Exit Exam All Forms

A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? "I should wash my hands a6er blowing my nose to prevent spreading the virus." "I need to avoid drinking fluids if I develop symptoms." "I need a flu shot every 2 years because of the different flu strains." "I should cover my mouth with my hand when I sneeze."

"I should wash my hands a6er blowing my nose to prevent spreading the virus."

A nurse is providing discharge teaching to a client who has a new prescrip5on for prednisone for asthma. Which of the following client statements indicates an understanding in teaching? "I will decrease my fluid intake while taking this medication." "I will be expected to have black, tarry stools." "I will take my medication with meals." "I will monitor for weight loss while on this medication."

"I will take my medication with meals."

A nurse is caring for a client who has prescriptions for furosemide and gentamicin. For which of the following complications should the nurse monitor the client? 1. Ototoxicity 2. Liver toxicity 3. Hyperkalemia

1. Ototoxicity

A nurse is assessing a young adult male client having an unusual rash on the palms of hands and bottom of his feet. The nurse should further assess for which of the following infections? 1. Syphilis 2. Herpes simplex virus 2 3. Gonorrhea 4. Hepatitis B

1. Syphilis

A nurse is teaching a client about a variety of stress management techniques. Which of the following instructions by the nurse is appropriate? 1. Tighten your muscles before relaxing them when using muscle relaxation techniques 2. Breathe in through your mouth and out through your nose when using deep breathing exercises 3. Imagine a situation that has been stimulating for you when practicing guided imagery 4. Talk to someone who you admire as the first step in using mindfulness techniques to relax

1. Tighten your muscles before relaxing them when using muscle relaxation techniques

A nurse in a family health clinic is caring for a client who requests information regarding the correct use of condoms. Which of the following statements should the nurse make? 1. When using implanted contraceptive methods, condoms should also be used to protect against STDs 2. Use of petroleum based lubricant with a condom increases the condom's effectiveness 3. Ensure that the condom fits snugly over the tip of the penis 4. Condoms are equally effective for birth control with or without the use of vaginal spermicides

1. When using implanted contraceptive methods, condoms should also be used to protect against STDs

A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching ? 1. "Repeat the dose if your child vomits w/in 1 hr taking the medication" 2. "Have your child drink a small glass of water after swallowing the medication" 3. "You can add the medication to a half cup of your child's favorite juice" 4. "Limit your child's potassium intake while she is taking this medication"

2. "Have your child drink a small glass of water after swallowing the medication"

A nurse has received clearance to go back to work after an occupational injury to her back. To reduce the risk of future lifting injuries, which of the following principles should the nurse use when lifting objects? 1. Bend at the waist to pick up the object 2. Keep the object close to her body as she lifts it 3. Twist at the waist when moving the object to her side 4. Stand with her feet close together when lifting the object

2. Keep the object close to her body as she lifts it

A nurse is caring for a client who is at 20 weeks of gestation and reports urinary frequency. Which of the following actions is appropriate? 1. Advise the client to limit her evening fluid intake 2. Obtain a specimen for culture and sensitivity 3. Check the client for rupture membranes 4. Assure the client that this is an expected finding during this trimester

2. Obtain a specimen for culture and sensitivity

A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching? 1. A nurse will draw blood from your baby's inner elbow 2. This test should be performed after your baby is 24 hrs old 3. This test will be repeated when your baby is 2 months old 4. Your baby will be given 2 ounces of water to drink prior to the test

2. This test should be performed after your baby is 24 hrs old

A nurse is caring for a client who has a prescription for a peripheral IV catheter. After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next? 1. Release the tourniquet 2. Retract the stylet 3. Advance the catheter into the vein 4. Flush the catheter with saline

3. Advance the catheter into the vein

A nurse is assessing a client who is receiving a unit of packed RBCs. Which of the following findings should indicate to the nurse that the client is experiencing a hemolytic reaction reaction? 1. Bradycardia 2. Urticaria (hives) 3. Low blood pressure 4. Jugular vein distention

3. Low blood pressure

A charge nurse is orienting a newly licensed nurse to the telemetry unit. Which of the following should the charge nurse identify as the purpose of telemetry monitoring? 1. To measure cardiac perfusion 2. To measure cardiac output 3. To identify dysrhythmias 4. To identify valve insufficiency

3. To identify dysrhythmias

A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? 1. Increased intracranial pressure 2. Upper extremity hypotension 3. Weak femoral pulses 4. Frequent nosebleeds

3. Weak femoral pulses

A nurse is administering medications to a group of clients. Which of the following occurrences requires the completion of an incident report? 1. A client requests his statin to be administered at 2100 2. A client asks for pain medication 1 hr early 3. A client vomits within 20mints of taking morning medications 4. A client receives his antibiotic 2 hrs late

4. A client receives his antibiotic 2 hrs late

A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first? 1. Administer an antiemetic medication 2. Replace the NG tube 3. Provide functioning of the suction device 4. Evaluate function of the suction device

4. Evaluate function of the suction device

A nurse is evaluating the outcomes for a client who had an amnioinfusion for oligohydramnios. Which of the following findings indicates an adverse response to this treatment? 1. Fetal cord compression 2. Placental insufficiency 3. Meconium aspiration 4. Uterine contractions

4. Uterine contractions

A nurse is caring for a client who has acute glomerulonephritis. Which of the following should the nurse expect? A Dumping syndrome B Ketoacidosis C Hepatotoxicity D Thyroid storm

A Dumping syndrome

A nurse in a mental health facility receives change-of-shift report for four clients. Which of the following clients should the nurse plan to assess first? A client placed in restrain due to aggressive behavior A client who will be receiving her first ECT treatment today A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety A newly admitted client who has a history of 4.5 kg (10 lb.) weight loss in the past 2 months

A client placed in restrain due to aggressive behavior

A nurse is reviewing assessment data from several clients. For which of the following clients should the nurse referral to a dietitian? An older adult client who has a BMI of 24 A client who has a nonhealing leg ulcer An older adult client who has presbyopia A client who has an albumin level of 3.7g/Dl

A client who has a nonhealing leg ulcer

A nurse is caring for a client who has a prescription for warfarin. When reviewing the client's current medications, which of the following medications should the nurse identify as contraindicated for use with warfarin? (Select all that apply) A. Aspirin B. Magnesium sulfate C. Gingko biloba. D. Cetirizine E. Ibuprofen.

A, C, E

A nurse is teaching a prenatal class about infection at a community center. Which of the following statements by a client indicates an understanding of the teaching? A. "I can visit my nephew who has chickenpox 5 days after the sores have crusted." B. "I can clean my cat's litter box during my pregnancy." C. "I should take antibiotics when I have a virus." D. "I should wash my hands for 10 seconds with hot after working in the garden."

A. "I can visit my nephew who has chickenpox 5 days after the sores have crusted."

A nurse is providing teaching to the parents of a newborn genetic screening. Which of the following statement should the nurse include in the teaching? A. "This test should be performed after your baby is 24 hours old." B. "A nurse will draw blood from your baby's inner elbow." C. "Your baby will be given 2 ounces of water to drink prior to the test." D. "This test will be repeated when your baby is 2 months old."

A. "This test should be performed after your baby is 24 hours old."

A school nurse is teaching a parent about absent seizures. Which of the following information should the nurse include? A. "This type of seizure can be mistaken for daydreaming." B. "This type of seizure lasts 30 to 60 seconds." C. "The child usually has an aura prior to onset." D. "This type of seizure has a gradual onset."

A. "This type of seizure can be mistaken for daydreaming."

A charge nurse is teaching a newly licensed nurse about the administration of total parenteral nutrition. Which of the following should the charge nurse include? A. "You will need to monitor the client's electrolytes daily" B. "You will need to change the IV dressing site once per week" C. "You will need to warm the solution in the microwave before administration" D. "You need to weigh the client twice per week"

A. "You will need to monitor the client's electrolytes daily"

A nurse is calculating the body mass index (BMI) of a client who weighs 75 kg (165.3 lb) and is 1.8 m (5 ft 9 in) tall. The nurse should calculate the client's BMI value as which of the following? A. 23 B. 42 C. 32 D. 8

A. 23

A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings should the nurse report to the provider? A. 3+ deep tendon reflexes B. Protruding Hemorrhoids C. Urinary Frequency D. Supine Hypotension Rationale:

A. 3+ deep tendon reflexes

A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow up care? A. A client who received a Mantoux test 48hr ago and has an induration B. A client who is schedule for a colonoscopy and is taking sodium phosphate C. A client who is taking warfarin and has an INR of 1.8 D. A client who is takin bumetanide and has a potassium level of 3.6 mEq/L

A. A client who received a Mantoux test 48hr ago and has an induration

A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child. Which of the following instructions should the nurse take? A. Administer the feeding over 30 min. B. Place the child in as supine position after the feeding. C. Charge the feeding bag and tubing every 3 days. D. Warm the formula in the microwave prior to administration.

A. Administer the feeding over 30 min.

A nurse is reviewing a client's medical record. Which of the following findings places the client at increased for the development of heart failure? (SATA) A. Alcohol use disorder B. Osteoarthritis C. Sleep apnea D. Diabetes mellitus E. BMI 23

A. Alcohol use disorder C. Sleep apnea D. Diabetes mellitus

A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take? A. Allow the client enough time to perform rituals. B. Give the client autonomy in scheduling activities. C. Discourage the client from exploring irrational fears. D. Provide negative reinforcement for ritualistic behaviors

A. Allow the client enough time to perform rituals.

A nurse is caring for a client who has received a first dose of losartan. Which of the following adverse effects should the nurse report to the provider immediately? A. Angioedema airway B. Cough C. Hypotension D. Itching

A. Angioedema airway

A nurse is caring for a client who has diaper dermatitis. Which of the following actions should the nurse take? A. Apply zinc oxide ointment to the irritated area. B. (Unable to read) C. Wipe stool from the skin using store bought baby wipes. D. Apply talcum powder to the irritated area.

A. Apply zinc oxide ointment to the irritated area.

A nurse is caring for a client who is comatose and has advance direc5ves that indicate the client does not want life-sustaining measures. The client's family want the client to have life-sustaining measures. Which of the following ac5on should the nurse take? A. Arrange for an ethics committee meeting to address the family's concerns. B. Support the family's decision and initiate life-sustaining measures. C. Complete an incident report. D. Encourage the family to contact an attorney.

A. Arrange for an ethics committee meeting to address the family's concerns.

A nurse is assessing a client who is immediately postoperative following a subtotal thyroidectomy. Which of the following should the nurse expect to administer? A. Calcium gluconate. B. Sodium bicarbonate. C. Potassium chloride. D. Sodium phosphate.

A. Calcium gluconate.

A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? A. Chest pain B. Muscle spasms. C. Cool, moist skin. D. Incisional pain.

A. Chest pain

A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate effectiveness of the procedure? A. Compare the client's current weight with pre-procedure weight. B. Check the client's serum albumin levels C. Examine for leakage at this site of the procedure D. Confirm that the client is able to urinate

A. Compare the client's current weight with pre-procedure weight.

A nurse is preparing to administer an IV medication to a client and accidently punctures the IV bag causing the medication to leak on the counter. Which of the following medications requires the nurse to follow facility procedures in the safe handling of biohazardous material spill? A. Doxorubicin hydrochloride B. Ampicillin sodium C. Metronidazole D. Phenytoin

A. Doxorubicin hydrochloride

A nurse is preparing education material for a client. Which of the following techniques should the nurse use in creating material? A. Emphasize important information using bold lettering. B. Use 7th grade reading level. C. Avoid using cartoons in the teaching material. D. Use words with three or four syllables.

A. Emphasize important information using bold lettering.

A charge nurse is observing a conflict between two nurses who both insist that the charge nurse favors the other when making assignments. Which of the following conflict-resolution strategies should the charge nurse use? A. Encourage collaboration between the two nurses when making the assignments B. Arrange for the nurses to have as few shifts together as possible C. Tell the nurses that the assignments will be more equitable in the future D. Ask each nurse to take turns making the assignments

A. Encourage collaboration between the two nurses when making the assignments

A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse? A. Increase in frequency of swallowing B. Moderate sanguineous drainage on the drip pad C. Bruising to the face D. Absent gag reflex

A. Increase in frequency of swallowing

A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? A. Increased creatine. B. Increased hemoglobin. C. Increased bicarbonate. D. Increased calcium.

A. Increased creatine.

A charge nurse is teaching a newly licensed nurse about medication administration. Which of the following information should the charge nurse include? A. Inform clients about the action of each medication prior to administration. B. (Unable to read) two times prior to administration. C. Complete an incident report if a client vomits after taking a medication. D. Avoid preparing medications for more than two clients at one time.

A. Inform clients about the action of each medication prior to administration.

A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken affect. Which of the following actions should the nurse prepare to take first? A. Inform the provider of the time of the last dose of pain medication. B. Document the sequence of events as they occur. C. Provide non-pharmacological pain management interventions. D. Instruct the client about the steps of the procedure.

A. Inform the provider of the time of the last dose of pain medication.

A nurse is assessing a client's pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications? A. Left ventricular failure B. Cardiogenic shock C. Hypovolemia D. Hypotension

A. Left ventricular failure

A nurse is assessing a client who has acute kidney injury and a respiratory rate of 34/min. The client's ABG results are ph. 7.28 HCO3 18 mEq/L. (Unable to read) PaO2 90 mm Hg. Which of the following conditions should the nurse expect? A. Metabolic acidosis. B. Metabolic alkalosis. C. Respiratory acidosis. D. Respiratory alkalosis.

A. Metabolic acidosis.

A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take? A. Offer fluids every 2hr. B. Document the client's behavior prior to being placed in seclusion. C. Discuss with the client his inappropriate behavior prior to seclusion. D. Assess the client's behavior once every hour.

A. Offer fluids every 2hr.

A client who is pregnant voice her concern that her 3y/o son will feel left out one the newborn arrives. Which of the following statements by the nurse is appropriate? A. Offer your son a gift when the baby receives one B. Move your son to a toddler bed when the baby arrives C. Tell your son to kiss the baby D. Teach your son to change the baby diapers

A. Offer your son a gift when the baby receives one

A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations? A. Orthostatic Hypertension B. Dependent Edema C. Decreased Hematocrit D. Neck Vein Distension

A. Orthostatic Hypertension

A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness? A. Participate in community drills and mock events. B. Vaccinate susceptible children and adults against smallpox C. Assess types, levels and scopes of disasters. D. Make quarantine preparations for those exposed to anthrax Rationale:

A. Participate in community drills and mock events.

A nurse is caring for a client who is experiencing acute mania. Which of the following foods should the nurse provide for this client? A. Peanut butter sandwich B. Oatmeal with butter C. Chicken noodle soup D. Celery sticks

A. Peanut butter sandwich

A Nurse is assessing a client who has hyponatremia and is receiving IV fluid therapy. Which of the following findings indicate the client is developing a complication of therapy? A. Peripheral edema B. Increased thirst. C. Flattened neck veins. D. Hypotension

A. Peripheral edema

A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? A. Place the cap from the solution sterile side up on clean surface B. Open the outermost flap of the sterile kit toward the body C. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field sterile drape or wrap that is considered contaminated. D. Set up the sterile field 5 cm (2 in) below waist level

A. Place the cap from the solution sterile side up on clean surface

A nurse is providing teaching about the use of crutches using a three-point gait to a client who has tibia fracture. Which of the following actions by the client indicates an understanding of the teaching? A. Positioning both hands on the grips with his elbows slightly flexed B. Supporting his body weight while leaning on the axillary crutch pads C. Stepping with his affected leg first when going up stairs D. Moving both crutches with the stronger leg forward

A. Positioning both hands on the grips with his elbows slightly flexed

A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? A. Previous violent behavior B. A history of being in prison C. Experiencing delusions D. Male gender

A. Previous violent behavior

A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurse is the use demonstrating? A. Quality improvement. B. Patient (Unable to read) C. Evidence based practice. D. Informatics.

