (over the span of 24 hours). A. The neonate: 14 to 15 hours of sleep each day B. The infant: 13 to 14 hours of sleep each day C. The toddler: 12 to 14 hours of sleep each day D. The preschool age child: 12 to 14 hours of sleep each day
Define the task to be done Determine who should do the task Monitor the performance of the task Provide feedback
The RN in charge is making assignments for the shift. The steps in the delegation process include the following: Provide feedback Define the task to be done Determine who should do the job Monitor the performance of the task Place these steps in the correct ordered sequence.
B
The charge nurse is planning client care assignments for the medical-surgical unit. Which client should the charge nurse assign to the nurse floated from labor and delivery? A client A. receiving a continuous infusion of heparin for pulmonary embolism. B. eight post-operative following an open appendectomy. C. with a water-seal chest tube for a pneumothorax. D. admitted with an exacerbation of congestive heart failure (CHF).
C
The client in the unit is expressing to the nurse that his son's complaining is making him feel anxious. He asks the nurse if she will talk to his son during his visit later in the day. Which is the most therapeutic response by the nurse? A. "Tell me about your son's complaints." B. "What do you think are the reasons for his complaints?" C. "Let's talk about how you can bring this up later when he arrives." D. "He's your son, why do you want me to talk to him?"
D
The client is admitted to the ER for atrial fibrillation. The physician on duty decides to cardiovert the patient in order to reverse the dysrhythmia and the nurse commences to prepare the patient for the procedure. All of the following are accurate preparations, except: A. Obtain informed consent. B. Maintain NPO and acquire a patent IV line. C. Give the client a brief explanation of the procedure and what he will be expecting. D. Have another nurse hold the client down when doing the procedure.
C
The client is undergoing labor in the delivery room. The fetal monitor shows that there are late decelerations. What is the initial action of the nurse? A. Call the doctor immediately. B. Let the client deep-breathe slowly and relax. C. Let the client lie on her left side. D. Prepare for Cesarian delivery.
A
The health care provider (HCP) has prescribed 50,000 units of heparin via subcutaneous injection for a client with a pulmonary embolism (PE). The vial on hand contains 20,000 units per mL. The nurse calculates that the drug volume to be administered will be 2.5 mL. The nurse verifies that the client understands the action of the medication when the client states: "This medication will help prevent blood clots." After double-checking the dosage to be administered, the nurse decides to do which of the following? A. Hold administration and contact the health care provider (HCP) to clarify the medication order B. Administer 0.2 mL of the medication instead of the calculated volume of 2.5 mL C. Administer the prescribed dose while monitoring the client for signs of bleeding D. Administer the medication as prescribed, initiate bleeding precautions, and instruct the client to remain in bed to prevent injury
A, C, D
The new nurse understands that the high-quality cardiopulmonary resuscitation (CPR) for an adult consists of which of the following: Select all that apply. A. Compression rate of 100 to 120 per minute. B. Compression depth of 1.5 inches. C. Allow full chest recoil between compressions. D. Rotate compressor at least every 2 minutes.
D
The nurse has been made aware of the following client situations. The nurse should initially follow up with the client who is A. receiving albuterol via a nebulizer and reports feeling 'nervous'. B. awaiting a home healthcare referral following total hip arthroplasty. C. six hours post-op from a hysterectomy and is reporting nausea. D. reporting that their arm is 'sleeping' after having a cast for a fracture applied three hours ago.
A, C, D
The nurse is assessing a client with hepatitis A. Which of the following would be an expected finding? Select all that apply. A. Pruritus B. Bloody stools C. Abdominal pain D. Scleral icterus E. Periumbilical bruising
C
The nurse cares for a client and receives a phone call from the laboratory department regarding a critical sodium level of 122 mEq/L. The nurse should take which initial action? A. Notify the primary healthcare provider B. Implement seizure precautions C. Read back the result for verification D. Recollect the laboratory specimen
A, C
The nurse educates a family with a child with phenylketonuria (PKU). It would be appropriate for the nurse to recommend that the child avoid which foods? Select all that apply. A. Pork tenderloin B. Green beans C. Cheese omelets D. Pears E. Almond milk
B
The nurse has received a prescription for rivaroxaban. The nurse understands that this medication is prescribed to treat which condition? A. Pulmonary Hypertension B. Venous Thromboembolism (VTE) C. Congestive Heart Failure D. Hyperlipidemia
B
The nurse identifies that one of her clients will need education on caring for their stoma and education on how to self-catheterize by three weeks post-op. Based on this information, which of the following urinary diversion methods does this client have? A. Vesicostomy B. Kock Pouch C. Ileal conduit D. Condom Catheter
A
The nurse in charge of the labor and delivery department is making the patient assignments for the day. Which patient should the most experienced nurse receive? A. A 40-week pregnant patient attached to the fetal monitor having late decelerations. B. A 39-week pregnant patient in labor with contractions 3 minutes apart. C. A 33-week pregnant patient with triplets who is on bed rest. D. A 26-week pregnant patient who is having Braxton Hicks contractions.
C
The nurse in the nursery is caring for a 24-hour-old infant. The nurse suspects the infant of having pyloric stenosis. Which of the following manifestation be most indicative of the nurse's suspicion? A. Melena B. Currant jelly stools C. Projectile vomiting D. Steatorrhea
B
The nurse in the post-anesthetic care unit has just received a patient from the OR that has undergone a coronary artery bypass graft (CABG). The nurse formulates a nursing diagnosis of "decreased cardiac output related to alterations in preload/afterload/contractility/heart rate." What nursing interventions should be implemented in the nursing care plan based on the formulated nursing diagnosis? A. Monitor the patient's arterial blood gas constantly. B. Monitor the patient's weight daily and calculate the change. C. Administer prescribed opioids. D. Monitor mediastinal chest tubes for hourly output.
