Evolve HESI multidisciplinary practice quiz

During a client assessment, the client says, "I can't walk very well." Which action should the nurse implement first

Identify the problem

A peak and trough level must be drawn for a client receiving antibiotic therapy. What is the optimum time for the nurse to obtain the trough level

Immediately before the next antibiotic dose is given

The nurse is planning a wellness program aimed at primary prevention in the community. Which action should the nurse implement

Immunizations that decrease occurrences of many contagious diseases

A 32-year-old female client complains of severe abdominal pain each month before her menstrual period, painful intercourse, and painful defecation. Which additional history should the nurse obtain that is consistent with the client's complaints

Inability to get pregnant

The nurse is assessing the parents of a nuclear family who are attending a support group for parents of adolescents. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic

Increased self-understanding

In planning the care of a 3-year-old child with diabetes insipidus, it is most important for the nurse to caution the parents to be alert for which condition

Increased thirst

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period will be

January 30-31

A client who is one week postoperative after an aortic valve replacement suddenly develops severe pain in the left leg. On assessment, the nurse determines that the client's leg is pale and cool, and no pulses are palpable in the left leg. After notifying the healthcare provider, which action should the nurse take

Keep the client in bed in the supine position

When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastro-esophageal reflux, which intervention is most important for the nurse to implement

record the weight daily

An adult client is admitted to the hospital burn unit with partial-thickness and full-thickness burns over 40% of the body surface area. In assessing the potential for skin regeneration, what should the nurse remember about full-thickness burns

regenerative function of the skin is absent because the dermal layer has been destroyed

Which documentation indicates that the nurse correctly evaluated a pain medication's effectiveness after administration? The client

reports decrease in pain

the healthcare provider prescribes naloxone (Narcan) for a client in the emergency room. Which assessment data would indicate that the naloxone has been effective? The client's

respiratory rate is 16 breaths/minute

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility

the client voluntarily signed the form

which action by the nurse is most helpful in communicating with a preschool-aged child

use a doll to play and communicate

Which topic should the nurse include in planning a secondary prevention project for the local retirement community

vision and hearing screening

An older woman asks the registered nurse how she can decrease her chances of getting cystitis. What information should the RN provide

void and empty the bladder completely every 2 to 3 hours

in evaluating the effects of lactulose (Cephulac), which outcome would indicate that the drug is performing as intended

watery, diarrhea stools

The nurse is planning care for a client with newly diagnosed diabetes mellitus that requires insulin. Which assessment should the nurse identify before beginning the teaching session

willingness of the client to learn the injection sites.

A young adult female arrives at the emergency center with a black right eye and is bleeding from the left side of her head. She reports that her boyfriend has been abusing her physically. The nurse performs a history and physical examination. How should the nurse document these findings

young adult female presents with periorbital ecchymosis on the right side, 3 cm laceration on left parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is abusive

The registered nurse (RN) is an assisted living community is assisting an Orthodox Jewish client make weekly dinner choices. Which main course selections should the RN suggest that are suitable for a kosher diet

Lamb chops with mint jelly

A mother is crying as she holds and rocks her child with tetanus who is having muscular spasms and crying. After administering diazepam (Valium) to the child, what action should the nurse implement

Lay the child down and ask the mother to stay near the child in the crib

A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client

Let me call and leave a message for your healthcare provider

Twenty hours after a client returns from surgical gastric bypass, the RN observes a large amount of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock

Lethargy

The RN is teaching an obese adolescent. Which is an effective strategy for the RN to recommend to the adolescent about weight managment

Limit juices and soda drinks

On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-four hours after admission, the nurse notes that the client is withdrawn and isolated. It is best for the nurse to encourage this client to become involved in which activity

Participate in a group quilting project

The RN is caring for a client who was recently diagnosed with cirrhosis of the liver. The RN should instruct the client to limit which foods from the diet

Peanut butter

A client has myxedema, which results from a deficiency of thyroid hormone synthesis in adults. The nurse knows that which medication would be contraindicated for this client?

Pentobarbital sodium (Nembutal Sodium) for sleep.

What instruction should the nurse give a client who is diagnosed with fibrocystic changes of the breast

Perform a breast self-exam (BSE) procedure monthly

The nurse reviews the latest laboratory results for a child who received chemotherapy last week and identifies a reduced neutrophil count. Which nursing diagnosis has the highest priority for this child

Risk for infection

The nurse reviews the complete blood count (CBC) findings of an adolescent with acute myelogenous leukemia (AML). The hemoglobin is 13.8 g/dl, hematocrit is 36.7%, white blood cell count is 8200 mm3, and platelet count is 115000mm3. Based on these findings, what is the priority nursing diagnosis for this client's plan of care

Risk for injury

Which nursing diagnosis is important to include in the plan of care for a client receiving the angiotensin-2 receptor antagonist irbesartan (Avapro)

Risk for injury

Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen

Roast beef, baked potato with butter, and iced tea

A client is admitted with right upper quadrant (RUQ) pain after eating. What should the registered nurse (RN) assess about the meal's content that precipitated the pain

Saturated fat content

A client with multiple sclerosis has experienced an exacerbation of symptoms, including paresthesias, diplopia, and nystagmus. Which instruction should the nurse provide

Schedule extra rest periods

The nurse should explain to a 30 year old gravid client that alpha fetoprotein testing is recommended for which purpose

Screen for neural tube defects

A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation?

Secondary prevention

A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician dextrose 5% and 0.25% normal saline with 2 mEq KCL/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment

Serum BUN and creatinine levels

A 46 year old feamle client is admitted for acute renal failure secondary to diabetes and hypertension. Which test is the best indicator of adequate glomerular filtration

Serum creatinine

Attendance at a community health clinic is rising and clients have long waits for service. The charge nurse believes that a computer system would be helpful in decreasing the time needed to conduct intake and exit processing. What is the best way for the nurse to introduce the idea of obtaining a computer system for the clinic

Submit a written proposal to the Board of Directors about hardware and software improvement needs

The RN is preparing dietary information for a client with a simple goiter. Which foods should the RN instruct the client to eliminate from the diet

Turnips

In evaluating the effects of lactulose (Cephulac), which outcome would indicate that the drug is performing as intended

Two or three soft stools per day

Which client at highest risk for chronic kidney disease (CKD) secondary to diabetes mellitus (DM)

Type 1 DM and retinopathy and mild vision loss

The clinic nurse is taking the history for a new 6-month-old client. The other reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain

Type of reaction to loud noises

The RN is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. Which condition should the RN ask the client about his medical history?