A. Quality improvement.

A nurse is admitting a client who had a stroke and exhibits facial drooping, drooling and hoarseness. Which of the following is the nurse's priority? A. Refer the client to a speech language pathologist. B. Monitor the client's prealbumin levels C. Measure the client's weight. D. Place the client on NPO status.

A. Refer the client to a speech language pathologist.

A nurse is caring for a client who has depression and reports taking ST. John's wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances? A. Serotonin syndrome B. Tardive dyskinesia C. Pseudo parkinsonism. D. Acute dystonia.

A. Serotonin syndrome

A nurse is obtaining a client's medical history before initiating 1000 ml of 0.9% NaCl with 20 mEq/L KCl IV to correct hypokalemia. Which of the following findings is a contraindication to the client receiving this IV solution? A. Severe renal impairment. B. Chronic alcohol use disorder C. Multiple sclerosis D. Advanced cardiac disease.

A. Severe renal impairment.

A nurse is caring for an adolescent who has sickle-cell anemia. Which of the following manifestations indicates acute chest syndrome and should be immediately reported to the provider? A. Substernal retractions. B. Hematuria. C. Temperature 37.9 C (100.2 F). D. Sneezing

A. Substernal retractions.

A public health nurse is managing several projects for the community. Which of the following interventions should the nurse identify as a primary prevention strategy? A. Teaching parenting skills to expectant mothers and their partners. B. Conducting mental health screenings at the local community center. C. Referring client who have obesity to community exercise programs. D. Providing crisis intervention through a mobile counseling unit.

A. Teaching parenting skills to expectant mothers and their partners.

A nurse is caring for a client who has bipolar disorder. Which of the following client findings is an indication that the client is about to experience a manic phase? A. The client is restless and has changes in his sleep pattern B. The client laughs out loud and is overly cheerful C. The client has disorganized thoughts and is easily distracted D. The client shows poor judgment and demands attention

A. The client is restless and has changes in his sleep pattern

A nurse is caring for a 3-month-old infant who has gastroenteritis and is receiving monitoring for dehydration. For which of the following findings should the nurse monitor? A. Weight loss B. Bradycardia C. Bulging fontanel D. Distended jugular vein

A. Weight loss

A nurse is caring for a client who has deep vein thrombosis and is receiving heparin therapy. Which of the following tests should the nurse use to monitor and regulate the dosage of the medications? A. aPTT. B. Pyro (Unsure if that's the writing) C. Platelet count. D. INR.

A. aPTT.

A nurse is caring for a client who is 2 hr postoperative following a cardiac catheterization. Which of the following is the priority assessment finding? Report of burning sensation at the insertion site Absence of pedal pulse in the affected extremity Urinary output 25 Ml/hr Oxygen saturation 91 %

Absence of pedal pulse in the affected extremity

A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make? A. "Dehydration is treated with calcium supplements" B. "Dehydration can increase the risk of preterm labor" C. "Dehydration associated gastroesophageal reflux D. "Dehydration is caused by a decreased hemoglobin and hematocrit"

B. "Dehydration can increase the risk of preterm labor"

A nurse in an emergency department is assessing an adolescent who has conduct disorder. Which of the following questions is the priority for the nurse to ask the client? A. "How do you get along with your peers at school?" B. "Do you have thoughts of harming yourself" C. "How do you manage your behavior?" D. "Do you have a criminal record?"

B. "Do you have thoughts of harming yourself"

A nurse is providing teaching to a client who is on glucocorticoid therapy. Which of the following statements by the client indicates an understanding of the teaching? A. "I have my eyes examines annually" B. "I take a calcium vitamin supplement daily" C. "I limit my intake of foods with potassium" D. "I constantly take my medication between 8 and 9 each evening"

B. "I take a calcium vitamin supplement daily"

A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching? A. "This medication can decrease my immune response." B. "I take this medication to prevent asthma attacks." C. "I need to take this medication with food." D. "This medication has a slow onset to treat my symptoms."

B. "I take this medication to prevent asthma attacks."

A nurse is creating for a client who has aids. The client states, "My mouth is sore when I eat." Which of the following instructions should the nurse provide? A. "Add salt to season" B. "Ice chips" C. "Rinse your mouth with an alcohol-based mouthwash" D. "Eat foods served at hot temperatures"

B. "Ice chips"

A nurse received a telephone call from a parent reporting that their school-age child has a nosebleed and that they cannot stop the bleeding. Which of the following instructions should the nurse provide to the provider? A. "Have your child lie down and turn their head to their side for 10 minutes" B. "Use your thumb and forefinger to apply pressure to the (Unable to read) of your child's nose" C. "Place a warm wet washcloth over your child's forehead and the bridge of their nose" D. "Tell your child to blow their nose gently and then sit down and tilt your head back"

B. "Use your thumb and forefinger to apply pressure to the (Unable to read) of your child's nose"

A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include? A. Use the client's children to provide interpretation. B. (Answer was the nurse was going to do the interpretation) C. Offer client's translation services for a nominal fee. D. Evaluate the clients' understanding at regular intervals.

B. (Answer was the nurse was going to do the interpretation)

A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider? A. Potassium level 4.2 mEq/L. B. Apical pulse 58/min. C. Digoxin level 1 ng/ml. (digoxin level 0.5 a 2) D. Constipation for 2 days.

B. Apical pulse 58/min.

A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take? A. Insert an indwelling urinary catheter. B. Apply fetal heart rate monitor. C. Initiate fundal massage. D. Initiate an oxytocin IV infusion.

B. Apply fetal heart rate monitor.

A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicates a break in surgical aseptic technique? A. Applying a sterile gown after applying a sterile mask B. Balancing the bottle on the sterile basin while pouring the liquid C. Placing the supplies on the sterile filed and leaving a 1- inch perimeter D. Putting on sterile gloves after preparing the sterile field

B. Balancing the bottle on the sterile basin while pouring the liquid

A nurse is using an IV pump for a newly admitted client. Which of the following actions should the nurse take? A. Ensure that the electric outlet has two prolongs for the IV pump B. Check the clouds of the IV pump for fraying C. Grasp the IV pump cord when unplugging it from the electrical outlet D. Remove the safety inspection sticker before plugging in the IV pump

B. Check the clouds of the IV pump for fraying

A CN (charge nurse) is providing teaching for group of newly licensed nurse about grieving process. Which of the following information should the CN include in the teaching? A. Client can expect to have feeling of hopelessness B. Client might feel guilt over some aspect of their loss C. Client will experience anhedonia D. Client will experience low self-esteem

B. Client might feel guilt over some aspect of their loss

A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first? A. Teach the client relaxation techniques B. Confirm the client's perception of the event C. Help the client identify personal strengths. D. Notify the client's support person.

B. Confirm the client's perception of the event

A nurse is caring for a client who had gastric bypass surgery 1 week ago and has manifestations of early dumping syndrome. Which of the following findings should the nurse expect? (Select all that apply) A. Hypertension B. Diaphoresis C. Syncope D. Fever E. Dizziness

B. Diaphoresis C. Syncope E. Dizziness

A nurse is caring for a male client who has a spinal cord injury. Which of the following techniques should the nurse use when providing perineal care? A. Wash the penis from the scrotum to the tip using a spiral motion B. Discard the washcloth after cleansing the urethral meatus C. Don sterile gloves to prevent infection D. Use water with no soap to prevent skin irritation

B. Discard the washcloth after cleansing the urethral meatus

A charge nurse is evaluating the time management skills of a newly licensed nurse. For which of the following actions by the newly licensed nurse should the charge nurse intervene? A. Takes assigned breaks at regular intervals B. Documents the clients care tasks at the end of the shift. C. assisting with ADLs to perform time sensitive activities D. Gather necessary supplies before beginning a dressing change.

B. Documents the clients care tasks at the end of the shift.

A nurse is assessing a client who is receiving packed RBCs. Which of the following findings indicate fluid overload? A. Low back pain. B. Dyspnea. C. Hypotension. D. Thready pulse.

B. Dyspnea.

A nurse is assessing a client who is immediately post-operative following hip arthroplasty, which of the following considerations should the nurse take when positioning the client? A. Place the client's heels directly against the bed mattress B. Ensure that the client's hips remain in an abducted position. C. Maintain the client in a supine position for the first 24 hr. after surgery. D. Flex the client's hip up to 120° when sitting in a chair.

B. Ensure that the client's hips remain in an abducted position.

A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma? A. Gender B. Environmental allergies C. Alcohol use D. Race

B. Environmental allergies

A nurse is caring for a client who request the creation of a living will. Which of the following actions should the nurse take? A. Schedule a meeting between the hospital ethics committee and the client. B. Evaluate the client's understanding of life-sustaining measures. C. Determine the client's preferences about postmortem care. D. Request a conference with the client's family.

B. Evaluate the client's understanding of life-sustaining measures.

A nurse is preforming a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following action should the nurse take? A. Instill 500 ml of solution through the NG tube. B. Insert a large-bore NG tube. C. Use a cold irrigation solution. D. Instruct the client to lie on his right side.

B. Insert a large-bore NG tube.

A nurse is planning care for a client who has cancer and is about to receive low dose brachytherapy via a vaginal implant applicator. Which of the following interventions should the nurse include in the plan of care? A. Removal of vaginal packing B. Insertion of an indwelling urinary catheter C. Ambulation four times daily D. Maintenance of NPO status until therapy is complete

B. Insertion of an indwelling urinary catheter

A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the following developmental tasks should the toddler be able to perform? A. Hop on one foot B. Kick a ball forward C. Climb Stairs with alternate feet D. Ride a tricycle

B. Kick a ball forward

A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." which of the following responses by the nurse is appropriate? (SATA) A. Hospice will take good care of your mom, so I wouldn't worry about that. B. Let's talk about your mom's cancer and how things will progress from here. C. Tell me how you are feeling about your mom dying. 02. D. Tell her not to worry. She still has plenty of time left. E. You sound like you have ques5ons about your mom dying. Let's talk about it.

B. Let's talk about your mom's cancer and how things will progress from here. C. Tell me how you are feeling about your mom dying. E. You sound like you have ques5ons about your mom dying. Let's talk about it.

A nurse is collaborating with social services in the discharge planning for a young adult client who is below the poverty income level and will require home IV therapy. Which of the following resources the nurse recommend? (SATA) A. Medicare Part A B. Medicaid C. Adult day care D. Food stamps E. Respite care

B. Medicaid D. Food stamps

A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion? ON THE REPORT needs double checking A. Urine output 20 ml/hr. B. Montevideo units constantly 300 mm Hg. C. FHR pattern with absent variability. B. Montevideo units constantly 300 mm Hg.

B. Montevideo units constantly 300 mm Hg.

A nurse is providing care for a client following a thoracentesis. If the client develops a pneumothorax, which of the following assessment findings should the nurse expect? A. Stridor B. Pain on inhalation C. Friction rub D. Bradycardia

B. Pain on inhalation

charge nurse is delegating care for a group of clients. Which of the following tasks should the charge nurse assign to a licensed practical nurse? A. Complete a discharge teaching for a client who has a new diagnosis of diabetes mellitus B. Perform a sterile dressing change for a client who has an abdominal wound C. Perform an admission assessment for a client who is scheduled for surgery D. Complete the Glasgow Coma Scale for a client who has an evolving stroke

B. Perform a sterile dressing change for a client who has an abdominal wound

A nurse is caring a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? A. Hold hand flat to perform percussion on the child B. Perform the procedure twice a day C. Administer a bronchodilator after the procedure D. Perform the procedure prior to meals

B. Perform the procedure twice a day

A nurse is caring for an adult client who has prescriptions for multiple medications. Which of the following (Unable to read) as an age-related change that increases the risk for adverse effects from this medication? A. Rapid gastric emptying. B. Prolonged medication half-life. C. Increased medication elimination. D. Decreased medication sensitivity.

B. Prolonged medication half-life.

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report? A. The client was intubated without complications. B. The estimated blood loss was 250 milliliters. C. There was a total of 10 sponges used during the procedures. D. The client is a member of the board of directors.

B. The estimated blood loss was 250 milliliters.

A nurse is discussing group treatment and therapy with a client. The nurse should include which of the following as being a characteristic of a therapeutic group? A. The group is organized in an autocratic structure. B. The group encourages members to focus on a particular issue. C. The group must be led by a licensed psychiatrist. D. The group encourages clients to form dependent relationships.

B. The group encourages members to focus on a particular issue.

Intradermal Injection area? A. Buttocks. B. Upper back. C. Hamstring area.

B. Upper back.

A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following action should nurse take? (SATA) A. Place the client in a semi-private room B. Wear a lead apron when providing care C. Limit visitors to 30 mins D. Instruct visitors who are pregnant to remain 3 ft from the client E. Close the door to the client's room

B. Wear a lead apron when providing care C. Limit visitors to 30 mins E. Close the door to the client's room

A nurse is caring for a client 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer? Antibiotic Beta-blocker Antiviral Beta2 agonist

Beta2 agonist

A nurse is providing discharge teaching to a client who is postoperative following a colon resection and has a new ascending colostomy. Which of the following statements by the client indicates an understanding of the teaching? A. "My stool will become fully formed within 3 weeks" B. "My skin will need to be cleaned with alcohol before I apply a new pouch" C. "I should avoid eating popcorn and fresh pineapple" D. "I should expect bruising around the stoma"

C. "I should avoid eating popcorn and fresh pineapple"

A charge nurse is providing teaching to a newly licensed nurse about acceptable client identifiers before administering medications. Which of the following statements by the newly licensed nurse requires intervention? A. "I will check the client's hospital arm band before administering medication" B. "I will ask the client for his hospital assigned number prior to giving medication" C. "I should check the client's room number prior to giving medication" D. "I should ask the client to state his name before administering medication"

C. "I should check the client's room number prior to giving medication"

A certified IV nurse is providing education about peripherally inserted catheters (PICC) to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicated an understanding of the teaching? A. "Use a vein in the middle of the lower arm to insert a PICC." B. "Flush a PICC using a 3-milliliter syringe." C. "Informed consent is required prior to PICC placement." D. "Position the client's arm in adduction for PICC placement."

C. "Informed consent is required prior to PICC placement."

A nurse is performing physical therapy for a client who has Parkinson's disease. Which of the following statements by the client indicates the need for a referral to physical therapy? B. "I noticed that I am having a harder time holding on to my toothbrush" C. "Lately, I feel like my feet are freezing up, as they are stuck to the ground" D. "Sometimes, I feel I am making a chewing motion when I'm not eating"

C. "Lately, I feel like my feet are freezing up, as they are stuck to the ground"

A nurse is caring for a client who is postpartum and request information about contraception. Which of the following instructions should the nurse include? A. "The lactation amenorrhea method is effective for your first year postpartum" B. "You can continue to use the diaphragm used before your pregnancy" C. "Place transdermal birth control patch on your upper arm" D. "I should avoid vaginal spermicides while breast feeding."