D
The nurse is assessing a pediatric client who presented with signs of intussusception. Which of the following parameters holds the least weight with the nurse? A. Abdominal girth B. Quality of vomitus C. Pain pattern D. Familial history
A, B, E
The nurse is assigned to care for a client with a sodium level of 122 mEq/L. Which assessment findings does the nurse anticipate based on this lab result? Select all that apply. A. Confusion B. Abdominal cramps C. Tall, peaked t-waves D. Hypoactive bowel sounds E. Nausea and vomiting
B
The nurse is assisting the physician with a lumbar puncture to assess for meningitis. What should be the first nursing action of the nurse? A. Lay the client on his side. B. Ask the client to void. C. Obtain an advanced directive from the client. D. Withhold food and drinks from the client prior to the procedure.
A, B, D
The nurse is caring for a 30-year-old patient who has developed iron-deficiency anemia during pregnancy. Which complication would this patient be at an increased risk for due to iron deficiency anemia? Select all that apply. A. Low birth weight B. Preterm delivery C. Gestational diabetes D. Perinatal mortality
D
The nurse is caring for a 4-year-old child who is being hospitalized due to complications from an autoimmune disorder, frequent infections, and a low white blood cell count. This child is very nervous about being in the hospital. Which intervention should the nurse implement to address this child's fears? A. Provide the child with a private room B. Encourage them to play with other children in the common area C. Advise the parents to only visit during visiting hours D. Allow the parents to stay as much as they'd like
B
The nurse is caring for a client admitted to the acute care facility. The nurse takes a phone call from the client's neighbor who wants to know where the client is located. The nurse should A. inform the individual that this information cannot be released. B. provide the caller with the client's current location. C. not acknowledge the presence of this individual. D. inquire with the caller as to the reasoning for the information.
B, C, E
The nurse is caring for a client at 32 gestational weeks. Which laboratory data should be reported to the primary healthcare provider (PHCP)? Select all that apply. A. Hemoglobin 11.5 g/dL B. Platelets 90,000 mm3 C. Fasting blood glucose 254 mg/dL D. White blood cell 9,500 mm3 E. Creatinine 3.9 mg/dL
A
The nurse is caring for a client diagnosed with multiple myeloma. The nurse reviews the client's lab values and notes a serum calcium level of 14 mg/dL. What is the priority action the nurse should take? A. Notify the physician B. Document the finding C. Continue to monitor the patient D. Remove the patient from the telemetry monitor
B
The nurse is caring for a client following a bedside thoracentesis. Which action should the nurse take immediately following the procedure? A. Instruct the client to take slow, shallow breaths B. Assess the client's respiratory status C. Label the lab specimen for culture D. Provide nasal cannula oxygen
B
The nurse is caring for a client following a large volume paracentesis. To prevent hypovolemic shock, the nurse anticipates the primary healthcare provider (PHCP) to prescribe an infusion of A. 0.9% saline. B. Albumin. C. Mannitol. D. 0.45% saline.
A
The nurse is caring for a client immediately following transsphenoidal hypophysectomy. It would be essential for the nurse to obtain a prescription for which medication? A. Ondansetron B. Methimazole C. Omeprazole D. Methylphenidate
B
The nurse is caring for a client in the emergency department. The client is short of breath upon arrival to the ED and is coughing up purulent sputum. Oxygen is being administered at 2 liters per minute via nasal cannula. The client's blood pressure is 100/58 mmHg, pulse is 88, and respiratory rate is 24. The client is afebrile with an oxygen saturation of 92%. The results of arterial blood gas testing are: pH = 7.25, PaO2 = 93, PaCO2 = 69, and HCO3 = 25. The nurse understands that this ABG shows: A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis
A, B
The nurse is caring for a client newly diagnosed with heart failure. Which of the following medications would the nurse anticipate to be prescribed? Select all that apply. A. Furosemide B. Lisinopril C. Diltiazem D. Naproxen E. Prednisone
A, C, D
The nurse is caring for a client on bed rest for a week following a right hip fracture. Which of the following findings, if noted in the client, would indicate signs of complications due to immobility? Select all that apply. A. An area of the client's sacrum is unable to be blanched B. The skin and the sclerae are yellow C. Crackles in the bases of the client's lungs D. Swelling and tenderness in the left calf E. The client is using the bedpan to void
C
The nurse is caring for a client presenting to the clinic with reports of abdominal cramping, bloating, and diarrhea after drinking milk. The nurse suspects that the client is at the highest risk for A. Pancreatitis B. Celiac disease C. Lactose intolerance D. Peptic ulcer disease
200 mL
The nurse is caring for a client receiving a continuous infusion of heparin. The label reads 25,000 units of heparin in 500 mL of Dextrose 5% in water (D5W). The client is receiving 1,250 units per hour. How many milliliters (mL) did the client receive in an eight-hour shift? Fill in the blank.