Ulcerative colitis

The RN is teaching a client who has a goal of losing 25 pounds about diet and weight loss. Which is the most common problem that the RN should recognize about the accuracy of client reporting about daily food intake

Under reporting of food intake

Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent

Upper arm circumference

To assess the effectiveness of an analgesic administered to a 4-year-old, what intervention is best for the nurse to implement

Use a happy-face/sad-face pain scale

A male client with a history of chronic back pain that was managed with opiate analgesics calls the nurse after having back surgery. The client reports that the back pain is finally gone, but after stopping the pain medication, the client has been having severe diarrhea and painful muscle cramps. Which assessment information should the nurse obtain next

When did the symptoms begin after the last dose of opiate analgesic?

A client scheduled for surgery is to receive an IV infusion of 0.9% sodium chloride with prochlorperazine edisylate (Compazine) 10mg/50ml over 30 minutes. The nurse should program the infusion pump to deliver how many ml/hour

100

A client who weights 176 pounds is receiving an IV infusion with esmolol hydrochloride (Brevibloc) at 48 ml/hr. The IV solution is labeled with the concentration of Brevibloc 10mg/ml. How many mcg/kg/minute is the client receiving

100

A client with a gastrostomy tube (GT) receives a prescription for a 250 ml bolus feeding of Glucerna 60% enteral formula. The nurse should dilute the full-strength formula with how many ml of water

100

A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client

Restrict salt and fluid intake

The RN is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the RN instruct the client to use at home

Sphygmomanometer

When engaging in planned change on the unit, what should the nurse-manager establish first?

Staff members are aware of the need for change

The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the nurse include

Wear the brace over a T-shirt 23 hours per day

The healthcare provider prescribes IV solution of 5% dextrose in water with magnesium sulfate 4g/50ml to be infused over 30 minutes for a client with preeclampsia. The nurse should program the infusion pump to deliver how many ml/hr

100

A client with cardiogenic shock weighs 220 lb and is receiving dopamine at the rate of 3 mcg/kg/min. The solution strength available is dopamine 400 mg in 250 ml of D5W. The nurse should set the infusion pump to deliver how many ml/hour

11.3

Which symptoms are serious adverse effects of beta-adrenergic blockers such as propranolol (Inderal)?

Wheezing, hypotension, and AV block

The nitrate isosorbide dinitrate (Isordil) is prescribed for a client with angina. Which instruction should the nurse include in this client's discharge teaching plan

Do not get up quickly. Always rise slowly

The parents of a child with hemophilia A ask the nurse about their probability of having another child with hemophilia A. Which information is the basis for the nurse's response

-Sons of female carriers have a 50% chance of inheriting hemophilia -Hemophilia is an X-linked recessive disorder

The registered nurse (RN) is assessing the client's knowledge of low-sodium menu selections. Which food items listed by the client confirm appropriate choices

-White rice with steamed vegetables -Cottage cheese with sliced tomatoes

During labor, the nurse determines that a full-term client is demonstrating late decelerations. In which sequence should the nurse implement these nursing actions

Reposition the client Increase the IV fluid Provide oxygen via face mask Call the healthcare provider

The parents of a 14 year old boy bring their son the hospital. He is lethargic, but responsive. The mother states, "I think he took some of my pain pills" During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents.

if he might have taken any other drugs

The nurse knows that lab values sometimes vary for the older client. Which data would the nurse expect to find when reviewing laboratory values of an 80 year old male

increased protein in the urine, slightly increased serum glucose levles

Which information should the nurse give a client with chronic kidney disease (CKD)

Avoid salt substitutes

A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan

Avoid sharing towels and washcloths with siblings

A nurse is planning to teach self-care measures to a female client about prevention of yeast infections. Which instructions should the nurse provide

Avoid tight-fitting clothing and do not use bubble-bath or bath salts

A client is admitted with the diagnosis of total placenta previa. Which finding is most important for the nurse to report to the healthcare provider immediately

onset of uterine contractions

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care

patellar reflex 4+

A client who is HIV positive asks the nurse, "How will I know when I have AIDS?" Which response is best for the nurse to provide

"AIDS is diagnosed when a specific opportunistic infection is found in an otherwise healthy individual."

A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast was applied. When preparing the parents to take the child home, which discharge instruction has the highest priority

"Call the healthcare provider immediately if his nail beds appear blue"

A 25yo female client has been particularly restless and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me go! I must leave because the secret police are after me." Which response is best for the nurse to make

"Come with me to your room and I will sit with you."

A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client

"Complete bedrest decreases oxygen needs and demands on the heart muscle tissue

preoperative nursing care for a child with Wilms' tumor should include which intervention

put a sign on the bed reading, "DO NOT PALPATE ABDOMEN"

A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time

Stagnation

A child who is scheduled for a kidney transplant receives a prescription for basiliximab (Simulect) 20 mg IV 2 hours prior to surgery. The medication is available in a 20 mg vial that is reconstituted by adding 5 ml sterile water for injection, and adminstered in a 50ml bag of normal saline over 30 minutes. The nurse should program the infusion pump to deliver how many ml/hour

110

A client has prescription for inamrinone (Inocor) 0.75 mg/kg IV bolus to be delivered over 3 minutes. The client weighs 80kg. Inamrinone is available for injection 100 mg/20 ml. How many ml of inamrinone should the nurse administer

12

The mother of a 6 month old asks the nurse when her baby will get the first measles, mumps and rubella (MMR) vaccine. Based on the recommended childhood immunization schedule published by the Centers for Disease Control, which response is accurate

12 to 15 months

A loading dose of acetylcysteine (Mucomyst) 8 grams, which is available as a 20% solution (200 mg acetylcysteine per ml) is prescribed by nasogastric tube for a client with acetaminophen toxicity. How many ml of diluent should be added to the medication to obtain a 1:4 concentration?

120

A client is admitted for dehydration, weight loss, and a flat affect. After reviewing the client's history, the registered nurse (RN) discovers that the client's spouse died 2 weeks ago. Which nursing interventions should the RN implement to help the client begin the process of dealing with loss

-establish trust by creating a safe atmosphere for sharing -help the client identify ways to adapt lifestyle to accommodate loss -explore ways to assist the client to make new emotional investments

During the quarterly evaluations of the clients in the assisted living community, the RN assesses for findings of failure to thrive in the older population. Which findings should the RN document and report as manifestations related to failure to thrive

-unintentional weight loss -increased weakness -increased amounts of sleep

A male client with schizophrenia tells the nurse that the voices he hears are saying, "You must kill yourself." To assist the client in coping with these thoughts, which response is best for the nurse to provide

"Tell yourself that the voices are unreasonable"

A client who has been admitted to the psychiatric unit tells the nurse, "My problems are so bad that no one can help me." Which response is best for the nurse to make

"How can I help?"

The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which statement by a parent indicates understanding of the phototherapy

"I will keep the baby's eyes covered when the baby is under the light."

