ATI Comp Book Review

An expectant mother who plans to breastfeed is eager to learn about newborn care. Which of the following informations should the nurse provide? (Select all that apply.) A. Schedule feedings every 4 hr. B. Place bumper pads in the crib. C. Position on back when sleeping. D. Expect stools to be yellow in color. E. Anticipate three wet diapers in 24 hr. F. Delay tub bath until cord has fallen off.

C. Position on back when sleeping. D. Expect stools to be yellow in color. F. Delay tub bath until cord has fallen off.

A nurse observes a stage I pressure ulcer on a client's heel. Which of the following treatments should the nurse initiate? A. Wet-to-dry dressing B. Oral antibiotic therapy C. Pressure-relieving device D. Intermittent wound irrigation

C. Pressure-relieving device

A client states "I have not been sleeping well." The nurse should recommend which of the following activities prior to bedtime? A. Walk briskly. B. Watch television. C. Take a warm bath. D. Drink a glass of wine.

C. Take a warm bath.

A nurse prepares to administer morphine 2 mg IV to a client. The vial available contains morphine 4 mg per 2 mL. Which of the following actions should be taken? A. Administer 2 mL of morphine. B. Call pharmacy for the exact medication dose. C. Waste morphine 1 mL with another nurse as a witness. D. Notify the charge nurse of inaccurate narcotic count.

C. Waste morphine 1 mL with another nurse as a witness.

A client who is newly admitted requests information about advance directives. The nurse should include which of the following statements in the discussion? A. "An advance directive may not be changed." B. "Advance directives are only discussed with terminally ill clients." C. "You will need to designate a relative to act as your health care proxy." D. "I will give you a pamphlet with written information about advance directives."

D. "I will give you a pamphlet with written information about advance directives."

Which of the following actions should the nurse implement prior to administering levothyroxine to a client who has continuous enteral feeding? A. Place in high-Fowler's position. B. Flush the tube with 60 mL of water. C. Pause the infusion pump for 30 min. D. Inject air into the tube to verify correct placement.

C. Pause the infusion pump for 30 min.

A client's wound eviscerates following bariatric surgery. Which of the following actions should the nurse implement? (Select all that apply.) A. Call for help. B. Obtain vital signs. C. Reinsert protruding organs. D. Place in high-Fowler's position. E. Cover wound with moist sterile dressing.

A. Call for help. B. Obtain vital signs. E. Cover wound with moist sterile dressing.

A nurse cares for a client who is receiving mechanical ventilation, and the high-pressure alarm sounds. Which of the following conditions can cause this to occur? (Select all that apply.) A. Coughing B. Kinked tubing C, Bronchospasm D. Tube is disconnected E. Occluded endotracheal tube

A. Coughing B. Kinked tubing C, Bronchospasm E. Occluded endotracheal tube

A nurse assessing a client who has Gullian-Barre syndrome. Which of the following findings would be expected for this client? (Select all that apply.) A. Diplopia B. Paresthesias C. Thrombocytopenia D. Rebound tenderness E. Hyperactive reflexes

A. Diplopia B. Paresthesias

An adolescent arrives to the emergency department and reports being sexually assaulted within the past hour. Which action should the nurse perform first? A. Perform a self-assessment. B. Evaluate risk for pregnancy. C. Place in a private room for an examination. D. Obtain an informed consent for photographs.

A. Perform a self-assessment.

A nurse provides care for a client who has a Jackson-Pratt (JP) drain. Which of the following actions will ensure proper function? A. Coil tubing of drain. B. Empty bulb everyday. C. Keep bulb compressed. D. Place drain to wall function.

C. Keep bulb compressed.

A client is talking to himself and watching a vacant area of the room. Which of the following interventions should the nurse recognize as most important? A. Ask the client if he is hearing voices. B. Monitor the client for signs of anxiety. C. Encourage the client to listen to music. D. Address the client's underlying feelings.

A. Ask the client if he is hearing voices.

A nurse provides teaching to a client who has gastroesophageal reflux disease (GERD). Which of the following instructions should be included? (Select all that apply.) A. Avoid tobacco products. B. Eat small frequent meals. C. Prepare a snack before bedtime. D. Sleep with the head of the bed elevated. E. Refrain from caffeinated beverages.

A. Avoid tobacco products. B. Eat small frequent meals. D. Sleep with the head of the bed elevated. E. Refrain from caffeinated beverages.