C. "Place transdermal birth control patch on your upper arm"

A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? A. "Taking furosemide can cause your potassium levels to be high" B. "Eat foods that are high in sodium" C. "Rise slowly when getting out of bed" D. "Taking furosemide can cause you to be overhydrated"

C. "Rise slowly when getting out of bed"

A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. "The client might act seductively." B. "The client is overly concentrated about minor details." C. "The client exhibits impulsive behaviors." D. "The client is exceptionally clingy to others."

C. "The client exhibits impulsive behaviors."

A nurse is caring for a client who asks for information regarding organ donation. Which of the following should the nurse make? A. "I cannot be a witness for your consent to donate." B. "Your name cannot be removed once you are listed on the organ donor list." C. "Your desire to be an organ donor must be documented in writing." D. "You must be at least 21 years of age to become an organ donor."

C. "Your desire to be an organ donor must be documented in writing."

A charge nurse is preparing to lead negotiations among nursing staff due to conflict about overtime requirements. Which of the following strategies should the nurse use to promote effective negotiation? A. Identify solutions prior to negotiation B. Focus on how the conflict occurred C. Attempts to understand both sides of the issue D. Personalize the conflict

C. Attempts to understand both sides of the issue

A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take? A. Obtain the newborn's body temperature using a tympanic thermometer. B. (Unable to read) FACES pain scale. C. Auscultate the newborn's apical pulse for 60 seconds. D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence.

C. Auscultate the newborn's apical pulse for 60 seconds.

A nurse is caring for a client who has Crohn's disease. Which of the following should the nurse recommend for the client? A. Navy beans B. Bacon C. Banana D. Hard-boiled egg

C. Banana

A nurse in a provider's office is preparing to administer the inactivated influenza vaccine. The nurse should collect additional (Unable to read) for which of the following client prior to administering the vaccine? A. (Unable to read B. Client has (Unable to read) HIV/AIDS C. Client has a sensitivity to eggs. D. Client is experiencing seasonal allergies.

C. Client has a sensitivity to eggs.

A nurse is planning care for a group of clients and is working with one licensed practical nurse LPN and one assistive personal AP. Which of the following actions should the nurse take first to manage her time effectively? A. Develop an hourly time frame for tasks B. Schedule daily activities C. Determine goals of the day D. Delegate tasks to the AP

C. Determine goals of the day

A nurse is planning a teaching session for a client who is postoperative following a colon resection. Which of the following actions should the nurse take first? A. Providing written material for the client to read B. Plan a short instruction about coughing and deep breathing. C. Determine the client's current pain level. D. Instruct the client about dietary restrictions.

C. Determine the client's current pain level.

A nurse is reviewing legal issues in health care with a group of newly licensed nurses. Which of the following recommendations should the nurse make? A. Place copies of incident reports in client's medical records B. Overestimate clients aculty to prevent short staffing C. Ensure that each client has a living will on file prior to treatment D. Obtain personal professional liability insurance coverage

C. Ensure that each client has a living will on file prior to treatment

A nurse is reviewing legal issues in health care with a group of newly licensed nurses. Which of the following recommendations should the nurse make? A. Overestimate client acuity to prevent short staffing B. Obtain personal professional liability insurance coverage C. Ensure that each client has a living will on file prior to treatment. D. Place copies of incident reports in client's medical records.

C. Ensure that each client has a living will on file prior to treatment.

A nurse is assessing a school-age child who has a urinary tract infection. Which of the following findings should the nurse expect? A. Periorbital edema. B. Decreased frequency of urination. C. Enuresis. D. Diarrhea.

C. Enuresis.

A nurse is assessing a toddler whose parent is concerned about the child's hearing ability. Which of the following findings indicates the need for further hearing evaluation? A. Lack of response to facial expressions B. Uses gestures to communicate C. Exaggerated startle response to sounds D. Prefers group over solitary play

C. Exaggerated startle response to sounds

A nurse is planning care for a client who has cancer and is about to receive low dose brachytherapy via a vaginal implant applicator. Which of the following interventions should the nurse include in the plan of care? A. Ambulation four times daily B. Removal of vaginal packing C. Insertion of an indwelling urinary catheter so you will not have to get up and use the restroom D. Maintenance of NPO status until therapy is complete

C. Insertion of an indwelling urinary catheter so you will not have to get up and use the restroom

A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia? A. Maternal fever B. Fetal anemia C. Maternal hypoglycemia D. Chorioamnionitis

C. Maternal hypoglycemia

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? A. Swaddle the newborn with this leg extended. B. Maintain eye contact with the newborn during feedings. C. Minimize noise in the newborn environment D. Administer naloxone to the newborn

C. Minimize noise in the newborn environment

A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? A. Notify the provider. B. Report the incident to the nurse manager. C. Monitor vital signs. D. Fill out an incident report.

C. Monitor vital signs.

A nurse is caring for a client who has pneumonia and has gained 4.2 kg (9.3 lb) over the last 5 days. The client's laboratory values this morning are the following: WBC 10,000/mm3, RBC 5.2 million/mm3, platelets 250,000/mm3, BUN, and serum creatinine 2.1 mg/dL. The nurse should report these finding to which of the following members of the interdisciplinary team? A. Dietitian B. Infection control nurse C. Nephrologist D. Cardiologist

C. Nephrologist

A nurse is obtaining a nutritional health hx on a client who reports problems with constipation. Which of the following should the nurse identify as a cause of constipation? A. Following high-fiber diet B. Currently taking probiotics- C. New prescription for an iron supplement D. Intolerance to lactose

C. New prescription for an iron supplement

A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 ml/hr. Which of the following interventions should the nurse anticipate? A. Clamp the (Unable to read) B. Administer fluid bolus. C. Obtain a urine specimen for culture and sensitivity D. Initiate continuous bladder irrigation.

C. Obtain a urine specimen for culture and sensitivity

A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include? A. Encourage the client to floss daily. B. Remove fresh flowers from the client's room. C. Provide the client what a stool softener. D. Avoid serving the client raw vegetable.

C. Provide the client what a stool softener.

A nurse is caring for a client following a paracentesis. Which of the following findings should the nurse identify as an indication of a complication? A. Decreased hematocrit. B. Increased blood pressure. C. Tachycardia. D. Hypothermia.

C. Tachycardia.

A nurse is assessing a preschooler who has recently experienced an unexpected death in the family. Which of the following should the nurse recognize as an expected finding? A. The child expresses curiosity about the death process. B. The child refuses to talk about death. C. The child believes the person will return. D. The child focuses on his own mortality.

C. The child believes the person will return.

A nurse is assessing a client following a ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider? A. The client reports a metallic taste in his mouth B. A client reports a decreased appetite C. The client coughs after swallowing D. The client has poor fitting dentures

C. The client coughs after swallowing

A nurse is admitting a client who has been taking prednisone 10 mg PO daily for 10 months. Which of the following assessment findings should the nurse identify as an adverse effect of this medication therapy? A. Absence of hair on legs below the knees B. Swelling and decreased range of motion of the joints C. Thin extremities with obesity of the abdomen D. Bradycardia and postural hypotension

C. Thin extremities with obesity of the abdomen

A nurse is caring for a client who has pernicious anemia, Which of the following laboratory values should the nurse evaluate effectiveness of the treatment? A. Folate level B. INR level C. Vitamin b12 level

C. Vitamin b12 level

A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching? A. Remove the protective gown after the client's room. B. Place the client in a room with negative pressure. C. Wear gloves when providing care to the client. D. Wear a mask when changing the linens in the client's room.

C. Wear gloves when providing care to the client.

A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective? A. Increased blood pressure B. Decreased inflammation C. Weight loss D. Decreased pain

C. Weight loss

A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first? Calculate the fluid replacement based on vital signs and urinary output Determine the location and depth of burns Administer antibiotics to prevent sepsis. Check the mouth for smooth and smoky breath

Check the mouth for smooth and smoky breath

A nurse in a clinic is assessing a 6-month-old infant. Which of the following should the nurse report to the provider? Pulse 140/min Closed anterior fontanel Respiratory rate 26/min Abdominal breathing

Closed anterior fontanel

nurse manger is reviewing documentation with a newly licensed nurse. Which of the following notations by the newly licensed nurse indicates an understanding of the teaching? UNSURE IF ON THE REPORT A. "OOB with assistance for breakfast" B. "Given 2 mg MSO4 IM for report of pain" C. "Dressing changed qd" D. "Administered 8 u regular insulin sq."

D. "Administered 8 u regular insulin sq."

A nurse is providing teaching about digoxin administration to the parents of a toddler which as heart failure. Which of the following statements should the nurse include in the teaching? A. "Limit your child's potassium intake while she is taking this medication." B. "You can add the medication to a half-cup of your child's favorite juice." C. "Repeat the does if your child vomits within 1 hour after taking the medication." D. "Have your child drink a small glass of water after swallowing the medication."

D. "Have your child drink a small glass of water after swallowing the medication."

A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take? B. "I recommend that you take this medication as prescribed" C. "Do you know why this medication is being prescribed to you?" D. "I will call the pharmacist now to check on this medication"

D. "I will call the pharmacist now to check on this medication"

A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse plan to include in the teaching? A. "The cord stump will fall off in 5 days." B. "Contact the provider if the cord stump turns black." C. "Clean the base of the cord with hydrogen peroxide daily." D. "Keep the cord stump dry until it falls off."

D. "Keep the cord stump dry until it falls off."

A charge nurse is teaching a newly licensed nurse about clients designating a health care proxy in situations that require a durable power of attorney for healthcare (DPAHC). Which of the following information should the charge nurse include? A. "The proxy can make financial decisions if the need arises" B. "The proxy should manage legal issues for the client" C. "The proxy should make healthcare decisions for the client regardless of the client's ability to do so" D. "The proxy can make treatment decisions if the client is under anesthesia"

D. "The proxy can make treatment decisions if the client is under anesthesia"

A nurse is caring for a client who has end-stage liver cancer. Which of the following statements should the nurse make to support the client's right to autonomy? A. "You should trust that your care team has your best interest at heart" B. "I will not share any personal information without your permission C. "The health care team will do their best to keep any promise we make to you" D. "We encourage you to participate in all decisions about your treatment"

D. "We encourage you to participate in all decisions about your treatment"

A nurse is teaching a parent of a school-age child who is to begin a daily dose of methylphenidate. Which of the following should the nurse include in the teaching? A. "Your child should avoid foods containing tyramine" B. "Your child should avoid excess sodium intake" C. "You should administer the medication at bedtime" D. "You should administer the medication after breakfast"

D. "You should administer the medication after breakfast"

A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge? B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago. C. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage. D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration.

D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration.

A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A. A client who has COPD and a respiratory rate of 44/min B. A client who has cancer with a sealed implant for radiation therapy C. A client who is receiving heparin for deep-vein thrombosis D. A client who is 1 day postoperative following a vertebroplasty

D. A client who is 1 day postoperative following a vertebroplasty

A nurse is developing a plan of care for an older adult client who has hearing loss. Which of the following instructions the nurse include in the plan? A. Increase the pitch of voice when speaking to the client low pitch B. Avoid using hand motions when speaking to the client C. Rephrase statements that the client misunderstands D. Ask the client to confirm an understanding of the instructions by nodding.

D. Ask the client to confirm an understanding of the instructions by nodding.

A nurse is assessing a newborn who has patent ductus arteriosus. Which of the following findings should the nurse except? A. Increase PaO2 B. Hypoglycemia C. Board-like abdomen D. Bounding pulse

D. Bounding pulse

A nurse in a provider's office is reviewing the laboratory results of a group of clients. Which to report? A. Herpes simplex. B. Human papillomavirus C. Candidiasis D. Chlamydia

D. Chlamydia

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? A. Vomiting B. Hypertension C. Epigastric pain D. Contractions

D. Contractions

A nurse manager is planning to promote client advocacy among staff in a medical unit. Which of the following actions should the nurse take? A. Encourage staff to implement the principle of paternalism when a client is having difficulty making a choice. B. Tell staff to explain procedures to clients before obtaining informed consent. C. Instruct unit staff to share personal experiences to help clients make decisions. D. Develop a system for staff members to report safety concerns in the client care environment.

D. Develop a system for staff members to report safety concerns in the client care environment.

A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client? A. Match the client's blood type with the type and cross match specimens. B. Confirm the provider's prescription matches the number on the blood component. C. Ask the client to state the blood type and the date of their last blood donation. D. Ensure that the client's identification band matches the number on the blood unit.

D. Ensure that the client's identification band matches the number on the blood unit.

A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider? A. WBC count 8,000/mm3. B. Platelets 150,000/mm3. C. Aspartate aminotransferase 10 units/L. rate 5 a 40 units/L D. Erythrocyte sedimentation rate 75 mm/hr

D. Erythrocyte sedimentation rate 75 mm/hr

A nurse is caring for a client who has a spinal cord injury. Which of the following support devices should the nurse plan to use to prevent plantar flexion contractures? A. Sheepskin heel pad B. Trochanter roll C. Abduction pillow D. Footboard

D. Footboard

nurse is providing discharge teaching to a client who has hyperlipidemia and is to start treatment with atorvastatin. The nurse should instruct the client to avoid taking the medication with which of the following? A. Aged cheese B. Caffeinated beverages C. Green, leafy vegetables D. Grapefruit juice

D. Grapefruit juice

A nurse is caring for a client who experienced a traumatic brain injury 72 hr. ago. Which of the following findings should the nurse identify as an indication of intercranial pressure? A. Tachycardia. B. Narrowed pulse pressure. C. Hypotension. D. Increasingly severe headache.

D. Increasingly severe headache.

A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? A. Restrict the client's total fluid intake to 250 mL/hr B. Give the protamine if signs of magnesium sulfate toxicity occur C. Monitor the FHR via Doppler every 30min D. Measure the client's urine output every hour

D. Measure the client's urine output every hour

A nurse is reviewing admission prescriptions for a group of clients. Which of the following prescriptions should the nurse identify as complete? A. Furosemide 20 mg BID B. Nitroglycerin transdermal patch. C. Aspirin 1 tablet daily. D. Metoprolol 5mg IV now.

D. Metoprolol 5mg IV now.

A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take? A. Confront the nurse about the suspected alcohol use. B. Inform another nurse on the unit about the suspected alcohol use. C. Ask the nurse to finish administering medications and then go home. D. Notify the nursing manager about the suspected alcohol use.

D. Notify the nursing manager about the suspected alcohol use.

A nurse is planning on care for a client who is recovering from an acute myocardial infarction that occurred 3 days ago. Which of the following instructions should the nurse include? A. Perform an ECG every 12 hr. B. Place the client in a supine position while resting. C. Draw a troponin level every 4hr. D. Obtain a cardiac rehabilitation consultation.

D. Obtain a cardiac rehabilitation consultation.

A nurse is caring for a client who has left-sided heart failure, and the provider is concerned that the client might develop (Unable to read) Which of the following actions should the nurse take? A. Maintain the client's oxygen saturation level at 89%. B. Place the client's lower extremities on two pillows. C. Recommended that the client follow a 3g sodium diet. D. Place the client in high fowler's position.

