Exit HESI Prep

The health care provider prescribes an intramuscular dose of 200,000 units of penicillin G benzathine for an adult client. The label on the 10-mL ampule sent from the pharmacy reads, "Penicillin G benzathine,300,000 units/mL." How many milliliters of medication does the nurse prepares to ensure administration of the correct dose? (Round to the nearest tenth.)

0.7

An emergency department (ED) nurse is triaging victims of an explosion at a nearby manufacturing plant. To which victims should the nurse assign the emergent (priority 1) designation? Select all that apply. A. A victim with a limb amputation Correct B. A victim who is alert but complaining of loss of vision Correct C. A victim who is bleeding profusely from a head laceration Correct D. A victim who is dazed and staggering around the other victims E. A victim who has sustained minor bruising of an arm and the lower legs

A. A victim with a limb amputation B. A victim who is alert but complaining of loss of vision C. A victim who is bleeding profusely from a head laceration

A nurse in a postanesthesia care unit (PACU) receives a client from the operating room. For what finding should the PACU nurse assess the client first? A. Airway patency B. Active bowel sounds C. Adequate urine output D. Orientation to surroundings

A. Airway patency

A client with a genitourinary tract infection has been prescribed metronidazole and fluid therapy. The nurse concludes that the client understands the dietary regimen to be followed while taking the medication when the client states to eliminate which from the diet? A. Alcohol B. Diet cola C. Bran flakes D. Chicken livers

A. Alcohol

A nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt. Which instruction does the nurse plan to include? A. Call the health care provider if the infant is lethargic. B. Expect increased urine output with the shunt. C. Call the health care provider if the anterior fontanel bulges when the infant cries. D. Position the infant on the side of the shunt for sleep.

A. Call the health care provider if the infant is lethargic.

A nurse is taking the vital signs of a woman who delivered a healthy newborn 1 hour ago. The nurse notes that the woman's radial pulse rate is 55 beats per minute. Based on this finding, which action by the nurse is most appropriate? A. Documenting the finding B. Helping the woman get out of bed and walk C. Performing active and passive range-of-motion exercises D. Reporting the finding to the nurse-midwife or health care provider immediately

A. Documenting the finding

A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths per minute. Based on this finding, what is the most appropriate action for the nurse to take? A. Documenting the findings B. Contacting the pediatrician C. Placing the infant in an oxygen tent D. Wrapping an extra blanket around the infant

A. Documenting the findings

A nurse is preparing a client for transfer to the operating room. Which action should the take in the care of this client at this time? A. Ensuring that the client has voided B. Administering all daily medications C. Practicing postoperative breathing exercises D. Verifying that the client has not eaten for the last 24 hours

A. Ensuring that the client has voided

A nurse is providing instructions to a nursing assistant who will be caring for a client in hand restraints. The nurse instructs the nursing assistant to release the restraints to permit muscle exercise: A. Every 2 hours B. Every 3 hours C. Every 4 hours D. Every 30 minutes

A. Every 2 hours

The health care provider (HCP) prescribes "enemas until clear" for a client. The nurse has administered three enemas to the client, but the client is still passing brown stool and fluid. Which action should the nurse take? A. Notify the HCP B. Continue administering enemas until the fluid returns clear C. Administer a glycerin suppository and then administer one more enema D. Allow the client to rest for 1 hour and then continue with another enema

A. Notify the HCP

A client with cirrhosis has an increased ammonia level. Which diet does the nurse anticipate will be of benefit to the client? A. One low in protein B. One high in fluids C. One high in carbohydrates D. One with a moderate amount of fat

A. One low in protein

A client who experienced a stroke (brain attack) is experiencing residual dysphagia. Which foods should the nurse remove from the client's meal tray? A. Peas B. Scrambled eggs C. Cheese casserole D. Mashed potatoes

A. Peas

The nurse teaches a client who has begun taking phenelzine, a monoamine oxidase inhibitor (MAOI), about the medication. Which foods are allowed in the diet of the client taking phenelzine? Select all that apply. A. Peas B. Broccoli C. Potatoes D. Red wine E. Avocados F. Cereal with raisins

A. Peas B. Broccoli C. Potatoes

A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first? A. Realigning the client B. Asking the client to wiggle her toes C. Removing some of the traction weights D. Medicating the client with the prescribed analgesic

A. Realigning the client

A nurse is supervising a student in preparing the physical environment for an interview with a client. Which action by the student is correct? A. Setting the room temperature at a comfortable level B. Placing a chair for the client across from the nurse's desk C. Providing seating for the client so that the client faces a strong light D. Setting up seating so that the client and nurse are not at eye level

A. Setting the room temperature at a comfortable level

A client brought to the emergency department by the police after being mugged is extremely agitated, trembling and hyperventilating. What is the appropriate initial nursing action? A. Staying with the client B. Teaching the client how to relax C. Asking the client questions about the mugging D. Allowing the client to be alone in a room at the end of the emergency department corridor, where it is quiet

A. Staying with the client

A nurse is providing dietary instructions to a client with uric acid renal calculi. The nurse should provide the client with which instruction? A. To increase the intake of legumes B. That seafood should be included in the diet C. That organ meats should be included in the diet D. To have at least one serving each day of a citrus fruit

A. To increase the intake of legumes

A nurse is watching as a nursing student suctions a client through a tracheostomy tube. Which actions on the part of the student would prompt the nurse to intervene and demonstrate correct procedure? Select all that apply. A. Setting the suction pressure to 60 mm Hg B. Applying suction throughout the procedure C. Assessing breath sounds before suctioning D. Placing the client in a supine position before the procedure E. Hyperoxygenating the client with 100% oxygen before suctioning

A. Setting the suction pressure to 60 mm Hg B. Applying suction throughout the procedure D. Placing the client in a supine position before the procedure

A registered nurse (RN) is supervising a nursing assistant ambulating a client with right-sided weakness. The RN would conclude that the nursing assistant is performing the procedure incorrectly after observing that the nursing assistant: A. Stands behind the client B. Stands on the right side of the client C. Positions the free hand on the client's shoulder D. Grasps the security belt in the midspine area of the small of the client's back

A. Stands behind the client

A nurse, assessing a client's readiness for discharge, is performing a home safety assessment to determine whether there are any environmental hazards in the home. Which of the following statements, if made by the client, would prompt the nurse to investigate further? Select all that apply. A. "I live in a single-story house." B. "I don't have any nightlights in the house." C. "I've removed the scatter rugs from the house." D. "I keep my personal items within reach when I sit in my easy chair." E. "I haven't changed the batteries in the smoke detectors in my home for quite a few years now."

B. "I don't have any nightlights in the house." E. "I haven't changed the batteries in the smoke detectors in my home for quite a few years now."

A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which action should the nurse take first? A. Contact the health care provider B. Check for kinks in the drainage system C. Check the client's blood pressure and heart rate D. Connect a new drainage system to the client's chest tube

B. Check for kinks in the drainage system

A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first? A. Continue suctioning to remove the blood B. Check the degree of suction being applied C. Encourage the client to cough out the bloody secretions D. Remove the suction catheter from the client's nose and begin vigorous suctioning through the mouth

B. Check the degree of suction being applied

A nurse is preparing to administer medications to a client by way of a nasogastric (NG) tube. Before administering the medication, the nurse must first: A. Check the client's apical pulse B. Check the placement of the tube C. Check when the last feeding was given D Check when the last medications were given

B. Check the placement of the tube

The nurse preparing to admit a client with obsessive-compulsive disorder (OCD) to the mental health unit observes the client for certain characteristic behaviors. Which characteristic behavior should the nurse observe? A. Hostility B. Inflexibility C. Adaptability D. Extreme fear

B. Inflexibility

A nurse is providing instruction to a client who is taking codeine sulfate for severe back pain. Which instruction should the nurse provide to the client? A. Decrease fluid intake B. Maintain a high-fiber diet C. Avoid all exercise to help prevent lightheadedness D. Avoid the use of stool softeners to help prevent diarrhea

B. Maintain a high-fiber diet

A client tells the nurse that he has been experiencing frequent heartburn and has been "living on antacids." For which acid-base disturbance does the nurse recognize a risk? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Metabolic alkalosis

A client who is experiencing suicidal thoughts says to the nurse, "It just doesn't seem worth it anymore. Why shouldn't I just end it all?" Which statement should the nurse use to gather additional data from the client? A. "Did you sleep at all last night?" B. "Tell me what you mean by that." C. "I know you've had a stressful night." D. "I'm sure that your family is worried about you."

B. "Tell me what you mean by that."

The mental health home care nurse says to the client, "Do you feel ready to try attending a group session at the clinic?" The client shakes his head. Which nursing statement would be therapeutic? A. "No? Why not?" B. "You seem to be saying no. Would you tell me more about your reluctance?" C. "OK, but I hope you will let me know when you feel ready to attend a group session at the clinic." D. "Perhaps a group session would be too overwhelming for you right now. How about just seeing me?"

B. "You seem to be saying no. Would you tell me more about your reluctance?"

A nurse is reviewing laboratory results for a client who is at risk for nephrotoxicity because of medications being taken. Which serum creatinine result does the nurse document as normal? A. 0.2 mg/dL (17.6 μmol/L) B. 1.0 mg/dL (88.3 μmol/L) C. 2.8 mg/dL (247.3 μmol/L) D. 3.9 mg/dL (344.5 μmol/L)

B. 1.0 mg/dL (88.3 μmol/L)

At 1300, the nurse is documenting the receipt of a unit of packed blood cells at the hospital blood bank. The nurse calculates that the transfusion must be started by which time? A. 1315 B. 1330 C. 1345 D. 1400

B. 1330

A nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. For how long does the nurse plan to stay with the client after the unit of blood is hung? A. 5 minutes B. 15 minutes C. 45 minutes D. 60 minutes

B. 15 minutes

Intravenous tobramycin sulfate is prescribed for a client with a respiratory tract infection. For which of the following symptoms, indicative of an adverse effect, does the nurse monitor the client? A. Nausea B. Vertigo C. Vomiting D. Hypotension

B. Vertigo

For which vitamin deficiency should the nurse monitor the client who is on a vegan diet? A. Vitamin A B. Vitamin B12 C. Vitamin C D. Vitamin E

B. Vitamin B12

A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client's record indicate an unexpected outcome and the need for follow-up? Select all that apply. A. A client is performing his own colostomy irrigations. B. A client with a central venous catheter has a temperature of 100.6° F. C. A client with a new diagnosis of diabetes mellitus is self-administering insulin. D. A client who has just undergone surgery has a urine output of more than 30 mL/hr. E. A client who has just undergone surgery is getting relief from the prescribed pain medication.

B. A client with a central venous catheter has a temperature of 100.6° F.

A nurse conducting a physical assessment of a client plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal: A. Loss of hearing acuity B. A problem with balance C. A problem with distant hearing D. A problem discriminating high-pitched and low-pitched sounds

B. A problem with balance

A cardiac monitor alarm sounds, and a nurse notes a straight line on the monitor screen. The nurse immediately: A. Calls a code B. Assesses the client C. Checks the cardiac leads and wires D. Obtains a rhythm strip from the monitor device

B. Assesses the client

The nurse, performing an abdominal examination, inspects the client's abdomen. Which assessment technique does the nurse perform next? A. Percussion B. Auscultation C. Light palpation D. Deep palpation

B. Auscultation

During a one-to-one nurse-client session, the client plays with her pack of cigarettes and says, "I just get a couple of DVDs and watch movies so I won't have to look at my husband or talk to him." Which coping mechanism does the nurse recognize in the client's behaviors? A. Self-blame B. Avoidance C. Reframing D. Wishful thinking

B. Avoidance

A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over which area? A. Chest of the fetus B. Back of the fetus C. Carotid artery in the neck of the fetus D. Brachial area of one extremity of the fetus

B. Back of the fetus

A nurse is teaching a client with heart disease about a low-fat diet. Which foods should the nurse tell the client are acceptable to eat? Select all that apply. A. Avocados B. Baked tuna C. Green olives D. Baked potato E. Fresh cherries F. Cream cheese

B. Baked tuna D. Baked potato E. Fresh cherries

A nurse employed at a hospital is asked by a nurse manager to review the organizational chart. The nurse reviews the chart so that he will: A. Understand the organization's reason for existence B. Be familiar with the organization's line of authority C. Be familiar with the beliefs and values of the organization D. Be aware of the geographical area that the organization serves

B. Be familiar with the organization's line of authority

A schizophrenic client is seen seemingly talking to someone who isn't there. Which nursing statement would be most therapeutic initially? A. "Today is my birthday. Would you like to go on an outing with my family?" B. "You need to wash up and get ready to go to supper in the cafeteria with the other clients now." C. "I've noticed your eyes darting back and forth, and I wondered whether you might be hearing voices." D. "You were telling me yesterday that your mother died last June of cancer. Can you tell me more about that?"

C. "I've noticed your eyes darting back and forth, and I wondered whether you might be hearing voices."

A post office employee with suspected skin anthrax asks the emergency department nurse whether the infection is curable. What is the appropriate response by the nurse? A. "You really need to ask your doctor about that." B. "That's hard to say. We won't know for a week or two." C. "Antibiotic therapy is usually prescribed and will cure the infection." D. "It is not curable, but fortunately, unlike inhalation anthrax, it is not deadly."

C. "Antibiotic therapy is usually prescribed and will cure the infection."

The emergency department staff prepares for the arrival of a child who has ingested a bottle of acetaminophen. Which medication does the nurse ensure is available? A. Pancreatin B. Phytonadione C. Acetylcysteine D. Protamine sulfate

C. Acetylcysteine

A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the nurse should: A. Call the client's health care provider B. Contact the nursing supervisor for directions C. Administer cardiopulmonary resuscitation (CPR) D. Administer oxygen to the client and call the health care provider

C. Administer cardiopulmonary resuscitation (CPR)

A nurse reviewing a client's record notes that the result of the client's latest Snellen chart vision test was 20/80. How should the nurse interpret this data? A. Is legally blind B. Has normal vision C. Can read at a distance of 20 feet what a client with normal vision can read at 80 feet D. Can read at a distance of 80 feet what a client with normal vision can read at 20 feet

C. Can read at a distance of 20 feet what a client with normal vision can read at 80 feet

A regular diet has been prescribed for a client with a leg fracture who has been placed in skeletal traction. Which foods that will promote wound healing does the nurse encourage the client to select from the hospital menu? A. Spare ribs, rice, gelatin, tea B. Pasta, garlic bread, ginger ale C. Chicken breast, broccoli, strawberries, milk D. Peanut butter and jelly sandwich, chocolate cake, tea

C. Chicken breast, broccoli, strawberries, milk

Which food should the nurse offer to a client who has been prescribed a full liquid diet? A. Toast B. Plain bagel C. Cooked custard D. Scrambled eggs

C. Cooked custard

A nurse is discussing accident prevention with the family of an older client who is being discharged from the hospital after hip surgery. Which items in the home increase the client's risk for injury? Select all that apply. A. A nightlight in the bathroom B. Elevated toilet seat with armrests C. Cooking equipment such as a stove D. Smoke and carbon monoxide detectors E. Common household objects such as doormats F. A water heater thermostat adjusted to a low setting

C. Cooking equipment such as a stove E. Common household objects such as doormats

The mother of a 3-year-old child tells the nurse that her child hit her doll after the mother scolded her for picking the neighbors' flowers. Which defense mechanism used by the child does the nurse identify in the mother's report? A. Projection B. Sublimation C. Displacement D. Identification

C. Displacement

The first bag of total parenteral nutrition (TPN) solution has arrived on the clinical unit for a client beginning this nutritional therapy. The solution is to be infused by way of a central line. Which essential piece of equipment should the nurse obtain before hanging the solution? A. Pulse oximeter B. Blood glucose meter C. Electronic infusion device D. Noninvasive blood pressure monitor

C. Electronic infusion device

A client undergoing chemotherapy is found to have an extremely low white blood cell count, and neutropenic precautions, including a low-bacteria diet, are immediately instituted. Which of these food items will the client be allowed to consume? Select all that apply. A. Fresh apple B. Raw celery C. Italian bread D. Tossed salad E. Baked chicken F. Well-cooked cheeseburger

C. Italian bread E. Baked chicken F. Well-cooked cheeseburger

A nurse is assessing the carotid artery of a client with cardiovascular disease. The nurse performs this assessment by: A. Palpating the carotid artery in the upper third of the neck B. Palpating both arteries simultaneously to compare amplitude C. Listening to the carotid artery, using the bell of the stethoscope to assess for bruits D. Instructing the client to take slow, deep breaths while the nurse listens to the carotid artery

C. Listening to the carotid artery, using the bell of the stethoscope to assess for bruits

Which of the following points should the nurse include when documenting information about a client who is wearing wrist restraints? Select all that apply. A. The client's temperature B. The client's 24-hour urine output C. Skin integrity of the restrained body part D. The procedure used in applying the restraint E. The date and time of application of the restraint F. Circulatory and neurovascular status of the restrained extremities

C. Skin integrity of the restrained body part D. The procedure used in applying the restraint E. The date and time of application of the restraint F. Circulatory and neurovascular status of the restrained extremities

A client has just had a plaster leg cast applied, and the nurse has given the client instructions on cast care. Which statement by the client indicates theneed for further instruction? A. "I may feel cool while the cast is drying." B. "I shouldn't use anything to scratch underneath the cast." C. "If I smell any odor from the cast, I should call the doctor." D. "I can dry the cast faster if I use a hairdryer on the hot setting."

D. "I can dry the cast faster if I use a hairdryer on the hot setting."

A nurse provides information to a client about the use of a diaphragm. Which statement indicates to the nurse that the client needs further information on how to use the diaphragm? A. "I need to reapply spermicidal cream with repeated intercourse." B. "The diaphragm needs to be filled with spermicidal cream before insertion." C. "The diaphragm can be inserted as long as 6 hours before intercourse." D. "I can leave the diaphragm in place as long as I want after intercourse."

D. "I can leave the diaphragm in place as long as I want after intercourse."

A nurse has a written prescription to remove an intravenous (IV) line. Which item should the nurse obtain from the unit supply area for use in applying pressure to the site after removing the IV catheter? A. Alcohol swab B. Adhesive bandage C. Sterile 2 × 2 gauze D. Povidone-iodine (Betadine) swab

C. Sterile 2 × 2 gauze

A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The health care provider has prescribed a clear liquid diet for the client. Which item does the nurse ensure is available in the client's room before allowing the client to drink? A. Straw B. Napkin C. Suction equipment D. Oxygen saturation monitor

C. Suction equipment

A client is receiving intravenous meperidine hydrochloride as prescribed. For which side/adverse effects does the nurse assess the client while the clientis receiving this medication? Select all that apply. A. Polyuria B. Diarrhea C. Tachycardia D. Hypotension E. Mental clouding

C. Tachycardia D. Hypotension E. Mental clouding

A nurse is teaching a client with diabetes mellitus who requires insulin about methods of preventing diabetic ketoacidosis (DKA) when the client is ill. The nurse tells the client to: A. Contact the health care provider if a fever over 102° F occurs B. Refrain from eating or drinking during periods of vomiting C. Take the prescribed insulin dose even if he is unable to eat D. Contact the health care provider when the premeal blood glucose value is greater than 350 mg/dL

C. Take the prescribed insulin dose even if he is unable to eat

A nurse has taught a client how to ambulate with the use of a cane. The nurse determines that the client needs additional instruction if which is observed? A. The client holds the cane close to the body B. The client holds the cane on the unaffected side C. The client moves the cane and the unaffected side together D. The client uses the cane to support the affected side and to maintain balance

C. The client moves the cane and the unaffected side together

A nurse performing a physical assessment of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data? A. The client appears anxious. B. Blood pressure is 170/80 mm Hg. C. The client states that he has a rash. D. The client has diminished reflexes in the legs.

C. The client states that he has a rash.

A client has been taking metoprolol. Which finding indicates to the nurse that the medication is effective? A. The client's ankles are swollen. B. The client's weight has increased. C. The client's blood pressure has decreased. D. The client has wheezes in the lower lobes of the lungs.

C. The client's blood pressure has decreased.

A home health care nurse is visiting a male African-American client who was recently discharged from the hospital. Which family member does the the nurse ensure is present when teaching the client about his prescribed medications? A. The client's son B. The client's father C. The client's mother D. The client's grandson

C. The client's mother

Cyclophosphamide has been prescribed for a client with a diagnosis of breast cancer, and the nurse is providing instructions to the client. The nurse should provide which information to the client? A. To avoid salt while taking this medication B. That it is best to take the medication with food C. To increase fluid intake to 2000 mL to 3000 mL/day D. To drink at least 2 glasses of orange juice every day

C. To increase fluid intake to 2000 mL to 3000 mL/day

A nurse is preparing a plan of care for a pregnant client who will be given oxytocin to induce labor. Which occurrence does the nurse include in the plan of care as a reason for immediate discontinuation of the oxytocin infusion? A. Uterine atony B. Severe drowsiness C. Uterine hyperstimulation D. Early decelerations of the fetal heart rate

C. Uterine hyperstimulation

An emergency department nurse is caring for a client with acute pancreatitis who will be admitted to the hospital. Into which position that will ease the abdominal pain does the nurse assist the client? A. Prone B. Supine with the legs straight C. With the knees drawn up to the chest D. Side-lying with the head of the bed flat

C. With the knees drawn up to the ches

A nurse employed in a community hospital as a nurse manager understands that in this position, the term authority most appropriately refers to: A. Being responsible for what staff members do B. Accepting the responsibility for the actions of others C. Carrying the legal responsibility for others' performance of tasks D. The official power to see that an organizational decision is enforced

D. The official power to see that an organizational decision is enforced

A nurse is preparing to auscultate a client's breath sounds. To assess vesicular breath sounds, the nurse places the stethoscope over: A. Major bronchi B. The xiphoid process C. The trachea and larynx D. The peripheral lung fields

D. The peripheral lung fields

In which of the following situations would the nurse use this type of restraint (see figure)? Select all that apply. A. To secure the shoulders and the waist B. To immobilize a client's arm and shoulders C. To prevent the client from getting out of bed D. To prevent dislodgment of an intravenous line E. To prevent the client from turning from side to side F.To prevent the use of the hands while allowing free arm movement

D. To prevent dislodgment of an intravenous line F.To prevent the use of the hands while allowing free arm movement

A client has been found to have a bladder infection. When planning care, which area of dysfunction would cause the nurse to monitor the client most closely for signs of a kidney infection? A. Urethra B. Nephron C. Glomerulus D. Ureterovesical junction

D. Ureterovesical junction

A nurse is preparing to listen to a client's breath sounds. The nurse should: A. Ask the client to lie down B. Listen to the right lung, then the left lung C. Ask the client to take shallow rapid breaths through the mouth D. Use the diaphragm of the stethoscope, holding it firmly against the client's chest

D. Use the diaphragm of the stethoscope, holding it firmly against the client's chest

Intramuscular phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomical site does the nurse administer it? A. Gluteal muscle B. Deltoid muscle C. Rectus femoris muscle D. Vastus lateralis muscle

D. Vastus lateralis muscle

A nurse is administering care to a client with angina pectoris who is attached to a cardiac monitor. The monitor alarm sounds, and the nurse notes the rhythm shown here. How does the nurse interpret the rhythm? A. Atrial fibrillation B. Sinus tachycardia C. Sinus bradycardia D. Ventricular tachycardia

D. Ventricular tachycardia

A nurse giving a client a bed bath drops the towel on the floor. The nurse should: A. Use a bath blanket as a towel B. Borrow a towel from the client's roommate C. Wash her hands, pick up the towel, and shake the towel out D. Wash her hands and go to the linen room to obtain another towel

D. Wash her hands and go to the linen room to obtain another towel

A nurse is caring for a client who is being treated for congestive heart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which assessment finding causes the nurse to determine that the client's condition has improved? A. Dyspnea B. 1+ edema in the legs C. Moist crackles in the lower lobes of the lungs D. Weight loss of 4 lb in 24 hours

D. Weight loss of 4 lb in 24 hours

Which event would require a nurse to complete and file an incident report? A. A client has a seizure. B. The nurse determines that a client would benefit from the use of a walker to ambulate. C. The nurse, preparing an intravenous infusion, notes that the battery of an intravenous infusion pump is not working. D. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood pressure and takes the visitor to the emergency department for treatment.