A nurse provides teaching to a client who is prescribed spironolactone. The nurse should limit the intake of which of the following foods? (Select all that apply.) A. Bananas B. White rice C. Tomatoes D. Avocados E. Sweet potatoes

A. Bananas C. Tomatoes D. Avocados E. Sweet potatoes

A nurse provides teaching to a client regarding the use of a hearing aid. Which of the following information is needed? (Select all that apply.) A. "Avoid hairspray while wearing the aid." B. "A whistling sound indicates a proper fit." C. "The hearing aid can be worn continuously." D. "Batteries should be removed when not in use." E. "Follow-up with an audiologist is recommended."

A. "Avoid hairspray while wearing the aid." D. "Batteries should be removed when not in use." E. "Follow-up with an audiologist is recommended."

A nurse explains what to expect during a thoracentesis. Which client statement validates that teaching was effective? A. "I need to be still during the procedure." B. "It will be difficult to swallow for a few hours." C. "A cough may develop during aspiration of fluid." D. "My breathing may be labored for several minutes."

A. "I need to be still during the procedure."

A client is prescribed sertraline for depression. Which of the following instructions should the nurse include with the teaching? (Select all that apply.) A. "It may take 3 weeks before you feel better." B. "Discontinue the medication if nausea occurs." C. "Call your provider if you become more depressed." D. "You may experience symptoms of sexual dysfunction." E. "Sit up straight for 30 minutes after taking the medication."

A. "It may take 3 weeks before you feel better." C. "Call your provider if you become more depressed." D. "You may experience symptoms of sexual dysfunction."

The electronic medication list from the referring clinic is different from the client's medication. Which of the following actions should the home health nurse perform? A. A. Clarify prescriptions with provider. B. Document the recent prescriptions. C. Disregard the missing prescriptions. D. Call pharmacy to order prescriptions.

A. A. Clarify prescriptions with provider.

A school nurse teaches a course about health and safety for 11-year-old students. Which of the following topics should be appropriate for this class? (Select all that apply.) A. Activity and exercise B. STIs and pregnancy C. Alcohol and drug use D. Memory and cognition E. Peer pressure and violence F. Eating disorders and nutrition

A. Activity and exercise B. STIs and pregnancy C. Alcohol and drug use E. Peer pressure and violence F. Eating disorders and nutrition

A client who has acute pulmonary edema is to receive furosemide 40 mg IV. Which of the following is an appropriate action by the nurse? A. Administer over 2 min. B. Dilute with 0.9% sodium chloride. C. Monitor the client for hyperkalemia. D. Determine if the client has peripheral edema.

A. Administer over 2 min.

A client reports, "I have been working in a hostile environment for the past year." The nurse should recognize which of the following findings is a response to prolonged stress? (Select all that apply.) A. Amenorrhea B. Increased energy C. Poor attention span D. Decreased respirations E. Increased sinus infections

A. Amenorrhea C. Poor attention span E. Increased sinus infections

A home health nurse provides care to an older adult client who appears malnourished and is wearing clothes that are soiled. Which of the following interventions should the nurse implement? (Select all that apply.) A. Document client-caretaker interactions. B. Evaluate client access to basic necessities. C. Ask the care taker if the client is being abused. D. Encourage admission to a hospital for monitoring. E. Report suspected client neglect to proper authorities.

A. Document client-caretaker interactions. B. Evaluate client access to basic necessities. E. Report suspected client neglect to proper authorities.

A client is prescribed clozapine. The nurse should monitor for which of the following complications? A. Dyslipidemia B. Osteoporosis C. Hypertension D. Thrombocytopenia

A. Dyslipidemia

A client has a modified radical mastectomy yesterday. Which of the following actions should the nurse implement to prevent transient edema of the effected arm? (Select all that apply.) A. Elevate arm on pillow. B. Administer furosemide. C. Apply heating pad to site. D. Milk drainage device tubing. E. Encourage gentle arm exercises.

A. Elevate arm on pillow. E. Encourage gentle arm exercises.

A nurse provides care to a client who is admitted for sepsis. Which of the following circumstances requires an occurrence report? (Select all that apply.) A. Eye glasses are lost. B. Visitor falls in hallway. C. Syncopal episode occurs. D. Oxygen therapy is refused. E. Blood cultures are positive.