D. Place the client in high fowler's position.

A nurse is reviewing the laboratory report of a client who has a prescription for digoxin. For which of the following laboratory results should the nurse withhold the medication and notify the provider? A. Digoxin 0.8 ng/ml B. Sodium (Was out of range) C. BUN 15 D. Potassium 3.1 mEq/L.

D. Potassium 3.1 mEq/L.

A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery? A. Fasting blood glucose 108 mg/dl B. WBC 9,800/mm C. Creatinine 0.9 mg/dl D. Potassium 5.2 mEq/L

D. Potassium 5.2 mEq/L

A nurse is completing an admission assessment for a client who has narcissistic personality disorder. Which of the following findings should the nurse expect? A. Ritual behavior B. Suspicious of others C. Exhibits separation anxiety D. Preoccupied with aging

D. Preoccupied with aging

A nurse is caring for a client who speaks a language different from the nurse. Which of the following should the nurse take? A. Request an interpreter of a different sex from the client. B. Request a family member or friend to interpret information for the client. C. Direct attention toward the interpreter when speaking to the client. D. Review the facility policy about the use of an interpreter.

D. Review the facility policy about the use of an interpreter.

A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with an interpreter? A. Pause in the middle of sentences B. Use gestures when speaking with the client C. Direct statements to the interpreter D. Speak in a normal voice at a natural pace

D. Speak in a normal voice at a natural pace

A nurse is providing care for a client who is in the advance stage of amyotrophic lateral sclerosis. (ALS). Which of the following referrals is the nurse's priority? A. Psychologist. B. Social worker. C. Occupational therapist. D. Speech-language pathologist.

D. Speech-language pathologist.

A nurse is teaching a female client about personal hygiene. Which of the client actions indicates an understanding go the teaching? A. The client takes a hot bubble bath every day. B. The client wipes back to front when toileting. C. The client washes her perineum first when bathing. D. The client brushes her teeth twice daily.

D. The client brushes her teeth twice daily.

A nurse is reviewing the medical record of a client who is postoperative following a total hip arthroplasty. For which of the following findings should the nurse contact the provider? A. Hear rate 100/min B. Temperature 37.8C (100F) C. Albumin level 4.0 g/dL. D. WBC count 14,000 mm3

D. WBC count 14,000 mm3

A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? A. Heart rate 58/min B. Fasting blood glucose 100 mg/dL C. Hgb 14 g/dL D. WBC count 2,900/mm3

D. WBC count 2,900/mm3

A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make? A. I'm sure you can find alternative remedies through an online support group B. If there are therapies available to you, your provider will tell you about them C. Feel free to try whatever therapies that fit within your personal belief system D. We can review some information to help you select a safe alternative practitioner.

D. We can review some information to help you select a safe alternative practitioner.

A nurse is building a therapeutic relationship with a new admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship? Determine previous coping skills used by the client Establish the responsibilities of the nurse and client Facilitate the clients problem-solving skills Assist the client in expressing alternative behaviors

Establish the responsibilities of the nurse and client

A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take? . Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion Check the client's vital signs from the previous shift prior to the initiation of the transfusion Set the IV infusion pump to administer the blood over 6 hr Administer the blood via a 21-gauge IV needle

Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion

A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct in her diet to prevent a neural tube defect? A. Folate B. Zinc C. Iron D. Calcium

Folate

A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis. Which of the following statements indicates that the client understands the teaching? I need to have an enema before the test I should urinate before the test I will lie on my left side during the test I will drink an oral glucose solution during the test

I should urinate before the test

A nurse is providing teaching about car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? I can turn my baby's car seat around when she weighs 15 pounds I can place my baby in the front seat with the airbag turned off I will place my baby in a forward-facing car seat in my back seat I will position my baby at a 45-degree angle in the car seat

I will position my baby at a 45-degree angle in the car seat

A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority? Maintain NPO status for client Change client's position every 2 hours Perform range-of-motion exercises to client's extremities. Place the client's right hand in supination position.

Maintain NPO status for client

A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take? Monitor the dorsalis pedis pulse every 15 min Keep the client NPO for 24 hr. Place the client in fowlers position Maintain strict bedrest for the first 12 hr.

Monitor the dorsalis pedis pulse every 15 min

A nurse is caring for several clients on a medical-surgical unit. For which of the following nursing activities is it required that the nurse use sterile gloves? Inserting an NG tube Administering total parenteral nutritional through a central venous access device Initiating IV access Performing tracheostomy care

Performing tracheostomy care

A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which if the following findings should the nurse identify as a contraindication for heat therapy? Phlebitis Abdominal aortic aneurysm Osteoarthritis Peripheral neuropathy

Peripheral neuropathy

A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse? Inform the transferring agency of the client's condition. Privately interview the client about her condition. Notify risk management Contact the family regarding the client's condition.

Privately interview the client about her condition.

Where is McBurney's point located?

RLQ

A nurse is caring for a client who is in labor and has received an epidural. Which of the following actions should the nurse take? Decrease the maintenance infusion rate of IV fluid Have protamine sulfate available at the bedside Reposition the client side-to side each hour Monitor the client for hypertension

Reposition the client side-to side each hour

A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the following clinical manifestations is an expected finding for this client? Report of occipital headache Scratchy, high pitched sound upon chest auscultation ECG demonstrates a depressed ST segment White, diffuse peritonsillar pustules

Scratchy, high pitched sound upon chest auscultation

A home health nurse is preparing to assess a client who reports tingling around the mouth and laxative use at least once daily. Which of the following assessments should the nurse perform first? Test the client for Trousseau's sign Assess the client's skin turgor Check the client's motor strength Measure the client's pupil size

Test the client for Trousseau's sign

A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should the nurse make? We can provide a copy of your records, but the therapists notes are not included I don't think you will benefit from reviewing your therapists notes right now Why are you interested in seeing your therapist's notes? Are you not happy with your treatment?

We can provide a copy of your records, but the therapists notes are not included

The school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? a. " This type of seizure can be mistaken for daydreaming" b. "The child usually has an aura prior to onset" c. This type of seizure last 30-60 sec" d. "This type of seizure has a gradual onset"

a. " This type of seizure can be mistaken for daydreaming"

A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? a. "I will let the client know that I am available as the interpreter." b. "I will receive a small fee for interpreting for this client." c. "I am glad I'm available today, but when I'm not, you can use a family member." d. "I will let the client know that an interpreter is unavailable during the night shift."

a. "I will let the client know that I am available as the interpreter."

A public health nurse is teaching a group of new parents about SIDS. Which of the following statements by the parents indicates an understanding of the teaching a. "I will make sure the mattress in my baby's crib is firm" b. "My baby will no longer be at risk for SIDS when he reaches 6 months c. I can keep my newborn in bed with me at night to make bottle feeding easier d. I will avoid giving my baby a pacifier during naptimes

a. "I will make sure the mattress in my baby's crib is firm"

A nurse is caring for a client who is receiving intravenous antibiotics every 6 hr. Which of the following responses by the client is the priority for the nurse to evaluate? a. "My throat feels tight." b. " I don't understand why I am getting this antibiotic." c. "My arms burn each time that medication is running." d. "This medication bag is still full."

a. "My throat feels tight."

A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on con5nuous oxygen. Which of the following is an appropriate response by the nurse? a. "There are portable oxygen delivery systems that you can take with you." b. "When you go out, you can remove the oxygen and then reapply it when you get home." c. "You probably will not be able to go out at much as you used to." d. "Home health services will come to see you so you will not need to get out."

a. "There are portable oxygen delivery systems that you can take with you."

A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching? a. "You should not have this procedure if you are allergic to iodine." b. "You should not have this procedure if you have a tattoo." c. "The nurse will ask you to wear protective eyewear during this procedure." d. "The nurse will ask you to remove any transdermal patches prior to the procedure."

a. "You should not have this procedure if you are allergic to iodine."

A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 90.7 (200 lb). The nurse should identify the weight of the following total percentage. a. 7.5% b. 15% c. 8.1% d. 13.3%

a. 7.5%

A nurse is reviewing the health records of ?ve clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.) a. A client who experienced a near-drowning incident b. A client following coronary artery bypass gra6 surgery c. A client who has a hemoglobin of 15.1 mg/dL d. A client who has dysphagia e. A client who experienced a drug overdose

a. A client who experienced a near-drowning incident b. A client following coronary artery bypass gra6 surgery d. A client who has dysphagia e. A client who experienced a drug overdose

A nurse is caring for a group of clients. Which of the following clients are at risk for pulmonary embolism? (Select all that apply.) a. A client who has a BMI of 30 b. A female client who is postmenopausal c. A client who has a fractured femur d. A client who is a marathon runner e. A client who has chronic atrial fibrillation

a. A client who has a BMI of 30 c. A client who has a fractured femur e. A client who has chronic atrial fibrillation

A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first? a. A client who has hyporeflexia while receiving magnesium sulfate b. A client who reports abdominal pain during breastfeeding- normal, since your stimulating oxytocin c. A client who reports changing her perineal pad every 2 hr... q 15 minutes would be a problem d. A client who has a output of 250 mL in 6hr= 30 x 6 = 180

a. A client who has hyporeflexia while receiving magnesium sulfate

A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first? a. A client who was just given a glass of orange juice for a low blood glucose level b. A client who is schedule for a procedure in 1 hr c. A client who has 100 mL fluid remaining in his IV bag 13 of 28 d. A client who received a pain medication 30 min ago for postoperative pain

a. A client who was just given a glass of orange juice for a low blood glucose level

A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider? a. A two-day old newborn who has a respiratory rate of 70 b. A 16-hour old new newborn who has yet to pass meconium c. A 2-day old newborn who has a small amount of blood tinged vaginal discharge d. A 16 hr old newborn whose blood glucose is 45 mg/dl

a. A two-day old newborn who has a respiratory rate of 70

A nurse manager is planning a staff in-service to address advocacy in client care. The nurse should promote which of the following practices during the in-service? (select all that apply) a. Addressing client needs when providing resources * b. Making decisions about health care on client's behalf c. Promoting health care access* d. Encouraging clients to seek further information from the provider *

a. Addressing client needs when providing resources * c. Promoting health care access* d. Encouraging clients to seek further information from the provider *

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The bag has 20 mL remaining to infuse but the new bag is not readily available. Which of the following actions should the nurse take? a. Administer dextrose 10% in water b. Slow the infusion rate c. Temporarily discontinue the infusion d. Give 500 mL of lactated Ringer's solution

a. Administer dextrose 10% in water

A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate? a. Administer enalapril 2.5 mg PO twice daily b. Ambulate the client every 4 hr while awake c. Provide the client with 4 g sodium diet d. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr

a. Administer enalapril 2.5 mg PO twice daily

A nurse in a long term care facility is caring for an older adult who has a dementia. The client believes he needs to get ready for work and is becoming increasingly agitated. Which of the following actions should the nurse take? a. Assist the client in selecting clothing for the day b. Tell the client that his behavior is unacceptable c. Administer an anti anxiety medication d. Inform the client that he no longer has a job to go to

a. Assist the client in selecting clothing for the day

A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching? a. Avoid hot tub while wearing the patch b. Apply patch to your forearm c. Avoid high-fiber foods while taking this medication

a. Avoid hot tub while wearing the patch

A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first? a. Clarify the source of the referral b. Implement the nursing process c. Schedule a time for the home visit d. Contact the family by phone

a. Clarify the source of the referral

A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? (Select all that apply.) a. Client who has dysphagia b. Client who has AIDS c. Client who was vaccinated for pneumococcus and influenza 6 months ago d. Client who is postoperative and received local anesthesia. e. Client who has a closed head injury and is receiving ventilation f. Client who has myasthenia gravis

a. Client who has dysphagia b. Client who has AIDS e. Client who has a closed head injury and is receiving ventilation f. Client who has myasthenia gravis

A nurse is admitting a client to a med-surg unit. When performing medication reconciliation for the client. Which of the following actions should the nurse take? a. Compare new prescription with the list of medications the clients reports. b. Encourage the client to make his own list after he returns to his home. c. Exclude nutritional supplements from the list of medication the client reports. d. Include any adverse effects of the medication the client might develop.

a. Compare new prescription with the list of medications the clients reports.

A nurse is admitting a client who has dementia to a long-term facility. The client tells the nurse that she lived in this facility years ago and took care of all the residents by herself. The nurse should document this as which of the following findings? a. Confabulation b. Perseveration c. Agnosia d. Projection

a. Confabulation

A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention? a. Continue the monitor the fetal heart rate a. Providing pain management b. Offering emotional support c. Preventing infection

a. Continue the monitor the fetal heart rate

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications? a. Contractions b. Hypertension c. Vomiting d. Epigastric pain

a. Contractions

A nurse is planning to delegate the fasting blood glucose testing for a client who has DM to an assistive personnel. Which of the following actions should the nurse take? a. Determine if the AP has the skills to perform the test b. Assign the AP to ask the client if she has taken her antidiabetic meds today c. Help the AP perform the blood glucose test d. Have the AP check the medical record for the prior blood glucose test results

a. Determine if the AP has the skills to perform the test

A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? a. Eat 1g/kg of protein per day b. Drink at least 3L of fluid daily c. Consume foods high in potassium d. Take magnesium hydroxide for indigestion

a. Eat 1g/kg of protein per day

A nurse is providing dietary teaching to a client who has heart failure. Which of the following recommendations is appropriate for this client? a. Encourage seasoning with dry herbs b. Increase fluids to 2L/day c. Use saturated oils when cooking d. Increase consumption of dairy products

a. Encourage seasoning with dry herbs

A nurse in the emergency department is assessing a client who has major depressive disorder. Which of the following actions should the nurse take first ? a. Encourage the client to verbalize feelings. b. Implement seizure precautions for the client. c. Administer ondansetron to the client for nausea. d. Obtain the client's weight.

a. Encourage the client to verbalize feelings.