D. When a visitor suddenly becomes weak and dizzy, the nurse checks the visitor's blood pressure and takes the visitor to the emergency department for treatment.

A client says to the nurse, "What does my psychiatrist mean when she says that my illness is biologically based?" Which nursing statement would be the most informative? A. "Mental illness always has its roots in the family." B. "Mental illness is a result of environmental factors." C. "Today we know that all mental illness is genetically inherited." D. "There are many possible physical causes of mental illness, and they include problems in the brain."

D. "There are many possible physical causes of mental illness, and they include problems in the brain."

A 2-year-old child is a suspected victim of child abuse and the nurse is interviewing the child's parent. Which statement by the parent indicates the possibility of child abuse? A. "My child can't be expected to learn everything at once." B. "I can expect my child to talk using some words at this age." C. "I expect my child to try doing some things without my help." D. "When I tell my child to do something, I don't expect to have to repeat myself."

D. "When I tell my child to do something, I don't expect to have to repeat myself."

A young adult client says to the nurse, "All my friends are married and have children. I can't seem to meet anyone, and I know I'll never be happy until I meet someone I can care about enough to marry." Which statement by the nurse would assist the client in reframing the situation? A. "Sounds as if you're exaggerating your situation and looking only at the half-full glass." B. "It seems that you measure your life and what you need to do against the behaviors of others." C. "Aren't you a little young to be thinking in such negative terms? You do still have plenty of time before your biological clock winds down." D. "You can't seem to meet someone that you care about? You can still find enjoyment in friendships, work, books, and other things as well."

D. "You can't seem to meet someone that you care about? You can still find enjoyment in friendships, work, books, and other things as well."

A mother asks the nurse when her child should have his first dentist visit. What should the nurse tell the mother? A. At age 3 B. Just before beginning kindergarten C. Twelve months after the first primary tooth erupts D. Soon after the first primary tooth erupts, usually around 1 year of age

D. Soon after the first primary tooth erupts, usually around 1 year of age

A nurse manager is planning client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant (unlicensed assistive personnel)? A. A client scheduled for a cardiac stress test B. A client who had a mastectomy 2 days ago C. A client scheduled for a laparoscopic cholecystectomy D. A client with renal calculi whose urine must be strained

D. A client with renal calculi whose urine must be strained

A fever develops in a client who has been hospitalized for 2 months and is receiving parenteral nutrition by way of a central venous line, and central venous line-related sepsis is diagnosed. The nurse interprets this finding as meaning that this infection is: A. An iatrogenic infection B. A result of bacterial colonization C. A community-acquired infection D. A healthcare-associated infection

D. A healthcare-associated infection

A nurse sees documentation in the client's record indicating that the physician has noted the presence of adventitious breath sounds. The nurse knows that these types of sounds are: A. Normally heard in the lungs B. Hollow sounds heard over the trachea and larynx C. Rustling sounds heard over the peripheral lung fields D. Abnormal sounds that should not be heard in the lungs

D. Abnormal sounds that should not be heard in the lungs

A hospitalized client, experiencing confusion, is at risk of falling because she continually tries to climb out of bed. Which of these safety devices that the nurse might suggest is the least restrictive? A. Belt B. Wrist C. Elbow D. Ambularm

D. Ambularm

A client who had a stroke has left-side weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral? A. Home care B. Social services C. Physical therapy D. Occupational therapy

D. Occupational therapy

A community health nurse is instructing a group of female clients about breast self-examination (BSE). The nurse instructs the clients to perform the examination: A. At the onset of menstruation B. Every month during ovulation C. Weekly, at the same time of day D. One week after menstruation begins

D. One week after menstruation begins

A client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting which finding? A. Urine output of 40 mL/hr B. Blood pressure of 118/76 mm Hg C. Respiratory rate of 18 breaths/min D. Pallor and coolness of the right leg

D. Pallor and coolness of the right leg

A nurse preparing a sterile field is placing sterile items on the field. The nurse understands that the border of the sterile drape is considered contaminated. How many inch(es) is the contaminated border? Type your answer in the box provided. _____ inch(es)

1

A 74-year-old widower of 3 months says to the nurse, "When my wife died, I lost my love and my best friend. Everyone I cared about is dead. We both were only children, and we had no kids. I'm more than ready to go when the time comes." Which nursing response should the nurse make? A. "Are you thinking of ending your life because your time has come?" B. "Did you know that many people live happier lives without children?" C. "It must seem very lonely to you. I can't believe that you never had any children." D. "When my dad died, my mother said some of the things you're saying now, and she had three kids."

A. "Are you thinking of ending your life because your time has come?"

A female victim of incest says to the nurse, "I've had tons of therapy but still can't let my fiancé get too close. He knows I've been sexually abused by my dad and older brother, but I'm wondering whether I'll ever be able to lead a normal sexual life." Which statement by the nurse would be therapeutic? A. "Can you share with me some of the strategies you've been using?" B. "Do you want a normal sexual life? If you do, you will have one, I'm sure." C. "It almost seems that you're saying that you will never be able to love your fiancé." D. "You seem to be saying that you and your fiancé haven't been close, yet you found each another."

A. "Can you share with me some of the strategies you've been using?"

A client who was formerly a workaholic has lost his job and is being supported financially by his wife. The client says to the nurse, "I know that my wife is disappointed in me, but I can't seem to get a job doing what I've done for 25 years. Why should I take a low-level job when she's able to support us financially?" Which response by the nurse would be therapeutic? A. "Can you tell me a little more about this?" B. "I would dig ditches if it contributed to my family's well-being." C. "Sounds as if you're lucky to have your wife's job to fall back on." D. "I'm surprised that such a hardworking man is not able to find a job."

A. "Can you tell me a little more about this?"

A nurse prepares to teach a client with chronic vertigo about safety measures to help prevent exacerbation of symptoms and injury. Which instructions should the nurse provide to the client? Select all that apply. A. "Change positions slowly." Correct B. "Remove clutter from your home." Correct C. "Use public transportation as much as possible." D. "Drive your car only if you're not feeling dizzy." E. "Turn your head slowly when someone speaks to you."

A. "Change positions slowly." B. "Remove clutter from your home."

An older adult client who is dying says to the nurse, "My son is 40 years old, but he works in a very poorly paying job and is always borrowing money from me. I don't know how he's going to manage without me." Which response by the nurse would be therapeutic? A. "Could you share your feelings with your son just as you have with me?" B. "Sounds as if your son will never grow up and learn to take care of himself." C. "Goodness. At 22, I supported myself and never asked my mother for anything." D. "I wonder why you're so worried about your adult son when you need to concentrate on you?"

A. "Could you share your feelings with your son just as you have with me?"

The unit supervisor of an emergency department (ED) is called at home and told by an emergency department nurse who is on duty that an airplane crash has occurred and numerous casualties will be arriving at the ED. What should the initial response by the unit supervisor be? A. "Has the disaster plan been activated?" B. "Call as many nursing staff as you can to come in to work." C. "Make sure all of the rooms are well stocked with supplies." D. "Be sure that the nursing staff finds as many stretchers as they can."

A. "Has the disaster plan been activated?"

A client who delivered a baby 4 months ago says, "I keep thinking that this boy is some sort of demon. All he does is cry. It's as if I can't feed him enough or satisfy him in any way. My daughter never gave me this kind of trouble. I really can't stand it." Which statement by the nurse is most important? A. "Have you been having any thoughts of hurting your baby?" B. "Do you think that something physically wrong is causing your baby to cry?" C. "Do you think that your baby cries so frequently because he's not getting enough nourishment from breastfeeding?" D. "You say that he doesn't seem to be satisfied. Do you feel that this is significantly different from when your daughter was a baby?"

A. "Have you been having any thoughts of hurting your baby?"

A client who was employed as a corporate manager before being laid off says to the nurse, "My wife thinks that I should work in a menial job to maintain our lifestyles until I find another job as a corporate manager, but I don't feel I should have to humiliate myself like that." Which nursing response would be therapeutic? A. "Have you shared your feelings with your wife?" B. "You seem to feel that a less prestigious job would be humiliating for you." C. "Oh, I agree with you. Let her get another job if she needs that much money." D. "How soon will you be able to find work? If this is permanent, you may need to swallow your pride."

A. "Have you shared your feelings with your wife?"

A 61-year-old client whose two sons and daughter-in-law died in a nightclub fire says to the nurse, "We were going to retire early, but now we are the only ones who can care for our two grandchildren." Which response by the nurse would be therapeutic? A. "I am sorry you've had so many losses." B. "I lost my nephew in that nightclub fire, so I understand your sorrow." C. "Your grandchildren sound as if they will give you a run for your money." D. "Don't you just want to scream at someone when such bad things happen? Do you have to work to support your grandchildren?"

A. "I am sorry you've had so many losses."

Family members awaiting the outcome of a suicide attempt are tearful. Which response by the nurse would be most therapeutic to the family at this time? A. "I can see that you are worried." B. "You have nothing to worry about." C. "You can see your loved one soon." D. "Everything possible is being done."

A. "I can see that you are worried."

A home health nurse has instructed a client about safety measures during the use of an oxygen concentrator in the home. Which statement by the client indicates to the nurse that the client has understood the directions? Select all that apply. A. "I need to follow the oxygen prescription exactly." B. "I can use my electric razor while I'm using oxygen." C. "I have to keep the oxygen concentrator out of direct sunlight." D. "I need to keep the oxygen concentrator as close to the wall as possible or put it in a corner." E. "I have to tell everyone that they can't smoke or have an open flame within 10 feet of the oxygen concentrator."

A. "I need to follow the oxygen prescription exactly." C. "I have to keep the oxygen concentrator out of direct sunlight." E. "I have to tell everyone that they can't smoke or have an open flame within 10 feet of the oxygen concentrator."

A home care nurse has provided instructions to the father of a child with croup regarding treatment measures. Which statement by the father indicates a need for further instruction? A. "I should put a steam vaporizer in her room." B. "I'll take her out into the cool, humid night air." C. "I can open the freezer door and encourage her to breathe in the cool air." D. "I can run the hot water in my bathroom and cuddle her in the steamy room."

A. "I should put a steam vaporizer in her room."

A client with osteoporosis is at risk for falls. Which statement by the client indicates the need for instruction regarding measures to prevent falls? A. "I took the bathmat out of my tub." B. "I use a shower chair when I bathe." C. "I've placed nightlights in my hallway." D. "The railings on my stairs are sturdy and secure."

A. "I took the bathmat out of my tub."

A home care nurse is providing instructions to the mother of a 3-year-old with hemophilia regarding care of the child. Which statements by the mother indicate a need for further instructions? Select all that apply. A. "I will be so glad when my baby outgrows all of this bleeding." B. "I need to cancel all of the dental appointments that I've made for him." C. "If he gets a cut, I should hold pressure on it until the bleeding stops." D. "I should check the house for any household items that could fall over easily." E. "I should move furniture with sharp corners out of the way and pad the corners of the furniture."

A. "I will be so glad when my baby outgrows all of this bleeding." B. "I need to cancel all of the dental appointments that I've made for him."

In planning the care of a client dying of cancer, the nurse seeks to have the client verbalize acceptance of his impending death. Which statement indicates to the nurse that this goal has been met? A. "I'd like to have my family here when I die." B. "I'll be ready to die once my daughter gets married." C. "I want to go to my family reunion; then I'll be ready to die." D. "I just want to live to see my grandchildren graduate from college."

A. "I'd like to have my family here when I die."

A client with heart failure being discharged home will be taking furosemide. Which statement by the client indicates to the nurse that the teaching has been effective? A. "I'll weigh myself every day." B. "I'll take my pulse every day." C. "I'll measure my urine output." D. "I'll check my ankles every day for swelling."

A. "I'll weigh myself every day."

A client with a thoracic spinal cord injury is receiving dantrolene sodium. Which statement by the client indicates to the nurse that the client is experiencing an adverse effect of the medication? A. "I'm feeling really drowsy." B. "My legs are very relaxed." C. "I can't seem to get enough to eat." D. "I urinate about the same amount as I always did."

A. "I'm feeling really drowsy."

The nurse is talking to a client whose spouse died 10 months ago. Which statement by the client indicates successful mourning? A. "I'm planning a trip to England next fall to tour the mansions and their gardens." B. "I must confess that I have taken to drinking more than I should at night, but a drink or two helps me to sleep alone in that big house." C. "My son has taken over managing my money because I got into a little mischief with my charge cards. I'm restricted to one debit card now." D. "Last night they had to treat me in the emergency department because I swallowed a few too many pills. Lately I've felt as if I can't go on alone."

A. "I'm planning a trip to England next fall to tour the mansions and their gardens."

A dying client with agoraphobia says to the nurse, "I've been unable to leave this house without tremendous effort for so long, and now it doesn't matter." Which statement by the nurse would be therapeutic? A. "It doesn't matter? Can you share your feelings with me?" B. "Your gardens are beautiful now. Would you like to stroll in them after our work?" C. "Did you go through systematic desensitization with your doctor? I understand that it works well." D. "I know what you mean. I spent more than $2,000 on a dental implant and still wound up with false teeth."

A. "It doesn't matter? Can you share your feelings with me?"

The wife of a dying man is ignoring his rapid physiological decline and imminent death. She continues with her usual activities, exhibits inability to remember what others have just told her, and misses important appointments. Which therapeutic statement should the nurse make to the wife? A. "It isn't unusual for family to suffer from anticipatory grief when a loved one is dying." B. "I cannot emphasize how much your husband needs you to be there for him right now. He is in the stage of denial." C. "You will need to concentrate on getting to these appointments on time and write down what everyone says so you will remember." D. "Can you talk about what's happening to you right now? Your behavior is not appropriate at this stage of your husband's illness. You seem to be having sympathy pains for him, like men during their wives' pregnancies."

A. "It isn't unusual for family to suffer from anticipatory grief when a loved one is dying."

The nurse is caring for a bereaved man with acquired immunodeficiency syndrome who lost his twin brother in a rock-climbing accident a month ago. Which statement by the client should cause the nurse to be concerned? A. "Lately I've been feeling that life isn't that great." B. "You'd have thought that I would be the one to die first." C. "I should have made him stay home. He was always clumsy." D. "I miss him so much. We were close and talked almost daily."

A. "Lately I've been feeling that life isn't that great."

The husband of a terminally ill client says to the nurse, "My company went bankrupt, my son is a drug addict, my daughter is an alcoholic, and now this! My doctor wants me to try some stress reduction because my blood pressure is up. Whose wouldn't be? I've tried music and relaxation, but they don't work." Which statement by the nurse would be therapeutic? A. "Let's talk more about what has been helpful to you in the past." B. "Before we talk about stress management, let's discuss your children." C. "You have a lot of problems. How long does your wife have to live, and what is her relationship with your children?" D. "Can you afford to pay for therapy sessions? I see that your benefits are pretty much maxed out, and I'd hate to ask you to take on any additional burden."

A. "Let's talk more about what has been helpful to you in the past."

A home care nurse makes a visit to a new mother who delivered a 7-lb girl 72 hours ago. The mother tells the nurse that her newborn seems to sleep almost all day. The nurse most appropriately responds by making which statement to the mother? A. "Most newborns sleep about 16 hours a day" B. "We should probably have the baby checked out by the doctor." C. "If you see any other neurological alterations, call the pediatrician." D. "It's important to wake the baby every hour to provide stimulation.

A. "Most newborns sleep about 16 hours a day"

The nurse performing a lethality assessment asks the client whether he is thinking of suicide. Which statement by the client would be of most concern to the nurse? A. "No, I wasn't, but I am now, thanks to you." B. "I hadn't thought of that, but I can see that you are." C. "Of course not, but there are days when I think that I should be." D. "What is suicide going to do for me except get me excommunicated from the church?"

A. "No, I wasn't, but I am now, thanks to you."

A client says to the nurse, "My doctor tells me that I need to start progressive muscle relaxation(PMR) to ease my stress, but I just can't get the hang of it." Which response by the nurse would be most helpful? A. "PMR requires training sessions. Let's check into classes that you can attend to learn the technique." B. "I want you to practice it as often as you can. Play soft, soothing music in the background when you practice your exercises." C. "For it to be effective and produce deep relaxation, the technique requires your complete receptivity to its benefit and your need for it." D. "I could never master the technique myself, so I understand your frustration. Would you like me to explain its difficulty for you to the doctor?"

A. "PMR requires training sessions. Let's check into classes that you can attend to learn the technique."

A university professor meeting with the mental health nurse for his weekly therapy session says, "I have a very intelligent student who keeps disrupting my classroom by bragging, and all I want to do is say, 'OK, you're great and you know it all! Now shut up!' But I just don't want to be rude." Which statement by the nurse is therapeutic? A. "Sounds like you feel pretty helpless, yet you are the professor here." B. "Just say, 'Gee where did you earn your doctorate?' and move on with your lecture." C. "Just smile and say nothing. Go on with your lecture and then talk with the student after class." D. "You're having a pretty strong reaction to this student, aren't you? Why not ask the student to leave the room and use the time to write down his or her thoughts so you can give the others your complete attention?"

A. "Sounds like you feel pretty helpless, yet you are the professor here."

An acutely ill schizophrenic client says to the nurse, "He keeps saying that he likes you, and I keep telling him you're married, but he won't listen, and I think he's going to get fresh with you." Once the nurse has determined that the client is hallucinating, which response to the client would be most appropriate statement? A. "Try not to listen to the voices right now so that I can talk with you." B. "I think that you can help him stop his behavior if you concentrate." C. "Tell him I said to mind his p's and q's or I'll call the police on him." D. "I think that you're trying to share your own feelings toward me, but you're shy."

A. "Try not to listen to the voices right now so that I can talk with you."

The nurse is talking to a client with depression when the client says, "I don't know why my son turned out like he did. I never thought that he would rob a bank! I don't know what I did wrong. I know that he didn't grow up with a father, but I gave him everything. I wish I could start over and do things differently." Which response by the nurse would be therapeutic? A. "You seem to be feeling regret." B. "Don't blame yourself. Some people just turn out bad no matter what." C. "All we can do is give our children love and do our very best. The rest is up to them." D. "Do I hear you saying that you feel that your son's behavior was caused by his upbringing?"

A. "You seem to be feeling regret."

The nurse is caring for a 39-year-old client who has experienced a mild brain attack (stroke). The client is recently widowed, is very active physically, and has two young sons. The client says to the nurse, "I don't know what my sons will do if anything permanent happens to me. We have no other relatives, even on my late wife's side." Which of the following nursing responses would be therapeutic? A. "You seem to be feeling very troubled." B. "You are working to get better, but you're worrying about things that aren't going to happen." C. "You seem to be feeling very powerless right now, yet you're getting better, so why worry about what won't happen?" D. "I am troubled that you are worried over the worst possible things that could happen rather than worrying about the efforts needed to strengthen your family situation."

A. "You seem to be feeling very troubled."

An adolescent client says, "I'm just a burden to my folks. They wish I'd never been born. My dad told me he had to marry Mom because she got pregnant." Which response by the nurse would be therapeutic? A. "You're feeling that your folks didn't want you, but they chose to marry and have you." B. "You feel that you were a burden and not wanted? Let's talk with your parents to see whether you're right." C. "Let's speak with your parents about what you've just told me. Let's ask whether you were truly unwanted." D. "Sounds like your father was very inappropriate, but I'm certain that he didn't mean that you were a burden to him."

A. "You're feeling that your folks didn't want you, but they chose to marry and have you."

A 25-year-old client says to the nurse, "I got my degree in criminal justice. I graduated first in my class from the police academy and had just started as a patrolman when my partner and I responded to a domestic violence call in the most rural part of our patrol area. Someone started shooting at us, and I'm terrified. Maybe I'm not right for this job." Which statement by the nurse would be therapeutic? A. "You're saying that because you felt afraid in a violent situation, you may not be right for the job?" B. "Did you really think that you wouldn't be frightened? You're fortunate if this is the first time you've ever been afraid." C. "You seem to be surprised that you were frightened by the violence. Have you talked with your co-workers about their experiences?" D. "My earlier work as a nurse involved trips through our local crack houses. Wait until you've had some experience working narcotics and then tell me how you feel."