A. Eye glasses are lost. B. Visitor falls in hallway.

A nurse assesses a client who has acute pyelonephritis. Which of the following findings would be expected? (Select all that apply.) A. Fever B. Flank pain C. Tachycardia D. Cough and dyspnea E. Nausea and vomiting

A. Fever B. Flank pain C. Tachycardia E. Nausea and vomiting

A client who is Rh-negative should receive Rh(D) immune globulin at which of the following times? (Select all that apply.) A. Following an amniocentesis B. After a spontaneous abortion C. Within 72 hr following delivery D. During a nonstress test (NST) E. Routinely at 28 weeks of gestation

A. Following an amniocentesis B. After a spontaneous abortion C. Within 72 hr following delivery E. Routinely at 28 weeks of gestation

A client has a documented allergy to sulfamethoxazole-trimethoprim. The nurse should question the prescription for which of the following medications? A. Glipizide B. Sertraline C. Amoxicillin D. Loratadine

A. Glipizide

A nurse should prepare to notify public health officials about which of the following client infections? (Select all that apply.) A. Gonorrhea B. Hepatitis C C. Clostridium difficile D. Chlamydia trachomatis E. Meningococcal disease

A. Gonorrhea B. Hepatitis C D. Chlamydia trachomatis E. Meningococcal disease

A nurse provides care to a client who is on a clear-liquid diet. Which of the following food choices may be included? (Select all that apply.) A. Hard candy B. Chicken broth C. Orange sherbert D. Vanilla milkshake E. Chocolate pudding F. Fruit-flavored gelatin

A. Hard candy B. Chicken broth F. Fruit-flavored gelatin

A client who is of Hispanic origin is admitted to a medical surgical unit. Which of the following factors should the nurse consider when providing culturally competent care? (Select all that apply.) A. Home remedies are commonly used. B. Maintaining eye contact is a sign of respect. C. Concept of time is more focused on the future. D. Females in the family make health care decisions. E. Specific foods may be requested to treat the illness.

A. Home remedies are commonly used. E. Specific foods may be requested to treat the illness.

A nurse provides care to a client who has a fractured femur after falling from a ladder. Which of the following actions may reduce the incidence of fat emboli? A. Immobilize the extremity. B. Provide supplemental oxygen. C. Maintain a semi-Fowler's position. D. Administer subcutaneous heparin.

A. Immobilize the extremity.

A client who has liver failure is scheduled for a paracentesis. Which of the following actions should the nurse implement prior to the procedure? (Select all that apply.) A. Instruct client to void. B. Insert nasogastric tube. C. Elevate head of the bed. D. Measure abdominal girth. E. Obtain informed consent.

A. Instruct client to void. C. Elevate head of the bed. D. Measure abdominal girth. E. Obtain informed consent.

A nurse should recognize which of the following signs as a manifestation of sepsis in the neonate? (Select all that apply.) A. Lethargy B. Tachypnea C. Hypothermia D. Sunken fontanel E. Low serum glucose

A. Lethargy B. Tachypnea C. Hypothermia E. Low serum glucose

A nurse reviews client room assignments. Which of the following infectious diseases requires droplet precautions? (Select all that apply.) A. Mumps B. Measles C. Varicella D. Pertussis E. Pneumonia

A. Mumps D. Pertussis E. Pneumonia

An unresponsive client who has a respiratory rate of 8/min and pinpoint pupils is brought to the emergency department. The nurse should administer which of the following medications? A. Naloxone B. Disulfiram C. Methadone D. Succinylcholine

A. Naloxone

A nurse prepares to perform a dressing change. Which of the following identifiers should the nurse use to ensure client safety? (Select all that apply.) A. Name B. Birthdate C. Phone number D. Facility armband E. Photo identification F. Hospital room number

A. Name B. Birthdate C. Phone number D. Facility armband E. Photo identification

A nurse plans care for a client who requires continuous ambulatory peritoneal dialysis. Which of the following actions is appropriate? (Select all that apply.) A. Notify provider of cloudy or opaque effluent. B. Prepare client for exchange two or three times weekly. C. Apply mask to client during system connect and disconnect. D. Require client to remain in reclining position during exchange. E. Warm dialysate bag by applying heating pad prior to installation.

A. Notify provider of cloudy or opaque effluent. C. Apply mask to client during system connect and disconnect. E. Warm dialysate bag by applying heating pad prior to installation.