A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of low dose dopamine. Which of the following findings is the highest priority? a. Erythema 5 cm (2in) above the IV site b. Blood pressure 92/68 mm Hg - c. Urine output 35mL/hr d. Pedal pulse of +1 bilaterally

a. Erythema 5 cm (2in) above the IV site

A nurse is providing teaching to a client about the adverse effects of Sertraline. Which of the following adverse effects should the nurse include? a. Excessive sweating b. Metallic taste in mouth c. Increased urinary frequency d. Dry cough

a. Excessive sweating

A nurse is preparing to witness a client's signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (SATA) a. Explain the procedure b. Expected outcome of the procedure c. Potential complications d. Possible alternative treatments e. Cost of the procedure

a. Explain the procedure b. Expected outcome of the procedure c. Potential complications d. Possible alternative treatments

A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medica5ons should the nurse anticipate administering with this medica5on? (Select all that apply.) a. Fentanyl b. Furosemide c. Midazolam d. Famotidine e. Dexamethasone

a. Fentanyl c. Midazolam

A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin? a. Give the dose over 60 min b. Administer the medication undiluted c. Obtain trough level 30 min after the medication infusion d. Inject 1% lidocaine prior to each dose

a. Give the dose over 60 min

A nurse is caring for a client who is to receive thromboly5c therapy. Which of the following factors should the nurse recognize as a contraindica5on to the therapy? a. Hip arthroplasty 2 weeks ago b. Elevated sedimentation rate c. Incident of exercise-induced asthma 1 week ago d. Elevated platelet count

a. Hip arthroplasty 2 weeks ago

A nurse is preparing to administer a dose of a new prescrip5on of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medica5on? (Select all that apply.) a. Hypokalemia b. Tachycardia c. Fluid retention d. Nausea e. Black, tarry stools

a. Hypokalemia c. Fluid retention e. Black, tarry stools

A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity? a. Hyporeflexia b. Tachypnea c. Pruritus d. Polyuria

a. Hyporeflexia

A nurse providing teaching about nutritional needs to an adolescent client. Which of the following statements by the client indicates an understanding of the teaching? a. I should consume about 1,300 milligrams of calcium a day b. Protein should be my main source of caloric intake c. I should limit my daily fat intake to 40 percent d. I should consume about 8 milligrams of iron a day

a. I should consume about 1,300 milligrams of calcium a day

A nurse is caring for a client who has tuberculosis. The client tells the nurse he has not been taking his medication because he can no longer afford to purchase it. Which of the following statements should the nurse make? a. I will ask the social worker to come speak with you about this situation b. I will tell your provider that you do not want take the medication c. You should budget your money to be able to purchase this medication d. You should ask your family to purchase the medication for you

a. I will ask the social worker to come speak with you about this situation

A nurse is providing discharge instructions to the parent of a newborn. Which of the following statement by the parent indicates an understanding of the teaching? a. I will suction my baby's mouth before I suction his nose. b. I will lubricate the tip of the syringe with water prior to suction his nose. c. I should insert the syringe into the center of his mouth. d. I should compress the bulb after inserting it into the mouth.

a. I will suction my baby's mouth before I suction his nose.

A nurse is caring for a client who has experienced a right-hemispheric stroke. Which of the following are expected findings? (Select all that apply.) a. Impulse control di2culty b. Le6 hemiplegia c. Loss of depth perception d. Aphasia e. Lack of situa:onal awareness

a. Impulse control di2culty b. Le6 hemiplegia c. Loss of depth perception e. Lack of situational awareness

A nurse is caring for a child who has sickle cell anemia and experiencing vaso-constrictive crisis. Which of the following actions should the nurse include in the plan of care? a. Initiate IV fluid replacement b. Start a 24-hr urine collection c. Give aspirin to reduce pain d. Encourage ambulation

a. Initiate IV fluid replacement

A nurse is planning care for a client who is in labor and has gonorrhea. Which of the following actions should the nurse include in the plan for delivery? a. Instill erythromycin ointment into the newborn's eye b. Apply miconazole vaginal cream to the mother prior to delivery c. Give oral sulfadiazine to the mother prior to delivery d. Administer penicillin G procaine IM to the newborn

a. Instill erythromycin ointment into the newborn's eye

A A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care? a. Instruct the client to empty her bladder prior to the procedure. b. Position the client over an overbed table prior to the procedure. c. Administer 1 L dextrose 5% in water IV bolus prior to the procedure. d. Initiate NPO status 4 hr prior to the procedure.

a. Instruct the client to empty her bladder prior to the procedure.

A nurse is caring for an older adult client who has hemiparesis following a stroke. Which of the following actions should the nurse take to prevent falls? (SATA) a. Leave the client's bathroom light on b. Have the client wear shoes while ambulating to the bathroom c. PLace a nonskid mat on the shower floor d. Place the client's bedside table at the foot of the bed e. Keep the client's bed in the lowest position

a. Leave the client's bathroom light on b. Have the client wear shoes while ambulating to the bathroom c. PLace a nonskid mat on the shower floor e. Keep the client's bed in the lowest position

A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the client's information? a. Level of consciousness. b. Skin turgor c. Deep tender Reflex D. Bowel Sounds

a. Level of consciousness.

A nurse is caring for a client who has new prescription for enalapril. The client report tingling and swelling around the mouth 1hr after receiving the medication. Which of the following actions should the nurse take first? a. Notify the rapid response team b. Obtain IV access c. Document findings d. Elevate the lower extremity.

a. Notify the rapid response team

A nurse is teaching the family of an infant who has decreased cardiac output to congenital heart disease. Which of the following instruction should the nurse include in the teaching? a. Observe for manifestations of hunger in order to feed the infant before crying occurs keep crying to a minimum, crying increases workload of heart b. Bathe the infant and change the bed linens daily to reduce the risk of infection. c. maintain the infant in supine position when sleeping. d. Perform infant care activities frequently and intermittently throughout the day.

a. Observe for manifestations of hunger in order to feed the infant before crying occurs keep

A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (Select all that apply.) a. Oxygen b. Sterile water c. Enclosed hemostat clamps d. Indwelling urinary catheter e. Occlusive dressing

a. Oxygen b. Sterile water c. Enclosed hemostat clamps e. Occlusive dressing

A nurse on a medical-surgical unit is delegating tasks to an assistive personnel (AP). Which of the following client care tasks is within the scope of practice for the AP? a. Performing postmortem care b. Explaining the steps for a 24-hr urine collection c. Assisting with low-carbohydrate diet selections d. Interpreting blood glucose values

a. Performing postmortem care

A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.) a. Persistent cough b. Weight gain c. Fatigue d. Night sweats e. Purulent sputum

a. Persistent cough c. Fatigue d. Night sweats e. Purulent sputum

A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of insulin. The client's lab findings reveal a potassium level of 5.5 mEq/L, BUN of 15 mg/dL, and a creatinine level of 1 mg/dL. Which of the following interventions is appropriate for the nurse to take? a. Place a cardiac monitor on the client b. Stop the IV infusion of insulin c. Administer oral potassium to the client- potassium is already high d. Initiate a 24 hr urine collection

a. Place a cardiac monitor on the client

A nurse is admitting a client who tells the nurse he has brought a copy of his advance directives. Which of the following actions should the nurse take? a. Place a copy of the document in the client's medical record. b. Request a social worker to review the document with the client c. Ask the client to keep the document in his bedside table. d. D. Have the provider approve the document.

a. Place a copy of the document in the client's medical record.

nurse is positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take? a. Place a wedge under one of the client's hips b. Assist the client into the lithotomy position c. Position the client in reverse trendelenburg d. Insert a pillow under the client's knees

a. Place a wedge under one of the client's hips

A nurse is caring for a client who has CVC and develops an air embolism. Which of the following actions should the nurse take? a. Place the client in a left lateral trendelenburg position. b. Prepare the client for chest tube insertion c. Instruct the client to perform valsalva maneuver d. Remove the client catheter.

a. Place the client in a left lateral trendelenburg position.

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? a. Position the client in an upright position, leaning over the bedside table. b. Explain the procedure. c. Obtain ABG's. d. Administer benzocaine spray.

a. Position the client in an upright position, leaning over the bedside table.

A nurse is reviewing the laboratory levels of a client who is having elective surgery. Which of the following levels should the nurse report to the provider? a. Potassium 3.2 mEq/L b. BUN 16 mg/dL (Normal 10-20) c. PT 12.2 seconds (Normal 11-14) d. Fasting blood glucose 103 mg/dL

a. Potassium 3.2 mEq/L

A nurse is caring for a client who is 2 hr postpartum. The client states, " I'm having difficulty emptying my bladder." which of the following actions should the nurse take? a. Pour warm water from a squeeze bottle over the client's perineum b. Hold analgesic medication until the client voids c. Place a transcutaneous electrical nerve stimulation (TENS) unit over the client's bladder area d. Immerse the client's hands in cool water

a. Pour warm water from a squeeze bottle over the client's perineum

A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take? a. Provide anticipatory guidance classes to parents through public schools b. Have a nurse from the outside the community provide health lectures at the county hospital c. Encourage rural residents to focus health spending on tertiary health interventions d. Launch a media campaign to increase awareness about industrial pollution

a. Provide anticipatory guidance classes to parents through public schools

A nurse in a clinic is assessing a 6-month-old infant. Which of the following findings should the nurse report to the provider? a. RR 26/min b. Pulse 140/min c. Abdominal breathing d. Closed anterior fontanel

a. RR 26/min

A nurse is caring for a client who has a new diagnosis of Chlamydia trachomatis. Which of the following actions should the nurse take? a. Report the infection to the state department of health b. Schedule the client for retesting in 1 week c. Administer ceftriaxone via intermittent IV bolus d. Instruct the client to abstain from abstain from sexual intercourse for 1 month

a. Report the infection to the state department of health

A client's partner tells a staff nurse that he overhears laboratory staff discussing the result of the client's biopsy report while on the elevator. Which of the following actions should the nurse take? a. Report the information to the charge nurse b. Review confidentiality policies with laboratory employees Facility manager or someone who audits or teaches HIPAA stuff c. Contact the laboratory manager regarding the situation d. Notify the facilities legal department

a. Report the information to the charge nurse

A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, the nurse does not speak the same language as the client. The client partner and a 10-year-old child are accompanying her. Which of the following actions should the nurse take to gather the client's information? a. Request a female translator interpreter through the facility b. Ask a student nurse who speaks the same language to translate c. Have the child translate d. Allow the clients partner to translate

a. Request a female translator interpreter through the facility

A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse should expect the client to have an increase in which of the following laboratory values? a. Serum glucose level- b. Serum calcium level- c. Lymphocyte count- d. Serum potassium level-

a. Serum glucose level-

A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply.) a. Tachypnea b. Deviation of the trachea c. Bradycardia d. Decreased use of accessory muscles e. Pleuritic pain

a. Tachypnea b. Deviation of the trachea e. Pleuritic pain

A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client's ability to eliminate urine from the bladder is restored? a. Two voids of 150 mL each over the past 2 hours b. Fundus 2 fingerbreadths above the umbilicus c. Uterine atony d. Fundus firm and to the right of the abdominal midline

a. Two voids of 150 mL each over the past 2 hours

A nurse is assessing a client who has a stage IV pressure ulcer and is undergoing treatment prescribed by a wound care consultant. For which of the following findings should the nurse contact the consultant to revise the plan of care? a. Weight loss of 5% in 10 days B. Appearance of pink tissue under eschar c. Hgb 15 g/dL d. Albumin level 4.0 g/dL

a. Weight loss of 5% in 10 days

A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching? a. You can receive the immunization for influenza at any time during your pregnancy b. The immunization for varicella should be given at least 1 month prior to delivery c. The hepatitis B immunization should not be obtained until after you finish breastfeeding d. You can receive the rubella immunization during the third trimester of pregnancy

a. You can receive the immunization for influenza at any time during your pregnancy

A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make? a. You have right to decide who receives information b. You partner can be source of support for at this time c. Is there a reason you don't want your partner to know about your procedure? d. The provider will be tactful when talking to your partner

a. You have right to decide who receives information

A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? a. You may breastfeed unless your nipples are cracked or bleeding. b. You must use a breast pump to provide breast milk. c. You must use nipple shield when breastfeeding. You may breastfeed after your baby develops his antibiotics.

a. You may breastfeed unless your nipples are cracked or bleeding.

A nurse is preparing to document care in a client's electronic health record. Which of the following entries by the nurse demonstrates appropriate documentation? a. "Client drank orange juice at HS." b. "Client has a heart rate of 102/min" c. "Client is demanding of nurse's attention." d. "Client appears nervous."

b. "Client has a heart rate of 102/min"

A nurse receiving change-of-shift report from the nurse on the previous shift. Which of the following information should the nurse include in the report? a. "Client in room 302 has visitors." b. "Client in room 303 needs his 8am blood glucose before his scheduled insulin." c. "Client in room 301 is in the cardiac catheterization lab." d. "Client in room 304 is doing poorly."

b. "Client in room 303 needs his 8am blood glucose before his scheduled insulin."

A nurse is teaching a client who has atrial fibrillation and is to start taking dabigatran. Which of the following statements by the client indicates an understanding of the teaching? a. "I can store the medication in the refrigerator." b. "I should keep the medication in the original container." c. "I can crush the medication and mix with applesauce." d. "I should replace any unused medication every 6 months."

b. "I should keep the medication in the original container."

A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse? a. "I try to respond to the baby quickly." b. "I think the baby should be sleeping through the night by now. c. "I have several friends who come by to help out with the baby." d. "I want to meet other parents to see if they are going through the same thing."

b. "I think the baby should be sleeping through the night by now.

A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? a. "I will take sucralfate with meals three times per day" b. "I will avoid food and beverages that contain caffeine" c. "I will decrease my daily protein intake to 15 grams per day" d. "I will use ibuprofen as needed to control abdominal pain"

b. "I will avoid food and beverages that contain caffeine"

A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks of gestation about managing diabetes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? a. "I will decrease my protein intake during the third trimester" b. "I will need to increase my insulin doses later in my pregnancy" c. "I will increase my carbs at breakfast and limit them the rest of the day" d. "I will decrease my calorie consumption during the first trimester"

b. "I will need to increase my insulin doses later in my pregnancy"

A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol 1 mg PO daily. Which of the following client statements indicate the client understands the teaching? (Select all that apply.) a. "I can substitute one medication for another if I run out because that all fight infection." b. "I will wash my hands each :me I cough." c. "I will wear a mask when I am in a public area." d. "I am glad I don't have to have any more sputum specimens." e. "I don't need to worry where I go once I start taking my medications."

b. "I will wash my hands each :me I cough." c. "I will wear a mask when I am in a public area."

A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state? a. "How long have you been hearing the voices?" b. "What are the voices telling you?" c. "Have you taken your medication today?"

b. "What are the voices telling you?"

A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state? a. "How long have you been hearing the voices?" b. "What are the voices telling you?" c. "Have you taken your medication today?" d. "I realize the voices are real to you, but I don't hear anything."-

b. "What are the voices telling you?"

A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client? a. "Can you tell me who visited you today?" b. "What high school did you graduate from?" c. "Can you list your current medications?" d. "What did you have for breakfast yesterday?"

b. "What high school did you graduate from?"

A nurse manager is confronted by a staff nurse who complains that her assignment is unfair. Which of the following responses should the nurse manager make? a. "You are being unreasonable about your assignment." b. "You seem to be upset about your assignment." c. "I will always try to be fair when i make assignments." d. "I can't believe you think this assignment is unfair."

b. "You seem to be upset about your assignment."

A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching? a. "You will need to continue to take the multi-medication regimen for 4 months." b. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." c. "You will need to remain hospitalized for treatment." d. "You will need to wear a mask at all times."

b. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication."

A nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse assess first? Pain pallor pulselessness paresthesia a. A client who is 1 hr postoperative and has hypoactive bowel sounds b. A client who has fractured le@ 5bia and pallor in the aYected extremity c. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses d. A client who has a elevated AST level following administration of azithromycin

b. A client who has fractured le@ 5bia and pallor in the aYected extremity

A nurse on a medical-surgical unit is planning care for a group of clients. Which of the following clients should the nurse plan to see first? a. A client who has diabetes mellitus and a morning blood glucose level of 120 mg/dL. b. A client who has heart failure and an oxygen saturation level of 89% c. A client who has atrial fibrillation and a ventricular heart rate of 105/min d. A client who has polycystic kidney disease and a blood pressure of 130/85 mmHg

b. A client who has heart failure and an oxygen saturation level of 89%

A nurse is providing discharge teaching to a client who has undergone bowel surgery with placement of a colostomy. Which of the following information should the nurse include in the teaching? a. Eat a low-fiber diet if constipation occurs. b. Apply a skin sealant around the stoma before applying the pouch. c. Make a pinhole in the pouch to allow for gasses to vent. d. Cut the opening of the wafer 2 cm (0.8in) wider than the stoma

b. Apply a skin sealant around the stoma before applying the pouch.