A. "You're saying that because you felt afraid in a violent situation, you may not be right for the job?"

A client who recently lost his hand in a workplace accident says to the nurse, "I don't know how I'm going to support my family with a plastic hand. I might as well be dead." Which nursing response would be therapeutic? A. "You're saying that you feel useless without your hand?" B. "Perhaps you need to focus on being happy that you survived." C. "Don't worry about all of that at this point. You're going to be fine." D. "You'll never need to worry about work again, because your employer will cover all of your expenses and make a settlement that will support you for life."

A. "You're saying that you feel useless without your hand?"

A client who is a health care provider says to the nurse, after receiving a diagnosis of terminal lung cancer, "All my life I took care of my clients, and now my family is taking care of me." Which statement is a therapeutic nursing response? A. "Your family is caring for you now." B. "Well, you'd expect them to care for you, wouldn't you?" C. "It is an honor for all of us to care for you. We want to help you." D. "You can look back on so many wonderful people you saved and cared for."

A. "Your family is caring for you now."

A client has a prescription for a unit of packed red blood cells (RBCs). Which IV solution should the nurse obtain to hang with the blood product at the client's bedside? A. 0.9% sodium chloride B. Lactated Ringer's solution (LR) C. 5% dextrose in 0.9% sodium chloride D. 5% dextrose in water in 0.45% sodium chloride

A. 0.9% sodium chloride

A client with cardiovascular disease is scheduled to receive a daily dose of furosemide. Which potassium level would cause the nurse, reviewing the client's electrolyte values, to contact the health care provider before administering the dose? A. 3.0 mEq/L (3.0 mmol/L) B. 3.8 mEq/L (3.8 mmol/L) C. 4.2 mEq/L (4.2 mmol/L) D. 5.2 mEq/L (5.2 mmol/L)

A. 3.0 mEq/L (3.0 mmol/L)

A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which serum potassium reading does the nurse associate this finding? A. 3.1 mEq/L (3.1 mmol/L) B. 4.2 mEq/L (4.2 mmol/L) C. 4.5 mEq/L (4.5 mmol/L) D. 5.4 mEq/L (5.4 mmol/L)

A. 3.1 mEq/L (3.1 mmol/L)

A nurse is assessing the status of a client with diabetes mellitus. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated hemoglobin A1C (HbA1C) is less than which value? A. 7% B. 9% C. 10% D. 15%

A. 7%

A nurse working the 7 am-to-3 pm shift is reviewing the records of her assigned clients. Which client should the nurse assess first? A. A client scheduled for hemodialysis at 10 am B. A client scheduled for a nuclear scanning procedure at 10 am C. A client scheduled for contrast computed tomography (CT) at noon D. A client scheduled for hydrotherapy for treatment of a burn injury at 10:30 am

A. A client scheduled for hemodialysis at 10 am

Which clients does the nurse recognize as candidates for patient-controlled analgesia (PCA)? Select all that apply. A. A client who has undergone colectomy B. A client with acute pancreatitis C. A client who has undergone gastrectomy D. A client with renal insufficiency E. A client with Alzheimer's disease

A. A client who has undergone colectomy B. A client with acute pancreatitis C. A client who has undergone gastrectomy

A registered nurse (RN) has received the assignment for the day shift. Once the RN has made initial rounds and checked all of the assigned clients, which client will she plan to care for first? A. A client who is scheduled for surgery at 1 pm B. A client scheduled for physical therapy at 11 am C. A client in skeletal traction who has just received pain medication D. A client who is able to perform activities of daily living independently

A. A client who is scheduled for surgery at 1 pm

A nurse is preparing the client assignments for the day. One of the registered nurses on the team has just learned that she is pregnant. Which client does the nurse refrain from assigning to the pregnant team member? A. A client with a solid sealed cervical radiation implant B. A client with diarrhea for whom enteric precautions are in effect C. A client with metastatic cancer who is receiving a continuous infusion of intravenous morphine sulfate D. A client for whom contact precautions have been implemented and who requires frequent wound irrigations

A. A client with a solid sealed cervical radiation implant

The nurse is assigned to care for four clients. Which client does the nurse expect is likely to experience chronic pain? A. A client with osteoarthritis B. A client with angina pectoris C. A client who has undergone appendectomy D. A client with a leg fracture who is in skeletal traction

A. A client with osteoarthritis

A nurse is caring for a group of adult clients on an acute care nursing unit. Which clients does the nurse recognize as the most likely candidates for total parenteral nutrition (TPN)? Select all that apply. A. A client with pancreatitis B. A client with severe sepsis C. A client with renal calculi D. A client who has undergone repair of a hiatal hernia E. A client with a severe exacerbation of ulcerative colitis

A. A client with pancreatitis B. A client with severe sepsis E. A client with a severe exacerbation of ulcerative colitis

A Muslim woman and her husband are seen in the health care clinic because the woman suspects that she is pregnant. When planning for the physical assessment of the woman, which should the nurse ensure? A. A female health care provider examines the woman B. The woman's husband remains in the examining room at all times C. The woman is examined without any other people in the examining room D. Written permission is obtained from the woman to obtain subjective health data

A. A female health care provider examines the woman

A triage nurse in an emergency department (ED) is attending to the victims of a train crash. All victims are alert. Which of these clients does the nurse assign to the emergent category? Select all that apply. A. A victim with respiratory distress B. A victim with a fractured humerus C. A victim with partial amputation of the foot D. A victim with a forehead laceration that is not bleeding E. A victim with multiple nonbleeding bruises of the arms and legs

A. A victim with respiratory distress C. A victim with partial amputation of the foot

The mother of a 3-year-old calls a neighbor who is a nurse and reports that her child just drank some window cleaner that had been stored in a cabinet. The nurse should instruct the mother to immediately: A. Call a poison control center B. Administer an excessive amount of fluids to induce vomiting C. Call an ambulance to bring the child to the emergency department D. Leave a message at the physician answering service about the incident

A. Call a poison control center

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit values. The nurse takes the client's temperature orally before hanging the blood transfusion and notes that it is 100.0° F (37.7 C). What should the nurse do next? A. Call the health care provider B. Begin the transfusion as prescribed C. Administer an antihistamine and begin the transfusion D. Administer 2 tablets of acetaminophen and begin the transfusion

A. Call the health care provider

The nurse calls a health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The health care provider, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration. What is the appropriate action on the part of the nurse? A. Calling the health care provider who gave the telephone prescription to clarify the prescription B. Calling the nursing supervisor for assistance in determining the route of administration C. Administering the medication intravenously, because this route is generally used for clients with CHF D. Administering the medication orally and clarifying the prescription once the health care provider has finished caring for the client in the emergency department

A. Calling the health care provider who gave the telephone prescription to clarify the prescription

A 24-year-old schizophrenic client says, "I was in college and suddenly I was hearing voices telling me I was no good and that I should jump off the bridge by our college. My parents came and got me when I called them. We thought that I had inadvertently taken drugs at a party or something. My psychiatrist says that if I can improve, I can return to college next semester." Which guideline does the nurse plan to incorporate into teaching of the client and family about self-care on the client's return to college? A. Compliance with the treatment regimen, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and living a balanced lifestyle B. Telling all friends about the illness so that they support the client's avoidance of alcohol and drugs and help the client maintain a balanced lifestyle C. Limiting college attendance to commuter status to maintain a supportive family group and avoiding drugs, alcohol, and the strain of socialization D. Compliance with treatment, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and socialization with one supportive friend

A. Compliance with the treatment regimen, immediate reporting of any relapse signs, avoidance of alcohol and drugs, and living a balanced lifestyle

A registered nurse (RN) in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take her break. To ensure client safety during her break, which of the following actions should the nurse take? Select all that apply. A. Conducting client rounds before taking the break B. Taking the break in the staff lounge located on the nursing unit C. Asking the nursing assistant to administer a medication placed at the client's bedside if the client awakens D. Asking the nursing assistant to monitor a client's tube feeding and to contact the nurse when the feeding bag is empty E. Asking the nursing assistant to contact the health care provider during the nurse's break if a client's pain medication is not effective F. Informing the nursing assistant that she is leaving the nursing unit to get a cup of coffee from a vending machine in the lobby

A. Conducting client rounds before taking the break B. Taking the break in the staff lounge located on the nursing unit

A nurse in a long-term care facility recognizes the need to place wrist restraints on a client, but the client does not want the restraints applied. The appropriate nursing action would be to: A. Contact the physician B. Apply the restraints anyway C. Medicate the client with a sedative, then apply the restraints D. Compromise with the client and use only one wrist restraint instead of two

A. Contact the physician

A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion, compared with active motion, of the left arm. On the basis of these assessment findings, which action should the nurse take first? A. Contacting the health care provider B. Reassessing the client in 30 minutes C. Checking to see whether it is time for more pain medication D. Encouraging the client to continue active range of motion exercises of the left arm

A. Contacting the health care provider

A nurse is monitoring a client after transurethral resection of the prostate for benign prostatic hypertrophy. The client has a bladder irrigation infusing, and the urine output is a light cherry color. The nurse performs a follow-up assessment 1 hour later and notes that the urine output is now bright red in color with clots and that the client's blood pressure has dropped. Which action by the nurse is appropriate? A. Contacting the health care provider B. Continuing to monitor the client C. Increasing the flow rate of the intravenous (IV) solution D. Placing pressure on the bladder to aid expulsion of any additional clots

A. Contacting the health care provider

The nurse notes that a health care provider has documented the following prescription in a client's record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take? A. Contacting the health care provider B. Administering the medication C. Drawing up the medication in a syringe D. Planning to have the nurse on the next shift administer the medication

A. Contacting the health care provider

A health care provider writes a medication prescription in a client's record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the health care provider, who states that this is the dose that the client takes at home and that it is acceptable for this client's condition. What is the appropriate action for the nurse to take? A. Contacting the nursing supervisor B. Continuing to transcribe the prescription C. Asking the nurse assigned to care for the client to administer the medication D. Verifying the prescribed dose with the client before administering the medication

A. Contacting the nursing supervisor

A nurse is monitoring the nutritional status of a client receiving enteral nutrition. Which parameter does the nurse use to determine the effectivenessof the tube feedings? A. Daily weight B. Serum protein level C. Calorie count sheets D. Daily intake and output records

A. Daily weight

A nurse is preparing to examine a client's skin using a Wood light. What should the nurse do to facilitate this procedure? A. Darken the examining room B. Administer a local anesthetic C. Obtain a signed informed consent D. Shave the skin and scrub it with povidone-iodine (Betadine)

A. Darken the examining room

A nurse is preparing to perform a skin examination with the use of a Wood light. Which action should the nurse perform to prepare for this diagnostic test? A. Darken the room B. Obtain informed consent from the client C. Obtain a scalpel and a slide for diagnostic evaluation D. Obtain medication to anesthetize the skin area before proceeding with the examination

A. Darken the room

A nurse is assessing a client who is being hospitalized with a diagnosis of pneumonia. The client's husband tells the nurse that the client is taking donepezil hydrochloride. The nurse should ask the husband about the client's history of which disorder? A. Dementia B. Seizure disorder C. Diabetes mellitus D. Posttraumatic stress disorder

A. Dementia

A client who has been admitted to a surgical unit with a diagnosis of cancer is scheduled for surgery in the morning. When the nurse enters the room and begins the surgical preparation, the client states, "I'm not having surgery — you must have the wrong person! My test results were negative. I'll be going home tomorrow." Which defense mechanism should the nurse recognize that the client is using? A. Denial B. Psychosis C. Delusions D. Displacement

A. Denial

A nurse leader in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is "uncooperative and a real pain to care for." The nurse leader would most appropriately manage this issue by: A. Discouraging the judgmental comments B. Ignoring the comments made about the client C. Reporting the nurses' comments to administration D. Leaving articles about judgmental opinions in the nurses' report room

A. Discouraging the judgmental comments

Which action exemplifies the use of evidence-based practice in the delivery of client care? A. Donning sterile gloves to change an abdominal wound dressing B. Encouraging a client to take an herbal substance to treat his insomnia C. Advising a client to agree to the treatment recommended by her health care provider D. Taking a rectal temperature from a client for whom bleeding precautions have been instituted

A. Donning sterile gloves to change an abdominal wound dressing

A nurse performing a neurological assessment is inspecting the client's eyelids for ptosis. The nurse checks the client for: A. Drooping B. Pupil dilation C. Pupil constriction D. Deviation of ocular movements

A. Drooping

A nurse is attending an inservice program on disaster preparedness. Which of the following events is described as an example of a natural disaster? A. Drought B. Bus accident C. Terrorist attack D. Toxic waste spill

A. Drought

The emergency department nurse assesses a client who has a diagnosis of left-sided heart failure. Which findings does the nurse expect to note?Select all that apply. A. Dyspnea B. Dependent edema C. Neck vein distention D. Abdominal distention E. Crackles on auscultation of the lungs

A. Dyspnea

A clinic nurse about to meet a new client and plans to gather subjective data regarding the client's health history. Which actions should the nurse take to help ensure the success of the interview? Select all that apply. A. Ensuring that the room is private B. Seeing that distracting objects are removed from the room C. Having the client sit across a desk or table to give the client some personal space D. Maintaining a distance of 2 feet or closer between the nurse and client E. Switching on a dim light that will make the room cozier and help the client relax

A. Ensuring that the room is private B. Seeing that distracting objects are removed from the room

A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure? A. Flat B. Semi-Fowler C. Side-lying, with the head of the bed elevated D. Sitting up in a recliner with the feet elevated

A. Flat

A client with diabetes mellitus who takes a daily dose of NPH insulin has a hard time drawing the insulin into a syringe because he has difficulty seeing the markings on the syringe. To which of the following services does the nurse suggest a referral? A. Home care B. Social services C. Physical therapy D. Occupational therapy

A. Home care

A nurse is reviewing the assessment findings and laboratory results of a child with a diagnosis of new-onset glomerulonephritis. Which finding would the nurse expect to note? A. Hypertension B. Low serum potassium C. Increased creatinine level D. Cloudy yellow urine

A. Hypertension

A client taking hydrochlorothiazide reports to the clinic for follow-up blood tests. For which side/adverse effect of the medication does the nurse monitor the client's laboratory results? A. Hypokalemia B. Hypocalcemia C. Hypernatremia D. Hypermagnesemia

A. Hypokalemia

A nurse is preparing a plan of care for a client who will be receiving meperidine hydrochloride. Which side/adverse effects does the nurse make a note of needing to be alert to in the plan of care? Select all that apply. A. Hypotension B. Constipation C. Bradycardia D. Urine retention E. Respiratory depression

A. Hypotension B. Constipation D. Urine retention E. Respiratory depression

A client has been given a diagnosis of multiple myeloma. Which result does the nurse reviewing the client's laboratory findings recognize as being specifically related to this diagnosis? A. Increased calcium level B. Decreased blood urea nitrogen (BUN) C. Increased white blood cell (WBC) count D. Decreased number of plasma cells in the bone marrow

A. Increased calcium level

The nurse has been closely observing a client who has been displaying aggressive behaviors and notes that the client's aggressiveness is escalating. Which nursing intervention would be least helpful to this client at this time? A. Initiating confinement measures B. Acknowledging the client's behavior C. Assisting the client to an area that is quiet D. Maintaining a safe distance with the client

A. Initiating confinement measures

A nurse is assessing language development in a toddler from a bilingual family. What should the nurse expect about the child's language development? A. Is slower than expected B. Is developing as expected C. Is more advanced than expected D. Will require assistance from a speech therapist

A. Is slower than expected

A nurse is providing instructions to a client regarding the use of crutches. Which information should the nurse include in the teaching plan? Select all that apply. A. It is not safe to use someone else's crutches. B. Rubber crutch tips will not slip, even when wet. C. The client should use both crutches when navigating stairs. D. Lean into the crutches as needed to support the body's weight. E. Crutch tips are made of a material that will not wear down.

A. It is not safe to use someone else's crutches. C. The client should use both crutches when navigating stairs.

Which of these interventions does a nurse manager, reviewing infection control interventions with the nursing staff, tell the staff will reduce reservoirs of infection? Select all that apply. A. Keeping bedside table surfaces clean and dry B. Placing tissues and soiled dressings in paper bags C. Changing dressings that become wet or soiled Correct D. Placing capped needles and syringes in puncture-resistant containers E. Using soap and water to remove drainage, dried secretions, or excess perspiration from a client's skin F. Emptying urinary drainage systems (Foley catheter drainage) on each shift unless prescribed otherwise by a physician

A. Keeping bedside table surfaces clean and dry C. Changing dressings that become wet or soiled E. Using soap and water to remove drainage, dried secretions, or excess perspiration from a client's skin F. Emptying urinary drainage systems (Foley catheter drainage) on each shift unless prescribed otherwise by a physician

A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which of the following actions reflects the use of evidence-based practice in the care of the client? A. Keeping the door to the client's room closed B. Using a surgical mask when entering the client's room C. Placing the client in a semiprivate room with a cohort client D. Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all times

A. Keeping the door to the client's room closed

A nurse is preparing a client for colonoscopy. Into which position does the nurse assist the client for the procedure? A. Left Sims' position B. Lithotomy position C.Knee-chest position D. Right Sims' position

A. Left Sims' position

A client with right-sided weakness must learn how to use a cane. The nurse tells the client to position the cane by holding it in which way? A. Left hand, 6 inches lateral to the left foot B. Right hand, 6 inches lateral to the right foot C. Left hand, placing the cane in front of the left foot D. Right hand, placing the cane in front of the right foot

A. Left hand, 6 inches lateral to the left foot

A nurse suspects that a client receiving total parenteral nutrition (TPN) through a central line has an air embolism. The nurse immediately places the client in which position? A. Left side with the head lower than the feet B. Left side with the head higher than the feet C. Right side with the head lower than the feet D. Right side with the head higher than the feet

A. Left side with the head lower than the feet

A nurse provides home care instructions to a client with Ménière disease about measures to control and treat vertigo. The nurse should tell the client to: A. Limit sodium in the diet B. Increase fluid intake to at least 3000 mL/day C. Lie down when vertigo occurs and keep a light on in the room D. Move the head from the right to the left when vertigo occurs to determine the extent of its effects

A. Limit sodium in the diet

A client with tuberculosis is being started on isoniazid and the nurse stresses the importance of returning to the clinic for follow-up blood testing. Which blood test will be performed? A. Liver enzymes B. Serum creatinine C. Blood urea nitrogen D. Red blood cell count

A. Liver enzymes

A client is resuming eating after undergoing partial gastrectomy. What measures should the nurse tell the client to take to minimize the risk of complications? Select all that apply. A. Lying down after eating B. Eating high-protein foods C. Drinking liquids with meals D. Eating six small meals per day E. Eating concentrated sweets during the day

A. Lying down after eating B. Eating high-protein foods D. Eating six small meals per day

A client with the diagnosis of schizophrenia is unable to speak, although nothing is wrong with the organs of communication. The nurse plans care knowing that this condition is referring to which? A. Mutism B. Verbigeration C. Pressured speech D. Poverty of speech

A. Mutism

A nurse is reading the radiology report of a client with a chest tube attached to a closed drainage system who has undergone a chest x-ray. The report states that the client's affected lung is fully reexpanded. The nurse anticipates that the assessment of the chest tube system will reveal which finding? A. No fluctuation in the water seal chamber B. Continuous bubbling in the water seal chamber C. Increased drainage in the collection chamber D. Continuous gentle suction in the suction control chamber

A. No fluctuation in the water seal chamber

A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and the pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The nurse should take which immediate action? A. Notify the surgeon B. Continue the assessment C. Check the client's blood pressure D. Obtain a flashlight, gauze, and a curved hemostat

A. Notify the surgeon

A nurse is assisting the physician in performing transillumination of a client's scrotum. The nurse prepares for this procedure by: A. Obtaining a flashlight and darkening the room B. Instructing the client to drink three glasses of water C. Instructing the client to take several deep breaths and bear down D. Telling the client that the procedure is very uncomfortable but that the discomfort will only last for a few moments

A. Obtaining a flashlight and darkening the room

A nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to attach the IV tubing port to the solution bag, the tubing drops, hitting the top of the medication cart. Which action should the nurse take to maintain asepsis? A. Obtaining new IV tubing B. Obtaining a new IV solution bag C. Scrubbing the tubing port with an alcohol swab D. Wiping the tubing port with povidone-iodine solution (Betadine)

A. Obtaining new IV tubing

A nurse is discussing birth control methods with a client who is trying to decide which method to use. On which major factor that will provide the motivation needed for consistent implementation of a birth control method should the nurse focus? A. Personal preference B. Family planning goals C. Work and home schedules D. Desire to have children in the future

A. Personal preference

Phenelzine sulfate is being administered to a client with depression. The client suddenly complains of a severe frontally radiating occipital headache, neck stiffness and soreness, and vomiting. On further assessment, the client exhibits signs of hypertensive crisis. Which medication should the nurse prepare to administer, anticipating that it will be prescribed as the antidote to treat phenelzine-induced hypertensive crisis? A. Phentolamine B. Acetylcysteine C. Protamine sulfate D. Calcium gluconate

A. Phentolamine

Which of the following actions are means of maintaining medical asepsis to reduce and prevent the spread of microorganisms? Select all that apply. A. Practicing hand hygiene B. Reapplying a sterile dressing C. Sterilizing contaminated items D. Applying a sterile gown and gloves E. Routinely cleaning the hospital environment F. Wearing clean gloves to prevent direct contact with blood or body fluids

A. Practicing hand hygiene E. Routinely cleaning the hospital environment F. Wearing clean gloves to prevent direct contact with blood or body fluids

A nurse is caring for a client in the intensive care unit (ICU) who is being mechanically ventilated. As the nurse prepares medications, the client suddenly becomes anxious and pulls out the endotracheal tube. The nurse assesses the client for spontaneous breathing and then: A. Prepares for reintubation B. Restrains the client's wrists C. Calls the rapid response team (RRT) D. Administers an antianxiety medication to the client

A. Prepares for reintubation

The nurse is assigned to care for a client experiencing a crisis. What is the appropriate initial nursing intervention for this client? A. Providing authority and action B. Displaying an attitude of detachment and efficiency C. Providing hope and reassurance that the crisis is temporary D. Demonstrating confidence in the client's ability to deal with the crisis