A client is newly prescribed lurasidone. Which of the following actions should the nurse implement? A. Obtain baseline fasting blood glucose. B. Instruct client to avoid wine and aged cheese. C. Administer test dose and observe for anaphylaxis. D. Inform client temporary numbing of mouth may occur.

A. Obtain baseline fasting blood glucose.

A nurse plans care for a client who has a serum potassium of 7 mEq/L. Which of the following actions should be implemented? (Select all that apply.) A. Place on a cardiac monitor. B. Obtain a serum creatinine level. C. Infuse 100 mL of 10% glucose IV. D. Begin IV infusion of regular insulin. E. Administer sodium polystyrene sulfonate. F. Initiate 0.33% sodium chloride IV fluid bolus.

A. Place on a cardiac monitor. B. Obtain a serum creatinine level. C. Infuse 100 mL of 10% glucose IV. D. Begin IV infusion of regular insulin. E. Administer sodium polystyrene sulfonate.

A nurse receives a client's medication prescription over the telephone from the provider. Which of the following actions should the nurse take? A. Repeat the prescription back to the provider. B. Ensure the provider signs the prescription immediately. C. Instruct the client to submit the prescription electronically. D. Request another nurse to witness the provider's prescription.

A. Repeat the prescription back to the provider.

A nurse provides education to a preoperative client regarding use of an incentive spirometer (IS). Identify the sequence the client should follow. (Place the steps in selected order of performance. All steps must be used.) A. Sit up. B. Inhale slowly. C. Exhale slowly. D. Hold breath for 3 to 5 seconds. E. Create a tight seal around the mouthpiece. F. Perform 10 (IS) breaths per hour while awake.

A. Sit up. E. Create a tight seal around the mouthpiece. B. Inhale slowly. D. Hold breath for 3 to 5 seconds. C. Exhale slowly. F. Perform 10 (IS) breaths per hour while awake.

A nurse provides care for a client who is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following laboratory values would be expected? (Select all that apply.) A. Sodium 128 mEq/L B. Potassium 5.0 mEq/L C. Magnesium 1.5 mEq/L D. Urine specific gravity 1.035 E. Serum specific gravity 290 mOsm/kg

A. Sodium 128 mEq/L D. Urine specific gravity 1.035

During a home health assessment, the nurse witnesses a school-age child fall from a second story window. Which of the following is the priority action? A. Tell the client not to move. B. Provide support to the parents. C. Apply pressure to bleeding. D. Place the child on a rigid board.

A. Tell the client not to move.

A nurse reviews the client's arterial blood gas results: pH 7.48, PaCO2 44 mm Hg, HCO3 35 mEq/L. Which of the following acid-base imbalances is present? A. Uncompensated metabolic alkalosis B. Uncompensated respiratory acidosis C. Fully compensated respiratory alkalosis D. Partially compensated metabolic acidosis

A. Uncompensated metabolic alkalosis

A nurse provides care to a client who is receiving chemotherapy IV. After reviewing the policy, which of the following is an appropriate action if chemotherapy drips on the floor? A. Use a spill kit B. Dry the liquid C. Document waste D. Call housekeeping

A. Use a spill kit

A nurse provides discharge education to a client who has methicillin-resistant Staphylococcus aureus skin infection. Which of the following statements should be included? A. "Discontinue antibiotics after a scab forms." B. "Do not share athletic equipment with others." C. "Discard soiled bandages in a sealed plastic bag." D. "Keep the infected area covered with a dry bandage." E. "Showering is recommended rather than taking a bath." F. "Wash all uninfected skin areas prior to infected areas."

B. "Do not share athletic equipment with others." C. "Discard soiled bandages in a sealed plastic bag." D. "Keep the infected area covered with a dry bandage." E. "Showering is recommended rather than taking a bath." F. "Wash all uninfected skin areas prior to infected areas."

A client is prescribed sucralfate for treatment of a duodenal ulcer. The nurse recognizes which of the following statements indicates effective teaching? (Select all that apply.) A. "Treatment will be completed in 2 weeks." B. "I should drink 2000 mL of water each day." C. "Exercise should be limited during treatment." D. "This will turn into a paste and cover the ulcer." E. "My diet will include more fruits and vegetables." F. "The medication will be taken 1 hr before meals."