An older male client with Parkinson's disease (PD) is discharged home with levodopa-carbidopa (Sinemet) and instructions to his wife for his care. Which statement best indicates to the registered nurse (RN) that the wife understands her husband's needs

"I will notify the healthcare provider if my husband has increasing involuntary movements of his extremities."

The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive

124 gtt/min

The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which complaint related to administration of this drug would the nurse expect this client to make

"My mouth feels like cotton"

A client asks the nurse if glipizide (Glucotrol) is an oral insulin. Which response should the nurse provide

"No, it is not an oral insulin and can be used only when some beta cell function is present"

A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan

"Place a pillow between your knees while lying in a bed to prevent hip dislocation."

A nurse takes a female client to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states, "I have special undergarments that I do not remove for religious reasons." How should the nurse respond

"Tell me about your undergarments so we can discuss how you can have your examination comfortably."

Older clients are at highest risk for abuse and neglect due to which factors

-Needs are greater than the caretaker's abilities -Client's declining strength

A 57-year-old male client is scheduled to have a stress-thallium test the following morning and is NPO after midnight. At 0130, he is agitated because he cannot eat and is demanding food. Which response is best for the nurse to provide to this client

"The test you are having tomorrow requires that you have nothing by mouth tonight"

The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, "Yes, my love, I'll do it." When the nurse questions the client about her comment she states, "The news commentator is my lover and he speaks to me each evening. Only I can understand what he says." What is the best response for the nurse to make

"What do you believe the news commentator said to you?"

A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching

"When i return from my tropical island vacation, I will go to the clinic to get my Prolixin injection."

The registered nurse (RN) is making early morning rounds on a group of clients when a client begins exhibiting symptoms of an acute asthma attack. The RN administers a PRN prescription for a Beta 2 receptor agonist agent. Which client response should the RN expect

-Rapid resolution of wheezing -Improved pulse oximetry values

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation will the nurse provide

"Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day."

The RN obtains the assistance of an interpreter when caring for aprimiparous client from Mexico, who speaks very little English and who delivered a full term neonate yesterday. When educating the client on the dietary plan of care, what should the RN tell the interpreter to encourage the client to include in her diet

-Red meats -Leafy green vegetables -Fresh fruits

In preparing to administer intravenous albumin to a client following surgery, what is the priority nursing intervention

-Set the infusion pump to infuse the albumin within four hours -Administer through a large gauge catheter -Monitor hemoglobin and hematocrit levels -Assess for increased bleeding after administration

the healthcare provider prescribes continuous intravenous infusion of dextrose 5% and 0.45% sodium chloride with KCl 20mEq/1000 ml to be delivered over 8 hours. The nurse should program the infusion pump to deliver how many ml/hour

125

The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside

-A sterile glove -An amniotic hook -A doppler

Which measurements should be used to accurately calculate a pediatric medication dosage

-Child's height and weight -Body surface area of child -Nomogram determined mathematical constant

A female client with obsessive-compulsive disorder (OCD) is describing her obsessions and compulsions and asks the nurse why these make her feel safer. What information should the nurse include in this client's teaching plan

-Compulsions relieve anxiety -Anxiety is the key reason for OCD -Obsessive thoughts are linked to levels of neurochemicals -Antidepressant medications increase serotonin levels

Which foods should the registered nurse (RN) instruct a client who is receiving chemotherapy to eat

-Cooked broccoli, cauliflower, and boiled eggs -Baked potatoes -Pastas

The RN assesses a client who had a total colectomy 2 weeks ago. The client appears to be confident in the management of the new colostomy, but is having problems managing the odor. What instructions should the RN provide the client to help decrease odor in the colostomy bag

-Eat foods containing yogurt -Drink a glass of buttermilk -Eat sprigs of parsley

Which instructions should the nurse give to a female client who just received a prescription for oral metronidazole (Flagyl) for treatment of trichomonas vaginalis

-Inc fluid intake, especially cranberry juice -Avoid drinking alcohol while taking the medication -Use condoms until treatment is completed -Ensure that all sexual partners are treated at the same time

An older male client asks the RN how he can reduce his incidents of hemorrhoidal flare ups. What information should the RN offer the client about how to prevent rectal discomfort

-Increase fiber and liquids in the diet to help prevent constipation and straining -use the therapeutic cushion or frequent repositioning for periods of prolonged sitting -take frequent warm sitz baths and do not use abrasive paper that can traumatize tissues -Establish bowel habits by scheduling daily time to defecate when the client is not rushed

The RN is reinforcing discharge instructions to the family of an older client with failure to thrive. What information should the RN include to promote nutritional intake for the client

-Minimize stress level by providing the client with a quiet environment during meals -Provide food variations that the client can manage without assistance

A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The mother reports that her child bottle feeds for 5 minutes only and then falls asleep. The nurse auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic with a respiratory rate of 64 breaths per minute. What instruction should the nurse provide the mother to ensure the infant is receiving adequate intake

-Monitor the infant's weight and number of wet diapers per day -Increase the infant's intake per feeding by 1 to 2 ounces per week -Allow the infant to rest and refeed on demand or every 2 hours -Use a softer nipple or increase the size of the nipple opening

When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan

-Mood swings -Tearfulness

An infant with heart failure receives a prescription, digoxin 35 mcg PO. The RN calculates the desired dose for administration sing the available concentration of digoxin labeled, 0.05 mg/ml. How many milliliters should the RN prepare for administration.

0.7

The healthcare provider prescribes an IV infusion of 0.9% sodium chloride with 40 mEq KCL/500 ml to infuse over 3 hours for a client with hypokalemia. The nurse should program the infusion pump to deliver how many ml/hour

167

A client is receiving Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 ml IV at 1000 unit/hour per protocol for acute coronary syndrome (ACS). The client's partial thromboplastin time (PTT) is 76 seconds. Based on the ACS protocol, the infusion should be decreased by 100 units/hour for a PTT between 71 to 80 seconds. The nurse should program the pump to deliver how many ml/hour

18

A 180-pound adult male is admitted to the Emergency Center after receiving thermal burns to 60 percent of his body. Using the Parkland formula of 4 ml/kg/24 hours, the client should receive how many ml of fluid during the first 24 hours

19632

A client with pericardial effusion has phrenic nerve compression resulting in recurrent hiccups. The healthcare provider prescribes metoclopramide (Reglan) liquid 10mg PO q 6 hours. Reglan is available as 5 mg/5ml. A measuring device is marked in teaspoons is being used. How many teaspoons should the nurse administer

2

A client with type 2 diabetes is receiving metformin (Glucophage) 1 gram PO twice daily. The medication is available in 500 mg tablets. How many tablets should the nurse administer

2

A client is brought into the emergency department following a sudden cardiac arrest. A full code is started. Five minutes later the family arrives with a durable power of attorney signed by the client requesting that no extraordinary measures be taken, including intubation, to save the client's life. What action should the nurse take