A. Providing authority and action

A nurse conducting an interview with a client collects subjective data. During the interview, which action should the nurse take? A. Takes minimal notes to avoid impeding observation of the client's nonverbal behaviors B. Takes a great deal of notes to allow the client to continue at his or her own pace as the nurse records what he or she is saying C. Takes notes because this allows the nurse to break eye contact with the client, which may increase the client's level of comfort D. Takes notes to allow the nurse to shift attention away from the client, which may make the nurse more comfortable

A. Takes minimal notes to avoid impeding observation of the client's nonverbal behaviors

A client who has undergone an esophagogastroduodenoscopy (EGD) returns from the endoscopy department. After checking the client's gag reflex, which action should the nurse take? A. Taking the client's vital signs B. Giving the client a drink of water C. Monitoring the client for a sore throat D. Being alert to complaints of heartburn

A. Taking the client's vital signs

A health care provider informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The health care provider tells the nurse to perform a "slow code" and let the client "rest in peace" if she stops breathing. How should the nurse respond? A. Telling the health care provider that "slow codes" are not acceptable B. Telling the health care provider that the client would probably want to die in peace C. Telling the health care provider that all of the nurses on the unit agree with this plan D. Telling the health care provider that if the client stops breathing, the health care provider will be called before any other actions are taken

A. Telling the health care provider that "slow codes" are not acceptable

A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, "I don't want a bath. I've been up all night, and I'm clean enough." The student reports the client's refusal to the nurse in charge. Which action by the nurse in charge is appropriate? A. Telling the nursing student to allow the client to rest B. Telling the nursing student to give the client the bath anyway C. Telling the client that the health care provider will be informed of the refusal of care D. Telling the nursing student to persuade the client to have a bath so that the evening shift staff will not have to do it

A. Telling the nursing student to allow the client to rest

A man who is visiting his wife in a long-term care facility for people with Alzheimer's disease collapses and is transported to a hospital. The client remains unconscious, and testing reveals that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the wife's care facility report to the hospital health care provider that the client has no other family members and that his wife is mentally incompetent. What information regarding do-not-resuscitate (DNR) orders does the nurse remember? A. That a DNR order may be written by a client's health care provider B. That everything possible must be done if the client stops breathing C. That medications only may be given to the client if the client stops breathing D. That life support measures will have to be implemented if the client stops breathing

A. That a DNR order may be written by a client's health care provider

A client asks the nurse about the procedure for becoming an organ donor. What should the nurse tell the client? A. That anatomical gifts should be made in writing and signed by the client B. To speak with the chaplain about the psychosocial aspects of becoming a donor C. That this decision must be made by the next of kin at the time of the client's death D. To let the health care provider know about the request so that it may be documented in the client's record

A. That anatomical gifts should be made in writing and signed by the client

A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse tell the client about the procedure? Select all that apply. A. That informed consent is required Correct B. That the test takes about 4 hours to complete C. That no premedication for sedation will be necessary D. That food and fluids will be withheld before the procedure Correct Correct E. That multiple position changes may be necessary to pass the tube

A. That informed consent is required D. That food and fluids will be withheld before the procedure E. That multiple position changes may be necessary to pass the tube

The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. What should the nurse tell the parents? A. That this is normal behavior for an adolescent B. To restrict any social privileges until the behavior stops C. That this type of behavior is usually the result of parents' spoiling a child D. That their daughter will need to see a child psychologist if the behavior continues

A. That this is normal behavior for an adolescent

A new mother who is breastfeeding her newborn calls the nurse at the pediatrician's office and reports that her infant is passing mustard-yellow stools. What should the nurse tell the mother? A. That this is normal for breastfed infants B. To decrease the number of feedings by two per day C. That the stools should be solid and pale yellow to light brown D. To monitor the infant for infection and, if a fever develops, to contact the pediatrician

A. That this is normal for breastfed infants

A registered nurse (RN) must determine how best to assign co-workers (another RN and one licensed practical nurse [LPN]) to provide care to a group of clients. Which of the following is the best assignment? A. The RN is assigned to care for a woman with newly diagnosed leukemia who has a newborn at home. B. The LPN is assigned to provide discharge teaching about dressing changes and medications to a 35-year-old man. C. The LPN is assigned to care for a client with newly diagnosed diabetes mellitus who will need to be taught how to self-administer insulin. D. The RN is assigned to care for a 75-year-old woman, hospitalized for dehydration, who is being discharged home today with no medications.

A. The RN is assigned to care for a woman with newly diagnosed leukemia who has a newborn at home.

A nurse is performing nasotracheal suctioning on a client. Which observations should be cause for concern to the nurse? Select all that apply. A. The client becomes cyanotic. B. Secretions are becoming bloody. C. The client gags during the procedure. D. Clear to opaque secretions are removed. E. The heart rate varies from 80 to 82 beats/min.

A. The client becomes cyanotic. B. Secretions are becoming bloody.

Wrist restraints have been prescribed for a client who is constantly pulling at his gastrostomy tube. Which of the following findings does the nurse, developing a care plan, recognize as unexpected outcomes related to the use of restraints? Select all that apply. A. The client is agitated. B. The skin under the restraint is red. C. The client's left hand is pale and cold. D. The client verbalizes the reason for the restraints. E. The client is unable to reach the gastrostomy tube with his hands. F. The client slips his hand from its restraint and pulls at his gastrostomy tube.

A. The client is agitated. B. The skin under the restraint is red. C. The client's left hand is pale and cold. F. The client slips his hand from its restraint and pulls at his gastrostomy tube.

The nurse calls a health care provider to question a prescription written for a higher-than-normal dosage of morphine sulfate. The health care provider changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency's guidelines in the client's record. Which other statement does the nurse document in the nursing notes? A. The health care provider was called to clarify the prescription for morphine sulfate. B. The health care provider made an error in the written prescription for morphine sulfate. C. The health care provider was called to correct an error in the dosage of morphine sulfate. D. An incorrect dosage of morphine sulfate was prescribed and the health care provider was notified.

A. The health care provider was called to clarify the prescription for morphine sulfate.

An 18-year-old client is brought to the emergency department (ED) by emergency medical services after sustaining life-threatening injuries in an automobile accident. The client is unconscious and requires an emergency splenectomy. A nurse in the ED assists in quickly preparing the client for surgery and tries to contact the client's parents but is unsuccessful. In regard to informed consent for the surgery: A. The nurse understands that consent is not needed B. The nurse will contact the hospital clergy to provide informed consent C. The nurse will sign informed consent on behalf of the client and ask another nurse to witness the signature D. The nurse will prepare the client to undergo mechanical ventilation until the client's parents can be contacted

A. The nurse understands that consent is not needed

At the beginning of the 7 am-3 pm shift, the nurse checks her assigned clients and notes that a client with diabetes mellitus has an intravenous (IV) bag of 5% dextrose in water hanging and infusing instead of the prescribed 0.9% normal saline. The nurse verifies the prescription and changes the IV solution to the correct one. The nurse assesses the client noting that the blood glucose level at 7:15 am was 149 mg/dL, notifies the physician, and completes an incident report. Which information about the event is appropriate for inclusion on the incident report? Select all that apply. INCIDENT REPORT Events that Occurred A. The physician was contacted. B. The blood glucose level at 7:15 am was 149 mg/dL. C. An IV solution of 5% dextrose in water was infusing at 7 am. D. A solution of 5% dextrose in water was infusing instead of the prescribed 0.9% normal saline solution. E. A 5% dextrose in water solution is not usually prescribed for clients with diabetes, and the solution was changed immediately on its discovery.

A. The physician was contacted. B. The blood glucose level at 7:15 am was 149 mg/dL. C. An IV solution of 5% dextrose in water was infusing at 7 am.

A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication of which? A. The tube is patent B. There is probably a kink in the tubing C. Suction should be added to the system D. The client is retaining airway secretions

A. The tube is patent

A client who has been taking lisinopril complains to the nurse of a persistent dry cough. What should the nurse tell the client? A. This is a side effect of therapy B. He probably has an upper respiratory infection C. He needs to have his blood counts checked D. A chest x-ray is required because the cough is a sign of heart failure

A. This is a side effect of therapy

A nurse is questioning a client about hazards in the home environment. Which of the following items in the home is an indication that the client requires instruction about safety? Select all that apply. A. Untacked rugs on the stairs B. Small rugs in the living room C. Carpet on stairs secured with tacks D. Clothes hamper at the end of the hallway E. Cereal boxes, canned foods, and infrequently used cooking utensils stored on top of the refrigerator

A. Untacked rugs on the stairs B. Small rugs in the living room E. Cereal boxes, canned foods, and infrequently used cooking utensils stored on top of the refrigerator

A nurse is caring for a client who has a fever and is diaphoretic. The nurse monitors the client's urinary output and laboratory values, anticipating which about the client? A. Urine output will be decreased B. Urine production will be increased C. Serum osmolality will be decreased D. Urine specific gravity will decreased

A. Urine output will be decreased

A sexually active adolescent asks the school nurse about the use of latex condoms and the prevention of sexually transmitted infections (STIs). What should the nurse tell the adolescent? A. Use of a latex condom can prevent transmission of STIs B. The only way to prevent transmission of STIs is abstinence C. Use of a latex condom is a good method for preventing pregnancy D. A spermicide needs to be used along with a condom to prevent transmission of STIs

A. Use of a latex condom can prevent transmission of STIs

A nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly assesses the client, noting that the client is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with an automatic external defibrillator (AED). What should the nurse do next? A. Use the AED B. Stop the resuscitation efforts C. Perform CPR until emergency medical services arrives D. Check for a pulse for 30 seconds before continuing CPR

A. Use the AED

A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. What should the nurse tell the mother to do? A. Use water and a cotton swab and rub the teeth B. Use diluted fluoride and rub the teeth with a soft washcloth C. Use a small amount of toothpaste and a soft-bristle toothbrush D. Dip the infant's pacifier in maple syrup so that the infant will suck

A. Use water and a cotton swab and rub the teeth

A nurse is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the nurse: A. Uses a tuning fork B. Asks the client to puff out the cheeks C. Tests taste perception on the client's tongue D. Checks the client's ability to clench the teeth

A. Uses a tuning fork

A nurse is preparing to clean up a blood spill on the client's bedside table that occurred when a blood tube containing a specimen from the client broke. What steps should the nurse take to clean up the blood spill? Select all that apply. A. Using tongs to collect any broken glass B. Wearing gloves for the cleanup procedure C. Placing the pieces of broken glass in a plastic bag D. Blotting up the spill with a face cloth or cloth towel E. Disinfecting the area of the blood spill with a dilute bleach solution

A. Using tongs to collect any broken glass B. Wearing gloves for the cleanup procedure E. Disinfecting the area of the blood spill with a dilute bleach solution

A nurse is reading the medical record of a pregnant client in the second trimester with a diagnosis of abruptio placentae. Which clinical manifestation of the disorder does the nurse expect to see documented? A. Uterine tenderness B. Lack of uterine activity C. Painless vaginal bleeding D. Constipation

A. Uterine tenderness

A client with diabetes mellitus is scheduled to have blood drawn in the morning for a fasting blood glucose determination. What does the nurse tell the client that it is acceptable to consume on the morning of the test? A. Water Correct B.Tea without any sugar C. Coffee without any milk D. Clear liquids such as apple juice

A. Water

Which of the following safety guidelines should the nurse include in the plan of care for a client with an internal radiation implant? Select all that apply. A. Wear a lead shield when in the client's room. Correct B. Limit visits from family to 60 minutes per day. C. Wear a dosimeter film badge when in the client's room. D. Allow children to visit the client as long as they are at least 12 years old. E. Keep all bed linens and dressings in the client's room until the implant is removed.

A. Wear a lead shield when in the client's room. C. Wear a dosimeter film badge when in the client's room. E. Keep all bed linens and dressings in the client's room until the implant is removed

A nurse receives a telephone call from the admissions office and is told that a client scheduled for an internal radiation implant will be admitted to the nursing unit. Which of the following precautions does the nurse include in the client's plan of care? A. Wearing gloves when emptying the client's bedpan B. Allowing the client to ambulate in the hall only once a day C. Placing the client in a semiprivate room at the end of a hallway D. Placing used linen in double bags and sending a bag to the laundry room every evening

A. Wearing gloves when emptying the client's bedpan

A nurse performs an evaluation to determine whether a client's home is electrically safe. Which finding indicates the need for further investigation and intervention? A. Wiring for the television runs under the carpet. B. Electrical cords are free of frayed and damaged wires. C. Electrical kitchen appliances are located away from the sink. D. A safety-type extension cord is secured to the floor with electrical tape.

A. Wiring for the television runs under the carpet.

A nurse is providing instructions to a client who is scheduled to undergo a Papanicolaou (Pap) test in one week. Which statement does the nurse make to the client? A. "If you are menstruating, use pads instead of a tampon." B. "Avoid intercourse for 24 hours before the scheduled examination." C. "Get a douching kit from the pharmacy and douche 2 hours before the examination." D. "If you are having a vaginal discharge, obtain a sample of the discharge for inspection."

B. "Avoid intercourse for 24 hours before the scheduled examination."

A 52-year-old client is admitted to the hospital for surgery to treat lung cancer. The client says to the nurse, "I was an alcoholic for 15 years, and now that I'm 25 years sober, I'm being punished." Which statement by the nurse would be therapeutic? A. "You started drinking at 12 years of age — is that why you feel that the cancer is retribution?" B. "Because you seem to be blaming yourself unnecessarily, perhaps we can talk about your illness and what you can expect after surgery." C. "Sounds like you feel that you're being punished for your drinking, yet you've been sober, so perhaps you're being rewarded by having a cancer that's curable." D. "You feel that you're being punished even though you've been sober for 25 years. Your doctor must have told you that the cancer is unrelated to alcohol."

B. "Because you seem to be blaming yourself unnecessarily, perhaps we can talk about your illness and what you can expect after surgery."

A young widow of 18 months says to the nurse, "I'm going to need a babysitter, because I'm going on a blind date at my brother and sister-in-law's house. They fixed me up, but I think it may be too soon." Which statement by the nurse would be therapeutic? A. "Hello? You go girl! You can see it's only natural, can't you?" B. "By the end of a year, most people are able to renew their interest in other people and activities." C. "Nonsense. Your children need a new father, as your family knows. Your husband would want you to go on with life." D. "If it were me, I would be dating other men by now. After 6 months of mourning, most of society feels that it's okay."

B. "By the end of a year, most people are able to renew their interest in other people and activities."

A 35-year-old recently divorced parent of twins comes to the intake office of the psychiatric clinic for the first time with a possible diagnosis of generalized anxiety disorder. The client says to the nurse, "My mother always called me a worrywart like my nana, so I guess I come by my problems naturally. I keep worrying about things I can't change, like my divorce, and blaming myself when I know I'm not the only one responsible for the divorce." Which nursing statement would be therapeutic? A. "Yet you seem to be dwelling on the thought that the divorce is all your fault." B. "Can you tell me more about the worrying and blaming you are experiencing?" C. "I wonder whether you think you're responsible for making everything turn out right." D. "So you're a natural worrywart, divorced with twins. I guess you can be forgiven for a little worrying, but tell me about the blaming you've been doing."

B. "Can you tell me more about the worrying and blaming you are experiencing?"

A 35-year-old client says to the nurse, "I got divorced less than a year after getting married. I left the Navy SEALs shortly after I joined. Now I teach in the air marshal program to avoid being recalled for war, but I'd really like to quit. I start something, am great at it, then get bored and move on. I date, but I'm still living at home. I never seem to be on my own like other guys my age." Which response by the nurse is most appropriate? A. "You made the Navy SEALs but can't live on your own like an adult and can't stick with anything." B. "Can you tell me more about your marriage and relationships? If you leave home, what do you fear will happen?" C. "You have many years to find a new relationship, but moving out of your parents' home is a first step to growing up." D. "When will your mother let you go? Seems to me that jobs have come easy to you but that you can't grow up and separate from your parents."

B. "Can you tell me more about your marriage and relationships? If you leave home, what do you fear will happen?"

A client with an anxiety disorder who has been prescribed an antibiotic for otitis media asks the nurse, "Why'd the doctor tell me not to discontinue the medication until the pills are gone?" Which response by the nurse is appropriate? A. "Doctors always tell clients to take all of their medicine." B. "Completing the medication ensures that the infection will be resolved." C. "Medication is always prescribed for 1 month. Do you have a month's supply?" D. "It's because insurance companies pay for the medications and want to make sure that the client is healed."

B. "Completing the medication ensures that the infection will be resolved."

A nurse is gathering subjective data from a client who is seeking a prescription for an oral contraceptive. To identify risk factors associated with the use of an oral contraceptive, which question should the nurse ask? A. "Are you dieting?" B. "Do you smoke cigarettes?" C. "Do you engage in strenuous exercise such as jogging?" D. "Do you normally have menstrual cramps with your periods?"

B. "Do you smoke cigarettes?"

A postpartum nurse provides information to a new mother who is being discharged from the maternity unit about signs and symptoms that should be reported to her health care provider. Which statement by the mother indicates a need for further information? A. "My temperature needs to remain within a normal range." B. "Frequent urination and burning when I urinate are expected." C. "Feelings of pelvic fullness or pelvic pressure are a sign of a problem." D. "I will call my nurse-midwife if I get any redness, swelling, or tenderness in my legs."

B. "Frequent urination and burning when I urinate are expected."

The nurse has instructed a client who is about to begin external radiation therapy in how to maintain optimal skin integrity during therapy. Which statement by the client indicates a need for further instruction? A. "I need to keep the sun off the radiation site." B. "I can use over-the-counter cortisone cream on the radiation site if it gets red." C. "I need to be careful not to wash off the marks that the radiologist made on my skin." D. "I need to wash the skin at the radiation site with a mild soap and water and pat it dry."

B. "I can use over-the-counter cortisone cream on the radiation site if it gets red."

The nurse is monitoring a client who is in seclusion. The nurse determines that it is safe for the client to come out of seclusion when the client makes which statement? A. "I need to go to the bathroom." B. "I'm no longer a threat to myself or others." C. "I want to be alone for a while in my own room." D. "I can't breathe in here. The walls are closing in on me."

B. "I'm no longer a threat to myself or others."

A 79-year-old client, recently widowed, says to the nurse, "My wife kept up our condominium single-handedly, and now my kids expect me to cook and clean for myself. I'm not lazy, but I don't know how to cook and I've burnt myself twice just frying up what was supposed to be bacon and eggs. I'm so frustrated and I've already lost 10 lb this month." Which initial nursing statement should the nurse make to the client? A. "I'm calling the doctor immediately to obtain a homemaker for you!" B. "Seems as if you feel lost without your wife and maybe a bit ignored by your children." C. "First things first. What are you doing eating bacon and eggs? That's not a good meal for you." D. "Meals-on-Wheels can help you minimize the frustration you are having cooking. Are you a member of the local senior center?"

B. "Seems as if you feel lost without your wife and maybe a bit ignored by your children."

The nurse is caring for an older adult client who says, "I don't want to talk with you — you're only a nurse. I'll wait for my health care provider." Which response by the nurse would be therapeutic? A. "I'll leave you now and call your health care provider." B. "So you're saying that you want to talk to your health care provider?" C. "I'm angry with the way you've dismissed me. I am your nurse!" D. "I'm assigned to work with you. Your health care provider placed you in my hands."

B. "So you're saying that you want to talk to your health care provider?"

The 45-year-old husband of a client with breast cancer who just died says to the nurse, "If our doctor had operated sooner, my wife would be alive now." Which statement by the nurse would be therapeutic? A. Say nothing. Simply nod and say "Mm-hmm" noncommittally. B. "Sounds as if you're feeling angry and pretty helpless right now." C. "Let's focus not on what was not done but instead on what was done for your wife." D. "Your doctor did all he could for your wife. You know, health care providers can only apply their best clinical judgment."

B. "Sounds as if you're feeling angry and pretty helpless right now."

A dying client says to the nurse, "How do I tell my parents that I am dying of AIDS ?" Which statement by the nurse would be therapeutic? A. "Well, isn't it better that they learn from you than for them to learn on their own?" B. "Sounds as if you're thinking that it's time for you to tell your parents about your disease." C. "I've worked with this illness for many years now, and there just doesn't seem to be an easy way to do this." D. "Are you saying that your parents don't know about your illness?"

B. "Sounds as if you're thinking that it's time for you to tell your parents about your disease."

A client who is experiencing suicidal thoughts says to the nurse, "Life is just not worth it anymore." What is the appropriate initial response? A. "You have a lot to live for." B. "Tell me what you mean by that." C. "A good night's sleep will help you feel better." D. "You should feel grateful for everything you have."

B. "Tell me what you mean by that."

A single parent whose son was suspended from school for carrying a gun into the school says to the nurse, "I know he has no dad, but I've brought him up to know better, and anyway, where did he get the stupid gun? What should I do? He just won't listen to me." Which nursing response would be helpful at this time? A. "Boys who are cared for only by their moms are at highest risk for violent behavior." B. "There is quite a bit that you can do. Let's talk about what you're already doing first." C. "Do you know all of your son's friends, or is he left alone after school because you work?" D. "Many young people die of gunshots every day in this country, so your son's behavior is unacceptable."

B. "There is quite a bit that you can do. Let's talk about what you're already doing first."

A nurse is taking a morning break with the unit secretary in the nurses' lounge. The unit secretary says to the nurse, "I read in Mr. Gage's medical record that he has gonorrhea." How should the nurse respond to the secretary? A. "Oh, really? I didn't see that!" B. "We can't discuss a client's medical condition." C. "Yes, that's why we've imposed contact precautions." D. "Yes, he does, but be sure not to discuss this with anyone else."

B. "We can't discuss a client's medical condition."

A young female client with schizophrenia says to the nurse, "Since I started on olanzapine last year, I'm doing well in school and all, but I've gained so much weight, and it's really bothering me. What can I do about this?" Which response by the nurse would be therapeutic? A. "Well, I think you're overreacting. Today people think they should be skinny-minnies, even though it's not healthy." B. "Weight gain can be a side effect of the medication, so you need to watch your diet and exercise. How much weight have you gained?" C. "That medication isn't any more likely to cause weight gain than the others you're taking. Perhaps we could go over your diet and exercise habits." D. "I want you to stop taking this medication immediately, and I'm calling the doctor, because this is a very serious side effect and you may need dialysis."