B. "I should drink 2000 mL of water each day." D. "This will turn into a paste and cover the ulcer." E. "My diet will include more fruits and vegetables." F. "The medication will be taken 1 hr before meals."

A nurse provides discharge instructions to a client who is newly prescribed lisinopril. Which of the following statements indicates teaching was effective? (Select all that apply.) A. "I can continue using a salt substitute on food." B. "It is an emergency if my mouth starts to swell." C. "If I develop a cough my doctor will be notified." D. "My potassium level will need to be monitored." E. "Getting up quickly may cause me to feel dizzy."

B. "It is an emergency if my mouth starts to swell." C. "If I develop a cough my doctor will be notified." D. "My potassium level will need to be monitored." E. "Getting up quickly may cause me to feel dizzy."

A nurse cares for a client who has an implanted venous port. Which of the following actions should be implemented prior to administering medications? A. Withdraw and discard 10 mL of blood. B. Access port using a non-coring needle. C. Flush port with 5 mL of heparin 1000 units/mL. D. Auscultate and document presence of bruit.

B. Access port using a non-coring needle.

A client is admitted to the telemetry unit for sustained paroxysmal supraventricular tachycardia. Which of the following medications should the nurse prepare to administer? A. Atropine B. Adenosine C. Nitroprusside D. Norepinephrine

B. Adenosine

A nurse prepares for the admission of a client who has a temperature of 34 C (93 F). Which of the following rewarming methods should be implemented? A. Infuse warm IV fluids. B. Apply a heating blanket. C. Offer sips of warm coffee. D. Administer heated oxygen.

B. Apply a heating blanket.

A client is newly diagnosed with a terminal illness. Which of the following should the nurse assess first? A. Coping skills of the client. B. Client's perception of the diagnosis C. Level of support from family and friends D. Spiritual and cultural beliefs of the nurse

B. Client's perception of the diagnosis

A nurse participates in quality improvement to decrease hospital readmissions for clients who have heart failure. Which of the following actions should the nurse expect to perform? A. Discuss staff performance appraisals with team. B. Compare performance to current practice standard. C. Reinforce evidence-based practice guidelines to staff. D. Interview all nurses caring for client who are readmitted.

B. Compare performance to current practice standard.

A client receives terbutaline for the management of preterm labor. Which of the following findings should the nurse report immediately? A. Heart rate 110/min B. Dyspnea and crackles C. Tremors and headache D. Blood pressure 100/60 mm Hg

B. Dyspnea and crackles

A client who is at 16 weeks of gestation in scheduled for an amniocentesis. Which of the following instructions should the nurse provide? A. Do not drink any liquids after midnight. B. Empty your bladder prior to the procedure. C. This test will determine how well your baby is breathing. D. You will need to hold your breath while the needle is inserted.

B. Empty your bladder prior to the procedure.

An older adult who is receiving TPN states, "I am having trouble breathing." The nurse should perform which of the following actions? A. Check serum blood glucose. B. Evaluate fluid volume status. C. Replace filter on IV infusion set. D. Administer furosemide by mouth.

B. Evaluate fluid volume status.

A client who has COPD is prescribed ipatropium bromide. The nurse should instruct the client to report which of the following symptoms immediately? A. Nausea B. Eye pain C. Dry mouth D. Constipation

B. Eye pain

A nurse provides care for a client who has dementia and is recovering from knee arthroplasty. Which of the following findings requires intervention? A. Hgb 14 g/dL B. Facial grimacing C. Respirations 23/min D. Serous drainage on dressing

B. Facial grimacing

A nurse provides teaching to a client about the use of a cane. Which of the following instructions should the nurse include? A. Move the stronger leg forward with the cane. B. Hold the cane on the stronger side of the body. C. Keep the cane handle within 5 cm (2 in) of waist level. D. Place the cane approximately 30 cm (12 in) in front of foot.

B. Hold the cane on the stronger side of the body.

A client who has cellulitis reports a pain level as 2 on a 0 to 10 scale. The nurse should plan to administer which of the following medications? A. Morphine IV B. Ibuprofen PO C. Fentanyl patch D. Hydromorphone IM

B. Ibuprofen PO

A client who has deep vein thrombosis is receiving a heparin infusion. Current lab values include an aPTT of 40 seconds. Which of the following actions should the nurse implement? A. Stop the infusion. B. Increase the infusion. C. Decrease the infusion. D. No change in the infusion.