Stop the code immediately

A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is

A persistent cold

A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting an epidural for pain relief. Which assessment finding is most important for the nurse to report to the healthcare provider

A platelet count of 67,000

A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, "No, it's not MY fault. You can't blame me. I didn't kill him, you did." What action is best for the nurse to take

Assess the content of the hallucinations by asking the client what he is hearing

All of the following interventions can be used to evaluate the effectiveness of nursing and medical interventions used to treat diarrhea. Which intervention is least useful in the nurse's evaluation of a 20-month-old child

Assessing fontanels

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first

Assist the ambulating client back to the bed

Two days postoperative, a male client reports aching pain in his left leg. The nurse assesses redness and warmth on the lower left calf. What intervention would be most helpful to this clientt

Advise the client to remain in bed with the leg elevated

During an initial clinic visit, the nurse is taking the history for a client who wants to confirm her pregnancy. The client's last child has a history of low-birth-weight (LBW). Which additional finding is most important for the nurse to consider

African-american ethnicity

The nurse is planning the case for a 32-year-old male client with acute depression. Which nursing intervention would be best in helping this client deal with his depression

Assist the client in exploring feelings of shame, anger and guilt

The nurse is assessing a client with bacterial meningitis. Which assessment finding indicates the client may have developed septic emboli

Cyanosis of the fingertips

An occupational health nurse is reviewing a 20-year-old trend in the United States that has resulted in an increase in certain medical conditions due to the rapid expansion of an urban industrial workforce. Which medical conditions are specifically identified with this trend

Asthma Lung cancer

A client is receiving an IV solution of sodium chloride 0.9% (Normal Saline) 250 ml with amiodarone (Cordarone) 1 gram at 17ml/hr. How many mg/min of amiodarone is infusing

1.1

Secobarbital (Seconal) 150mg is prescribed at bedtime for a male client who is scheduled for surgery in the morning. The scored tablets are labeled 0.1 g/tablet. how many tablets should the nurse administer

1.5

A client returns to the nursing unit from surgery with a prescription for Lactated Ringer's solution 1000ml to be infused over 10 hours. The IV administration set delivers 60gtt/ml. The nurse should regulate the infusion to deliver how many gtts/min

100

The mother of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismal to her son when he "has a tummy ache." After reminding the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question

Do not give if the child has chickenpox, the flu, or any other viral illness

A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide

The tumor's estrogen receptor guides treatment options

A nurse is answering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to explain the use of tamoxifen (Nolvadex). Which response should the nurse provide

This anti-estrogen drug inhibits malignancy growth

What is the underlying pathophysiologic process between free radicals and destruction of a cell membrane

Enzyme release from lysosomes

The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client

Move the chair parallel to the right side of the bed, and stand the client on the right foot

A client with Mycobacterium avium complex (MAC) is receiving an infusion of 5% dextrose in water with amikacin (Amikin) 0.572 grams/100 ml every 12 hours. The nurse prepares the dose of amikacin using a vial labeled, "250mg/ml." How many ml should the nurse add to the infusion

2.3

The nurse prepares a 1000ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute

21

0.9% normal saline with inamrinone (Inocor) 0.1 grams/100 ml is prescribed for client with heart failure. The medication is to be delivered at a rate of 400mcg/minute. The nurse should program the infusion pump to deliver how many ml/hour

24

The healthcare provider prescribes oxytocin (Pitocin) 0.5 milliunits/minute for a client in labor. One liter Ringer's Lactate with 10 units of oxytocin (Pitocin) is infusing. The nurse should program the infusion pump at how many ml/hour?

3

The healthcare provider prescribes trimethoprim-sulfamethoxazole (Bactrim-DS oral suspension) 120 mg BID for a child with bronchitis. The Bactrim bottle is labeled "200mg/5ml". How many ml should the nurse administer at each dose

3

A client at 32 weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion

3+ deep tendon reflexes and hyperclonus

After abdominal surgery, a male client is prescribed low molecular weight heparin (LMWH). During administration of the medication, the client asks the nurse why he is receiving this medication. Which is the best response for the nurse to provide

This medication is a blood thinner given to prevent blood clot formation

Which approach should the nurse use when preparing a toddler for a procedure

Demonstrate the procedure using a doll

A client with hypertension who weighs 72.4 kg is receiving an infusion of nitroprusside (Nipride) 50 mg in D5W 250 ml at 75 ml/hour. How many mcg/kg/minute is the client receiving

3.5

A client with septic shock receives a prescription for dextrose 5% in water with dopamine (Inotropin) 0.6grams/250ml at a rate of 5 mcg/kg/minute. The client's weight is 148 lbs. The nurse should set the infusion pump to deliver how many ml/hour

34

A child with a urinary tract infection is receiving Cephalexin (Keflex) 100 mg suspension PO QID. Keflex oral suspension is labeled "125 mg in 5 ml." How many ml should the nurse administer

4

A client assigned to a female practical nurse (PN) needs total morning care and sterile wound packing with a wet to dry dressing. The PN tells the nurse that she has never performed a wound packing. Which intervention should the charge nurse implement

Demonstrate the wound care procedure to the PN while the PN assists

A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set the table for her deceased husband. What nursing problem best describes this problem

Denial related to the loss of a loved one

An older client who recently moved into an assisted living community refuses to eat or join any activities. When evaluating the client further, what should the registered nurse (RN) focus on during the next examination

Depression

A woman with Type 2 dm becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement

Describe diet changes that can improve the management of her diabetes

The parents of a 3-week-old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain

Description of vomiting episodes in past 24 hours

A 3 year old boy is brought to the emergency room because he swallowed an entire bottle of children's vitamin pills. Which intervention should the nurse implement first

Determine the child's pulse and respirations

After completing an assessment and determining that a client has a problem, which action should the nurse perform next

Determine the etiology of the problem

Prenatal diagnostic testing is recommended for a couple expecting their first child who have a family history of congenital disorders. The couple tells the nurse that they are opposed to abortion for religious reasons. Which concept should the nurse consider when responding to this couple

Diagnostic testing may indicate a fetal problem that could be treated prior to delivery

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first

Notify the healthcare provider of the family's request

A client has a continuous IV infusion of dopamine (Intropin) and an IV of normal saline at 50ml/hour. The nurse notes that the client's urinary output has been 20 ml/hour for the last two hours. Which interventions should the nurse initiate

Notify the healthcare provider of the urinary output

The nurse is preparing to give an enema to a laboring client. Which client would require the most caution when carrying out this procedure?