B. "Weight gain can be a side effect of the medication, so you need to watch your diet and exercise. How much weight have you gained?"

A health care provider (HCP) tells a client that she has cancer, that her illness is terminal, and that she has a 6-month prognosis. After the health care providerHCP leaves the client's room, which therapeutic statement should the nurse make to the client? A. "I am so sorry about this. You are my favorite client, and I will take good care of you." B. "What did your HCP tell you about your condition? Can you tell me what you're thinking about?" C. "Do you have any questions about what is happening with you? I can assure you that I will do everything I can to help minimize your pain." D. "Do you want me to get the phone so you can talk to your loved ones, or do you have questions for me about what's happening with you?"

B. "What did your HCP tell you about your condition? Can you tell me what you're thinking about?"

The parent of a 25-year-old man who has just been found to have a left frontal brain tumor says to the nurse, "At the local hospital, our doctor thought that his headaches were nothing and prescribed an analgesic. If I hadn't insisted on a CT scan, no one would have found the tumor." Which statement by the nurse would be therapeutic? A. "What's being planned for your son now?" B. "You and your son are having a very trying time. What's happened since your son's diagnosis?" C. "These days only the squeaky wheel gets the grease in medicine. Your squeaking was excellent advocacy." D. "Sounds like you have to be your own health care provider these days — good for you! — but I'm sure your health care provider was following medical protocol."

B. "You and your son are having a very trying time. What's happened since your son's diagnosis?"

A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability? Select all that apply. A. "Accountability can be delegated." B. "You are responsible for your own actions." C. "It carries legal implications for task performance." D. "You must answer for the care that you ask others to complete." E. "It refers to the process of answering or being responsible for what occurs."

B. "You are responsible for your own actions." C. "It carries legal implications for task performance." D. "You must answer for the care that you ask others to complete." E. "It refers to the process of answering or being responsible for what occurs."

The widow of a man who was killed a week ago in a hit-and-run accident while walking the family dog says, "I should have just let the dog run in the backyard or gone with my husband. Our own parish priest hit my husband and finally surrendered to the police. He brought a lawyer with him because he's worried about himself, not my husband. I hate him so much, my stomach hurts." Which nursing statement would be therapeutic? A. "Of course you're angry. Who wouldn't be? Yet nothing is ever clear cut, is it?" B. "You not only lost your husband but also learned it was at the hands of someone you looked up to." C. "You're having stomach pain? You should get checked for an ulcer or other gastric problem." D. "I wouldn't blame you if you never entered a church again. This is a terrible thing for the head of a church to do."

B. "You not only lost your husband but also learned it was at the hands of someone you looked up to."

The nurse employed in a home care agency is assigned a recently widowed client. When the nurse arrives at the client's home, the ordinarily immaculate house is in chaos and the client is disheveled, with the odor of alcohol on his breath. Which statement by the nurse would be therapeutic? A. "I can see that this isn't a good time to visit." B. "You seem to be having a very difficult time." C. "Do you think your wife would want you to behave like this?" D. "What are you doing? How much are you drinking, and how long has this been going on?"

B. "You seem to be having a very difficult time."

A nurse is reviewing the results of renal function testing in a client with renal calculi. Which finding indicates to the nurse that the client's blood urea nitrogen (BUN) level is within the normal range? A. 2 mg/dL (0.7 mmol/L) B. 18 mg/dL (6.3 mmol/L) C. 25 mg/dL (8.75 mmol/L) D. 35 mg/dL (12.25 mmol/L)

B. 18 mg/dL (6.3 mmol/L)

At 1600 the nurse checks a client's total parenteral nutrition (TPN) infusion bag and notes that the solution is running at a rate of 100 mL/hr. The bag was hung the previous day at 1800. The nurse plans to change the infusion bag and tubing this evening at what time? A. 1700 B. 1800 C. 2000 D. 2100

B. 1800

A nurse has taught a client how to stand on crutches. The nurse determines that the client understands the instructions if the client places the crutches in which position? A. 2 inches to the front and side of the toes B. 8 inches to the front and side of the toes C. 15 inches to the front and side of the toes D. 22 inches to the front and side of the toes

B. 8 inches to the front and side of the toes

A case manager is reviewing notations made in clients' records. Which note indicates an unexpected outcome and the need for immediate follow-up? A. A client who has sustained a stroke dresses herself. B. A client exhibits signs of increased intracranial pressure after a craniotomy. C. Normal neurological findings are noted in a client with a cerebral aneurysm. D. A client with a spinal cord injury transfers himself from a bed to a wheelchair.

B. A client exhibits signs of increased intracranial pressure after a craniotomy.

A nurse is planning the client assignments for the shift. Which client should the nurse assign to the nursing assistant? A. A client who needs a blood transfusion B. A client with diarrhea on whom contact precautions have been imposed C. A client with angina who needs to be ambulated for the first time since admission D. A client with a draining abdominal wound that requires frequent dressing changes

B. A client with diarrhea on whom contact precautions have been imposed

A client who is recovering from a brain attack (stroke) has residual dysphagia. Which measure does the nurse plan to implement at mealtimes? A. Giving the client thin liquids B. Alternating liquids with solids C. Giving foods that are primarily liquid D. Placing food in the affected side of the client's mouth

B. Alternating liquids with solids

Triamterene has been prescribed for a client with a history of hypertension. Which fruits should the nurse tell the client are acceptable to eat while taking this medication? Select all that apply. A. Prunes B. Apples C. Peaches D. Avocados E. Nectarines F. Cranberries

B. Apples C. Peaches F. Cranberries

A client has been given a prescription to begin using nitroglycerin transdermal patches for the management of angina pectoris. What should the nurse tell the client about the medication? A. Place the patch in the area of a skin fold to promote adherence B. Apply the patch at the same time each day and leave it in place for 12 to 16 hours as directed C. If the patch becomes dislodged, do not reapply and wait until the next day to apply a new patch. D. Alternate daily dose times between the morning and the evening to prevent the development of tolerance to the medication

B. Apply the patch at the same time each day and leave it in place for 12 to 16 hours as directed

A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection? A. Collect health history information first, then perform the physical examination B. Ask health history questions while performing the examination and initiating emergency measures C. Collect all information requested on the history form, including social support, strengths, and coping patterns D. Perform emergency measures and not ask any health history questions until the client's fractures have been treated in the operating room

B. Ask health history questions while performing the examination and initiating emergency measures

A nurse is performing an admission assessment on an older client who will be seen by a health care provider in a health care clinic. When the nurse asks the client about sexual and reproductive function, he reports concern about sexual dysfunction. What is the next action the nurse should take? A. Report the client's concern to the health care provider B. Ask the client about medications he is taking C. Document the client's concern in the medical record D. Tell the client that sexual dysfunction is a normal age-related change

B. Ask the client about medications he is taking

The nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client's necklace? A. Ask the client whether the necklace is gold B. Ask the client for permission to lock the necklace in the hospital safe C. Ask the client to remove the necklace and place it in the top drawer of the bedside table D. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure

B. Ask the client for permission to lock the necklace in the hospital safe

The alarm on a client's cardiac monitor goes off, and the nurse rushes to the client's bedside and finds the client unconscious. After noting the following rhythm on the monitor, the nurse immediately: A. Checks for a radial pulse B. Assesses the client's neurological status C. Increases the flow rate of the client's intravenous infusion D. Begins cardiopulmonary resuscitation (CPR)

B. Assesses the client's neurological status

The nurse developing a plan of care for a client whose spouse recently died determines the client has a problem with dysfunctional grieving. Which priority intervention does the nurse incorporate into the plan? A. Monitoring the client's sleep pattern B. Assessing the client's risk for violence toward self and others health care provider C. Obtaining a health care provider's prescription for an antidepressant D. Assisting the client in resolving the grief through emotional, cognitive, and behavioral means

B. Assessing the client's risk for violence toward self and others health care provider

The nurse preparing a client to go to the radiology department for a chest x-ray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take? A. Asking the client to remove the medal until the x-ray has been completed B. Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms C. Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department D. Telling the client that the medal and chain will be kept at the nurses' station for safekeeping while the client is undergoing the x-ray

B. Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms

A nurse in the newborn nursery, performing an assessment of a newborn, prepares to measure the chest circumference. Where should the nurse place the tape measure? A. In the axillary area B. At the level of the nipples C. 2 inches below the nipples D. At the level of the umbilicus

B. At the level of the nipples

A nurse is caring for a client with myasthenia gravis who is exhibiting signs of cholinergic crisis. Which medication does the nurse ensure is available to treat this crisis? A. Acetylcysteine B. Atropine sulfate C. Protamine sulfate D Pyridostigmine bromide

B. Atropine sulfate

A hospitalized client with chronic renal failure has returned to the nursing unit after a hemodialysis treatment. Which parameters contained in the predialysis and postdialysis documentation does the nurse utilize to determine if the procedure was effective? A. Weight and BUN B. Blood pressure and weight C. Potassium and creatinine levels D. Blood urea nitrogen (BUN) and creatinine levels

B. Blood pressure and weight

A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push? A. Cleansing breaths B. Blowing repeatedly in short puffs C. Holding her breath and using the Valsalva maneuver D. Deep inspiration and expiration at the beginning and end, respectively, of each contraction

B. Blowing repeatedly in short puffs

A nurse provides instructions to the mother of a newborn with hyperbilirubinemia who is being breastfed. The nurse determines that the mother understands the instructions if the mother says that she will: A. Bottle feed only B. Breastfeed the newborn every 2 to 3 hours C. Provide water feedings between breast feedings D. Feed her newborn less frequently until the bilirubin level drops

B. Breastfeed the newborn every 2 to 3 hours

A school nurse provides information to the parents of school-age children regarding appropriate dental care. What should the nurse tell the parents their children should do? A. Brush their teeth every morning and at bedtime B. Brush and floss their teeth after meals and at bedtime C. Brush and floss their teeth every morning and at bedtime D. Brush their teeth every morning and at bedtime and floss the teeth once a day, preferably at bedtime

B. Brush and floss their teeth after meals and at bedtime

A nurse reviewing a client's record notes documentation that the client has melena. How does the nurse detect the presence of melena? A. By checking the client's urine for blood B. By checking the client's stool for blood C. By checking the client's urine for a decrease in output D. By checking the client's bowel movements for diarrhea

B. By checking the client's stool for blood

A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client's advocate by taking which action? A. Reassuring the client that the risks are minimal B. Calling the surgeon and asking that the risks be explained to the client C. Noting in the client's record that the client was not told about the risks of the surgery D. Writing a note on the front of the client's record so that the surgeon will see it when the client arrives in the operating room

B. Calling the surgeon and asking that the risks be explained to the client

The health care provider (HCP)prescribes the administration of totalparenteral nutrition (TPN), to be started at a rate of 50 mL/hr by way of infusion pump through an established subclavian central line. After the first 2 hours of the TPN infusion, the client suddenly complains of difficulty breathing and chest pain. The nurse should take which immediate action? A. Obtain blood for culture B. Clamp the TPN infusion line C. Obtain an electrocardiogram (ECG) D. Obtain a sample for blood glucose testing

B. Clamp the TPN infusion line

A nurse manager arrives at work and is immediately faced with several activities that require his attention. Which activity will the nurse manager attend to first? A. Stocking the medication closet B. Client assignments for the day C. A phone message from a client's wife D. A phone message from employee health services

B. Client assignments for the day

A nurse is providing a change-of-shift report on his assigned clients, using an audiotape. Which of the following pieces of information should the nurse include in the report about each assigned client? Select all that apply. A. Family history B. Client needs and priorities of care C. Current diagnosis and any secondary diagnoses D. Results of laboratory studies conducted that day E. Client response to treatments implemented that day F. The steps used to perform the procedure for changing the client's sterile dressing at the gastrostomy tube site

B. Client needs and priorities of care C. Current diagnosis and any secondary diagnoses D. Results of laboratory studies conducted that day E. Client response to treatments implemented that day

A client arrives at the emergency department after sustaining an ankle injury, and the health care provider (HCP) prescribes the application of a cold compress to the ankle. The nurse, preparing to apply the compress, assesses the ankle and notes that it is extremely edematous. The nurse should take which action? A. Apply the cold compress to the ankle B. Consult with the HCP before applying the cold compress C. Apply the cold compress for 20 minutes, and then apply a hot compress for 20 minutes D. Elevate the ankle and place cold compresses under and on top of the ankle

B. Consult with the HCP before applying the cold compress

A nurse discontinues an infusion of a unit of packed red blood cells (RBCs) because the client is experiencing a transfusion reaction. After discontinuing the transfusion, which action should the nurse take next? A. Remove the IV catheter B. Contact the health care provider C. Change the solution to 5% dextrose in water D. Obtain a culture of the tip of the catheter device removed from the client

B. Contact the health care provider

A newborn infant's blood glucose level is analyzed by the laboratory. The laboratory staff calls the nurse and reports that the blood glucose level is 40 mg/dL. Based on this result, which action should the nurse take first? A. Hold the next scheduled feeding B. Contact the nurse-midwife or health care provider C. Document the results in the newborn's medical record D. Ask the laboratory to draw another blood sample in 2 hours and repeat the test

B. Contact the nurse-midwife or health care provider

A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she has does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse? A. Telling the client that it is her surgeon's responsibility to explain the procedure B. Contacting the surgeon and requesting that she visit the client to answer her questions C. Informing the client that she has the right to cancel the surgical procedure if she wishes D. Telling the client that she needed to ask these questions before signing the informed consent for surgery

B. Contacting the surgeon and requesting that she visit the client to answer her questions

Risperidone is prescribed for a client with a diagnosis of schizophrenia. Which laboratory study does the nurse expect to see among the health care provider's prescriptions? A. Platelet count B. Creatinine level C. Sedimentation rate D. Red blood cell count

B. Creatinine level

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds that this would be harmful because it could cause which effect? A. Be drying to nasal passages B. Decrease the client's oxygen-based respiratory drive C. Increase the risk of pneumonia as a result of drier air passages D. Decrease the client's carbon dioxide-based respiratory drive

B. Decrease the client's oxygen-based respiratory drive

A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply. A. Decreased pulse B. Decreased urine output C. Increased blood pressure D. Increased respiratory rate E. Decreased respiratory depth

B. Decreased urine output

A nurse educator describes the standards of care formulated by the American Nurses Association to a group of new nursing graduates hired by the hospital. Which of the following options are accurate descriptions of these standards of care? Select all that apply. A. Are specific guidelines B. Define professional practice C. Have some similarity to policies and procedures D. Are statements that relate only to the agency in which the nurse is employed E. Are authoritative statements that describe a common or acceptable level of client care or performance

B. Define professional practice C. Have some similarity to policies and procedures E. Are authoritative statements that describe a common or acceptable level of client care or performance

A health care provider repeatedly asks a nurse to write his verbal prescriptions in his clients' charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and explains this to the physician, but the health care provider tells the nurse that she will be reported if she does not write the prescriptions. How should the nurse manage this conflict? A. Fulfilling the physician's request B. Discussing the situation with the nurse manager C. Reporting the health care provider to the chief of medicine at the hospital D. Stating to the physician, "I don't really care whether you report me. I am not writing your prescriptions."

B. Discussing the situation with the nurse manager

A nurse is teaching a client how to mix regular and NPH insulin in the same syringe. The nurse should provide the client with which information about the insulin? A. Keep insulin refrigerated at all times B. Draw the regular insulin into the syringe first C. Shake the NPH insulin bottle before mixing the two types D. Remove all of the air from the bottle before mixing the two types

B. Draw the regular insulin into the syringe first

A nurse is caring for a client with a diagnosis of chronic kidney disease who is receiving dialysis. Epoetin alfa, to be administered subcutaneously, has been prescribed, and the nurse is drawing the medication from a single-use vial. What should the nurse do to prepare the medication? A. Shake the vial before drawing up the medication B. Draw up the medication and discard the unused portion C. Obtain the medication from the medication freezer and allow it to thaw D. Mix the medication with 0.1 mL of heparin before administration to prevent clotting

B. Draw up the medication and discard the unused portion

A home health nurse provides instructions to a client who is taking allopurinol for the treatment of gout. Which instruction should the nurse provide to the client? A. Place an ice pack on the lips if they swell B. Drink at least 8 glasses of fluid every day C. Take the medication on an empty stomach 2 hours before meals D. Use an over-the-counter (OTC) antihistamine lotion if a rash develops

B. Drink at least 8 glasses of fluid every day

A client with chronic kidney disease is undergoing his first hemodialysis treatment, and the nurse is monitoring the client for signs of disequilibrium syndrome. For which signs of this syndrome does the nurse monitor the client? A. Fever and tachycardia B. Headache and confusion C. Bradycardia and hypothermia D. Irritability and generalized weakness

B. Headache and confusion

A client is taking a folic acid supplement. Which laboratory parameter does the nurse use to evaluate the effectiveness of this therapy? Select all that apply. A. Magnesium B. Hemoglobin C. Blood glucose D. Hematocrit E. Alkaline phosphatase

B. Hemoglobin D. Hematocrit

A female client is seen in the clinic for a gynecological examination. The nurse begins collecting subjective data. Which of the following topics does the nurse ask the client about first? A. Her sexual history B. Her menstrual history C. Her obstetrical history D. The presence of vaginal drainage

B. Her menstrual history

A client who was admitted to the mental health unit 1 month ago with agoraphobia is cooperative, shares with peers, and makes appropriate suggestions during group discussions. Which is most consistent with the client's behavior? A. Manipulation B. Improvement C. Attention-seeking D. A desire to be accepted

B. Improvement

Fluoxetine hydrochloride is prescribed for a client, and the nurse provides instruction regarding the use of the medication. The nurse tells the client that it is best to take the medication at what time? A. At lunchtime B. In the morning C. With the evening meal D. Midafternoon, with an antacid

B. In the morning

A client taking a potassium-retaining diuretic has a serum potassium level of 5.8 mEq/L (5.8 mmol/L). The nurse understands that the kidneys will respond to this via which physiological action? A. Increased sodium retention B. Increased sodium excretion C. Increased glucose retention D. Increased magnesium excretion

B. Increased sodium excretion

A client with peripheral artery disease tells the nurse that pain develops in his left calf when he is walking and subsides with rest. The nurse documents that the client is most likely experiencing: A. Venous insufficiency B. Intermittent claudication C. Sore muscles from overexertion D. Muscle cramps related to musculoskeletal problems

B. Intermittent claudication

A nurse notes that a client has a diagnosis of acute back pain. The nurse plans care based on which characteristic of acute pain? A. It has a prolonged presence B. It is a result of injury C. It lasts longer than 6 months D. It is usually the result of a chronic disorder

B. It is a result of injury

A nurse is caring for a client who has been taking acetazolamide for glaucoma. Which, if documented in the assessment data, indicates to the nurse that the client may be experiencing an adverse effect of the medication? A. Tinnitus B. Jaundice C. No change in peripheral vision D. Pupillary constriction in response to light

B. Jaundice

A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, which action should the nurse take? A. Spend as much time as possible with the toddler B. Keep hospital routines as similar as possible to those at home C. Allow the toddler to play with other children in the nursing unit playroom D. Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room

B. Keep hospital routines as similar as possible to those at home

A client who has recently been started on enteral feedings complains of abdominal cramping and diarrhea. The nurse reviews the nutritional content on the label of the can of feeding solution. Which ingredient is the nurse looking for that may be causing this problem? A. Maltose B. Lactose C. Sucrose D. Fructose

B. Lactose

A nurse is preparing to assess the dorsalis pedis pulse. The nurse palpates this pulse by placing the fingertips: A. Behind the knee B. Lateral to the extensor tendon of the big toe C. In the groove between the malleolus and the Achilles tendon D. Below the inguinal ligament, halfway between the pubis and the anterior superior iliac spines

B. Lateral to the extensor tendon of the big toe

A nurse is caring for a client who is vomiting. For which acid-base imbalance does the nurse assess the client? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosi

B. Metabolic alkalosis

A nurse caring for a client with leukemia who is undergoing chemotherapy reviews the latest laboratory results and notes that the neutrophil count is below 500 cells/mm3. Which of the following interventions does the nurse implement on the basis of this finding? Select all that apply. A. Providing a soft toothbrush for oral care B. Monitoring the client's oral temperature C. Maintaining sterile occlusion of intravenous (IV) catheters D. Requiring the client to use an electric shaver rather than a razor E. Performing meticulous skin decontamination before venipuncture F. Avoiding overinflation of the blood pressure cuff and rotating the cuff among several sites when measuring the blood pressure

B. Monitoring the client's oral temperature C. Maintaining sterile occlusion of intravenous (IV) catheters E. Performing meticulous skin decontamination before venipuncture

A nurse is assessing a fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take? A. Asks the mother to lie still while both the FHR and the radial pulse rate are counted. B. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart. C. Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds. D. Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse.

B. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart.