A nurse is planning discharge care for an older adult client who tells the nurse he does not like living alone because he is afraid of falling. Which of the following resources should the nurse assist the client to explore prior to discharge? a. Ambulatory care center b. Assisted living center c. Skilled nursing facility d. Hospice care

b. Assisted living center

A nurse is caring for a 2 yr old toddler. Which of the following food choices should the nurse recommend to promote independence in eating? a. Grapes b. Banana slices c. Hot dogs d. Popcorn

b. Banana slices

A nurse is teaching a client who has a new prescription for an MAOI. Which of the following foods is contraindicated for this medication? a. Eggs b. Cheese c. Grapefruit d. Potatoes

b. Cheese

A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection? a. Drain the specimen from the drainage bag b. Clamp the catheter distal to the injection port c. Collect 2 mL of urine for each specimen d. Obtain the urinalysis specimen before the culture specimen

b. Clamp the catheter distal to the injection port

A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients current IV infusion and the information received during the shift report. Which of the following actions should the nurse take? a. Complete an incident report and place it in the client's medical record. b. Compare the current infusion with the prescrip5on in the client's medication record. c. Contact the charge nurse to see if the prescription was changed. d. Submit a written warning for the nurse involved in the incident.

b. Compare the current infusion with the prescrip5on in the client's medication record.

A nurse is caring for a client who has a chest tube drainage. Which of the following findings indicates the nurse the presence of an air leak? a. Gentle bubbling in the suction chamber b. Continuous bubbling in the water seal chamber c. Fluid rising with inspiration and falling with expiration in the water seal chamber d. D. Serosanguineous fluid in the drainage collection chamber.

b. Continuous bubbling in the water seal chamber

A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? (Select all that apply.) a. Bradycardia b. Cyanosis c. Hypotension d. Dyspnea e. Paradoxical chest movement

b. Cyanosis c. Hypotension d. Dyspnea e. Paradoxical chest movement

A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively? a. Delegate tasks to the AP. b. Determine goals of the day c. Schedule daily activities. d. Develop an hourly time frame for tasks.

b. Determine goals of the day

A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first? a. Encourage the family to assign specific tasks to individual family members. b. Determine the roles of individual family members. c. Assist the family to establish a daily routine

b. Determine the roles of individual family members.

A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. After notifying the provider, which of the following actions is appropriate for the nurse to take? a. Summon a security guard b. Explain the risks of leaving c. Complete an incident report d. Notify a social worker

b. Explain the risks of leaving

A nurse is providing discharge teaching to the provider who has a tracheostomy. Which of the following information should the nurse include in the teaching? a. How to change the tracheostomy dressing using clean technique b. How to operate the portable suction machine c. How to change the non disposable tracheostomy tube daily d. How to secure the tracheostomy tube with ties at the back of the neck

b. How to operate the portable suction machine

A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use? a. Asthma b. Hypertension c. Fibromyalgia d. Fibrocystic breast condition

b. Hypertension

A charge nurse is concerned about a recent increase in facility-acquired catheter infections. Which of the following actions should the nurse take first? a. Schedule nursing staff training for infection control procedures b. Identify possible precipitating factors related to the infections c. Meet with providers to discuss measure to decrease the infections d. Revise the current policy for catheter care

b. Identify possible precipitating factors related to the infections

A nurse is caring for a client who is at 32 weeks of gestation and has a history of cardiac disease. Into which of the following positions should the nurse place the client to best promote optimal cardiac output? a. High-Fowler's b. Left-lateral c. Supine d. Standing

b. Left-lateral

A nurse is discharging a client who has a colostomy. The client states that she would like to use her moisturizing soap to clean around the stoma. Which of the following responses by the nurse is appropriate? a. It is acceptable to use this soap if it makes you comfortable. b. Lubricants in moisturizing soaps can interfere with adhesion of the appliance c. You may want to try other soaps to determine what is the best to clean around the stoma d. Use of moisturizing soaps can contribute to skin infections.

b. Lubricants in moisturizing soaps can interfere with adhesion of the appliance

A Nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan? a. Maintain eye contact with the newborn during feedings b. Minimize noise in the newborn's environment c. Administer naloxone to the newborn. d. Swaddle the newborn with his legs extended

b. Minimize noise in the newborn's environment

A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? a. Give scheduled doses of acetaminophen every 6 hr b. Monitor the child's cardiac status c. Administer antibiotics via intermittent IV bolus for 24 hr d. Provide stimulation with children of the same age in the playroom

b. Monitor the child's cardiac status

A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal space. Which of the following is an appropriate documentation of the findings? a. Fourth heart sound at the aortic area b. Murmur at the mitral area c. Third heart sound at the tricuspid area d. Pericardial friction rub at the pulmonic area

b. Murmur at the mitral area

A nurse is providing information for a client who has a new prescription for simvastatin. For which of the following should the nurse instruct the client to monitor and report to the provider? a. Fever b. Muscle weakness- statin drugs c. Weight loss d. edema

b. Muscle weakness- statin drugs

A nurse is reviewing the prescrip5ons for a client who has a pneumothorax. Which of the following actions should the nurse perform first? a. Assess the client's pain. b. Obtain a large-bore IV needle for decompression. c. Administer lorazepam. d. Prepare for chest tube insertion.

b. Obtain a large-bore IV needle for decompression.

A nurse is planning care for a client who has stage II Parkinson's Disease. Which of the following actions should the nurse include in the plan of care? a. Offer clear liquids with and between meals b. Offer high-calorie nutrition supplements c. Encourage the client to concentrate on looking at his feet while walking. d. Encourage the client to participate in small muscle dexterity activities.

b. Offer high-calorie nutrition supplements

A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? a. Assess effectiveness of antiemetic medication b. Perform chest compressions during cardiac resuscitation c. Perform a dressing change for a new amputee d. Apply a transdermal nicotine patch

b. Perform chest compressions during cardiac resuscitation

A nurse in an ER is planning care for a client who has abdominal trauma from a MVC. Which of the following provider prescription should the nurse implement first? a. Administer RBC b. Place a large bore IV catheter in an upper extremity c. Insert an indwelling urinary catheter d. Obtain a specimen for ABG analysis

b. Place a large bore IV catheter in an upper extremity

A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? a. Perform fundal massage b. Pour water from a squeeze bottle over the client's perineal area. c. Insert an indwelling urinary catheter. d. Apply cold therapy to the client's perineal area.

b. Pour water from a squeeze bottle over the client's perineal area.

A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding? a. Iron 90 mcg/dl b. Prealbumin 10 mcg/dl c. Serum creatinine 0.8 mg/dl d. Calcium 9.5 mg/dl

b. Prealbumin 10 mcg/dl

A nurse is caring for a toddler who has cancer and is experiencing stomatitis from chemotherapy. Which of the following intervention should nurse implement? a. Apply viscous lidocaine. b. Provide soft, nonacidic food c. Give peroxide mouth washes. d. Administer antiemetics

b. Provide soft, nonacidic food

A nurse is planning care for a client who has severe respiratory distress system (SARS). Which of the following ac5ons should be included in the plan of care for this client? (Select all that apply.) a. Administer antibiotics. b. Provide supplemental oxygen. c. Administer antiviral medications. d. Administer bronchodilators. e. Maintain ventilatory support.

b. Provide supplemental oxygen. d. Administer bronchodilators. e. Maintain ventilatory support.

A nurse is caring for a client who has COPD and is 5kg (11lb) below her ideal body weight. The client experiences shortness of breath when eating. Which of the following actions should the nurse take? a. Administer a bronchodilator following meals. b. Request non gas forming foods from the dietary department c. Limit the client's food consumption between meals. d. Arrange for a low protein diet.

b. Request non gas forming foods from the dietary department

A nurse is planning care for a client who has small-bore NG feeding tube in the jejenum. Which of the following is an appropriate action for the nurse to take to confirm placement? a. Instill two drops of blue food coloring formula b. Review an abdominal x-ray report. c. Verify the glucose level aspirated content. d. Auscultate for bubbling sound while injecting air through the tube.

b. Review an abdominal x-ray report.

A nurse is assessing a client Telemetry strip. Which of the following findings should the nurse report to the provider? a. Heart rate 98 per minute c. 2 PVCs per minute b. ST segment elevations d. Widened P wave

b. ST segment elevations

A nurse is planning care for a client who follows Buddhist dietary practices. Which of the following food selections should the nurse recommend for the client's meal tray? a. Vegetable beef soup b. Spinach and strawberry salad c. Ham and cheese sandwhich d. Baked fish

b. Spinach and strawberry salad

A nurse is providing preoperative teaching to a client who is scheduled for uterine surgery and asks about the reason for the indwelling urinary catheter. Which of the following responses should the nurse make? a. The catheter will be used to administer pain medication after surgery. b. The catheter will decompress your bladder during surgery. c. The catheter will decrease the risk for UTI from surgery. d. The catheter will immobilization after surgery.

b. The catheter will decompress your bladder during surgery.

A nurse is caring for a client who has a new diagnosis of schizophrenia and a prescription for an antipsychotic medication. The nurse should recognize that which of the following indicates an adverse effect that must be reported to the provider? a. The client states, "Being in the sun seems to really hurt my eyes." b. The client is observed displaying a shuffling gait while walking in the hall. c. The client is observed mumbling quietly while alone in the day room. d. The client states, "I feel light-headed when i stand up quickly."

b. The client is observed displaying a shuffling gait while walking in the hall.

A nurse is assessing a client who had a colostomy 24 hr ago. Which of the following finding is priority? a. The client reports a pain level of 6 b. The stoma appears dark purple in color c. The colostomy has had no output d. The client refuses to look at the colostomy

b. The stoma appears dark purple in color

A nurse is providing teaching to a client about risk factors for breast cancer. Which of the following factors should the nurse include as placing the client at an increased risk for developing breast cancer? a. A BMI less than 25 b. Use of hormone replacement therapy c. Early menopause d. Fibrocystic breast disease

b. Use of hormone replacement therapy

A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine? a. Hgb 14 g/dL b. WBC count 2,900/mm c. Fasting blood glucose 100 mg/dL d. Heart rate 58/min

b. WBC count 2,900/mm

A nurse is teaching a group of newly licensed nurses caring for a client who has a Clostridium difficile infection. Which of the following instructions should the nurse include in the teaching? a. Apply a mask when providing care. b. Wear a gown while providing personal hygiene. c. Place the client in a room with negative airflow. d. Wipe the stethoscope with alcohol after leaving the client's room.

b. Wear a gown while providing personal hygiene.

A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take? a. Shave hairy areas of skin prior to application b. Wear gloves to apply the patch to the client's skin c. Apply the patch within 1 hr of removing it from the protective pouch d. Remove the previous patch and place it in a tissue

b. Wear gloves to apply the patch to the client's skin

A nurse is admitting a client who is to undergo paracentesis for removal of ascetic fluid. Which of the following actions should the nurse take? a. Ensure the client has a full bladder just prior to the procedure b. Weight the client before and after the procedure c. Administer a low-volume hypertonic enema the night before the procedure d. Place the client in a side-lying position for the procedure

b. Weight the client before and after the procedure

A nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (Select all that apply.) a. SaO2 95% b. Wheezing c. Retraction of sternal muscles d. Pink mucous membranes e. Premature ventricular complexes (PVC's)

b. Wheezing c. Retraction of sternal muscles e. Premature ventricular complexes (PVC's)

A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? A. Avocados b. Whole grain bread c. Pepperoni pizza d. Smoked salmon

b. Whole grain bread

A nurse is completing an admission assessment for a client who is scheduled for surgery. Which of the following client allergies should the nurse report to the provider? a. Eggs b. peanuts c. Wheat d. Shellfish

b. peanuts

A nurse is providing teaching to a parent of a child who has varicella. Which of the following statements should the nurse include in the teaching? a. "Your child can return to school after a negative titer result." b. "Your child can return to school 24 hours after beginning antibiotics." c. " Your child can return to school once the lesions have crusted over." d. "Your child can return to school once the fever has subsided."

c. " Your child can return to school once the lesions have crusted over."

A nurse is providing discharge teaching to a client who has COPD and a new prescrip5on for albuterol. Which of the following statements by the client indicates and understanding of the teaching? a. "This medication can increase my blood sugar levels." b. "This medication can decrease my immune response." c. "I can have an increase in my heart rate while taking this medication." d. "I can have mouth sores while taking this medication."

c. "I can have an increase in my heart rate while taking this medication."

A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching? a. "I should clean my stoma with warm water" b. "My stoma should be bright pink or red" c. "I should change the stoma pouch every day" d. "I should cut my pouch opening 1⁄8 inch larger than my stoma"

c. "I should change the stoma pouch every day"

A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? a.I should advise a client about what I feel to be his best health care decision. b. "I will inform a client that his family should help make his health care decisions." c. "I will intervene if there is a conflict between a client and his provider." d. "I should not advocate for a client unless he is able to ask me himself."

c. "I will intervene if there is a conflict between a client and his provider."

A nurse is providing discharge instructions to a client who is 1-day postoperative following a vertical banded gastroplasty for morbid obesity. Which of the following statements demonstrates an understanding of the dietary teaching? a. "I will be limited to pureed foods for the next 6 months." b. "I should eat three meals per day." c. "It should take me 30 to 60 minutes to eat a meal." d. "Vomiting is common ant I will have to learn to live with it."

c. "It should take me 30 to 60 minutes to eat a meal."

nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multi- medication regimen. Which of the following instructions should the nurse give the client related to ethambutol? a. "Your urine can turn a dark orange." b. "Watch for a change in the sclera of your eyes." c. "Watch for any changes in vision." d. "Take vitamin B6 daily."

c. "Watch for any changes in vision."

A nurse is preparing to administer a new prescrip5on for isoniazid (INH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? a. "You might notice yellowing of your skin." b. "You might experience pain in your joints." c. "You might notice tingling of your hands."

c. "You might notice tingling of your hands."

A nurse in a mental health facility receives change-of-shift report for four clients. Which of the following clients should the nurse plan to assess first? a. A newly admitted client who has a hx of 4.5 kg (10lb) weight loss in the past 2 months b. A client who will be receiving her first ECT treatment today c. A client placed in restraints due to aggressive behavior d. A client who received a PRN dose of haloperidol 2 hr ago for increased anxiety

c. A client placed in restraints due to aggressive behavior

A nurse is caring for four clients. Which of the following client data should the nurse report to the provider? a. A client who is 4 hr postoperative and has a heart rate of 98/min b. A client who has a total of 110 mL of serosanguineous fluid from a Jackson-Pratt drain within the first 24 hr following surgery c. A client who has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3 d. A client who has pleurisy and reports pain of a 6 on a scale of 0 to 10 when coughing

c. A client who has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3

A nurse on a medical-surgical unit is receiving report for four client. Which of the following clients should the nurse assess first? a. A client who is scheduled for chemotherapy and has an RBC count of 4 million/mm3 b. A client who is 24hr postoperative following a transurethral resection of the prostate and has small blood clots in the drainage tubing c. A client who is receiving a blood transfusion and reports low-back pain d. A client who is 2 days postoperative following placement of an ascending colostomy and has shreds of bloody mucus in the bag

c. A client who is receiving a blood transfusion and reports low-back pain

A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6 C (101.4 F), and SaO2 92% on room air. Which of the following actions should the nurse take first? a. Obtain a chest ex-ray. b. Prepare for chest tube insertion. c. Administer oxygen via high flow mask d. Initiate IV access.

c. Administer oxygen via high flow mask

A nurse is assessing a client who received a Mantoux skin test 72hr ago for TB screening. Which of the following findings indicates a positive test? a. An area of ecchymosis b. A blister like area c. An elevated hardened area. d. A cool, blanched area.

c. An elevated hardened area.