A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is not engaged

As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider

A 6 month-old with failure to thrive that has a closed anterior fontanel

After the fourth dose of gentamicin sulfate (Garamycin) IV, the nurse plans to draw blood samples to determine peak and trough levels. When are the best times to draw these samples

5 minutes before and 30 minutes after the next dose

A client reports unprotected sexual intercourse one week ago and is worried about HIV exposure. An initial HIV antibody screen (ELISA) is obtained. The nurse teaches the client that seroconversion to HIV positive relies on antibody production by B lymphocytes after exposure to the virus. When should the nurse recommend the client return for repeat blood testing

6 to 12 weeks

A 3 month old boy weighing 10 lbs 150oz has an axillary temperature of 98.9 F. The nurse determines the daily caloric need for this child is approximately

600 calories

A three-month old boy weighing 10 lbs 15 oz has an axillary temperature of 98.9 F. The nurse determines the daily caloric need for this child is approximately

600 calories per day

A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg

61

At the end of the shift, the nurse is recording the fluid balance for a client receiving a continuous gastrostomy tube (GT) feeding. Based on the client's records, how many ml should the nurse record for the total fluid balance (intake - output) for the shift that started at 0700 and ended at 1900

695

A healthcare provider prescribes a continuous infusion of 0.9% sodium chloride with pacuronium (Pavulon) 25mg/250ml at a rate of 0.1mg/kg/hr for a client with coronary artery bypass grafting. The client weighs 78 kg. The nurse should program the infusion pump to deliver how many ml/hour

78

A healthcare provider prescribes a continuous infusion of 0.9% sodium chloride with pancuronium (Pavulon) 25mg/250ml at a rate of 0.1 mg/kg/hr for a client with coronary artery bypass grafting. The client weighs 78kg. The nurse should program the infusion pump to deliver how many ml/hour

78

A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow

8 a.m., 4 p.m., and midnight

The healthcare provider prescribes an IV infusion of 1000ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min

83 gtt/min

The nurse is preparing the change-of-shift report for a client who has a 265 ml secondary infusion that was started 2 hours ago at a rate of 85ml/hour via an infusion pump. The nurse should report that how many ml remain to be infused by the on-coming nurse

95

Which example should the nurse identify as a significant outcome for the leading health indicators of Healthy People 2020

A community has adopted a no smoking policy

A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding would indicate that the therapeutic drug level has been achieved

A decrease in respiratory rate from 24 to 16

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults?

A decreased flow rate could result in the formation of a thrombosis

A client is admitted to the Emergency Department with tension pneumothorax. Which assessment should the nurse expect to identify

A deviation of the trachea toward the side opposite the pneumothorax

A client who is receiving a whole blood transfusion develops chills, fever, and a headache 30 minutes after the transfusion is started. Then nurse should recognize these symptoms as characteristic of what reaction

A febrile transfusion reaction

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein

A lactating woman nursing her 3-day-old infant

The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands

A pregnant woman

The nurse is assigning care for a 4-year-old child with otitis media and is concerned about the child's increasing temperature over the past 24 hours. When planning care for this child, it is important for the nurse to consider that

A tympanic measurement of temperature will provide the most accurate reading

Which client should the nurse identify as being at highest risk for complications during the use of an opioid analgesic

A young adult with inflammatory bowel disease

The nurse is caring for a client with a stroke resulting in right-sided paresis and aphasia. The client attempts to use the left hand for feeding and other self-care activities. The spouse becomes frustrated and insists on doing everything for the client. Based on this data, which nursing diagnosis should the nurse document for this client

Disabled family coping related to dissonant coping style of significant person

A 49 yo female client arrives at the clinic for an annual exam and asks the nurse why she becomes excessively diaphoretic and feels warm during nighttime. What is the nurse's best response

Discuss perimenopause and related comfort measures

A nurse whose tuberculosis (TB ) skin test result reveals an 8 mm induration obtains a negative chest radiograph, which indicates latent tuberculosis. The employee-health nurse should implement which intervention for this nurse

Administer isoniazid (INH) daily for 6 to 9 months

The RN is assigned the care of an older client who returns to the unit after surgery for closed angle glaucoma. Which intervention in the plan of care should the RN bring to the attention of the healthcare team

Administer morphine 4 mg IM q2 hour PRN pain

A 16 ear old is brought to the emergency center with a crushed leg after falling off a horse. The adolescent's last tetanus toxoid booster was received eight years ago. What action should the nurse take

Administer tetanus toxoid booster

A client's dose of isosorbide dinitrate (Imdur) is increased from 40 to 60 mg PO daily. When the client reports the onset of a headache prior to the next scheduled does, which action should the nurse implement

Administer the 60 mg dose of Imdur and a PRN dose of acetaminophen

A client receiving albuterol (Proventil) tablets complains of nausea every evening with her 9:00 p.m. dose. What action can the nurse take to alleviate this side effect

Administer the dose with a snack

A woman bring her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with

Dissociative disorder

When observing a client for symptoms of a large bowel obstruction, the nurse should assess for which finding

Distention of the lower abdomen

While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement

Acknowledge that she is supporting the arm correctly

The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem

Activity intolerance related to postoperative pain

A client with a fractured right radius reports severe, diffuse pain that has not responded to the prescribed analgesics. The pain is greater with passive movement of the limb than with active movement by the client. The nurse recognizes that the client is most likely exhibiting symptoms of which condition

Acute compartment syndrome

At 8 a.m. the UAP informs the charge nurse that a female adolescent client with acute glomerulonephritis has a blood pressure of 210/110. The 4 a.m. blood pressure reading was 170/88. The client reports to the UAP that she is upset because her boyfriend did not visit last night. What action should the nurse take first

Administer PRN prescription of nifedipine (Procardia) sublingually

A 6-month-old boy and his mother are at the healthcare provider's office for a well-baby check-up and routine immunizations. The healthcare provider recommends to the mother that the chiled receive an influenza vaccine. What medications should the nurse plan to administer today

All the immunizations with the influenza vaccine given at a separate site from any other injection

Which rationale best supports an older client's risk of complications related to a dysrhythmia

An older client is intolerant of decreased cardiac output which may cause dizziness and falls

The healthcare provider prescribes naproxen (Naproxen) twice daily for a client with osteoarthritis of the hands. The client tells the nurse that the drug does not seem to be effective after three weeks. Which is the best response for the nurse to provide

Another type of nonsteroidal antiinflammatory drug may be indicated

The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take

Ask the client if she has felt any movement

To assess a client's pupillary response to accommodation, a nurse should perform which activity

Ask the client to look at a distant object and then at an object held 10 cm from the nose

Since his arrival in an assisted living community, an older male client is having difficulty going to sleep. Which intervention should the RN implement first

Ask the client what has helped him in the past

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention

Assess for bladder distention

A 2 year old child recently diagnosed with hemophilia A is discharged home. What information should the nurse include in a teaching plan about home care

Apply pressure and ice for bleeding while elevating and resting the extremeties

An adult client is given a prescription for a scopolamine patch (Transderm Scop) to prevent motion sickness while on a cruise. Which information should the nurse provide to client

Apply the patch at least 4 hours prior to departure

A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of anger." Which nursing intervention is most important to include in the client's plan of care

Ask client to describe triggers of anger

The RN is teaching a pregnant client about her dietary needs. What amount of protein grams/day should the RN instruct the client to add to her daily diet

Divide pre-pregnant weight by 2 equals protein needs

The registered nurse (RN) is instructing a client with acute cholecystitis about dietary recommendations. Which food selection demonstrates to the RN that the client understands dietary teaching

Baked fish and tomatoes with lettuce

Which medications should the nurse caution the client about taking while receiving an opioid analgesic

Benzodiazepines

The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception

Between the time the temperature falls and rises

A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which assessment data would indicate to the nurse that the client is experiencing magnesium sulfate toxicity

Blood pressure 140/90

A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer

Calcium loss from bones can be slowed by increasing calcium intake and exercise

Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between healthcare providers?