A, B, D, E
The nurse is caring for a client taking prescribed clozapine. Which clinical data should the nurse monitor? Select all that apply. A. Weight B. Complete blood count (CBC) C. Urine specific gravity (USG) D. Fasting blood glucose E. Total cholesterol
A, C, E
The nurse is caring for a client who arrives to the emergency department (ED) complaining of chest pain radiating to the arm. The nurse should do which of the following? Select all that apply. A. Obtain an electrocardiogram (ECG) B. Prepare the client for prescribed cardioversion C. Establish intravenous (IV) access D. Insert an indwelling urinary catheter E. Administer prescribed nitroglycerin
A
The nurse is caring for a client who has been prescribed depot medroxyprogesterone acetate. Which of the following statements, if made by the client, requires follow-up? A. "I will need another injection in 8 weeks." B. "I may gain weight while on this medication." C. "I can expect increased vaginal bleeding." D. "I should increase my weight-bearing exercises."
A
The nurse is caring for a client who has been prescribed olanzapine. Which of the following assessment findings would warrant immediate notification to the primary healthcare physician (PHCP)? A. Muscle rigidity B. Weight gain C. Hyperglycemia D. Fatigue
D
The nurse is caring for a client who has been prescribed sertraline for major depressive disorder. It would be a priority for the nurse to assess for which of the following? A. Insomnia B. Sexual side-effects C. Weight gain D. Suicidal ideation
A, B, E
The nurse is caring for a client who has developed Malignant Hyperthermia. Which of the following actions should the nurse take? Select all that apply. A. Apply a cooling blanket B. Insert indwelling urinary catheter C. Monitor hourly blood glucose D. Obtain blood cultures E. Administer prescribed Dantrolene
B
The nurse is caring for a client who has fluid volume deficit receiving intravenous fluids. Which of the following would indicate the client is achieving the treatment goals? A. Urine output 20 mL/hr B. BUN 15 mg/dL C. Urine specific gravity 1.039 D. Flattened jugular veins
A
The nurse is caring for a client who has pertussis. Which infection control precaution should the nurse implement? Select all that apply. A. Wear a surgical mask when working within three feet of the client B. Provide disposable dishes for meals C. Keep the patient's room door closed D. Provide the patient with a portable fan E. Maintain negative air pressure F. Apply an N95 mask to the patient during transport G. Place the patient in a room near the nurse's station
B
The nurse is caring for a client who is of the Islamic faith. The client has died. The nurse should take which appropriate action? A. Prepare the client for cremation B. Position the client facing Mecca C. Keep the client's eyelids open D. Keep the client uncovered
A
The nurse is caring for a client who is postoperative and at risk for venous thromboembolism (VTE). Which of the following medications would prevent this complication? A. Enoxaparin B. Verapamil C. Tranexamic acid D. Aspirin
B
The nurse is caring for a client who is receiving prescribed doxorubicin. Which of the following findings would warrant immediate follow-up? A. Anorexia B. Fever C. Alopecia D. Malaise
A, D
The nurse is caring for a client who is receiving prescribed ketorolac. Which of the following client findings would indicate a therapeutic response? Select all that apply. A. Decreased pain B. Increased urinary output C. Decreased blood pressure D. Decreased temperature E. Increased muscle coordination
B, C, D
The nurse is caring for a client who is receiving prescribed olanzapine. Which findings would indicate that the client has an undesired effect of this medication? Select all that apply. A. Weight loss B. Hyperglycemia C. Weight gain D. Hyperlipidemia E. Nystagmus
A, B, C, F
The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect? Select all that apply. A. Unilateral frontotemporal pain B. Drowsiness C. Phonophobia D. Shuffling gait E. Dysphagia F. Vomiting
B
The nurse is caring for a client with a paralytic ileus following an appendectomy. Which intervention would be appropriate for the nurse to take? A. Assess the client for hyperkalemia B. Prepare for the insertion of a nasogastric tube C. Assess the surgical wound for approximation D. Instruct the client to chew their food more slowly
A, D, F
The nurse is caring for a client with acute pulmonary edema. The nurse plans to take which actions? Select all that apply. A. Administer prescribed furosemide B. Elevate the head-of-the-bed to 60 degrees C. Obtain a STAT chest computed tomography (CT) scan D. Notify the Rapid Response Team (RRT) E. Provide oxygen via nasal cannula F. Administer prescribed morphine
B
The nurse is caring for a client with angle-closure glaucoma. It would be correct to place the client in which position? A. High fowler's B. Supine C. Semi fowler's D. Left lateral recumbent
A
The nurse is caring for a client with cancer experiencing chronic pain and episodes of breakthrough pain. Which prescription should the nurse request from the primary healthcare provider (PHCP) to provide effective pain control? A. Hydromorphone via patient-controlled analgesia (PCA) B. Morphine intramuscular (IM) as needed (PRN) for pain C. Oxycodone extended-release (ER) by mouth (PO) D. Ketorolac via intravenous (IV) push
D
The nurse is caring for a client with end-stage renal disease who receives prescribed sevelamer. Which of the following findings would indicate a therapeutic response? A. Decreased serum calcium levels B. Increased hemoglobin and hematocrit C. Decreased serum potassium levels D. Decreased serum phosphorus levels
A
The nurse is caring for a client with hypernatremia. Which prescribed intravenous fluid (IVF) would be appropriate? A. Dextrose 5% in water (D5W) B. 3% saline C. Lactated ringers D. 0.9% Saline
A
The nurse is caring for a client with hypokalemia scheduled to receive the prescribed 20 mEq of intravenous (IV) potassium. Which client assessment requires notification of the primary healthcare provider (PHCP)? A. Oliguria B. Abdominal distention C. Muscle weakness D. Weak peripheral pulses
B, C
The nurse is caring for a client with incontinence-associated dermatitis. The nurse should take which action? Select all that apply. A. Cleanse the affected area with isopropyl alcohol B. Apply zinc oxide to the affected area C. Use an incontinence pad instead of a brief D. Applying an extra incontinence brief to encapsulate the moisture E. Apply a transparent dressing to the affected area
C
The nurse is caring for a client with urge incontinence. Which of the following actions would be appropriate for the nurse to take? A. Administer prophylactic antibiotics. B. Teach the client intermittent self-catheterization. C. Have the client void on a timed schedule. D. Provide caffeinated beverages with meals.