A nurse is performing an abdominal assessment of a client with suspected cholecystitis. Which of the following findings does the nurse expect to note if cholecystitis is present? A. Homan sign B. Murphy sign C. Blumberg sign D. McBurney sign

B. Murphy sign

A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client? Select all that apply. A. Paresthesias B. Muscle weakness C. Increased urine output D. Chvostek sign E. Hyperactive deep tendon reflexes

B. Muscle weakness C. Increased urine output

Baclofen is prescribed for a client with a spinal cord injury who is experiencing muscle spasms. While providing instructions to the client, which side effect does the nurse tell the client is possible? A. Photosensitivity B. Nasal congestion C. Increased appetite D. Increased salivation

B. Nasal congestion

A nurse in the emergency department is performing a musculoskeletal assessment of a client. The presence of which of the following conditions would cause the nurse to avoid testing range of motion (ROM) of the cervical spine? A. Headache B. Neck trauma C. Sinus infection D. Muscle spasms

B. Neck trauma

The nurse in the emergency department is helping care for a young female victim of sexual assault. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withdrawn, confused, and, at times, physically immobile. The nurse interprets these behaviors as which type of reaction? A. Signs of depression B. Normal reactions to a devastating event C. Indicative of the need for hospital admission D. Evidence that the client is at high risk for suicide

B. Normal reactions to a devastating event

A nurse is taking the vital signs of a pregnant client who has been admitted to the labor unit. The nurse notes that the client's temperature is 100.6° F, the pulse rate is 100 beats per minute, and respirations are 24 breaths per minute. Based on these findings, what is the most appropriate nursing action? A. Recheck the vital signs in 1 hour B. Notify the nurse-midwife of the findings C. Continue collecting subjective and objective data D. Document the findings in the client's medical record

B. Notify the nurse-midwife of the findings

A nurse conducting an eye examination notes that the client exhibits rapid, involuntary oscillating movements of the eyeball when looking at the nurse. How should the nurse document this finding? A. Ptosis B. Nystagmus C. Scleral icterus D. Exophthalmos

B. Nystagmus

The nurse is preparing to provide nursing unit information to a client who does not speak English who is being admitted to the mental health unit. Which action is best for the nurse to take to ensure that the client understands the information? A. Asking a family member to translate for the client B. Obtaining a hospital interpreter to communicate with the client C. Asking a hospitalized client who speaks the same language as the client to translate D. Providing the client with a pamphlet that explains the nursing unit information in the client's language

B. Obtaining a hospital interpreter to communicate with the client

A client with diabetes mellitus who has been taught about dietary management of the disease wishes to have 8 oz of nonfat yogurt with breakfast. The nurse determines that the client understands diet management when the client states that which action will be taken after eating the nonfat yogurt? A. Not eating ice cream for 2 days B. Omitting 8 oz of skim milk from that meal C. Omitting salad dressing and butter at lunchtime D. Eating only half of an allowed meat product at supper

B. Omitting 8 oz of skim milk from that meal

A nurse reviewing a client's healthcare record notes documentation that the client has Heberden nodes of the distal interphalangeal joints. Which disorder does the nurse determine that the client has? A. Scoliosis B. Osteoarthritis C. Rotator cuff lesions D. Carpal tunnel syndrome

B. Osteoarthritis

A new nurse employed at a community hospital is reading the organization's mission statement. The new nurse understands that this statement: A. Describes the benefits available to employees B. Outlines what the organization plans to accomplish C. Identifies the policies and procedures of the organization D. Defines the rules of the organization that the employees must follow

B. Outlines what the organization plans to accomplish

A nurse observes an unlicensed assistive personnel (UAP) communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the UAP performs which action? A. Uses short sentences B. Overarticulates words C. Uses facial expressions or gestures D. Speaks at a normal rate and volume

B. Overarticulates words

A client has been scheduled for magnetic resonance imaging (MRI). For which condition, a contraindication to MRI, does the nurse check the client's medical history? A. Pancreatitis B. Pacemaker insertion C. Type 1 diabetes mellitus D. Chronic airway limitation

B. Pacemaker insertion

A nurse is reviewing the medical notes of a client seen by the health care provider to determine whether the client is pregnant. The nurse determines that pregnancy was confirmed if which finding is documented? A. Amenorrhea B. Palpable fetal movement C. Thinning of the cervix D. Positive result on home urine test for pregnancy

B. Palpable fetal movement

Performing an abdominal assessment, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner because: A. It is less painful for the client B. Palpation and percussion can increase peristalsis C. It identifies any potential areas of abdominal tenderness D. It gives the client more time to become comfortable with the examiner

B. Palpation and percussion can increase peristalsis

Methylergonovine intramuscularly is prescribed for a postpartum client. Before administering the medication, the nurse explains to the client that the medication will promote which effect? A. Reduce lochial drainage B. Prevent postpartum bleeding C. Maintain a normal blood pressure D. Decrease the strength of uterine contractions

B. Prevent postpartum bleeding

A nurse is reading an article about the role of the American Red Cross (ARC) in a disaster. Which of the following responsibilities does the article ascribe to the ARC? A. Declaring a disaster B. Providing disaster relief C. Activating disaster medical assistant teams D. Developing a federal disaster response plan

B. Providing disaster relief

A nurse is caring for a client whose urine output was 25 mL for 2 consecutive hours. When planning care, which client-related factors does the nurse recognize as increasing blood flow to the kidneys? A. Physiological stress B. Release of dopamine C. Release of norepinephrine D. Sympathetic nervous system stimulation

B. Release of dopamine

A nurse caring for a 9-month-old who has undergone repair of a cleft palate applies elbow restraints to the child. The mother visits her child and asks the nurse to remove the restraints. According to the guidelines for the use of restraints, what should the nurse do in response to the mother's request? A. Remove both restraints B. Remove a restraint from one extremity C. Tell the mother that the restraints may not be removed D. Loosen the restraints after telling the mother that they may not be removed

B. Remove a restraint from one extremity

A client receiving total parenteral nutrition (TPN) requires fat emulsion (lipids), which will be piggybacked to the TPN solution. On obtaining a bottle of fat emulsion, the nurse notes that fat globules are floating at the top of the solution. Which action should the nurse take? A. Shake the bottle vigorously B. Request a new bottle from the pharmacy C. Rotate the bottle gently back and forth to mix the globules D. Run the bottle under warm water until the globules disappear

B. Request a new bottle from the pharmacy

A nurse is caring for a client who has undergone pulmonary angiography with catheter insertion through the right femoral vein. The nurse assesses for allergic reaction to the contrast medium by monitoring for the presence of which? A. Bradycardia CorrectB. Respiratory distress C. Hematoma in the right groin D. Discomfort in the right groin

B. Respiratory distress

A nurse administers an oil retention enema to a client. Afterward, the nurse should provide which instruction to the client? A. Immediately expel the enema B. Retain the enema for several hours C. Expect to defecate within 30 minutes D. Expect to experience cramping induced by the solution

B. Retain the enema for several hours

A schizophrenic client arrives for a scheduled appointment with the mental health nurse. The nurse notes that the client's hygiene is poor and that the client is having difficulty concentrating on what the nurse is saying and responding appropriately. Which nursing intervention would be most appropriate? A. Saying nothing and contacting the psychiatrist to sign a commitment order B. Saying, "I notice that you don't seem to be caring for yourself. Are you taking your medication?" G. Giving the client his antipsychotic medication and asking him to return in the morning for a follow-up visit D. Asking, "Will you voluntarily admit yourself for a couple of days so that you can straighten out your medicine and thinking?"

B. Saying, "I notice that you don't seem to be caring for yourself. Are you taking your medication?"

A client who is taking bupropion in an attempt to stop smoking tells a nurse that he has been doubling the daily dose to make it easier to resist smoking. The nurse warns the client that doubling the daily dosage is dangerous. Of which adverse effect of the medication does the nurse warn the client? A. Insomnia B. Seizures C. Weight gain D. Orthostatic hypotension

B. Seizures

A nurse is reviewing the results of serum laboratory studies of a client with suspected hepatitis. Which increased parameter is interpreted by the nurse as the most specific indicator of this disease? A. Hemoglobin B. Serum bilirubin C. Blood urea nitrogen (BUN) D. Erythrocyte sedimentation rate (ESR)

B. Serum bilirubin

A woman in labor suddenly complains of abdominal tenderness and pain and states that she felt as though "something ripped." For which manifestations does the nurse, suspecting uterine rupture, assess the client? Select all that apply. A. Bradypnea B. Severe chest pain C. Absence of fetal heart tones D. Increased blood pressure E. Increased frequency of uterine contractions

B. Severe chest pain C. Absence of fetal heart tones

A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client's wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife? A. A bone scan is being performed. B. She will have to discuss the prescribed test with the client. C. The radiology department is not clear as to which test has been prescribed. D. She can read the client's medical record to determine what the health care provider prescribed.

B. She will have to discuss the prescribed test with the client.

A nurse is to administer a dose of digoxin to a client with atrial fibrillation and notes that the client has a potassium level of 4.6 mEq/L (4.6 mmol/L). The nurse determines which about the administration of the dose? A. Should be withheld that day B. Should be administered as prescribed C. Should be preceded with a dose of potassium D. Should be withheld and the health care provider notified

B. Should be administered as prescribed

A health care provider states that a client's insensible fluid loss is approximately 600 mL/day. The nurse interprets this statement to reflect fluid loss occurring through which routes? A. Wound drain and skin B. Skin and mechanical ventilator C. Nasogastric tube and wound drain D. Foley catheter and nasogastric tube

B. Skin and mechanical ventilator

A client has been placed in Buck's extension traction. The nurse can provide counter traction to reduce shear and friction by implementing which measure? A. Flexing the feet against a footboard B. Slightly elevating the foot of the bed C. Keeping the head of the bed elevated 45 degrees D. Placing the bed in reverse Trendelenburg position

B. Slightly elevating the foot of the bed

A client with renal calculi is instructed to follow an alkaline ash diet. Which menu choice by the client indicates to the nurse that the client understands the prescribed regimen? A. Chicken, potatoes, and cranberries B. Spinach salad, milk, and a banana C. Peanut butter sandwich, milk, and prunes D. Linguini with shrimp, tossed salad, and a plum

B. Spinach salad, milk, and a banana

A nurse in a newborn nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (meningomyelocele type) will be transported to the nursery. Which item does the nurse, preparing for the arrival of the newborn, make a priority of placing at the newborn's bedside? A. Flashlight B. Sterile dressing C. Cardiac monitor D. Blood pressure cuff

B. Sterile dressing

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. Which assessment finding indicates to the nurse that the client is experiencing magnesium toxicity? A. Proteinuria of +3 B. Sudden drop in fetal heart rate C. Presence of deep tendon reflexes D. Serum magnesium level of 2.5 mEq/L (1.25 mmol/L)

B. Sudden drop in fetal heart rate

An adolescent is returning home after an acute psychiatric hospitalization for a suicide attempt. Which strategy will be least effective in preparing the client for discharge? A. Encouraging the sharing of feelings B. Suggesting that the client's mother quit her job C. Identifying the family's strengths and weaknesses D. Offering and providing the family options and resources

B. Suggesting that the client's mother quit her job

A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client? A. Assessing the client's chest for crepitus once every 24 hours B. Taping the connections between the chest tube and the drainage system C. Adding 20 mL of sterile water to the suction control chamber every shift D. Recording the volume of secretions in the drainage collection chamber every 24 hours

B. Taping the connections between the chest tube and the drainage system

A client who has undergone adrenalectomy is prescribed prednisone. Which finding indicates that the client is experiencing an adverse effect of the medication? A. Dry mouth B. Tarry stools C. Hypotension D. Hypoglycemia

B. Tarry stools

A client is receiving heparin sodium by way of continuous IV infusion. For which adverse effects of the therapy does the nurse assess the client?Select all that apply. A. Tinnitus B. Tarry stools C. Slowed pulse D. Bleeding from the gums E. Increased blood pressure

B. Tarry stools D. Bleeding from the gums

The mother of a newborn who was circumcised before discharge from the hospital calls the nurse at the pediatrician's office and tells the nurse that she is concerned because she has noticed a yellow crust over the circumcision site. Which instruction should the nurse give the mother? A. To bring the infant to the pediatrician's office to be checked B. That the crust is to be expected as a normal part of healing C. To remove the crust, using a warm, wet face cloth and a mild soap D. That it could indicate a sign of an infection and that the infant's temperature should be checked every 2 hours

B. That the crust is to be expected as a normal part of healing

A client admitted to the hospital has a do-not-resuscitate (DNR) order in his medical record. The nurse understands that: A. The DNR order may not be changed once it is in effect B. The DNR order requires frequent review as specified by state or agency policy C. The only people who may change the DNR order are members of the client's immediate family D. The DNR order, as written on admission, must remain in effect for the duration of the client's hospitalization

B. The DNR order requires frequent review as specified by state or agency policy

A registered nurse is instructing a group of nursing assistants in the principles of body mechanics. Which of these observations tell the nurse that a student is using the principles appropriately? Select all that apply. A. The assistant leans forward when turning a client in bed. B. The assistant positions a box that is to be lifted between his knees. C. The assistant turns his back to change position while moving a client. D. The assistant keeps the object to be moved as close to his body as possible. E. The assistant helps a client requiring total care into a chair without additional assistance.

B. The assistant positions a box that is to be lifted between his knees D. The assistant keeps the object to be moved as close to his body as possible

The nurse working with a victim of rape in a clinic setting is developing a plan of care for the client. Which short-term initial goal is most appropriate? A. The client will care for her own physical wounds. B. The client will verbalize her feelings about the event. C. The client will identify an appropriate treatment plan. D. The client will resolve feelings of fear and anxiety related to the rape trauma.

B. The client will verbalize her feelings about the event.

A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record reflects the correct use of guidelines for documentation? A. The client seems anxious B. The client's intake was 360 mL C. The client's wound is healing well D. The client is voiding large amounts

B. The client's intake was 360 mL

A nurse is assessing the language development of a 9-month-old infant. Which developmental milestone does the nurse expect to note in an infant of this age? A. The infant babbles. B. The infant says "Mama." C. The infant smiles and coos. D .The infant babbles single consonants.

B. The infant says "Mama."

A client with a new diagnosis of tuberculosis (TB) is being admitted to the hospital. During the collection of data from the client, which of the following considerations is especially important? A. The religious affiliation or church of preference B. The names of close friends and family member C. What medications have been prescribed and what the client knows about their side effects D. The name of the person from whom the client contracted TB, so that the person may be reported for follow-up care

B. The names of close friends and family members

A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the test indicate a CD4+ count of 450 cells per cubic millimeter of blood. The nurse interprets this test result as indicating which? A. Improvement in the client B. The need for antiretroviral therapy C. The need to discontinue antiretroviral therapy D. An effective response to the treatment for HIV

B. The need for antiretroviral therapy

The nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, "The medication is needed to prevent the spread of infection, and if you don't take it orally I will have to give it to you in an intramuscular injection." Which statement accurately describes the nurse's response to the client? A. The nurse could be charged with battery. B. The nurse could be charged with assault. C. The nurse is justified in administering the medication by way of the intramuscular route, because the client has a communicable disease. D. The nurse will be justified in administering the medication by the intramuscular route once a prescription has been obtained from the physician

B. The nurse could be charged with assault.

After discussing the use of restraints with a client and family, a physician has written a prescription for wrist restraints to be applied to a client. The nurse instructs the nursing assistant to apply the restraints. Which of the following observations by the nurse indicates that the nursing assistant is using the restraints safely and correctly? Select all that apply. A. The restraints are applied tightly. B. The restraints are being released every 2 hours. C. A safety knot has been used to secure the restraints D. The restraints have been tied to the siderails of the bed. E. The call light has been placed within reach of the client.

B. The restraints are being released every 2 hours. C. A safety knot has been used to secure the restraints E. The call light has been placed within reach of the client.

A nurse performing a skin assessment uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. What does the nurse determine? A. The client has a fever B. The skin temperature is normal C. The client needs to drink additional fluids D. The client needs to have the blanket removed

B. The skin temperature is normal

A nurse educator is providing inservice sessions to the nursing staff regarding employee safety and the prevention of occupationally acquired HIV infection. Which of the following precautions does the nurse instruct the nursing staff to take as a means of preventing accidental needlesticks? Select all that apply. A. The use of latex gloves B. The use of shielded needles C. The use of recessed needles D. The use of needleless devices E. Disposal of needles in special puncture-resistant containers

B. The use of shielded needles C. The use of recessed needles D. The use of needleless devices E. Disposal of needles in special puncture-resistant containers

A mother calls the clinic and tells the nurse that her newborn's umbilical cord site looks red and swollen. The nurse should tell the mother: A .That this is a normal occurrence B. To bring the newborn to the clinic C. To increase the number of cord site cleanings each day D. To place an ice pack on the cord for 10 minutes three times a day

B. To bring the newborn to the clinic

A nurse is providing instructions to a client regarding quinapril hydrochloride. The nurse should teach the client to implement which measure? A. To take the medication with meals B. To rise slowly from a lying to a sitting position C. To discontinue the medication if nausea occurs D. That a therapeutic effect will be felt immediately

B. To rise slowly from a lying to a sitting position

A nurse is conducting an assessment of a client with mild preeclampsia. Which sign indicates improvement in the client's condition? A. Complaint of headache B. Trace protein in the urine C. Blood pressure 148/94 mm Hg D. Blood urea nitrogen (BUN) of 40 mg/dL (14.2 mmol/L)

B. Trace protein in the urine

A nurse has obtained a unit of blood from the blood bank and properly checked the blood bag with another nurse. Which parameter should the nurse assess just before hanging the transfusion? A. Skin color B. Vital signs C. Latest platelet count D. Urine output over the last 24 hours

B. Vital signs

The wife of a client who is dying says to the nurse, "I am able to take off the 6 months from work our doctor feels that my husband will live, but what if he lives beyond that time?" Which therapeutic response should the nurse make? A. "Only you and your husband can determine how you should best allocate your work leave." B. "Your husband has managed to be active up to now, so he could live longer than predicted, but his actual lifespan remains unclear." C. "Are there other options for you in taking work leave? Perhaps you could simply reduce your work hours at first so that you can extend your compassionate leave." D. "Why not write down the pros and cons of taking work leave all at once and any other options and then decide with your husband and family which would be most helpful?"

C. "Are there other options for you in taking work leave? Perhaps you could simply reduce your work hours at first so that you can extend your compassionate leave."

A client who is undergoing psychiatric counseling calls a nurse on a hotline, crying, and states, "My priest assaulted me when I was an altar boy, and my dad just found out. He's got a gun, and he's driving over to the church rectory. I don't know what to do." Which response by the nurse is most appropriate initially? A. "How did your dad learn of your abuse by clergy?" B. "Call the police immediately and then call the priest to warn him that your dad has a gun." C. "Call the priest immediately and tell him to lock the doors until the police arrive. I'll call the police." D. "You will want to come in to see our psychiatrist with your father, but, for now, call the police and tell them what happened."

C. "Call the priest immediately and tell him to lock the doors until the police arrive. I'll call the police."

A client who delivered a baby 4 weeks ago says, "I'm feeling as if I'm hanging on by a thread to keep my wits about me." Which statement by the nurse would be therapeutic? A. "Can your husband help you with the baby and your chores? Is he on paternity leave? B. "You have a beautiful new baby, and caring for her will help you feel better. Your hormones will be back in balance soon." C. "Can you share with me more specifically how you feel that you're hanging on by a thread? Are you having thoughts of hurting yourself?" D. "You seem to be experiencing postpartum depression. I suggest that you have someone take your baby for a while until your hormones level off."

C. "Can you share with me more specifically how you feel that you're hanging on by a thread? Are you having thoughts of hurting yourself?"

A 32-year-old married woman who recently gave birth to her first child by cesarean section says, "My husband and I worry about our baby all the time. We did everything right, yet he had so many problems at birth." Which statement by the nurse would be therapeutic? A. "I'd like to ask you a series of parenting questions to determine your fitness." B. "What's been happening since you all came home? As I understand it, the baby is thriving." C. "Can you tell me more about the worrying? What's been happening since you brought your baby home?" D. "Lots of women do everything right but wind up having cesarean sections. Why worry when it won't change anything?"

C. "Can you tell me more about the worrying? What's been happening since you brought your baby home?"

A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information? A. "I can mix the food in the my infant's bottle if he won't eat it." B. "Fluoride supplementation is not necessary until permanent teeth come in." C. "Egg white should not be given to my infant because of the risk for an allergy." D "Meats are really important for iron, and I should start feeding meats to my infant right away."

C. "Egg white should not be given to my infant because of the risk for an allergy."

A client in halo traction says to the nurse, "I can't get used to this contraption. I can't see properly on the side, and I keep misjudging where everything is." Which response by the nurse is therapeutic? A. "No one ever gets used to that thing! It's horrible." B. "If I were you, I'd have had the surgery rather than suffer like this." C. "Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up, before you move." D. "Why do you feel like this when you could have died of a broken neck? This is the way it will be for several months. You need to accept it, don't you think?"

C. "Halo traction involves many difficult adjustments. Practice scanning with your eyes after standing up, before you move."

A client in the mental health unit tells the nurse, "My husband makes all the decisions about money, but I'm the one who's making the money now, not him. He needs to back off, but he's always directing every decision we make." Which nursing response would be the most therapeutic? A. "Have you told your husband to back off"? B. "You're making the most money, so the decisions should be left to you." C. "How do you feel the money decisions could best be handled in your household?" D. "You seem frustrated with your husband's habit of controlling financial decisions."

C. "How do you feel the money decisions could best be handled in your household?"

A nurse provides instructions to a client about the use of an electric heating pad. The nurse determines that the client needs further instruction if the client makes which statement? A. "I shouldn't lie on the pad." B. "I'll avoid using the high setting." C. "I can pin the pad around the affected area." D. "I'll need to keep an eye on my skin for redness."

C. "I can pin the pad around the affected area."

A nurse provides instructions to a client about measures to prevent an acute attack of gout. The nurse determines that the client needs additional instructions if the client states: A. "It's important for me to drink a lot of fluids." B. "A fad diet or starvation diet can cause an acute attack." C. "I don't need medication unless I'm having a severe attack." D. "Physical and emotional stress can cause an attack."

C. "I don't need medication unless I'm having a severe attack."

A nurse provides instructions to a client with rheumatoid arthritis about joint exercises that are important to prevent deformity and reduce pain. Which statement by the client indicates the need for further instruction? A. "I should always maintain good posture." B. "I should stop my exercises if I get tired." C. "I should avoid all exercise when my joints are inflamed." D. "Doing range-of-motion exercises every day will ease the pain."

C. "I should avoid all exercise when my joints are inflamed."

The nurse is evaluating the coping skills of a client with a diagnosis of depression. Which statement indicates to the nurse the need to help the client learn and appropriately use these skills? A. "I need to take my medications." B. "I know that I can't do everything." C. "I won't ever be depressed again." D. "I have learned ways to deal with stress."

C. "I won't ever be depressed again."

A postpartum client says to the nurse, "Sometimes I hear voices telling me to kill my baby to save her all the heartache I've been through." Which statement by the nurse would be most therapeutic? A. "The voices will disappear in a few weeks as your hormones stabilize." B. "This must be very distressing to you. Can you tell me more about the voices?" C. "It is so good that you shared your feelings and thoughts with me. I'm going to help you get immediate attention for your voices." D. "You will want to tell the health care provider about them when you visit him next week. He is very interested in these voices and will want to help you with them."