B. Increase the infusion.

A nurse receives an end of shift report. Which of the following client assessment findings should the nurse address first? A. Blood pressure of 105/70 mm Hg in a client who is dehydrated B. New onset of confusion in a client who has a left femur fracture C. Blood glucose of 140 mg/dL in a client who has diabetes mellitus D. Decreased bowel sounds in a client who is 2 days postoperative

B. New onset of confusion in a client who has a left femur fracture

A nurse provides care for a client who has anorexia nervosa. Which of the following are appropriate nursing interventions? (Select all that apply.) A. Rotate caregiver assigned to client. B. Promote cognitive-behavioral therapies. C. Provide a high fiber and low sodium diet. D. Assess for bradycardia and hypotension. E. Avoid client involvement in decision making.

B. Promote cognitive-behavioral therapies. C. Provide a high fiber and low sodium diet. D. Assess for bradycardia and hypotension.

A nurse provides care for a client who is agitated. Which of the following actions would be appropriate to implement? (Select all that apply.) A. Restrain the client. B. Reduce room noise. C. Play soothing music. D. Assess for urinary retention. E. Administer a benzodiazepine.

B. Reduce room noise. C. Play soothing music. D. Assess for urinary retention. E. Administer a benzodiazepine.

A bladder irrigation is prescribed for a client who has an occluded indwelling urinary catheter. Which of the following actions should the nurse take when unsure of how to perform this procedure? A. Refuse to perform and notify provider. B. Refer to the policy and procedure manual. C. Instill solution slowly and observe for signs of pain. D. Delay irrigation and inform next nurse assigned.

B. Refer to the policy and procedure manual.

A nurse provides teaching to a client who has a newly applied short-arm fiberglass cast. Which of the following instructions should the nurse discuss? (Select all that apply.) A. Expect injured area to be warm and painful. B. Report numbness or tingling to your provider. C. Keep arm elevated above the heart during rest. D. Blow cool air from a hairdryer to relieve itching. E. Wrap cast with plastic covering prior to showering.

B. Report numbness or tingling to your provider. C. Keep arm elevated above the heart during rest. D. Blow cool air from a hairdryer to relieve itching. E. Wrap cast with plastic covering prior to showering.

A client is prescribed acetaminophen 650 mg PO every 4 hr PRN pain. Which of the following findings should alert the nurse to question this prescription? A. Manual BP 145/86 mm Hg B. Reports drinking six beers daily C. Oral temperature of 37 C (98.6 F) D. Smokes two packs of cigarettes weekly

B. Reports drinking six beers daily

A client is prescribed alendronate tablets. Which of the following information should the nurse include in the teaching? A. Take at mealtime with 60 mL of water. B. Sit upright for 30 min after administration. C. Increase the amount of vitamin D in your diet. D. Wear sunglasses when exposed to outside sunlight.

B. Sit upright for 30 min after administration.

A nurse provides end of life care to a client of Chinese heritage. Which of the following rituals may be practiced by the family following death? A. The bed will be placed facing east. B. The oldest child will bathe the body. C. A window will be opened by the partner. D. A priest will place an amulet on the pillow.

B. The oldest child will bathe the body.

A nurse observes a staff member's behavior when a client becomes angry. Which of the following actions requires an immediate intervention? A. Maintains eye contact. B. Walks away from the client. C. Speaks in short sentences. D. Provides the client personal space.

B. Walks away from the client.

A nurse provides care to a client who has a sealed radiation implant. Which of the following actions should be implemented? (Select all that apply.) A. Limit each visitor to 1 hr per day. B. Wear a lead apron when providing care. C. Instruct visitors to stand 6 ft from the client. D. Double glove to dispose of the radiation source. E. Place "Caution: Radioactive Material" sign on the door.

B. Wear a lead apron when providing care. C. Instruct visitors to stand 6 ft from the client. E. Place "Caution: Radioactive Material" sign on the door.

A nurse provides education to a client who is 1 day postpartum about receiving a rubella vaccine. Which of the following instructions should be included? A. Breast feeding is not recommended. B. An allergy to peanuts is a contraindication. C. A method of contraception is required for the next 30 days. D. Contact provider if injection site is sore within the first 24 hr.

C. A method of contraception is required for the next 30 days.

A client who has stage IV pancreatic cancer decides to discontinue all treatment. Which of the following actions should the nurse take? A. Offer alternative medications. B. Encourage the client to reconsider. C. Ask the client to discuss the decision. D. Request a mental health consultation.