A
The nurse is caring for a group of premature infants. Which action is most important in preventing healthcare-acquired infection? A. Performing frequent hand hygiene B. Disinfecting commonly touched surfaces C. Screening visitors for illness D. Administer prophylactic antibiotics
A
The nurse is caring for a one week post-operative right below-the-knee amputation client with peripheral arterial occlusive disease. The nurse cannot palpate a pedal pulse in the client's left foot. What is the nurse's next action? A. Ask the client if he feels numbness on the left foot and ask him to move his left foot. B. Check the pulse using a doppler device. C. Lower the client's leg and check for a pulse again. D. Apply a warm compress to the client's leg.
C
The nurse is caring for a patient who is recovering from open-heart surgery. For the first 24 hours following the surgery, there is a noticeable pinkish fluid oozing from the incision site. Which phase of the inflammatory response does this represent? A. Vascular response B. Cellular response C. Exudate formation D. Healing
A
The nurse is caring for a patient with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins including a minimal amount of serous exudate. Which of the following interventions is contraindicated for this patient? A. Apply TED hose to bilateral legs B. Assess the need for smoking cessation C. Physical therapy consult D. Obtain Ankle-Brachial Index (ABI) with a hand-held Doppler
C
The nurse is caring for a post-operative client at high risk for pneumonia. Which intervention would be most effective in the prevention of this complication? A. Passive range of motion B. Sequential compression devices (SCDs) C. Early ambulation D. Prophylactic antibiotics
A
The nurse is caring for an infant with developmental dysplasia of the hip (DDH). Which of the following prescriptions would the nurse anticipate from the primary healthcare provider (PHCP)? A. Pavlik harness B. Compression hose C. Knee immobilizer D. Continuous passive motion
D
The nurse is caring for an older adult client undergoing bowel prep for a scheduled colonoscopy. Which nursing diagnosis is the priority to integrate into the care plan? A. Deficient knowledge B. Altered elimination pattern C. Impaired skin integrity D. Risk for falls
A
The nurse is caring for assigned clients. The nurse should recognize that the client at greatest risk for compartment syndrome is the client who has which of the following? A. A left tibial fracture that was recently placed in a cast B. Swelling in the ankles and is wearing compression stockings C. Chronic osteomyelitis of the right femur D. Skin traction following a left hip fracture
B
The nurse is developing a care plan for a toddler who has autism. What information regarding the child is most important to obtain from the parents? A. Height and weight B. Bedtime routine C. Vaccine history D. Developmental stage
D, E
The nurse is developing a plan of care for a client with a wet-suction chest tube prescribed wall suction. Which interventions would be appropriate to include? Select all that apply. A. Apply clamps to the tubing to secure it to the bed. B. Strip the tubing at least once every eight hours. C. Report any bubbling in the suction control chamber. D. Ambulate the client with the device below the insertion site. E. Palpate around the insertion site for any crackles or popping.
A, B, C, D
The nurse is developing a staff in-service on negligence. It would indicate correct understanding if the participant states that which element must be met in a negligent lawsuit? Select all that apply. A. Duty owed B. Breach of duty owed C. Causation D. Harm or damages E. Beneficence
A
The nurse is discussing sudden infant death syndrome (SIDS) with the parents of a newborn. Which of the following statements, if made by the parents, would require follow-up? A. "I have been keeping my baby warm with extra blankets while he sleeps." B. "I give my baby a pacifier at night while he sleeps." C. "I am keeping my baby up to date on his scheduled vaccinations." D. "I replaced my baby's sheepskin bedding with a firm mattress."
D
The nurse is going over the list of assigned clients for the shift. The nurse knows which client is most at risk for experiencing a fluid volume deficit? A. A client with cirrhosis B. A client with an ileostomy and normal amount of output C. A client with a BUN of 32 and creatinine of 2.7 D. A client with diabetes insipidus and an NG tube set to low intermittent wall suction
B
The nurse is implementing orders for a client undergoing a barium enema. Aside from the radiology department, which hospital department should be notified of the procedure? A. The cardiac catheterization department. B. The dietary department. C. The nuclear medicine department. D. The hospital laboratory department.
D
The nurse is interviewing a client in the clinic looking to establish care. The nurse determines the client is demonstrating altruism by A. justifying illogical ideas, actions, or feelings by developing acceptable explanations. B. reverting to an earlier, more primitive, and childlike pattern of behavior. C. channeling anger from an unacceptable activity to one that is acceptable. D. a largely unconscious motivation to feel caring and concern for others.
A
The nurse is interviewing a client who is assessed to have poor muscle coordination, stooped posture, and slow movements. Which medication on the client's daily medication list would most likely cause these findings? A. Haloperidol B. Nifedipine C. Venlafaxine D. Prazosin
A
The nurse is observing a client ambulate with crutches. It would require follow up by the nurse if the client is observed A. with the crutches placed 2 inches in front of and 4 inches to the side of each foot. B. placing weight on the crutch and then steps up the first step of stairs with the unaffected leg. C. drying the rubber tips of the crutches with a paper towel after they have become wet. D. with both of their elbows flexed between 15 and 30 degrees.