C. "It is so good that you shared your feelings and thoughts with me. I'm going to help you get immediate attention for your voices."

The client says to a nurse, "Do you know that after 24 years of marriage I still serve my husband breakfast in bed? After all I do for him, he still doesn't treat me well. He should treat me better." Which nursing response is appropriate? A. "You know, you could work and make money serving food to people." B. "I agree. If you can do all that for your husband, he should treat you better." C. "It seems that you feel that your husband could treat you well just as you treat him." D. "Ask your husband to do the things you'd like. If he doesn't, tell him you're leaving him."

C. "It seems that you feel that your husband could treat you well just as you treat him."

A client in skeletal traction says to the nurse, "I can't get any help with my care! I call and call, but the nurses never answer my light. Last night one of them told me she had other patients besides me! I'm very sick, but the nurses don't care!" Which response by the nurse would be therapeutic? A. "You poor thing! I'm so sorry this happened to you. That nurse should be reported!" B. "I think you're being very impatient. The nurses work very hard and come as quickly as they can." C. "It's hard to be in bed and have to ask for help. You call for a nurse who never seems to come?" D. "I can hear your anger. That nurse had no right to speak to you that way. I will report her to the director. It won't happen again."

C. "It's hard to be in bed and have to ask for help. You call for a nurse who never seems to come?"

The young nurse has just completed postmortem care of a 16-year-old client who died of cancer. The nurse says to the nurse manager, "I never get sick, and this client kept telling me that he couldn't remember not being ill. I feel terrible and so bad for him and about what he went through." Which statement by the nurse manager would be therapeutic? A. "Next time, take someone else in with you for postmortem care, OK?" B. "Your feelings are normal and will go away after a good night's sleep." C. "Let's go for coffee and talk about this some more, shall we? We're both due for our coffee breaks." D. "I should never have assigned you someone so close to your own age. I'll be more careful in the future."

C. "Let's go for coffee and talk about this some more, shall we? We're both due for our coffee breaks."

As the nurse prepares to interview a client being admitted to the mental health unit, the client says, "I asked my family to bring me in here to talk to someone, but now I don't know where to begin." Which response by the nurse would be most helpful? A. "Why not just start talking and see where it takes you?" B. "If I were you, I'd begin with what you were doing this morning." C. "Perhaps you can start by sharing some of your most recent concerns." D. "Don't worry. Everyone who comes in here for the first time feels reluctant to talk."

C. "Perhaps you can start by sharing some of your most recent concerns."

A client says to the nurse, "I was cheating on my lover because I need the thrill of seeing someone new, and now my lover has left me to go live with this other woman. I know that this other woman wants more than friendship from my lover, and I can't make my lover see that I love her and that my affairs are meaningless. I don't want to lose her, but I can't stop cheating, because I need the thrill it brings." Which statement by the nurse would be therapeutic? A. "So she's left you for cheating on her. If you can't be monogamous, I guess you'll have to be content with one-night stands." B. "I'm confused. What is it that you've come to me for? It sounds like your lover refuses to share her lover with others, no matter how trivial the dalliances." C. "Perhaps your task is not to make your lover see that your dalliances are meaningless but to look at your own behavior and determine what you would like or not like to be different." D. "It sounds like you want to have your cake and eat it, too. If you can't have both things, which would you prefer — the thrills of one-night stands or the steady support of a loving relationship?"

C. "Perhaps your task is not to make your lover see that your dalliances are meaningless but to look at your own behavior and determine what you would like or not like to be different."

A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding? A. "The care map is developed by a nurse and identifies nursing diagnoses." B. "The care map is a plan that is used only by the nurse to provide client care." C. "The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge." D. "The care map is a standard plan, rather than an individualized one, that is developed strictly by a nurse and used for a client with a particular diagnosis."

C. "The care map outlines the day-to-day expected outcomes of care and the outcomes anticipated at discharge."

The wife of an alcoholic client says to the nurse, "I can't afford to bail my husband out of this mess. Our business is filing for bankruptcy, and the Internal Revenue Service has posted a notice of auction on our home." Which statement by the nurse would be therapeutic? A. "You're having a very difficult time, and the problem stems entirely from your husband's drinking." B. "It's a shame. So many troubling things have been happening to you both because of the disease of alcoholism." C. "The lack of money has stopped you from saving your husband? It sounds like you need to help yourself right now. What do you think?" D. "You're codependent with your husband. Don't you see this? Are you willing to attend some group meetings to learn about ways to deal more effectively with your problem?"

C. "The lack of money has stopped you from saving your husband? It sounds like you need to help yourself right now. What do you think?"

A schizophrenic client exhibits confused and unintelligible speech. Which nursing statement would be most therapeutic? A. "Got it. The 'blinks' are 'taking over' the 'bumpers.'" B. "I can't understand what you're saying. You have to talk more clearly!" C. "This morning you are participating in the tree-decorating ceremony for the unit." D. "I can't understand you. Are you asking me to stay with you while you eat supper?"

C. "This morning you are participating in the tree-decorating ceremony for the unit."

A client in a retirement center rings the night alarm and says to the nurse, "Look at this old man! He keeps breaking into my apartment! You've got to get him to stay out of here so I can sleep." Which statement by the nurse would be most therapeutic? A. "Why not just throw him out yourself and lock up once and for all?" B. "Now, you know that you're always seeing things and people at night who aren't there." C. "This must be very troubling to you, but I can't see the old man. Perhaps I could stay with you for an hour or so while you try to rest." D. "I'm sure you're very frightened right now. Do you recall my telling you that this is called sundowner syndrome? Go to sleep and he'll leave your apartment."

C. "This must be very troubling to you, but I can't see the old man. Perhaps I could stay with you for an hour or so while you try to rest."

A client says to the nurse, "I came in to see you because I've been off my medication for 4 years but I feel as though I may be getting depressed again. I've been despondent again and thinking I should have ended it. That's why I'm here to get help." Which response by the nurse would be therapeutic? A. "Well, you really have had a good long drug-free time, but it sounds as if the health care provider needs to reorder your medication at once." B. "If you've been able to be drug free all this time, you probably don't need to restart the medicine. You probably just need some therapy to help you manage stress." C. "Well, it's been more than 4 years, so you've done really well. Sounds like you're right about getting depressed again, though. Can you tell me what's been happening with you lately?" D. "Well, it's similar to when a client is battered — things have to boil over before the police can act — so you need to be suicidal to get admitted to a hospital or hurt yourself before the health care provider can restart the medication."

C. "Well, it's been more than 4 years, so you've done really well. Sounds like you're right about getting depressed again, though. Can you tell me what's been happening with you lately?"

Disulfiram is prescribed for a client. Which questions does the nurse make a priority of asking the client before administering this medication? Select all that apply. A. "When did you have your last full meal?" B. "Do you have a history of diabetes insipidus?" C. "When was your last drink of alcohol?" D. "Do you have a history of thyroid problems?" E. "Do you have a history of cancer in your family?"

C. "When was your last drink of alcohol?" D. "Do you have a history of thyroid problems?"

A client says to the nurse, "I have to do everything. My family can't plan or organize anything. My wife just wants to go out and socialize. My grown son and his wife live with us. They never do anything around the house but 'their' stuff, because they say they pay rent. We really need their rent money since I lost my job. My wife could work but she says 'it's too late to start over' for her. Well, that's what I'm doing—more work at far less money." Which response by the nurse would be therapeutic? A. "Do the terms 'divorce' and 'leave the nest' mean anything to you or your family?" B. "Would your family come in to see me so I can hear their version of the problems you cite?" C. "You seem to be going through quite a lot recently. I'd like to hear more from you about your concerns. Would your family come in and talk with us?" D. "You tell me that you do everything. You don't say what happens when you stop doing everything. Does your wife understand that you are not able to work as you once did and that you need her help?"

C. "You seem to be going through quite a lot recently. I'd like to hear more from you about your concerns. Would your family come in and talk with us?"

A client says to the nurse, "I've ruined my life. I left college with only a few credits to go. I keep telling myself that I'm going to make it as a writer, but I'll be a loser and a nothing for the rest of my life." Which response by the nurse is therapeutic? A. "What are you saying? Sounds like you need to pull yourself together and go back to school." B. "Having faith in yourself is one thing, but looking at your alternatives realistically is another." C. "You seem to be saying that your choices are final and that you've lost any other opportunities." D. "Sounds like you feel that things should come easy for you, unlike the rest of us, who work for what we get."

C. "You seem to be saying that your choices are final and that you've lost any other opportunities."

A client who has expressed suicidal ideation in the past says to the nurse, while shuffling several documents in an effort to organize them, "Well, I'm feeling so much better now since I got organized. My lawyer wrote my will and durable power of attorney." Which response by the nurse is most appropriate? A. "Good grief! You don't look organized to me." B. "Okay, what are you up to today? Your behavior is not appropriate." C. "You talk about getting organized. Are you thinking of killing yourself?" D. "If you keep behaving like this, you know that I'll have to tell the health care provider, and we'll have to seclude you."

C. "You talk about getting organized. Are you thinking of killing yourself?"

A client in group therapy says to the two nurses conducting the group, "You two are great at psychoanalyzing us, but what about you two? Do you have trouble being assertive with your bosses or the doctors like we do?" Which statement by one of the nurses would be most therapeutic? A. "Maybe some others in this group want to talk about the assignment that we all agreed would be completed today." B. "Why do I feel attacked by someone whom I'm trying to help? Could it be that you don't want to work in this group anymore?" C. "You're interested in talking with us about our assertiveness, but this group is for all of you here to help you to deal with problems more effectively." D. "Your deflection from your own problems here in this group is inappropriate. Let us remind you that you signed up for this group and agreed to participate in it."

C. "You're interested in talking with us about our assertiveness, but this group is for all of you here to help you to deal with problems more effectively."

The wife of a victim of a gas explosion says, "It's not bad enough that I've been left alone to care for two children — now the company is denying our claim for compensation and we have to join a class action suit to get my husband's pension." Which statement by the nurse would be therapeutic? A. "Get a lawyer! That's what you all need to do." B. "Do you believe that a class action suit is the correct thing and that you are in the right?" C. "You're saying that being left a widow with children is difficult enough, but now you've got to fight for your benefits." D. "Walk away. It's too much to even think about at your age, and how can you get caught up in all this with children and work, too?"

C. "You're saying that being left a widow with children is difficult enough, but now you've got to fight for your benefits."

A client who has twice attempted suicide says, "If people would just leave me alone and let me do what I want with my life, I could get on with what I want to do." Which response should the nurse give to the client? A. "Of course you can't be left alone to get on with what you want to do." B. "Okay, go ahead and do whatever you want to do. Human beings have free will." C. "You've tried to end your life twice, yet you feel that everyone should let you do what you want to do?" D. "Sounds like you're angry with people for caring enough about you to try to keep you from hurting yourself."

C. "You've tried to end your life twice, yet you feel that everyone should let you do what you want to do?"

A client's son and daughter were killed during a fellow student's murderous rampage at their high school 9 months ago. The client says to the nurse, "My wife and I just feel empty and exhausted. I can't believe that I had a vasectomy after our son and daughter were born because we wanted to give them both whatever they needed. We have college funds for both of them that they'll never use now." The nurse should make which appropriate statement to the client? A. "My parents would be devastated if they lost me and my sister, too. How can I be of service to you?" B. "Your feelings are appropriate for the extent of your loss and how your children's deaths happened." C. "Your loss touches me so. How truly devastated you both must be. Can you share what things you have been doing to grieve?" D. "Your loss is incalculable. Perhaps you could consider some ways in which to commemorate their lives for you and in your community."

C. "Your loss touches me so. How truly devastated you both must be. Can you share what things you have been doing to grieve?"

A nurse palpates a client's radial pulse, noting the rate, rhythm, and force, and concludes that the client's pulse is normal. Which of the following notations would the nurse make in the client's record to document the force of the client's pulse? A. 4+ B. 3+ C. 2+ D. 1+

C. 2+

A nurse reviewing the medical record of a client with the diagnosis of heart failure notes documentation indicating that the client has deep pitting edema, that the indentation remains for a short time, and that the leg looks swollen. How should the nurse document this finding? A. 1+ edema B. 2+ edema C. 3+ edema D. 4+ edema

C. 3+ edema

A nurse is preparing to administer a soap suds enema to an adult client. After explaining the procedure and positioning the client, the nurse begins the procedure. The nurse inserts the rectal tube into the client's rectum a maximal distance of of how many inches? A. 1½ inches B. 3 inches C. 4 inches D. 6 inches

C. 4 inches

An adult client rings the call bell and asks the nurse for assistance in getting to the bathroom to void. The nurse assists the clientestimating that the client has approximately how many mL inthe bladder if the client is feeling a sensation of fullness? A. 100 mL B. 250 mL C. 400 mL D. 800 mL

C. 400 mL

A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above which value? A. 85% B. 89% C. 95% D. 100%

C. 95%

Which client is at the highest risk for suicide? A. A 24-year-old man who is angry with his family B. A 71-year-old man with mild depression and social withdrawal C. A 75-year-old woman with severe depression and crippling arthritis D. A 30-year-old newly divorced woman who has custody of her children

C. A 75-year-old woman with severe depression and crippling arthritis

A registered nurse (RN) who has a licensed practical nurse (LPN) and a nursing assistant on the nursing team is planning client assignments for the day. Which of the following clients should the RN assign to the LPN? A. A client on bedrest who needs assistance with feeding B. A client who must be turned and repositioned every 2 hours C. A client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments D. A client with retinal detachment who is wearing eye patches and requires assistance with hygiene measures

C. A client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments

A registered nurse (RN) is planning client assignments for the day. Which of the following clients should the RN assign to the nursing assistant? A. A client who requires periodic suctioning B. A client who needs a colostomy irrigation C. A client who needs frequent ambulation with a walker D. A client who has undergone an arteriogram and requires close monitoring

C. A client who needs frequent ambulation with a walker

A registered nurse (RN) is planning client assignments for the day. Which clients should the nurse assign to a nursing assistant (unlicensed assistive personnel)? Select all that apply. A. A client with a permanent tracheostomy B. A client requiring a gastrostomy tube dressing change C. A client who requires transport to the radiology department in a wheelchair D. A client with a Foley catheter for whom a 24-hour urine collection is in progress E. A client who underwent surgery an hour earlier and has a nasogastric tube and a Foley catheter

C. A client who requires transport to the radiology department in a wheelchair D. A client with a Foley catheter for whom a 24-hour urine collection is in progress

A nurse is assigned to care for four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment? A. A client admitted with pneumonia with a fever of 100° F and some diaphoresis B. A client with congestive heart failure with clear lung sounds on the previous shift C. A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema D. A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms

C. A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema

An adolescent client has graduated high school and is preparing to leave home to attend college. The adolescent is distressed about this life change. The nurse plans to implement crisis interventions, knowing that this situation is characteristic of which type of crisis? A. A situational crisis B. An individual crisis C. A maturational crisis D. An adventitious crisis

C. A maturational crisis

A nurse listening to a client's chest to determine the quality of vocal resonance asks the client to repeat the word "ninety-nine" as the nurse listens through the stethoscope. As the client says the word, the nurse is able to hear the word clearly. The nurse documents this assessment finding as: A. Normal egophony B. Abnormal vesicular breath sounds C. Abnormal bronchophony D. Normal whispered pectoriloquy

C. Abnormal bronchophony

A client who has just undergone bronchoscopy was returned to the nursing unit 1 hour ago. With which assessment finding is the nurse mostconcerned? A. Oxygen saturation of 97% B. Equal breath sounds in both lungs C. Absence of cough and gag reflexes D. Respiratory rate of 20 breaths/min

C. Absence of cough and gag reflexes

A nurse enters the laundry room to empty a bag of dirty linen and discovers a fire in a laundry basket. What action should the nurse take first? A. Confining the fire B. Extinguishing the fire C. Activating the fire alarm D. Running for the fire extinguisher

C. Activating the fire alarm

A nurse notes that a client's serum potassium level is 5.8 mEq/L(5.8 mmol/L). The nurse interprets this as an expected finding in the client with: A. Diarrhea B. Wound drainage C. Addison disease D. Heart failure being treated with loop diuretics

C. Addison disease

A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about to take which action? A. Preparing the client for a perfusion scan B. Attaching the client to a cardiac monitor C. Administering oxygen by way of nasal cannula D. Ensuring that the intravenous (IV) line is patent

C. Administering oxygen by way of nasal cannula

A nurse is reviewing the medical records of the clients to whom she is assigned on the 7 am-7 pm shift. Which client will the nurse monitor most closely for excessive fluid volume? A. A 48-year-old client receiving diuretics to treat hypertension B. A 35-year old client who is vomiting undigested food after eating C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr D. A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy

C. An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr

A nurse who works in a medical care unit is told that she must float to the intensive care unit because of a short-staffing problem on that unit. The nurse reports to the unit and is assigned to three clients. The nurse is angry with the assignment because she believes that the assignment is more difficult than the assignment delegated to other nurses on the unit and because the intensive care unit nurses are each assigned only one client. The nurse should most appropriately: A. Refuse to do the assignment B. Tell the nurse manager to call the nursing supervisor C. Ask the nurse manager of the intensive care unit to discuss the assignment D. Return to the medical care unit and discuss the assignment with the nurse manager on that unit

C. Ask the nurse manager of the intensive care unit to discuss the assignment

A nurse is developing a plan of care for a client who reports difficulty sleeping. Which initial intervention does the nurse include in the plan of care? A. Offering the client a sleeping pill at night B. Providing the client with a snack at bedtime C. Asking the client what is done to prepare for sleep D. Leaving the television in the client's room on at a very low volume

C. Asking the client what is done to prepare for sleep

A client with schizophrenia and his parents are meeting with the nurse. One of the young man's parents says to the nurse, "We were stunned when we learned that our son had schizophrenia. He was no different than from his older brother when they were growing up. Now he's had another relapse, and we can't understand why he stopped his medication." Which response by the nurse is appropriate? A. Telling the parents, "Medication noncompliance is the most frequent reason that people with this diagnosis relapse." B. Telling the parents, "Well, it's his decision to take his medicine, but it's yours to have him live with you if he stops the medication." C. Asking the client, "How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?" D. Saying to the parents, "Your concerns are appropriate, but I wonder whether your son was having trouble telling someone that he had concerns about his medication."

C. Asking the client, "How can we help you to take your medicine or to tell us when you're having problems so that your medication can be adjusted?"

A nurse is assisting a health care provider in assessing a hospitalized client. During the assessment, the health care provider is paged to report to the recovery room. The health care provider leaves the client's bedside after giving the nurse a verbal prescription to change the solution and rate of the intravenous (IV) fluid being administered. What is the appropriate nursing action in this situation? A. Calling the nursing supervisor to obtain permission to accept the verbal prescription B. Changing the solution and rate of the IV fluid per the physician's verbal prescription C. Asking the health care provider to write the prescription in the client's record before leaving the nursing unit D. Telling the health care provider that the prescription will not be implemented until it is documented in the client's record

C. Asking the health care provider to write the prescription in the client's record before leaving the nursing unit

A nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The nurse should take which action? A. Asking the client to take slow, deep breaths B. Removing the catheter and contacting the health care provider (HCP) C. Aspirating the fluid, advancing the catheter farther, and reinflating the balloon D. Aspirating the fluid, withdrawing the catheter slightly, and reinflating the balloon

C. Aspirating the fluid, advancing the catheter farther, and reinflating the balloon

A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply). A. Clamp the chest tube B. Chang the drainage system C. Assess the system for an external air leak D. Reduce the degree of suction being applied E. Document assessment findings, actions taken, and client response

C. Assess the system for an external air leak

A nurse is reading the nurse practice act for the state in which she is employed. The nurse uses the information in this act to: A. Identify healthcare policies in her state B. Know how to perform certain procedures C. Be aware of the role of the professional nurse D. Be aware of hospital and long-term care facilities policies

C. Be aware of the role of the professional nurse

The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. What should the nurse tell the mother? A. Hepatitis B is a concern with body piercing B. Infection always occurs when body piercing is done C. Body piercing is generally harmless as long as it is performed under sterile conditions D. It is important to discourage body piercing because of the risk of contracting human immunodeficiency virus (HIV)

C. Body piercing is generally harmless as long as it is performed under sterile conditions

A client is found to have ulcerative colitis, and the nurse provides instructions to the client about the diet that should be followed while the disease is in remission. Which menu selection by the client indicates to the nurse that the client best understands the instructions? A. Milk B. Cabbage C. Boiled potatoes D. Coffee with cream

C. Boiled potatoes

The wife of a client with angina pectoris calls the health care provider's office and reports to the nurse that her husband is experiencing chest pain and has taken 2 sublingual nitroglycerin tablets 5 minutes apart, with no relief. The nurse tells the client's wife to: A. Have her husband rest and, if no relief is obtained, call back B. Discuss the situation with the doctor, who will call her as soon as he gets into the office C. Call Emergency Medical Services to take her husband to the emergency department (ED) immediately D. Give her husband a third tablet and, if no relief is obtained, call an ambulance to have him transported to the ED

C. Call Emergency Medical Services to take her husband to the emergency department (ED) immediately

A community health nurse is providing an educational session on childhood poisoning at a local school. The nurse tells the group that when an accidental poisoning occurs the first action is to: A. Induce vomiting B. Call an ambulance C. Call the poison control center D. Bring the child to the emergency department (ED)

C. Call the poison control center

A nurse manager of an emergency department (ED) arrives at work and is told that four registered nurses scheduled to work will not be reporting to work because they are ill. Every trauma room is busy, and emergency medical services (EMS) has just called to report that several victims involved in a 10-car wreck on the interstate will be brought to the ED. The nurse manager initially manages this situation by: A. Telling EMS to take the victims to another hospital B. Closing the emergency department temporarily to incoming clients C. Calling the nursing supervisor to discuss activation of the disaster plan D. Demanding that the nurses from the night shift stay until all of the victims have been treated