A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture? a. Align a trochanter wedge between the client's legs b. Place a towel roll under the client's neck c. Apply an orthotic to the client's foot d. Position a pillow under the client's knees

c. Apply an orthotic to the client's foot

A nurse is preparing information about skin care for a client who has cancer of the prostate and is receiving radiation therapy. Which of the following information should the nurse include? a. Clean the perineal area using a washcloth. b. Dry the perineal area by using a patting motion c. Apply heat packs to the affected

c. Apply heat packs to the affected

A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? a. Documenting the report of pain for a client who is postoperative b. Administering oral fluids to a client who has dysphagia- c. Applying a condom catheter for a client who has a spinal cord injury d. Reviewing active range-of-motion exercise with a client who had a stroke

c. Applying a condom catheter for a client who has a spinal cord injury

A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client, "I f you don't eat, I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts? a. Malpractice b. Battery- c. Assault- d. Negligence

c. Assault-

A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicates a break in surgical aseptic technique? a. Placing the supplies on the sterile field and leaving a 1-inch perimeter b. Applying a sterile gown after applying a sterile mask c. Balancing the bottle on the sterile basin while pouring the liquid d. Putting on sterile gloves after preparing the sterile field

c. Balancing the bottle on the sterile basin while pouring the liquid

A nurse is working in acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect? a. All or nothing thinking b. Euphoric mood c. Disorganized speech d. Hypochondriasis (anxiety disorder)

c. Disorganized speech

A community health nurse is planning a program to address substance use in the adolescent population. Which of the following interventions should the nurse include as a method of secondary prevention? a. Facilitate referrals to substance use treatment programs b. Create anti-substance use media messages c. Establish an early detection program for substance use d. Provide education about the danger of substance abuse.

c. Establish an early detection program for substance use

A charge nurse delegates to an AP the task of ambulating a client. At the end of the shift, the nurse discovers the client has not been ambulated. Which of the following actions should the nurse take first? a. Supervise the AP performing the task b. Remind the AP of her assigned tasks. c. Evaluate why the client was not ambulated. d. Ambulate the client on behalf of the AP.

c. Evaluate why the client was not ambulated

A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client? a. Food label recommendations from the institute of medicine b. Personal blogs about managing the adverse effects of diabetes medications c. Food exchange lists for meal planning from the american diabetes association d. Diabetes medication information from the physicians' desk reference

c. Food exchange lists for meal planning from the american diabetes association

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following indicates that the child maybe experiencing hemorrhage? a. Diminished breath sounds b. Elevated pain level c. Frequent swallowing d. Increased drowsiness

c. Frequent swallowing

A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching? a. I can go jogging after 2 weeks. b. I can lift objects that are less than 10 seconds. c. I can resume activities, such as sewing. d. I should bend at the waist when putting on my shoes.

c. I can resume activities, such as sewing.

A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? a. I will place my baby in a forward- facing car seat in my back seat b. I can place my baby in the front seat with the airbag turned off. c. I will position my baby at a 45 degrees angle in the car seat. d. I can turn my baby car seat around when she weighs 15 pounds.

c. I will position my baby at a 45 degrees angle in the car seat.

A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the clients indicates an understanding of the teaching? a. I will remove dairy products from my diet b. I will remove peanuts from my diet c. I will remove bananas from my diet d. I will remove gluten from my diet

c. I will remove bananas from my diet

A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first? a. Educate the client about current medical diagnosis b. Refer the client to a meal delivery program c. Identify environmental hazards in the home d. Arrange for client transportation to follow-up appointments

c. Identify environmental hazards in the home

A nurse in an ED is caring for a client who is having manifestations of an ischemic stroke that began 2 hr ago. Which of the following actions should the nurse take? a. Place the client in high-fowler's position b. Prepare the client for a chest x-ray c. Initiate fibrinolytic therapy d. Insert an indwelling urinary catheter

c. Initiate fibrinolytic therapy

A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory tests should the nurse monitor? a. Arterial blood gas b. Serum potassium c. Liver Function Test d. Serum creatinine

c. Liver Function Test

A nurse is assigning tasks to assistive personnel (AP). Which of the following tasks should the nurse assign to the AP? a. Suction a new tracheostomy b. Remove an NG tube c. Perform post mortem care d. Change the dressing on an implanted central venous access device

c. Perform post mortem care

A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at the peripheral IV site. Which of the following actions should the nurse plan to take? a. Insert a new IV catheter distal to the discontinued IV site b. apply pressure dressing at the IV site c. Place a warm moist compress on the site d. Express drainage from the IV site and send it to be cultured

c. Place a warm moist compress on the site

A nurse is reviewing laboratory findings for a client who is to receive a dose of enoxaparin. For which of the following laboratory values should the nurse withhold the dose and notify the provider? a. WBC 15,000/mm3 b. Urine specific gravity 1.035 c. Platelets 80,000/mm3- d. BUN 25 mg/dL

c. Platelets 80,000/mm3-

A nurse is assessing a client who is preoperative for abdominal surgery. Which of the following findings should the nurse identify as the priority? a. WBC 11,000/mm3 b. Temperature 38.1 C (100.5 F) c. Potassium 3.4 mEq/L d. Heart Rate 130/min

c. Potassium 3.4 mEq/L

A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? a. Offer the client saltine crackers between meals b. Suggest rinsing his mouth with an alcohol-based mouthwash c. Provide humidification of the room air d. Instruct the client on the use of esophageal speech

c. Provide humidification of the room air

A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication for the use of metformin? a. Seizure disorder b. Polycystic ovary syndrome c. Renal insufficiency d. Gluten intolerance

c. Renal insufficiency

A nurse is planning care for a child who has neutropenia due to leukemia. Which of the following interventions should the nurse include in the plan of care? a. Prepare the child for a platelet transfusion b. Initiate a low-protein diet for the child c. Screen the child's visitors for active infections d. Monitor the child for indications of active bleeding

c. Screen the child's visitors for active infections

A nurse is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect? a. Repeated acts of unlawful Behavior b. Suspicious demeanor c. Seductive Behavior d. Lack of remorse

c. Seductive Behavior

A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? a. Total bilirubin b. Urine ketones c. Serum potassium d. Platelet count

c. Serum potassium

A nurse is providing discharge teaching about oxycodone to a client who had an appendectomy. Which of the following information should the nurse include in the teaching? a. Decrease fiber intake while taking his medication to prevent diarrhea. b. Urinary frequency is an adverse effect of this medication. c. Slow respirations can occur when taking this medication. d. Pain relief should occur 5 min after taking this medication.

c. Slow respirations can occur when taking this medication.

A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care? a. Take quick breaths upon inhalation. b. Place you hand over your stomach. c. Take a deep breath in through your nose. d. Puff your cheeks upon exhalation.

c. Take a deep breath in through your nose.

A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? a. Instruct healthcare professionals to identify abusive situations b. Locate financial support to open a shelter for abuse survivors c. Teach parenting skills to families at risk for abuse d. Connect abuse survivors with legal counsel

c. Teach parenting skills to families at risk for abuse

A nurse is delegating tasks to an assistive personnel group of clients. Which of the following statements should the nurse make? a. Take the client in room 106 to radiology b. Take the vital signs of the clients on the side of the unit c. Tell me the standing weight of the client in room 102 before breakfast d. The client in room 109 has spilled his water pitcher

c. Tell me the standing weight of the client in room 102 before breakfast

A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender? a. The client takes vitamin C daily b. The client has a history of alcohol use disorder c. The client has a history of asthma d.The client takes furosemide twice daily

c. The client has a history of asthma

A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin . Which of the following should the nurse concludes if the client develops ataxia and incoordination? a. The client is experiencing an adverse reaction to rifampin 14 of 28 b. The client's seizure disorder is no longer under control c. The client is showing evidence of phenytoin toxicity d. The client is having adverse effects due to combination antimicrobial therapy

c. The client is showing evidence of phenytoin toxicity

A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects? a. Increased salivation b. Weight loss c. Urinary Retention d. Hypertension

c. Urinary Retention

A nurse is preparing to administer three medications to a client who is receiving continuous enteral tube feeding through an NG tube. Which of the following actions is appropriate for the nurse to take? a. ADD medication directly to enteral feeding b. Dissolve the medications together c. Use a syringe to allow the medications to Flow by gravity d. Flush the NG tube with 5 ml water

c. Use a syringe to allow the medications to Flow by gravity

A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? a. Use of tobacco might lead to alcohol and drug abuse b. Smoking in adolescence increases the risk of developing lung cancer later in life c. Use of tobacco decreases the level of athletic ability d. Smoking in adolescence increases the risk of lifelong addiction

c. Use of tobacco decreases the level of athletic ability

A nurse is observing a newly licensed nurse who is administering Total parenteral Nutrition tpn to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene? a. Plans for a check of the clients fingerstick glucose every 6 hours b. Schedules a bag and tubing change for 24 hours after the start of the infusion- ok c. Uses the tpn IV tubing to administer the clients next dose of antibiotic d. Increases the tpn infusion rate each hour until the prescribed rate is achieved

c. Uses the tpn IV tubing to administer the clients next dose of antibiotic

A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching? a. Round the edges of toenails when trimming. b. Use moisturizing lotion between the toes c. Wear clean cotton socks every day. d. Soak feet twice daily.

c. Wear clean cotton socks every day.

A nurse is performing a dietary assessment for a client. Which of the following questions should the nurse ask when assessing the client's dietary acculturation? a. "Are there any foods that you are allergic to?" b. "How do you feel about your current body weight?" c. "What questions do you have about reading food labels?" d. " Do you have special customs that you follow for meals?"

d. " Do you have special customs that you follow for meals?"

A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching? a. "Air should be instilled into the monitoring system prior to the procedure." b. "The client should be positioned on the le6 side during the procedure." c. "The transducer should be level with the second intercostal spaced after the line is placed." d. "A chest x-ray is needed to verify placement a6er the procedure."

d. "A chest x-ray is needed to verify placement a6er the procedure."

A nurse is providing prenatal teaching for a client who has herpes simplex virus. Which of the following client statements indicates an understanding of the teaching? a. "I won't pass herpes on to my baby if I've only had an outbreak for a week" b. "I can't take acyclovir during pregnancy because it might hurt my baby." c. "My herpes infection has to be reported to the Centers for Disease Control and Prevention." d. "I should have a cesarean delivery if I'm having an outbreak."

d. "I should have a cesarean delivery if I'm having an outbreak."

A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? a. "I will place the adapter on my finger to read my blood oxygen saturation level." b. "I will lie on my back with my knees bent." c. "I will rest my hand over my abdomen to create resistance." d. "I will take in a deep breath and hold it before exhaling."

d. "I will take in a deep breath and hold it before exhaling."

A nurse is reviewing discharge instruc5ons for a client who experienced a pneumothorax. Which for the following statement should the nurse use when teaching the client? a. "Notify the provider if you experience weakness." b. "You should be able to return to work in 1 week." c. "You need to wear a mask when in crowded areas." d. "Notify your provider if you experience a productive cough."

d. "Notify your provider if you experience a productive cough."

A nurse on a surgical pediatric care unit receives report prior to providing care for a group of clients. Which of the following clients should the nurse assess first? a. A 15-year-old who is 6 hr postop following a herniorrhaphy and reports pain at the IV site b. 3-month-old who is 1 day postop following cleft lip repair and has a pulse of 120 c. 12-year-old who is 2 days postop following an appendectomy and is refusing to ambulate d. 8-year-old client who is 12 hr postop following a tonsillectomy and is experiencing frequent swallowing - bleeding

d. 8-year-old client who is 12 hr postop following a tonsillectomy and is experiencing frequent swallowing - bleeding

A nurse is providing care for a group of clients. Which of the following client's should the nurse assess first? a. A client who has pneumonia with a productive cough b. A client who has a NG tube in place and reports nausea c. A client who received an opioid for pain following an appendectomy and has an SaO2 of 94% d. A client who has a fracture tibia and reports shortness of breath

d. A client who has a fracture tibia and reports shortness of breath

A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first? a. A client who is at 36 weeks of gestation and has a biophysical profile score of 8 b. A client who has pre-gestational diabetes mellitus and an HbA1c of 6.2% c. A client who is at 28 weeks of gestation and reports leukorrhea d. A client who has preeclampsia and reports a persistent headache

d. A client who has preeclampsia and reports a persistent headache

A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first? a. A client who has a fracture and is in balanced suspension traction b. A client who uses a wheelchair and is confused c. A client who is bedridden and wears a hearing aid d. A client who is ambulatory and receiving oxygen

d. A client who is ambulatory and receiving oxygen

A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care? a. Offer small amounts of clear liquids 6 hr following surgery b. Give cromolyn nebulizer solution every 6 hr c. Apply a warm compress to the operative site every 4 hr d. Administer analgesics on a scheduled basis for the first 24 hr

d. Administer analgesics on a scheduled basis for the first 24 hr

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take? + a. Position the client supine b. Prepare an IV bolus of dextrose 5% in water c. Administer methylergonovine IM d. Administer calcium gluconate IV

d. Administer calcium gluconate IV

A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring. The cardiac rhythm strips show a wavy baseline, no distinguishable P waves, and an increased heart rate. The nurse should identify the cardiac rhythm as which of the following? a. Ventricular asystole b. Second-degree heart block c. Sinus Tachycard d. Atrial fibrillation

d. Atrial fibrillation

A nurse in the intensive care unit is planning care for a client who has a closed head injury. The client's intracranial pressure (ICP) is being monitored via an intraventricular catheter. Which of the following actions should the nurse include in the plan of care? a. Keep the client in a supine position b. Maintain ICP at 20mm Hg c. Suction the client every 2 hr d. Avoid overstimulation of the client

d. Avoid overstimulation of the client

A nurse is providing preoperative teaching to an older adult female client who is scheduled for a laminectomy and uses supplements. Which of the following supplements should the nurse identify as increasing the client's risk for hypotension during surgery? a. Soy b. Flaxseed c. Probiotics d. Black cohosh

d. Black cohosh

A nurse is assessing a client who has type 1 diabetes mellitus and a blood glucose level of 52 mg/dL. Which of the following findings should the nurse expect? a. Deep respirations- b. Hot, dry skin- c. Bradycardia - d. Blurred vision

d. Blurred vision

A nurse is assessing a client's respirations which of the following actions should the nurse take? a. Assess respirations before counting radial pulsations b. Multiply the number of respirations in 15 seconds by 4 c. Inform the client that has breaths will be counted d. Count respirations for 1 minute if the rhythm is irregular

d. Count respirations for 1 minute if the rhythm is irregular

A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take? a. Discard the first 10 mL of urine. b. Apply EMLA cream prior to the procedure. c. Obtain a 12 French catheter. d. Don sterile gloves prior to the procedure.

d. Don sterile gloves prior to the procedure.