Case manager

While taking a nursing history, the client states, "I am allergic to penicillin." What related allergy to another type of antiinfective agent should the nurse ask the client about when taking the nursing history

Cephalosporins

A client with congestive heart failure (CHF) is being discharged with a new prescription for the angiotensin-converting enzyme (ACE) inhibitor captopril (Capoten). The nurse's discharge instruction should include reporting which problem to the healthcare provider

Dizziness

A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority

Check the client's gag and swallow reflexes

The RN is assessing a client regarding the need to increase vitamin B12 after undergoing a subtotal gastrectomy. Which foods should the RN instruct the client to include in the diet

Cheese, eggs, and fish

The registered nurse is assessing a client regarding the need to increase vitamin B12 after undergoing a subtotal gastrectomy. Which foods should the RN instruct the client to include in the diet

Cheese, eggs, and fish

The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a man who is reading the names on the hall doors, he identifies himself as a reporter for the local newspaper and requests information about the client's status. Which standard of nursing practice should the nurse use to respond

Confidentiality

The registered nurse (RN) is providing dietary instructions to the parents of a 6-month-old baby diagnosed with phenylketonuria (PKU). Which foods should the RN teach the parents to eliminate in the infant's diet

Chicken and fish

A 4 year old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information

Children need to retain a sense of initiative without impinging on the rights and privileges of others

During a well-woman exam, a sexually active female client asks the nurse about a recent vaginal infection and says she is afraid she has another sexually transmitted infection. The client discloses her history of previous STI. Which condition should the nurse identify as the most prevalent STI in the United States among women

Chlamydia

A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms

Chlordiazepoxide (Librium)

A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit

Choking, coughing, and cyanosis

During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem

Closed-ended questions

which milestone indicates to the nurse successful achievement of young adulthood

Completes education and becomes self-supporting

A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents' teaching plan

Consistently follow a set mealtime routine

The RN reviews the new prescription, phenelzine, a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess?

Consumption of any alcohol or tyramine-rich foods

A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, "Because he made me mad!" which goal is best for the nurse to include in the client's plan of care? The client will

Control impulsive actions toward self and others

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness

Correctly place the infant on the breast

The nurse hears short, high-pitched sounds just before the end of inspiration in the right and left lower lobes when auscultating a client's lungs. How should this finding be recorded

Crackles in the right and left lower lobes

A new resident in an assisted living facility is an older client who is experiencing short-term memory loss and confusion. Which activity should the RN schedule the client to do during the day

Daily exercise group

Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict

Deal with issues and not personalities

A client is admitted to the hospital for diagnostic testing for possible myasthenia gravis. The nurse prepares for intravenous administration of edrophonium chloride (Tensilon). What is the expected outcome for this client following administration of this pharmacologic agent

Decreased muscle weakness

A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider

Decreased thyroid stimulating hormone level

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure

Degree of flexion and extension of the client's knee joint

The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean-cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing behaviors. Which information is best for the nurse to provide?

Early adolescence is a developmental stage of normal experimentation

The nurse is caring for a woman with a previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern?

Edema, basilar rales and an irregular pulse

The home health RN is visiting an older client with chronic hypertension. What evaluation is most important for the RN to complete with each visit

Effectiveness of medication

A client is admitted to the medical intensive care unit with a diagnosis of myocardial infarction. The client's history indicates the infarction occurred ten hours ago. Which laboratory test result would the nurse expect this client to exhibit

Elevated CK-MB

When providing discharge teaching for a client with osteoporosis, the nurse should reinforce which home care activity

Elimination of hazards to home safety

Following major abdominal surgery, a male client's arterial blood gas analysis reveals Pa02 95 mmHg and PaC02 50 mmHg. He is receiving oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or deep breathe. Based on this information, what action should the nurse implement at this time?

Encourage the use of an incentive spirometer

An older client with chronic kidney disease (CKD) has an arteriovenous fistula (AV) in the left forearm for hemodialysis. After palpating the AV fistula, which finding is an indication that the AV fistula is functioning properly

Enlarged veins

The RN is teaching a primigravida client about a meal plan of foods rich in riboflavin. Which foods should the RN instruct the client to eat at least 2 servings daily

Enriched cereals

A client with acute hemorrhagic anemia is to receive four units of packed RBCs as rapidly as possible. Which intervention is most important for the nurse to implement

Ensure the accuracy of the blood type match

A postmenopausal client asks the nurse why she is experiencing discomfort during intercourse. What response is best for the nurse to provide

Estrogen deficiency causes the vaginal tissues to become dry and thinner

After liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the client. Which nursing intervention is most important for the RN to implement

Evaluate vital signs q10 to 20 minutes for 2 hours after procedure

Which dosing schedule should the nurse teach the client to observe for a controlled-release oxycodone prescription

Every 12 hours

A client is receiving substitution therapy during withdrawal from bensodiazepines. Which expected outcome statment has the highest priority when planning nursing care

Excessive CNS stimulation will be reduced

An older female client recently moved to an assisted living facility. The family explain to the RN that the client is unmanageable and always confused, disoriented, and depressed. The client asks the RN repeatedly, "Where am I?" How should the RN respond

Explain that she is in a new home called an assisted living community

A client in active labor complains of cramps in her leg. What intervention should the nurse implement

Extend the leg and dorsiflex the foot

During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing

Eye exams

The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)

Fever of 102 F

An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care

Gently lift the client when moving into a desired position

A female client tells the nurse that she does not know which day of the month is best to do breast self-exams (BSE). Which instruction should the nurse provide

Five to seven days after menses cease

What is the correct procedure for performing an ophthalmoscopic examination on a client's right retina

From a distance of 8 to 12 inches and slightly to the side, shine the light into the client's pupil

A 12 year old female is seen by the school nurse after recently experiencing increasing difficulty sitting still and paying attention in class, and increasingly illegible handwriting. The nurse observes that the child has protruding eyeballs and a staring expression. What action should the nurse take next

Gather additional data by taking a health history and measuring vital signs

A client in an ambulatory clinic describes awaking in the middle fo the night with difficulty breathing and shortness of breath related to paroxysmal nocturnal dyspnea. Which underlying condition should the registered nurse identify in the client's history

HF

A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant

Have a bulb syringe readily available to remove secretions

The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question provides information relevant to the client's plan of care

Have you ever been 'frozen' in one spot, unable to move?

a young woman tells the public health nurse that a friend was recently diagnosed with hepatitis B and she is concerned about getting the disease. during the assessment interview, which question is most important for the nurse to ask this woman

Have you shared an needles or had sex with your friend?