A
The nurse is observing a student prepare to perform a sterile procedure. Which action by the student would require follow-up? The student A. reaches over the sterile field to grab sterile gloves. B. establishes the sterile field on a dry surface. C. uses slow movements when setting up sterile drapes. D. keeps the sterile field at their waist level.
C
The nurse is performing a head-to-toe assessment for an older adult. Which finding from the integumentary assessment does the nurse recognize as a normal age-related change? A. Moist skin B. Increased nail growth C. Dry, itchy skin D. Increased skin pigmentation
B, C, D, E
The nurse is performing a physical assessment on a client with Cushing's disease. Which assessment findings should the nurse expect? Select all that apply. A. Hypotension B. Acne C. Hirsutism D. Buffalo hump E. Truncal obesity
C
The nurse is planning a community health course about the prevention of Lyme disease. Which of the following information should the nurse include? A. "You should try limiting your outdoor activities between 10 a.m. and 4 p.m." B. "Wear sunglasses that wrap around and block UVA and UVB rays." C. "Wear long-sleeved clothing when in heavily wooded areas." D. "Apply sunscreen with at least an SPF of 30."
D, E
The nurse is planning a staff development conference about pain management. Which statement would be appropriate to include? Select all that apply. A. Infants do not have developed pain sensors. B. A lack of behavioral signs of pain negates pain. C. The amount of pain has a positive correlation with the extent of tissue damage. D. Self-report is the most reliable method of pain assessment. E. Analgesics should be administered via the oral route when possible.
A, B, D
The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss? Select all that apply. A. Diabetes mellitus B. Menieres disease C. Excessive cerumen D. Exposure to loud noise E. Excessive fluid
A
The nurse is preparing to assess a child with cystic fibrosis at the outpatient clinic. The nurse anticipates that the primary healthcare provider (PHCP) will order which routine laboratory test? A. Blood glucose B. Total cholesterol C. 24-hour urine D. Blood cultures
B
The nurse is preparing to sign a patient's surgical consent form after the physician has explained the procedure to the patient and family. As the patient signs the form, she comments "I really didn't understand most of what the doctor said, but I have to have this procedure, so I want to sign." Which is the appropriate nursing action? A. Witness the document, as the patient states she wants to sign it. B. Notify the physician or nursing supervisor. C. Call the OR to cancel the procedure and reschedule at a later date. D. Explain the information she did not understand.
B, C, D, E
The nurse is providing discharge instructions to a client prescribed digoxin. Which statement, if made by the client, indicate effective teaching? Select all that apply. A. "If I note color vision changes, I will call my eye doctor right away." B. "I will check my pulse before each dose and if my pulse is less than 60 bpm, then I will not take the digoxin and call my doctor." C. "I will increase my calcium intake significantly." D. "I will ensure I get enough potassium in my daily diet." E. "The water pills that I am on may increase the risk of side effects with digoxin." F. "I should avoid medications that have licorice extract."
B
The nurse is reviewing laboratory data. Which laboratory data requires follow-up? A. Total Cholesterol 180 mg/dl B. Hemoglobin A1C 7.5% C. Calcium 9.2 mg/dl D. Creatinine 1.0 mg/dl
A
The nurse is taking a sample of the fluid pulled from a nasogastric tube to ensure proper placement. The nurse will confirm appropriate placement of the NG tube if the stomach contents have a pH of: A. 3.4 B. 7 C. 5.9 D. 8
D
The nurse is taking care of a client that is suffering from orthostatic hypotension. The client's health care provider is contemplating prescribing an alpha-adrenergic agonist. Which alpha-adrenergic agonist is most likely to be administered? A. Clonidine B. Phenylephrine C. Ephedrine D. Midodrine
C
The nurse is teaching a client about peptic ulcer disease. Which of the following statements should the nurse include? A. "You should take aspirin if you have mild aches or pains." B. "You will need to consume liquids one hour after each meal." C. "It will be important to reduce the stress in your life." D. "Take your prescribed omeprazole with food."
A, C, D
The nurse is teaching a client about the newly prescribed medication, esomeprazole. Which statement, if made by the client, would require further teaching? Select all that apply. A. "I should take this medication with meals and with water." B. "I should not take this with any other medication or food." C. "The medication will coat my ulcer so I can eat without pain." D. "I will need frequent laboratory tests while taking this medication." E. "I may need to take magnesium supplements while on this medication."
D
The nurse is teaching a group of older adults about effective sleep. Which of the following statements, if made by the client, would require further teaching? A. "Nicotine replacement gum may make insomnia worse." B. "I should try to limit my daily naps to no more than thirty minutes." C. "Reading before bed may help me fall asleep." D. "Drinking a cup of hot tea before bed is okay."
B, D
The nurse is teaching a parenting class on car seat safety. Which statements should the nurse include? Select all that apply. A. "Place the car seat rear-facing in the back seat and at 90 degrees." B. "The car seat straps should fit snugly over the shoulders." C. "Infants should ride in a car seat, rear-facing, in the back seat, until six months." D. "Rolled blankets may be needed between the crotch and legs to prevent slouching." E. "You may add padding underneath the infant to increase their comfort."