A nurse is preparing to administer several medications through a client's nasointestinal tube. The nurse should ask the pharmacist about the availability of a different form for which of the following medications? a. Oral anticoagulant b. Statin tablet c. Antibiotic suspension d. Enteric-coated aspirin

d. Enteric-coated aspirin

A nurse is reviewing a client's cardiac rhythm strips and notes a constant P -R interval of 0.35 sec. Which of the following dysrhythmia is the client displaying? a. Premature atrial complexes b. Complete heart block c. Atrial fibrillation d. First degree atrioventricular block

d. First degree atrioventricular block

A nurse is obtaining a blood specimen from a client who has a peripherally inserted central catheter. Which of the following actions should the nurse take? a. Use a 3mL syringe to flush the catheter b. Instruct the client to perform the Valsalva maneuver during the blood draw c. Cleanse the port with povidone-iodine prior to obtaining the specimen d. Flush with 20mL of 0.9% sodium chloride after obtaining the blood sample

d. Flush with 20mL of 0.9% sodium chloride after obtaining the blood sample

A nurse is planning care for a group of clients. Which of the following methods should the nurse use to manage time effectively? a. Complete partial assessments on all clients before planning the day b. Prioritize activities based on the nurse's needs c. Use the break time to perform documentation d. Gather supplies prior to completing a dressing change

d. Gather supplies prior to completing a dressing change

A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching? a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. > b. Blood glucose level greater than 200 mg/dL at bedtime c. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC d. HbA1c level less than 7%

d. HbA1c level less than 7%

A nurse in a prenatal Clinic is teaching a client about nonpharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching? a. My nurse can teach me biofeedback at the beginning of labor b. A transcutaneous electrical nerve stimulator will help with pelvic pressure. c. The nurse will initiate acupuncture when I arrive at the unit d. I can use my ultrasound picture as a focal point during contractions

d. I can use my ultrasound picture as a focal point during contractions

A nurse is teaching a client how to perform Kegel exercises. Which of the following client statements indicates understanding of the teaching? a. I will alternately contract and relax my gluteal muscles b. I will perform the exercises once each day before bed c. I will try to hold my urine for a little after i first feel the urge to urinate d. I will determine which muscles to contract by stopping and starting my stream of urine

d. I will determine which muscles to contract by stopping and starting my stream of urine

A nurse is providing teaching to a client who DM about glycosylated hemoglobin blood test. Which of the following statement by the client indicated an understanding of this test? a. I will need to drink a glucose solution to get an accurate result b. I will need to fast prior to taking this test not necessary c. I will use the result of this test daily to modify my insulin dosage. d. I will use this test to monitor how well I control my blood glucose.

d. I will use this test to monitor how well I control my blood glucose.

A nurse is caring for a client who has hyperthermia. Which of the following actions for the nurse to take? a. Submerge the adolescent feet in ice water b. Cover the adolescent with a thermal blanket c. Administer oral acetaminophen d. Initiate seizure precautions

d. Initiate seizure precautions

A nurse is assessing a client who has antisocial personality disorder. Which of the following characteristics should the nurse expect? a. Exaggerated expression of emotion b. Sensitive to criticism c. Needs continues reassurance d. Lack of remorse

d. Lack of remorse

A home health nurse is teaching the caregiver of a client who has AIDS about infection control in the home. Which of the following information the nurse include in the teaching? a. Dispose of recapped needles and syringes in biohazard bag. b. Wash clothing twice in cold water and laundry detergent. c. Designate a separate bathroom in the home for the clients use. d. Make a new solution of bleach and water each day for disinfection.

d. Make a new solution of bleach and water each day for disinfection.

A nurse is planning to delegate tasks to an A P. Which of the following tasks should the nurse assign to the AP? a. Record the client's BP reading by 1000- b. Obtain a client temp prior to surgery- this CT is unstable since they are going to surgery c. Reposition a client d. Measure a client's urine output

d. Measure a client's urine output

A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Give the client protamine if the signs of magnesium sulfate toxicity occur b. Monitor the FHR via doppler q30 min c. Restrict the client's total fluid intake to 250 mL/hr d. Measure the client's urine output every hour

d. Measure the client's urine output every hour

A nurse in a family practice clinic is screening an adolescent client for idiopathic scoliosis. Which of the following assessments should the nurse perform as part of this screening? a. Observe for sacral dimpling b. Observe for a positive Romberg sign c. Measure the anteroposterior diameter of the chest d. Measure the truncal rotation

d. Measure the truncal rotation

A nurse is assessing a client who requests an oral contraceptive. Which of the following findings in the client's medical history should the nurse identify as a contraindication for the use of a combination oral contraceptive? a. Concurrent use of levothyroxine b. Allergy to penicillin c. Recurrent urinary tract infections d. Migraines with aura

d. Migraines with aura

A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? a. Perform the procedure prior to meals b. Administer a bronchodilator after the procedure c. Hold hand flat to perform percussions on the child. d. Perform the procedure twice a day.

d. Perform the procedure twice a day.

A nurse is assessing a client who has been taking oral contraceptives for the past 6 months. Which of the following findings should the nurse immediately report to the provider? a. Frequent nausea b. Breast tenderness c. Weight Gain 2.3kg (5lb) d. Persistent headaches

d. Persistent headaches

A nurse is caring for a client who has a 22 gauge IV inserted 2 days ago and a new prescription for 2 packed RBCs. Which of the following actions should the nurse take? a. Transfuse each unit of packed RBCs over 5 hrs b. Replace the current IV site dressing prior to RBC infusion c. Start a new IV distal to the current IV site d. Place a larger gauge IV in the opposite extremity-

d. Place a larger gauge IV in the opposite extremity-

A nurse is teaching an adolescent who has a type 1 diabetes mellitus and his parents how to dispose of his insulin syringes and needles at home. Which of the following instructions is appropriate? a. Seal the needles in zipper lock plastic bags and place them in a metal trash can b. Place the needles in a plastic container and then pour alcohol into the container c. Recap the needles and wrap them and the syringes in paper towels d. Place the needles in an aluminum coffee can and store them on a high shelf

d. Place the needles in an aluminum coffee can and store them on a high shelf

A nurse is preparing a change of shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report? a. Hgb 12.8 g/dl b. Potassium 4.2 c. RBC 4.4 million/mm3 d. Platelets 100,000/mm3

d. Platelets 100,000/mm3

A nurse manager on an interprofessional team is creating a disaster plan. The nurse should include in the plan that which of the following actions is the responsibility of the unit nurse during a disaster? a. Determine the need for additional providers b. Act as a spokesperson to provider info to the media c. Decided which client should be transported for a higher level of care. d. Recommend to the provider a list of clients for early discharge

d. Recommend to the provider a list of clients for early discharge

A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia which of the following is the nurse's priority? a. Urinary output 35 ml/hr b. 2 + deep tendon reflexes c. 3 + pedal edema d. Respiratory rate 10/min

d. Respiratory rate 10/min

A nurse is preparing to administer methylprednisone sodium succinate to a client who has chronic inflammatory disorder. The nurse should plan to monitor which of the following laboratory tests while the client is taking this medication? a. INR b. PaO2 c. Troponin T d. Serum glucose

d. Serum glucose

A nurse is caring for an infant who has gastroenteritis. Which of the following assessments should the nurse report to the provider? a. Temperature 38 C(100.4 F) and pulse rate 124/min p b. Decreased appetite and irritability c. Pale and 24-hour fluid deficit of 30 mL d. Sunken fontanels and dry mucous membranes

d. Sunken fontanels and dry mucous membranes

A surgeon is obtaining informed consent from a client. When a nurse witnesses the client sign the consent form, which of the following legal requirements is the nurse confirming? a. The nurse explained the risks and benefits of the surgery b. The nurse explained the surgical procedure in detail c. The client knows she may not longer refuse the procedure d. The client agreed to the procedure voluntarily.

d. The client agreed to the procedure voluntarily.

A nurse is providing teaching about crutch safety to a client. Which of the following client actions indicates an understanding of the teaching? a. The client leans on both crutches to support body weight. (no) b. The client places the crutches 30cm (12in) to the front and side of each foot while standing (6in) c. The client flexes her elbows 10 degree when supporting weight by using the handgrips. d. The client keeps her axillae free of pressure.

d. The client keeps her axillae free of pressure.

A nurse is reviewing laboratory values for a client who has bipolar disorder and takes lithium carbonate. Which of the following values should the nurse report to the provider? a. Sodium 137 meq/L b. Lithium 1.0 meq/L c. WBC count 5,600 mm d. Thyroxine (t4) 2.8 mcg.dL

d. Thyroxine (t4) 2.8 mcg.dL

A nurse in a provider's office is reviewing a female client's medical record during a routine visit. The nurse should recommend increasing dietary intake of which of the following vitamins? (Exhibit) --only tab shown is Tab 3: a. Vitamin D b. Vitamin K c. Vitamin A d. Vitamin B12

d. Vitamin B12

A nurse is planning teaching for a client who has a newly implantable cardioverter/defibrillator. Which of the following information should the nurse include? a. Return in two weeks for a follow up MRI b. Expect to have a rapid pulse rate for the first few weeks? c. Resume tub baths and swimming after 24hr d. Wear loose fitting clothing

d. Wear loose fitting clothing

A nurse is caring for a client who has a new prescription for clozapine. Which of the following should the nurse recognize as an adverse effect of this medication? a. Diarrhea b. Hypoglycemia c. Urinary frequency d. agranulocytosis

d. agranulocytosis

A nurse is orienta5on a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching? e. "This medication is given to treat infection." f. "This medication is given to facilitate ventilation." g. "This medication is given to decrease inflammation." h. "This medication is given to reduce anxiety."

f. "This medication is given to facilitate ventilation."

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.) e. Confusion f. Pale skin g. Bradycardia h. Hypotension i. Elevation blood pressure.

f. Pale skin i. Elevation blood pressure.

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? f. Obtain a chest x-ray g. Apply sterile gauze to the insertion site. h. Place tape around the insertion site. i. Assess respiratory status.

g. Apply sterile gauze to the insertion site.

A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nurse's priority? g. Obtain baseline vital signs and oxygen saturation. h. Obtain a sputum culture. i. Obtain a complete history from the client. j. Provide a pneumococcal vaccine.

g. Obtain baseline vital signs and oxygen saturation.

A nurse is assessing a client who has a pulmonary embolism. Which of the following information should the nurse expect to find? (Select all that apply.) f. Bradypnea g. Pleural friction rub h. Hypertension i. Petechiae j. Tachycardia

g. Pleural friction rub i. Petechiae j. Tachycardia

A nurse is planning care for a client who has dysphagia and a new dietary prescrip5on. Which of the following should the nurse include in the plan of care? (Select all that apply.) j. Have suc:on equipment available for use. k. Feed the client thickened liquids. l. Place food on the unaDected side of the client's mouth. m. Assign an assis:ve personnel to feed the client slowly. n. Teach the client to swallow with her neck Gexed.

j. Have suc:on equipment available for use. k. Feed the client thickened liquids. l. Place food on the unaDected side of the client's mouth. n. Teach the client to swallow with her neck Gexed.

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected ?ndings? (Select all that apply.) j. Continuous bubbling in the water seal chamber k. Gentle constant bubbling in the suction control chamber l. Rise and fall in the level of water in the water seal chamber with inspiration and expiration m. Exposed sutures without dressing n. Drainage system upright at chest level

k. Gentle constant bubbling in the suction control chamber l. Rise and fall in the level of water in the water seal chamber with inspiration and expiration

A nurse is assessing a client following bronchoscopy. Which of the following ?ndings should the nurse report to the provider? i. Blood-tinged sputum j. Dry, nonproductive cough k. Sore throat l. Bronchospasms

l. Bronchospasms

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states she is anxious and is unable to get enough air. Vital signs are HR 117/min, respirations 38/min, temperature 38.4 C (101.2 F), and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority? k. Notify the provider. l. Administer heparin via IV infusion. m. Administer oxygen therapy. n. Obtain a spiral CT scan.

m. Administer oxygen therapy.

A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? j. Apply a vest restraint if self-extubating is attempted. k. Monitor ventilator settings ever 8 hours. l. Document tube placement in centimeters at the angle of jaw. m. Assess breath sounds every 1 to 2 hour

m. Assess breath sounds every 1 to 2 hour

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? (Select all that apply.) m. Oxygen equipment n. Incentive spirometer o. Pulse oximeter p. Sterile dressing q. Suture removal kit

m. Oxygen equipment o. Pulse oximeter p. Sterile dressing

A nurse is caring for a client who has global aphasia (both recep5ve and expressive.). Which of the following should the nurse include in the client's plan of care? (Select all that apply.) o. Speak to the client at a slower rate. p. Assist the client to use Gash cards with pictures. q. Speak to the client in a loud voice. r. Complete sentences that the client cannot Knish. s. Give instruc:ons one step at a :me.

o. Speak to the client at a slower rate. p. Assist the client to use Gash cards with pictures. s. Give instruc:ons one step at a :me.

A nurse is caring for a client who has dyspnea and will receive oxygen con5nuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? n. Nonrebreather mask o. Venturi mask p. Nasal cannula q. Simple face mask

o. Venturi mask

A nurse is caring for a client who has a new prescrip5on for heparin therapy. Which of the following statements by the client should indicate and immediate concern for the nurse? o. "I am allergic to morphine." p. "I take antacids several times a day." q. "I had a blood clot in my leg several years ago." r. "It hurts to take a deep breath."

p. "I take antacids several times a day."

A nurse is caring for a client following a thoracentesis. Which of the following manifesta5ons should the nurse recognize as risks for complica5ons? (Select all that apply.) r. Dyspnea s. Localized bloody drainage on the dressing t. Fever u. Hypotension v. Report of pain at the puncture site

r. Dyspnea t. Fever u. Hypotension

A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? o. Percussion of posterior lobes of lungs p. Auscultation of the trachea q. Inspection of the conjunctiva r. Palpation of the orbital areas

r. Palpation of the orbital areas

A nurse is assis5ng a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? o. Lie on it left side. p. Use the incentive spirometer. q. Cough at regular intervals. r. Perform the Valsalva maneuver.

r. Perform the Valsalva maneuver

A nurse is planning care for a client following the inser5on of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply.) s. Encourage the client to cough every 2 hours. t. Check the con:nuous bubbling in the suc:on chamber. u. Strip the drainage tubing every 4 hours. v. Clamp the tube once a day. w. Obtain a chest x-ray.

s. Encourage the client to cough every 2 hours. t. Check the continuous bubbling in the suction chamber. w. Obtain a chest x-ray.

A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increase the effort of the client's respiratory muscles should the nurse include in the plan of care? (Select all that apply.) r. Assist-control s. Synchronized interment mandatory ventilation t. Continuous positive airway pressure u. Pressure support ventilation v. Independent lung ventilation

s. Synchronized interment mandatory ventilation t. Continuous positive airway pressure u. Pressure support ventilation

A nurse is assessing a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? t. Impulse control di2culty u. Poor judgement v. Inability to recognize familiar objects w. Loss of depth perception

v. Inability to recognize familiar objects