C. Ask the client to discuss the decision.

A client requires an enteral feeding tube. Which of the following actions should the nurse perform immediately following insertion? A. Flush tube with 30 mL of sterile water. B. Inject 60 mL of air to verify placement. C. Aspirate gastric contents to measure pH. D. Apply low intermittent suction as prescribed.

C. Aspirate gastric contents to measure pH.

A school-age child who has ADHD is observed having an increased ability to focus and complete tasks. The nurse recognizes which of the following medications may have been a contributing factor? A. Disulfiram B. Alprazolam C. Chlorpromazine D. Methyphenidate

C. Chlorpromazine

A client requires vital sign assessment every 30 min. Which of the following actions should the nurse implement when using an electronic blood pressure device? A. Elevate the extremity prior to inflating the cuff. B. Ensure three finger fit between the cuff and skin. C. Compare the initial reading with auscultation results. D. Remove the device and assess the skin every 2 hr.

C. Compare the initial reading with auscultation results.

A nurse completes a home health assessment on an older adult who has broken his arm and has burn marks on his chest. The caregiver states injuries were sustained from a fall. Which of the following actions is needed at this time? A. Administer ibuprofen PRN. B. Implement seizure precautions. C. Contact adult protective services. D. Provide teaching to promote safety.

C. Contact adult protective services.

A nurse provides care for a newborn who is receiving phototherapy. Which of the following is an appropriate nursing intervention? (Select all that apply.) A. Weigh weekly. B. Apply lotion to skin. C. Cover male genitalia. D. Place mask over eyes. E. Monitor frequency of stools.

C. Cover male genitalia. D. Place mask over eyes. E. Monitor frequency of stools.

A client is receiving oxygen at 60% via a simple facemask. Arterial blood gas results are: pH 7.31, PaO2 99 mm Hg, PaCO2 51 mm Hg, and HCO3 28 mEq/L. Which of the following actions should the nurse implement? A. Request lab to repeat the test. B. Administer sodium bicarbonate. C. Decrease supplemental oxygen. D. Place on partial rebreather mask.

C. Decrease supplemental oxygen.

A nurse provides care for a client who was just admitted to the emergency department reporting chest pain. Which of the following diagnostic tests should the nurse prioritize? A. Echocardiogram B. Chest radiograph C. Electrocardiogram D. Cardiac angiography

C. Electrocardiogram

An older adult client who is receiving a blood transfusion develops an increase in blood pressure and crackles bilaterally. Which of the following medications should the nurse administer? A. Lisinopril B. Ampicillin C. Furosemide D. Diphenhydramine

C. Furosemide

A client who is prescribed phenelzine asks the nurse, "Why must I stop adding parmesan cheese to pasta?" The nurse understands which of the following complications may occur? A. Sedation B. Agranulocytosis C. Hypertensive crisis D. Extrapyramidal syndrome

C. Hypertensive crisis

A client arrives to the emergency department and reports a headache, neck stiffness, and sensitivity to light. Which of the following is the priority nursing action? A. Notify recent contacts. B. Administer acetaminophen. C. Implement droplet precautions. D. Decrease environmental stimuli.

C. Implement droplet precautions.

Identify the sequence a nurse should follow when moving client who can partially bear weight from a bed to a chair. (Place the steps in selected order of performance. All steps must be used.) A. Apply the transfer belt to the client. B. Rock the client to a standing position. C. Grasp the transfer belt along the client's sides. D. Assist the client to a sitting position on the side of the bed. E. Request the client pivot on the front farther from the chair.

D. Assist the client to a sitting position on the side of the bed. A. Apply the transfer belt to the client. C. Grasp the transfer belt along the client's sides. B. Rock the client to a standing position. E. Request the client pivot on the front farther from the chair.

A nurse reviews the plan of care for a client who has myasthenia gravis. Which of the following interventions require a revision? A. Monitor for sudden increases in weakness. B. Perform pulmonary percussion and postural drainage. C. Refer to speech and occupational therapy for evaluation. D. Assist with daily activities prior to medication administration.

D. Assist with daily activities prior to medication administration.

Which of the following actions should the nurse perform prior to obtaining a specimen from an indwelling urinary catheter for a client who has sepsis? A. Don sterile gloves. B. Provide catheter care. C. Elevate drainage bag above bladder. D. Clean tubing port with an antiseptic solution.