A, E
The nurse is teaching the parents of a client diagnosed with viral gastroenteritis. To prevent dehydration, the nurse should encourage the client to consume which dietary items? Select all that apply. A. Watermelon B. Ice Cream C. Cola D. Canned Vegetables E. Orange slices
B
The nurse is visiting a client who was recently prescribed antihypertensive medications. Which statement, if made by the client, requires follow-up? A. "My pulse decreases after taking my metoprolol." B. "I started taking my furosemide right before I went to sleep." C. "I am seasoning my foods with salt substitutes while taking my hydrochlorothiazide." D. "I wear my clonidine patch for seven days."
A
The nurse is working the night shift in the ER when a patient is suddenly rushed in with burns on his legs and torso. The nurse notices that the wounds appear moist and pale white with a sluggish capillary refill. The nurse can classify the injury as which of the following? A. Deep-partial B. Full-thickness C. Superficial-partial D. Superficial
B
The nurse observes the client having a tonic-clonic seizure. Which appropriate action should the nurse take? A. Call a code blue B. Note the time of when the seizure started C. Step out of the room to quickly bring pads for the side rails D. Elevate the client's head-of-bed
1.5 mL
The nurse receives a prescription from the primary healthcare provider (PHCP) for 0.375 mg of digoxin intravenously (IV). The nurse has a vial that reads digoxin 0.25 mg/mL. How many mL will administer the appropriate dose? Fill in the blank.
A, C, D
The nurse reviews lab values for a client and notes a serum sodium level of 125 mEq/L. The nurse knows that this sodium level could be attributed to which conditions? Select all that apply. A. Syndrome of inappropriate antidiuretic hormone (SIADH) B. Diabetes Insipidus C. Addison's disease D. Psychogenic polydipsia E. Salt water drowning
A, B
The nurse should expect to administer which of the following medications to the infant diagnosed with omphalocele? Select all that apply. A. Ceftriaxone B. D5W C. Albumin 25% D. Sodium bicarbonate
A
The patient recovering from hip surgery needs to regain strength in order to climb the flight of stairs leading to their bedroom at home. The nurse would expect which facility staff member to treat this patient's physical disability? A. Physical therapist B. Nutritionist C. Case Manager D. Occupational therapist
C
The pediatric nurse is taking vital signs on a one-year-old patient. Which of the following vital signs are abnormal? A. A respiratory rate of 30 breaths per minute B. An axillary temperature of 99.0 degrees Fahrenheit C. Blood pressure of 126/90 mmHg D. Heart rate of 120 beats per minute
0.5 capsules
The primary healthcare provider (PHCP) prescribes 0.5 grams of cefaclor by mouth, twice a day. The medication label reads cefaclor 500 mg capsule. The nurse prepares to administer how many capsules per dose?
38 gtts/minute
The primary healthcare provider (PHCP) prescribes 150 mL of sterile water to be administered over one hour. The drop factor is 15 gtts/mL. The nurse sets the flow rate at how many drops per minute? Round your answer to the nearest whole number. Fill in the blank.
B
The registered nurse (RN) is orienting a new RN to the charge nurse role. Which task would not be appropriate to delegate to a licensed practical nurse (LPN)? A. Obtaining an occult blood sample for a client with ulcerative colitis. B. Assessing a newly admitted client with chest pain. C. Reinforcing teaching to a client newly diagnosed with diabetes mellitus. D. Providing pin care for a client with external fixation of the wrist.
A, C, D, E
The school nurse is educating parents of children exposed to pediculosis capitis. Which of the following statements by the nurse would be appropriate to make? Select all that apply. A. Avoid sharing hats, caps, or scarves B. Dogs and cats need to be treated C. Nits are observable on the hair shaft D. You will need to repeat the treatment after seven to ten days E. Thoroughly vacuum carpets and upholstered furniture
B, C, D
The supervising nurse watches a newly hired nurse take care of a client who is at risk of developing a pressure ulcer. Which of the following interventions by the newly hired nurse requires follow-up? Select all that apply. A. Applies zinc oxide to the client's perineal skin. B. Provides a donut pillow while the client is sitting in the chair. C. Maintain the head of the client's bed at 90 degrees. D. Encourages the client to consume foods rich in carbohydrates. E. Uses a pillow to float the client's heels.
B
Upon gathering the lab results from your prenatal client's recent blood draw, the nurse notes that the patient's red blood cell levels have decreased since before pregnancy. The nurse believes that physiological anemia of pregnancy is likely occurring. This results from which of the following? A. Decrease in circulating red blood cells B. Increase in plasma C. Increase in iron demands from the body D. Decrease in heart size
A
What is the greatest priority of care for a client with the nursing diagnosis "at risk for self-directed violence"? A. The preservation of life B. The assessment of the client C. Encouraging the expression of the client's feelings D. Determining the client's social support systems
D
What would the nurse emphasize as an increased risk for an older adult patient? A. Blepharitis and chalazion B. Myopia and strabismus C. Exophthalmos and presbyopia D. Glaucoma and cataracts
B
When a patient presents with complaints of drooping of the eyelid on one side, the finding is documented as: A. Pharyngitis B. Ptosis C. Kernig sign D. Thyroglossal cyst
A
When an elderly home health client suddenly develops delirium, what is the first thing the home health nurse should assess for? A. Drug intoxication B. Increased hearing loss C. Cancer metastases D. Congestive heart failure
A
When assessing a four-month-old male infant, the nurse correctly evaluates his heart rate by performing which of the following actions? A. Auscultates the left 4th intercostal space for 60 seconds. B. Palpates the left 5th intercostal space for 30 seconds. C. Palpates the brachial pulse for 60 seconds. D. Auscultates the radial pulse for 30 seconds
A, D
When educating an adolescent diagnosed with bacterial conjunctivitis about how to prevent the spread of their infection, which of the following points should you include? Select all that apply. A. Do not share towels or washcloths with family members. B. Stay home from school until they have taken antibiotics for 48 hours. C. Apply a warm compress to lessen any irritation. D. Throw out the contact lenses and get new ones.