A male client, who has been smoking 1 pack of cigarettes every day for the last 20 years, is scheduled for surgery and will be unable to smoke after surgery. During preoperative teaching, the client asks the nurse what symptoms he may expect after surgery from nicotine withdrawal. Which response is best for the nurse to provide

Headache and hyperirritability are common

A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record?

Healthcare provider notified of client's refusal to have blood specimens collected for testing.

The nurse is preparing to administer a high volume saline enema to a client. Which information is most important for the nurse to obtain prior to administering the enema

History of inflammatory bowel disorders

The nurse is assessing a client with a ruptured small bowel and determines that the client has a temperature of 102.8 F. Which assessment finding provides the earliest indication that the client is experiencing septic shock

Hyperpnea

A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nurse monitor for during the infusion of Pitocin

Hyperstimulation

Which condition is associated with an oversecretion of renin

Hypertension

The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation

Hyperthyroidism

The nurse plans to help an 18-year-old female intellectually disabled client ambulate the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, "Get out of here! I'll get up when I'm ready!" Which response is best for the nurse to make

I'll be back in 30 minutes to help you get out of bed and walk around the room

A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse's mannerisms. The nurse knows that the client is using which defense mechanism

Identification

The nurse is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning

Ineffective denial related to situational anxiety

A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client

Inflammatory with peau d'orange

The nurse is caring for a client wo is receiving 24 hour total parenteral nutrition (TPN) via a central line at 54ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take

Infuse 10% dextrose and water at 54ml/hr

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse

Instruct the client that the stoma will become smaller when the initial swelling diminishes

The nurse is measuring blood pressure on all four extremities of a child with coarctation of the aorta. Which blood pressure finding should the nurse expect to obtain

Lower in the legs than in the arms

The RN is caring for a client with aplastic anemia who is hospitalized for weight loss and generalized weakness. Laboratory values show a white blood count (WBC) of 2500/mm3 and a platelet count of 160000/mm3. Which intervention is the primary focus in the client's plan of care for the RN to implement

Maintain strict protective precautions

A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in preterm labor. She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous. Which assessment is the highest priority for the nurse to monitor during the administration of this drug

Maternal and fetal heart rates

The nurse is preparing to discharge an elderly, recently widowed female client following a mild stroke. At this time she is able to walk with the aid of a walker. As part of the discharge planning, what referral is most important for the nurse to make

Meals-on-Wheels

The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment

Medication administration

A nurse working on a mental health unit receives a community call from a person who is tearful and states, "I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days." The nurse should initiate a referral based on which assessment

Moderate levels of anxiety

The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement

Monitor bleeding from IV sites

Which assessment finding by the nurse during a client's clinical breast examination requires follow-up

Newly retracted nipple

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action should the nurse implement first

Note which actions were not implemented

A 3 month old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder

Nystatin (Mycostatin)

The hospice nurse is completing a focused assessment of an older female client with end stage Alzheimer's disease, who recently fractured her hip. What technique should the RN use to determine the client's pain

Observe for facial grimacing

A client with a markedly distended bladder is diagnosed with hydronephrosis and left hydroureter after an IV pyelogram. The nurse catheterizes the client and obtains a residual urine volume of 1650ml. This finding supports which pathophysiological cause of the client's urinary tract obstruction?

Obstruction at the urinary bladder neck

A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent

Obtain the permission of the custodial parent for the surgery

A 26-year-old male client with Hodgkin's disease is scheduled to undergo radiation therapy. The client expresses concern about the effect of radiation on his ability to have children. What information should the nurse provide

Permanent sterility occurs in male clients who receive radiation

The RN is interviewing a female client who states she has a persistent productive cough during the winter caused by bronchitis. Which additional finding should the RN assess for bronchitis

Phlegm production and wheezing

Twenty minutes after a continuous epidural infusion anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action will the nurse take

Place the woman in a lateral position

The nurse is planning care for school-aged children at a community care center. Which activity is best for the children

Playing follow-the-leader

A client in an assisted living community is refusing to eat during the meal time. The RN discovers that the client has several mouth ulcers. What types of food should the RN recommend to promote adequate dietary and healing of ulcers

Poached or scrambled eggs

The RN is caring for a client who has a closed head injury from a motor vehicle collision. Which finding should the RN assess the client for the risk for diabetes insipidus (DI)

Polydipsia

What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period

Primary nursing

In developing a teaching plan for a 5 year old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first

Process of glucose testing

During a health fair, a 72 year old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom would the nurse expect this client to have

Productive cough with grayish-white sputum

The registered nurse is teaching a client who is newly diagnosed with emphysema how to perform pursed lip breathing. What is the primary reason for teaching the client this method of breathing

Promotes CO2 elimination

A 64-year-old client is admitted to the hospital with a fractured right hip. One of the concerns following surgical repair is to promote dorsiflexion. Which intervention would a nurse implement

Provide a foot board

A 27 year old female client is admitted to the psychiatric hospital with a diagnosis of bipolar disorder, manic phase. She is demanding and active. Which intervention should the nurse include in this client's plan of care

Provide a structured environment with little stimuli

A client with osteoarthritis is given a new prescription for a nonsteroidal antiinflammatory drug (NSAID). The client asks the nurse, "How is this medication different from the acetaminophen I have been taking?" Which information about the therapeutic action of NSAIDs should the nurse provide

Provide antiinflammatory response

A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse

Purulent sputum

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority

Put the newborn to breast

The nurse is analyzing the waveforms of a client's electrocardiogram. What finding indicates a distrubance in electrical conduction in the ventricles

QRS interval of 0.14 second

The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight on the growth chart and notes that the child's weight is in the 95th percentile for the child's height. What action should the nurse take?

Question the type and quantity of foods eaten in a typical day

A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first

Raise the foot of the bed

A client is receiving ampicillin sodium (Omnipen) for a sinus infection. Then nurse should instruct the client to notify the healthcare provider immediately if which symptom occurs

Rash

The RN is teaching a client how to prepare for a stool guaiac test. Which food should the RN instruct the client to avoid 3 days prior to collecting the specimen for this test?