D. Clean tubing port with an antiseptic solution.

After obtaining a blood specimen from a client's peripherally inserted central catheter (PICC), which of the following actions should the nurse take next? A. Resume continuous IV infusion. B. Perform sterile dressing change. C. Instill heparin solution 10 units/mL. D. Flush with 20 mL 0.9% sodium chloride.

D. Flush with 20 mL 0.9% sodium chloride.

A charge nurse reviews abbreviations used in client documentation. Which of the following is an approved entry? A. Enoxaparin 30 mg SC BID B. Zolpidem 5.0 mg PO qhs C. Digoxin .125 mg IV q 24 h D. Furosemide 60 mg PO daily

D. Furosemide 60 mg PO daily

A newborn is delivered by vaginal birth at 40 weeks of gestation. Which of the following findings should the nurse report to the provider? A. Heart rate 160/min and respirations 40/min B. Acrocyanosis and caput succedaneum C. Positive Babinski reflex and negative Ortolani's sign D. Head circumference 40 cm and chest circumference 32 cm

D. Head circumference 40 cm and chest circumference 32 cm

Which of the following actions should the nurse perform prior to removing a client's nasogastric tube? A. Inspect the tip of the tube. B. Auscultate for bowel sounds. C. Apply low intermittent suction. D. Measure pH of gastric contents.

D. Measure pH of gastric contents.

A young adult is newly prescribed levetiracetam for a seizure disorder. Which of the following information should the nurse discuss? A. Take medication with food to reduce nausea. B. Massage gums daily to prevent gingival hyperplasia. C. Regular blood test will be required to monitor levels. D. Mild periods of drowsiness may occur during the day.

D. Mild periods of drowsiness may occur during the day.

A nurse assigns care for a client who has diabetes mellitus to the licensed practical nurse (LPN) and assistive personnel (AP). Which of the following tasks should be delegated to the LPN? A. Measure urinary output. B. Apply antiembolic stockings. C. Assist with bedside commode. D. Obtain capillary blood glucose.

D. Obtain capillary blood glucose.

A client who has an alcohol use disorder begins to exhibit symptoms of withdrawal. Which of the following medications should the nurse administer? A. Disulfiram B. Methadone C. Varenicline D. Phenobarbital

D. Phenobarbital

Prior to administering a client's scheduled dose of enoxaprin sodium, which laboratory finding should the nurse evaluate? A. PT B. INR C. aPTT D. Platelets

D. Platelets

A unit manager observes several nurses working throughout the day. Which of the following cations represents a breach in client confidentiality? A. Shredding a client's printed laboratory results B. Giving report to the oncoming nurse at bedtime C. Logging off the computer prior to leaving workstation area D. Posting positive information about a client on a social media website

D. Posting positive information about a client on a social media website

A client who is newly diagnosed with type 2 diabetes mellitus states, "I feel dizzy and shaky." Which of the following actions should the nurse perform? A. Administer glucagon. B. Give 10 units of lispro. C. Check urine for ketones. D. Provide 8 oz of milk.

D. Provide 8 oz of milk.

A client has a new diagnoses of stage IV lung cancer. When the partner requests the diagnosis be withheld from the client, which of the following actions should the nurse take? A. Withhold the diagnosis from the client. B. Contact the institution's ethic committee. C. Document the request in the medical record. D. Request additional information from the partner.

D. Request additional information from the partner.

A nurse teaches an older adult client about measures to prevent constipation. Which of the following information should be included? A. Drink at least 4 cups of fluid daily. B. Eat one cup of yogurt with breakfast. C. Consume 10 grams of fiber each day. D. Take docusate sodium as prescribed.

D. Take docusate sodium as prescribed.

A client is to receive morphine 4 mg IV bolus through an existing continuous infusion. Identify the sequence of actions the nurse should follow when administering the medication. (Place the steps in selected order of performance. All steps must be used.) A. Inject medication. B. Withdraw syringe. C. Aspirate for blood return. D. Connect syringe to IV line. E. Clean port with antiseptic swab. F. Pinch tubing above injection port.

E. Clean port with antiseptic swab. D. Connect syringe to IV line. F. Pinch tubing above injection port. C. Aspirate for blood return. A. Inject medication. B. Withdraw syringe.