A
When providing instructions about the use of an MAO inhibitor to a patient with clinical depression, the nurse should instruct the client to: A. Avoid chocolate and cheese B. Take frequent naps C. Take the medication with milk D. Avoid walking without assistance
A, C
Which of the following alternative therapies are not considered a low-risk treatment? Select all that apply. A. St. John's Wort B. Meditation C. Acupuncture D. Relaxation techniques E. Guided imagery
B, C
Which of the following are features characteristic of fetal alcohol spectrum disorder? Select all that apply. A. Macrocephaly B. Attention deficit disorder C. Encephalopathy D. Enlarged philtrum
A, D
Which of the following clinical manifestations would alert the nurse to the possibility of Kawasaki's disease in an 8-year-old patient? Select all that apply. A. Strawberry tongue B. Fruity breath C. Drooling D. Bright red, swollen lips
B
Which of the following conditions would be a possible cause of hyperactive bowel sounds? A. Paralytic ileus B. Gastroenteritis C. Late bowel obstruction D. Peritonitis
B, C
Which of the following educational points regarding fevers in children is essential for the LPN to reinforce with a family being discharged home today? Select all that apply. A. Go to the emergency department for a temperature greater than 100.4 degrees F. B. Call the primary care office for a fever lasting longer than 3 days. C. Call the primary care office if the patient is not having any wet diapers. D. Go to the emergency department if the patient is eating less than usual and has a fever. [17%]
B, D
Which of the following electrolyte imbalances should the nurse monitor for in her patient with Celiac disease? Select all that apply. A. Hyperkalemia B. Hypomagnesemia C. Hyperphosphatemia D. Hypocalcemia
C
Which of the following expected outcomes is appropriate for a client with heart disease who is complaining of chest pain? A. The client will be free of neuropathic pain related to angina. B. The client will be free of hyperalgesia pain related to angina. C. The client will be free of visceral pain related to angina. D. The client will be free of somatic pain related to angina.
B, C
Which of the following findings would lead you to suspect non-accidental trauma in your 1-year-old burn victim patient? Select all that apply. A. Scalding on the anterior trunk B. Circumferential burns on the feet C. Same thickness of skin damage throughout the burn D. Burns to the soles of the feet
A
Which of the following indicators would most likely signify to the nurse that a patient with dementia is in pain? A. Rubbing a body part B. Facial droop C. Falling asleep D. A relaxed body position
A, B
Which of the following medications is contraindicated for a pregnant client? Select all that apply. A. Warfarin B. Finasteride C. Celecoxib D. Clonidine E. Transdermal Nicotine F. Clofazimine
C
Which of the following nursing diagnoses is appropriate for your client when your client is not coping with a progressive disease in an adaptive manner? A. Ineffective coping related to fear secondary to a progressive disease. B. Ineffective coping related to role ambiguity secondary to a progressive disease. C. Ineffective coping related to role changes secondary to a progressive disease. D. Ineffective coping related to role conflict secondary to a progressive disease.
C
Which of the following patients is at the highest risk for developing osteoporosis? A. A young male weight-lifter who drinks beer three times a week and has a stable job. B. A woman who works as a vice-president, drinks vodka five times weekly, and exercises regularly. C. A middle-aged woman of lower socioeconomic status who is a heavy smoker and drinks alcohol five times weekly. D. A retired man who drinks alcohol socially and is a non-smoker.
A, B
Which of the following practices does the nurse recognize as typical in the Amish community? Select all that apply. A. Health is viewed as a gift from God. B. They commonly use alternative healthcare. C. Women and men are equal and can both make healthcare decisions. D. Most of the Amish community choose to have health insurance.
C
Which of the following psychological symptoms, occurring at the end of life, is accurately paired with an appropriate intervention that you would incorporate into your client's plan of care? A. Spiritual distress: Diazepam B. Delirium: Lorazepam C. Hallucinations: Dopamine antagonist D. Agitation without delirium: Haloperidol
B, C
Which of the following signs and symptoms are characteristic of pyloric stenosis? Select all that apply. A. Weight gain B. Projectile vomiting C. Olive-shaped mass D. Anorexia
A, B
Which of the following statements about appendicitis are true? Select all that apply. A. McBurney's point tenderness is a sign of appendicitis. B. Appendicitis is more common among males. C. A low carbohydrate diet is a risk factor for appendicitis. D. Lower left quadrant pain is a sign of appendicitis.