Raw broccoli

What information best supports the nurse's explanation for promoting the use of alternative or complementary therapies

Recognizes the value of a client's input into their own health care

Several hours after surgical repair of an abdominal aortic aneurysm (AAA), the client develops left flank pain. The nurse determines the client's urinary output is 20 ml/hr for the past 2 hours. The nurse should conclude that these findings support which complication

Renal artery embolization

After checking the urinary drainage system for kinks in the tubing, the nurse determines that a client who has returned from the post-anesthesia care has a dark, concentrated urinary output of 54 ml for the last 2 hours. What priority nursing action should be implemented

Report the findings to the surgeon

A nurse-manager sees a colleague taking drugs from the unit. What action should the nurse-manager take

Report the incident to the immediate supervisor

The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP

Report the results of the vital signs to the nurse

An UAP places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP

Reposition in a Sim's position with the client's weight on the anterior ilium

The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical picture

Serum potassium of 5.5 mEq and total calcium of 6 mg/dl

Small bowel obstruction is a condition characterized by which finding

Severe fluid and electrolyte imbalances

The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has in implanted automatic defibrillator. What action should the nurse implement

Shock the client with 200 joules per hospital policy

A couple concerned because the woman has not been able to conceive, is referred to a healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which complaint would indicate to the nurse that the woman's fallopian tubes are patent

Shoulder pain

An older female client who is a new resident at an assisted living facility cannot remember how to get to her room. What action should the registered nurse implement

Show client how to foloow hallway signs to her room

Muscular Dystrophy is characterized by which pathophysiological condition

Skeletal muscle degeneration

The nurse is evaluating the client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions

Skim milk, turkey salad, roll, and vanilla ice cream

The nurse working in a community clinic that serves a population comprised mainly of migrant families. In planning the use of resources for secondary prevention, which activity should be the priority

Skin testing for tuberculosis

The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). This condition is most often related to which predisposing condition

Small cell lung cancer

What information should the nurse include in a teaching plan about the onset of menopause

Smoking Oophorectomy with hysterectomy Early menarche Genetic influence Chemotherapy exposure

Which pathophysiological response supports a client's vomiting experience

Spasmodic reflex of respiratory and gastric movements results from stimulation of the chemoreceptor trigger zone

Which intervention should the nurse include in the plan of care for a female client with severe postpartum depression who is admitted to the inpatient psychiatric unit

Supervised and guided visits with infant

The school nurse is reviewing health risks associated with extracurricular activities of grade-school children. Regular participation in which activity places the child at highest risk for developing external otitis

Swimming lessons in an indoor pool

A 43-year-old female client is receiving thyroid replacement hormone following a thyroidectomy. What adverse effects associated with thyroid hormone toxicity should the nurse instruct the client to report promptly to the healthcare provider

Tachycardia and chest pain

A client is being treated for osteoporosis with alendronate (Fomax), and the nurse has completed discharge teaching regarding medication administration. Which morning schedule would indicate to the nurse that the client reaching has been effective

Take medication, go for a 30 minute morning walk, then eat breakfast

A client with giardiasis is taking metronidazole (Flagyl) 2 grams PO. Which information should the nurse include in the client's instruction

Take the medication with food

During the assessment of a 21-year-old female client with bipolar disorder, the client tells the nurse that she has not taken her medication for three years, her mother will not let her return home, and she does not have transportation or a job. Which client goal is most important for this client

Taking medication, with community follow-up

An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, "Take me home. I want my Mommy." Which response is best for the nurse to provide

Tell the client that the nurse is there and will help her

A 17-year-old male student reports to the school clinic one morning or a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assess his vital signs: temperature 100 F, pulse 80, respirations 20, and blood pressure 122/82. What is the best action for the nurse to take

Tell the student to proceed directly to his regularly scheduled class

Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse

The body's receptors adapt over time as they are exposed to heat

A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to take his chart with him and states the chart is "his" and he doesn' t want any more contact with the hospital. How should the nurse respond

The chart is the property of the hospital but I will see that a copy is made for you

After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse assess first?

The client who has a new onset of difficult breathing

Prior to transferring a client to a chair using a mechanical lift, what is the most important client characteristic the nurse should assess

Tolerance of exertion

A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. The nurse should discontinue the oxytocin infusion for which pattern of contractions

Transition labor with contractions every 2 minutes, lasting 90 seconds each

The nurse suspects child abuse when assessing a 3 year old boy and noticing several small, round cigarette burns. Which parental behavior provides the greatest validation for such suspicions

The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn

The RN is caring for a client who has pernicious anemia. The RN recognizes which vitamin deficiency is associated with this type of anemia

Vitamin B12

A client with coronary artery disease who is taking digoxin (Lanoxin) receives a new prescription for atorvastatin (Lipitor). Two weeks after initiation of the Lipitor prescription, the nurse assesses the client. Which finding requires the most immediate intervention

Vomiting

A child falls on the playground and is brought to the school nurse with a small laceratio on the forearm. Which action should the nurse implement first

Wash the wound gently with mild soap and water

The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take

Withhold the medication and contact the healthcare provider

The nurse is preparing the 0900 dose of losartan (Cozaar), an angiotensin II receptor blocker (ARB), for a client with hypertension and heart failure. The nurse reviews the client's laboratory results and notes that the client's serum potassium level is 5.9 mEq/L. What action should the nurse take first

Withhold the scheduled dose

The nurse is planning a community-based project to reduce obesity in a school-aged population. Which outcome statement best supports the goal for this population

Within 2 years, students with a body mass index greater than 95% will be reduced by 50%

An older client with a decreased percentage of lean body mass is likely to receive a prescription that is adjusted based on which pharmacokinetic process

distribution

A 22 year old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage

he is unresponsive to instructions and is unable to cooperate with emetic therapy

A burned child is brought to the emergency room. In estimating the percentage of the body burned, the nurse uses a modified "Rule of Nines." Which part of a child's body is calculated as a larger percentage of total body surface than an adult's

head and neck

The RN is caring for a client who is receiving total parenteral nutrition (TPN). Which metabolic change in the client should the RN assess during administration of TPN

hyperglycemia

A client is being treated for hyperthyroidism with propylthiouracil (PTU). The nurse knows that the action of this drug is to

inhibit synthesis of T3 and T4 by the thyroid gland

Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse perform next

initiate positive pressure ventilation

When assessing a child with asthma, the nurse should expect intercostal retractions during

inspiration

The nurse is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam

intelligence is influenced by social and cultural beliefs

Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. how should the nurse record this finding

localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first

loosen the right wrist restraint

A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his

low self-esteem

A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. What assessment finding should the nurse expect this client to exhibit

lower left quadrant pain and a low-grade fever

Which finding in a 19 year old female client should trigger further assessment by the nurse

menstruation has not ocurred

A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma

metoprolol tartrate (Lopressor)