B
Which of the following statements about carbon monoxide is accurate? A. Carbon monoxide is a gas that is gray in color and deadly. B. Carbon monoxide is a gas that is clear, odorless, and deadly. C. Carbon monoxide is a gas that is yellow and odorless. D. Carbon monoxide is a gas that smells like rotten eggs
A
Which of the following statements correctly outlines the proper flow of blood through the heart? A. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Pulmonary valve → Pulmonary artery → Lungs → Pulmonary veins → Left atrium → Mitral valve → Left ventricle → Aortic valve → Aorta → Systemic circulation B. Superior and Inferior vena cavas → Right atrium → Mitral valve → Right ventricle → Pulmonary valve → Pulmonary artery → Lungs → Pulmonary veins → Left atrium → Tricuspid valve → Left ventricle → Aortic valve → Aorta → Systemic circulation C. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Pulmonary valve → Pulmonary veins→ Lungs → Pulmonary artery → Left atrium → Mitral valve → Left ventricle → Aortic valve → Aorta → Systemic circulation D. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Aortic valve → Pulmonary veins→ Lungs → Pulmonary artery → Left atrium → Mitral valve → Left ventricle → Pulmonary valve → Aorta → Systemic circulation
C, D
Which of the following statements is true regarding the premature rupture of membranes (PROM)? Select all that apply. A. PROM is when the membranes rupture before 37 weeks gestation. B. In a normal delivery, membranes are expected to rupture before labor begins. C. A priority nursing intervention with PROM is to monitor for infection. D. When observing the fluid after the rupture of membranes, it should be clear and without odor.
B
Which of the following would not be appropriate for the nurse to include in the teaching for a client with a diagnosis of acute low back pain? A. Smoking cessation B. Sleep in the prone position C. Use a firm mattress D. Bend at knees when lifting objects
C
Which of these would be most relevant to include in discharge teaching for a patient with a platelet count of 40,000 per mcL (40 x 10^9/L)? A. Be sure to take your aspirin with meals daily B. You may continue to shave with a straight edge razor C. Use a soft toothbrush and floss gently D. You should take a multivitamin daily
B
While auscultating a client's bowel sounds, the nurse notes a swooshing sound to the left of the umbilical area. What would be the nurse's priority action? A. Percuss over the area to assess for dullness B. Notify the primary healthcare provided (PHCP) C. Gently palpate the abdomen to assess for tenderness D. Ask the patient about recent bowel movements
A, B
While caring for a child who is six weeks old, the LPN checks their temperature and notes that it is 38.7 degrees C. Which of the following diagnostic tests does she expect the provider will order? Select all that apply. A. Blood culture B. Urine culture C. Echocardiogram D. MRI
A
While scheduling a client for thoracentesis, the nurse understands which of the following is the most preferred position for the procedure? A. Sitting up, leaning over a bedside table, and feet supported on the ground or stool. B. The head of the bed flat with the patient lying on the unaffected side. C. Prone position with both arms extended above the head. D. The head of the bed elevated 45 degrees, and the patient lying on the affected side.
A
While working in a pediatric cardiac unit, you are assigned to take care of an infant with tetralogy of Fallot. During report, you are told that the infant is having frequent 'tet spells'. To prepare for your shift, which medication do you ensure is readily available in case of a tet spell? A. Morphine sulfate B. Dexmedetomidine C. Fentanyl D. Atropine sulfate
A, D
While working in the PICU, your eight-year-old patient suddenly experiences cardiac arrest and cannot be resuscitated. Which of the following is true regarding the child's care after death? Select all that apply. A. Provide support and resources to the staff members involved. B. Remove all medical devices such as chest tubes, breathing tubes, and monitors before the family comes in to see the child. C. Do not permit any staff member to touch the child's body until the family has arrived. D. Notify the family that a complete autopsy is recommended once they have said their goodbyes.
B, D
You are beginning your shift in the Pediatric Intensive Care Unit and are reviewing your patient's labs. The client's primary diagnosis is leukemia, and he has been hospitalized for a secondary infection. He is on broad-spectrum antibiotics. Upon reviewing his labs (see the exhibit), what should be your priority nursing actions? Select all that apply. A. Notify the provider immediately. B. Ensure the patient has a private room. C. Request orders for 1 unit PRBCs to be transfused. D. Restrict visitors and enforce hand hygiene with all guests.
A, B, D
You are taking care of a 5-year old that presents with impetigo. Which of the following symptoms would be expected for this disease? Select all that apply. A. Lesions B. Burning C. Rhinitis D. Pruritus
A, B, C
You are working in the emergency department when a patient with a suspected stroke arrives. According to the American Heart Association (AHA), the general immediate assessment and stabilization should include: Select all that apply. A. Activate the stroke team B. Check and treat the glucose C. Order an immediate CT or MRI of the brain D. Administer rtPA
A
You have been assigned to serve on the Quality Assurance/Performance Improvement Committee. You would expect that the primary focus of this committee is which of the following? A. Outcome measures B. Process measures C. Structural measures D. Identification of individuals who have caused errors
A
Your client has just undergone a fecal diversion surgery and will be discharged to their home. Which type of social support person or support network is most likely to benefit this client in terms of post-discharge self-care and physical adaptations necessary for this client? A. A peer support network like an ostomy group in the community to promote self-care B. An emotional support person to help the client cope with the altered bodily image C. An instrumental support network to help with activities of daily living (ADLs) D. A church group of volunteers who can transport the client to health care provider (HCP) appointments
A, C
Your client is a patient with low potassium levels and accelerated hypertension. The physician has listed the cause as "hyperaldosteronism." Which of the following endocrine disorders cause an increased amount of aldosterone? Select all that apply. A. Cushing's disease B. Addison's disease C. Conn's syndrome D. Pheochromocytoma
A
Your client is at the end of life and experiences guilt for past transgressions. After a number of independent and dependent nursing functions, what is an expected outcome for this client? A. The client will articulate the nature of humans in terms of fallibility. B. The client will go to confession to ask for forgiveness. C. The client will perform relaxation techniques to dissolve guilt. D. The client will not express any more feelings at the end of life.