C. Calling the nursing supervisor to discuss activation of the disaster plan

A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client's urine output for the past hour was 25 mL. On the basis of this finding, the nurse should take which action first? A. Call the health care provider B. Increase the rate of the IV infusion C. Check the client's overall intake and output record D. Administer a 250-mL bolus of normal saline solution (0.9%

C. Check the client's overall intake and output record

A nurse is caring for a hospitalized client who is undergoing peritoneal dialysis. The nurse notes that the outflow is less than the inflow on the first exchange. What should the nurse do first? A. Irrigate the catheter B. Reposition the client C. Check the system for kinks D. Hang the second exchange and continue to monitor the outflow

C. Check the system for kinks

A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly assesses the client and notes that the client is diaphoretic, that his blood pressure has increased, and that his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client's bed and immediately: A. Documents the event B. Notifies the healthcare provider C. Checks the client's bladder for distention D. Checks to see whether the client has a prescription for an antihypertensive

C. Checks the client's bladder for distention

A schizophrenic client says, "I'm away for the day ... but don't think we should play or do we have feet of clay?" Which alteration in the client's speech does the nurse document? A. Neologism B. Word salad C. Clang association D. Associative looseness

C. Clang association

A client tells the nurse, "I am a queen. I'm mean, and I gleam." The nurse recognizes this as an example of which speech pattern? A. Echolalia B. Tangential speech C. Clang associations D. Loosened associations

C. Clang associations

A nurse administers scopolamine as prescribed to a client. For which side effect of this medication does the nurse monitor the client? A. Pupil constriction B. Increased urine output C. Complaints of dry mouth D. Complaints of feeling sweaty

C. Complaints of dry mouth

A nurse is monitoring a client who has undergone pleural biopsy. Which finding causes the nurse to suspect that the client is experiencing a complication? A. Warm, dry skin B. Mild pain at the biopsy site C. Complaints of shortness of breath D. Capillary refill time of less than 3 seconds

C. Complaints of shortness of breath

A nurse manager has announced a change to computerized documentation of nursing care. A licensed practical nurse (LPN) on the team, resistant to the change, is not taking an active part in facilitating implementation of the new procedure. Which of the following strategies would be the best approach to dealing with the conflict? A. Ignoring the resistance B. Telling the LPN that his noncompliance will be documented in his personnel record C. Confronting the LPN and encouraging him to express his feelings regarding the change D. Telling the LPN that a registered nurse will perform all of the computer documentation if he will document all intake and output and vital signs

C. Confronting the LPN and encouraging him to express his feelings regarding the change

A nurse manager tells the nursing staff that they will need to comply with the mandatory overtime policy that the hospital has implemented. Later that day, the nurse manager overhears a nurse complaining about the policy and telling other nurses that she will not work the overtime if she has made other plans after her regular shift. What is the best approach for the nurse manager to use in dealing with the conflict? A. Ignoring the complaints B. Avoiding assigning the nurse mandatory overtime C. Confronting the nurse regarding her behavior regarding the overtime policy D. Providing a positive reward system for the nurse so that the nurse will agree to work the mandatory overtime

C. Confronting the nurse regarding her behavior regarding the overtime policy

A nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client's blood pressure has dropped from 132/84 to 90/50 mm Hg and that the pulse has increased from 78 to 96 beats/min. On the basis of these findings, the nurse immediately: A. Suctions the client B. Obtains a pulse oximeter C. Contacts the health care provider D. Increases the rate of the client's intravenous (IV) solution

C. Contacts the health care provider

A nurse is preparing to perform a digital removal of feces on a client with an impaction. The nurse checks the client's heart rate before performing the procedure and counts 88 beats per minute. The nurse begins to loosen the fecal mass and then stops the procedure to allow the client to rest. During this time the nurse checks the client's heart rate again and counts 82 beats per minute. The nurse should take which action? A. Contact the health care provider B. Discontinue the digital removal procedure C. Continue the digital removal procedure D. Wait 1 hour and then continue the digital removal procedure

C. Continue the digital removal procedure

The nurse is preparing a discharge plan for a client who has attempted suicide. The nurse understands that the plan of care should have which focus? A. Follow-up appointments B. Providing the hospital phone number C. Contracts and immediate available crisis resources D. Encouraging the family to always be with the client

C. Contracts and immediate available crisis resources

A nurse is examining a 25-year-old client who was seen in the clinic 2 weeks ago for symptoms of a cold and is now complaining of chest congestion and cough. The nurse should proceed with the examination by collecting which? A. Data related to follow-up care B. A complete (total health) database C. Data related to the respiratory system D. Data related to the treatment for the cold

C. Data related to the respiratory system

A nurse is preparing to initiate a continuous tube feeding, using a tube-feeding pump. On bringing the pump to the bedside and preparing to plug the pump in, the nurse discovers that there is no available plug in the wall socket. What should the nurse do? A. Plug in the pump cord into an available plug above the sink B. Ask the physician to change the prescription to intermittent feedings C. Determine the need for the appliances now plugged into the needed wall socket D. Use a regular extension cord to allow the use of more than one electrical appliance

C. Determine the need for the appliances now plugged into the needed wall socket

A nurse is reviewing the medical record of an older client with presbycusis. Which finding should the nurse expect to note in the client's record? A. Unilateral conductive hearing loss B. Difficulty hearing low-pitched tones C. Difficulty hearing whispered words in the voice test D. Improved hearing ability during conversational speech

C. Difficulty hearing whispered words in the voice test

A client who needs to receive a blood transfusion has experienced a pruritic rash during previous transfusions. The client asks the nurse whether it is safe to receive the transfusion. Which medication does the nurse anticipate will most likely be prescribed before the transfusion? A. Ibuprofen B. Acetaminophen C. Diphenhydramine D. Acetylsalicylic acid

C. Diphenhydramine

A client has undergone pericardiocentesis to treat cardiac tamponade. For which signs should the nurse assess the client to determine whether the tamponade is recurring? A. Decreasing pulse B. Rising blood pressure C. Distant muffled heart sounds D. Falling central venous pressure (CVP)

C. Distant muffled heart sounds

Polyethylene glycol-electrolyte solution is prescribed for a hospitalized client scheduled for colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate? A. Administering a cleansing enema. B. Calling the health care provider C. Documenting the diarrhea in the medical record D. Giving intravenous replacement fluids in large amounts

C. Documenting the diarrhea in the medical record

A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR? A. Fetoscope B. Stethoscope C. Doppler transducer D. Pulse oximetry on the client and a fetoscope

C. Doppler transducer

A pelvic ultrasound is prescribed to evaluate a client's ovarian mass. What should the nurse giving preprocedure instructions tell the client that it important to do before the procedure? A. Eat only a light breakfast B. Wear comfortable clothing and shoes C. Drink 6 to 8 glasses of water without voiding D. Stop eating or drinking at midnight before the test

C. Drink 6 to 8 glasses of water without voiding

A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. Which menu selection, cited by the client as a good source of potassium, indicates to the nurse that the client needs further instruction? A. Pork B. Beef C. Eggs D. Raisins

C. Eggs

A nurse is developing a plan of care for an older client that will help maintain an adequate sleep pattern. Which action should the nurse include in the plan? A. Encouraging at least one daytime nap B. Discouraging the use of a night light at bedtime C. Encouraging bedtime reading or listening to music D. Discouraging social interaction, particularly at bedtime

C. Encouraging bedtime reading or listening to music

A nurse develops a plan of care for a postoperative client who is receiving intravenous morphine sulfate every 4 hours as needed for pain. Whichpriority intervention does the nurse include in the plan? A. Encouraging oral fluid intake B. Maintaining the client in a supine position C. Encouraging coughing and deep breathing D. Administering the morphine sulfate around the clock

C. Encouraging coughing and deep breathing

The mother of a 5-year-old asks the nurse how often her child should undergo a dental examination. When should the nurse tell the mother the child should have dental examinations? A. Once a year B. Every 3 months C. Every 6 months D. Whenever a new primary tooth erupts

C. Every 6 months

A schizophrenic client in the psychiatric inpatient unit is yelling, "The CIA is trying to kill me. I know they're plotting to kill me so they can overthrow the government." Based on the client's statement, which clinical manifestation should the nurse document in the client record? A. Demonstrates paranoia B. Exhibits ideas of reference C. Evidence of persecutory delusions D Evidence of ideas of somatic delusions

C. Evidence of persecutory delusions

A nurse educator is providing an inservice program to emergency department nurses about the signs of inhalation anthrax. The nurse educator tells the nurses that one early indication of inhalation anthrax is: A. Hemorrhage B. Signs of shock C. Flulike symptoms D. Respiratory distress

C. Flulike symptoms

A physician writes a prescription for the application of a heating pad to a client's back. Which of the following actions should the nurse take when implementing this prescription? Select all that apply. A. Placing the heating pad under the client B. Adjusting the heating pad to the high setting C. Frequently assessing the client's skin for signs of burns D. Assessing the client's medical history and risk factors for burns E. Assessing the heating pad periodically for proper electrical function

C. Frequently assessing the client's skin for signs of burns D. Assessing the client's medical history and risk factors for burns E. Assessing the heating pad periodically for proper electrical function

A nurse is caring for an older adult client. When planning care, which occurrence does the nurse recognize as part of the normal aging process? A. Tubular reabsorption increases. B. Urine-concentrating ability increases. C. Glomerular filtration rate (GFR) is diminished. D. Medications are metabolized in larger amounts.

C. Glomerular filtration rate (GFR) is diminished.

A registered nurse (RN) is watching as a new licensed practical nurse (LPN) suctions a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). Which of the following protective devices worn by the LPN would cause the RN to determine that the LPN was performing the procedure safely? A. Gloves and mask B. Gloves and gown C. Gloves, gown, and face shield. D. Gown and protective eyewear

C. Gloves, gown, and face shield.

The nurse is preparing a care plan for a client with obsessive-compulsive disorder (OCD). Which should be the nurse's primary focus? A. Group therapy B. Recreational therapy C. Goals and objectives D. The client's medical diagnosis

C. Goals and objectives

A nurse answers a call bell and finds that the total parenteral nutrition (TPN) solution bag of an assigned client is empty. The new prescription was written for a new bag at the beginning of the shift, but it has not yet arrived from the pharmacy. Which action should the nurse take first? A. Call the health care provider B. Call the pharmacy for further instructions C. Hang a solution of 10% dextrose in water D. Hang a solution of 5% dextrose in 0.9% sodium chloride

C. Hang a solution of 10% dextrose in water

A woman receives a subarachnoid (spinal) block for a cesarean delivery. For which adverse effect of the block does the postpartum nurse monitor the woman? A. Pruritus B. Vomiting C. Headache D. Hypertension

C. Headache

A nurse has a prescription to discontinue a client's nasogastric tube. The nurse auscultates the client's bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath and do what? A. Exhale during tube removal B. Bear down during tube removal C. Hold the breath during tube removal D. Breathe normally during tube removal

C. Hold the breath during tube removal

A nurse performing a musculoskeletal assessment of a client with suspected carpal tunnel syndrome plans to perform the Phalen test. The nurse should ask the client to: A. Dorsiflex the foot B. Plantarflex the foot C. Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds D. Hyperextend the fingers with the palmar surfaces of the hands touching, holding the position for 60 seconds

C. Hold the hands back to back while flexing the wrists 90 degrees for 60 seconds

A client who is mouth breathing is receiving oxygen by face mask. The unlicensed assistive personnel (UAP) asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to promote which goal? A. Prevent the client from getting a nosebleed B. Give the client added fluid by way of the respiratory tree C. Humidify the oxygen that is bypassing the client's nose D. Prevent fluid loss from the lungs during mouth breathing

C. Humidify the oxygen that is bypassing the client's nose

While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which of the following findings does the nurse expect to note when auscultating the client's bowel sounds? A. Hypoactive bowel sounds B. Low-pitched bowel sounds C. Hyperactive bowel sounds D. An absence of bowel sounds

C. Hyperactive bowel sounds

A nurse is assessing a client for the major risk factors associated with coronary artery disease (CAD). Which modifiable risk factor does the nurse obtain data on from the client? A. Age B. Ethnicity C. Hypertension D. Genetic inheritance

C. Hypertension

The psychiatric nurse is caring for a 15-year-old girl who has been hospitalized for bipolar disorder. The client tells the nurse that she had her hair styled just like her young math teacher, whom she admires. Which defense mechanism should the nurse recognize that the client is using? A. Projection B. Regression C. Identification D. Intellectualization

C. Identification

A moderately depressed client who was admitted to the mental health unit 2 days ago suddenly begins smiling and reports that the crisis is over. The client says to the nurse, "I'm finally cured." The nurse interprets this behavior as a cue to modify the treatment plan by: A. Suggesting a reduction of medication B. Allowing increased in-room activities C. Increasing the level of suicide precautions D. Allowing the client off-unit privileges as necessary

C. Increasing the level of suicide precautions

A nurse is assessing a child with increased intracranial pressure who has been exhibiting decorticate posturing. The nurse notes extension of the upper and lower extremities, with internal rotation of the upper arms and wrists and the knees and feet. The nurse determines that the child's condition: A. Indicates improved neurological status B. Indicates decreased intracranial pressure C. Indicates deterioration in neurological function D. Is unchanged from the previous neurological assessment

C. Indicates deterioration in neurological function

The nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client's lung has reexpanded and notifies the health care provider. The health care provider verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to asks that the chest tube be removed. Which action should the nurse take first? A. Call the nursing supervisor B. Explain the procedure to the client, then remove the chest tube C. Inform the health care provider that removal of a chest tube is not a nursing procedure D. Obtain petrolatum-impregnated gauze and ask another nurse to assist in removing the chest tube

C. Inform the health care provider that removal of a chest tube is not a nursing procedure

A client is found to have AIDS. What is the nurse's highest priority in providing care to this client? A. Providing emotional support to the client B. Discussing the cause of AIDS with the client C. Instituting measures to prevent infection in the client D. Identifying risk factors related to contracting AIDS with the client

C. Instituting measures to prevent infection in the client

A nurse has taught a client who is taking lithium carbonate about the medication. The nurse determines that the client needs additional teaching if the client makes which comment to the nurse? A. The medication should be taken with meals B. The lithium blood levels must be monitored very closely C. It is important to decrease fluid intake while taking the medication to avoid nausea D. The health care provider must be called if excessive diarrhea, vomiting, or diaphoresis occurs

C. It is important to decrease fluid intake while taking the medication to avoid nausea

A nurse is determining the estimated date of delivery for a pregnant client, using Nägele's rule, and notes documentation that the date of the client's last menstrual period was August 30, 2015. When does the nurse determine the estimated date of delivery to be? A. July 6, 2016 B. May 6, 2016 C. June 6, 2016 D. May 30, 2016

C. June 6, 2016

A nurse is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which coexisting problem is cause for the nurse to suspect that the oxygen saturation readings are not entirely accurate? A. Infection B. Hypertension C. Low blood pressure D. Loss of cough reflex

C. Low blood pressure

Acccording to the Federal Emergency Management Agency (FEMA) description of the phases of disaster management, in which phase are the available resources for the care of infants, older clients, the disabled, and people with chronic health problems addressed? A. Response B. Recovery C. Mitigation D. Preparedness

C. Mitigation

A nurse is monitoring the amount of lochia drainage on a perineal pad in a woman who is 1 hour postpartum and notes a 5-inch bloodstain (see figure). How does the nurse report the amount of lochial flow? A. Scant B. Light C. Moderate D. Heavy

C. Moderate

A nurse is planning dietary measures for an older client who is experiencing dysphagia. Which action should the nurse include in the plan of care? A. Encouraging the client to feed herself B. Ensuring that most of the diet consists of liquids C. Monitoring the client during meals to ensure that food is swallowed D. Consulting with the health care provider regarding feeding through an enteral tube

C. Monitoring the client during meals to ensure that food is swallowed

A client asks a nurse about complementary and alternative measures to promote sleep. What should the nurse suggest? A. Herbal therapy B. Acupuncture C. Muscle relaxation techniques D. Traditional Chinese medicine

C. Muscle relaxation techniques

A heroin addict who overdoses on the drug is brought into the emergency department. The client is having seizures, and the nurse notes that his pupils are dilated. Which intervention does the nurse anticipate that the emergency department health care provider will prescribe? A. Gastric lavage B. Intravenous fluid C. Naloxone (Narcan) D. Ammonium chloride

C. Naloxone (Narcan)

A nurse is monitoring a client who is receiving total parenteral nutrition (TPN). Which t signs and symptoms causes the nurse to suspect that the client is experiencing hyperglycemia as a complication? A. Pallor, weak pulse, and anuria B. Nausea, vomiting, and oliguria C. Nausea, thirst, and increased urine output D. Sweating, chills, and decreased urine output

C. Nausea, thirst, and increased urine output

A nurse is performing an abdominal assessment on a client. On auscultation of the abdomen the nurse hears a bruit over the abdominal aorta. Which action should the nurse take as a priority on the basis of this finding? A. Document the finding B. Palpate the area for a mass C. Notify the healthcare provider D. Percuss the abdomen to check for tympany

C. Notify the healthcare provider

A prescription is written to administer hepatitis B vaccine (Recombivax HB) to a newborn infant. Before administering the vaccine, which action should the nurse take? A. Check the infant for jaundice B. Check the infant's temperature C. Obtain parental consent to administer the vaccine D. Request that a hepatitis blood screen be performed on the infant

C. Obtain parental consent to administer the vaccine

Erythromycin is prescribed for a client with a respiratory tract infection. The nurse provides instructions to the client regarding the administration of the oral medication and tells the client that it is best to take the medication in which way? A. With juice B. With a meal C. On an empty stomach D. At bedtime, with a snack

C. On an empty stomach

A nurse is preparing to perform a Rinne test on a client who complains of hearing loss. In which area does the nurse first place an activated tuning fork? A. On the client's teeth B. On the client's forehead C. On the client's mastoid bone D. On the midline of the client's skull

C. On the client's mastoid bone

A nurse teaches a client about healthy dietary measures and explains the MyPlate food plan. The nurse determines that the client understands the information if the client says how many of his grains should be whole grains? A. One-quarter B. One-third C. One-half D. Two-thirds

C. One-half

A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula? A. Irrigate the fistula with 3 mL of normal saline solution B. Infuse 50 mL of normal saline once per 24 hours C. Palpate for a vibrating sensation at the fistula site D. Flush the fistula with 1 mL of heparin solution once per shift

C. Palpate for a vibrating sensation at the fistula site

An emergency department nurse is performing an assessment of a client who has sustained circumferential burns of both legs. What should the nurse assess first? A. Heart rate B. Radial pulse rate C. Peripheral pulses D. Blood pressure (BP)

C. Peripheral pulses

The nurse is admitting a client with a diagnosis of anorexia nervosa to the mental health unit. Which characteristic is a hallmark of this disorder? A. Social contacts are important. B. The client is not concerned about food and meal planning. C. Personal relationships tend to become more superficial and distant. D. The client with anorexia will usually keep his or her weight near normal weight.

C. Personal relationships tend to become more superficial and distant.

A nurse in the labor room is performing a vaginal assessment of a pregnant client who is in active labor. The nurse notes that the umbilical cord is protruding from the vagina and immediately: A. Pushes the cord gently back into the vagina B. Prepares the client for cesarean delivery C. Places the client in the knee-chest position D. Prepares to administer a tocolytic medication

C. Places the client in the knee-chest position

A nurse has been assigned to care for an infant with tetralogy of Fallot. The infant suddenly exhibits rapid, deep respirations; irritability; and cyanosis. The nurse determines that the infant is experiencing a hypercyanotic episode and immediately: A. Calls a code B. Holds the infant in an upright position C. Places the infant in the knee-chest position D. Contacts the respiratory therapy department

C. Places the infant in the knee-chest position

A nurse caring for a client who is under airborne precautions notes that the client is scheduled for a nuclear scan. Which action on the part of the nurse is appropriate? A. Planning to have the nuclear scan performed at the bedside B. Asking the technicians in the nuclear scan department to wear masks C. Placing a surgical mask on the client for transport and for contact with other individuals D. Calling the nuclear medicine department and telling the technician that the test will have to be delayed until airborne precautions have been discontinued

C. Placing a surgical mask on the client for transport and for contact with other individuals

A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. Which action should the nurse take immediately? A. Notify the nurse-midwife or health care provider B. Perform a vaginal examination on the mother C. Position the mother so that her hips are elevated D. Insert a gloved finger into the mother's vagina to feel for cord compression

C. Position the mother so that her hips are elevated

A male client reports difficulty concentrating, outbursts of anger, and a feeling of being keyed up all the time and states that peer relations are poor. He then tells the nurse that the symptoms started after his best friend was killed in the terrorist attack at the World Trade Center. The nurse suspects that the client is experiencing which disorder? A. Social phobia B. Panic disorder C. Post-traumatic stress disorder D. Obsessive-compulsive disorder

C. Post-traumatic stress disorder

The nurse working in a mental health unit reads a client's medical record and notes documentation that the client has been experiencing flashbacks. The nurse interprets this as a classic sign of which disorder? A. Depression B. Schizophrenia C. Post-traumatic stress disorder D. Obsessive-compulsive disorder

C. Post-traumatic stress disorder

A client recovering from acute kidney injury (AKI) is being discharged home. The nurse determines that the client understands the therapeutic dietary regimen when the client states that he will plan to eat foods that are low in which substance? A. Fats B. Vitamins C. Potassium D. Carbohydrates

C. Potassium

The mental health nurse is conducting the initial assessment of an obese client. The client confides that she was sexually molested at age 7 and began putting on weight thereafter. The nurse determines that the client's symptoms are compatible with a somatization disorder and recalls that obesity for this client most likely represents which? A. Satisfaction with self B. A form of functional coping C. Protection from the risk of intimacy D. Long-term lack of compliance with weight programs

C. Protection from the risk of intimacy

A nurse is developing a plan of care for a client with a new diagnosis of Graves disease. Which intervention does the nurse include in the plan? A. Keeping the room warm B. Placing extra blankets on the client C. Providing a high-calorie, high-protein diet D. Encouraging frequent ambulation and activities

C. Providing a high-calorie, high-protein diet

A nurse is developing a plan of care for an older client who is being admitted to a long-term care facility. Which intervention should the nurse include in the plan of care to help maintain an appropriate bowel elimination pattern? A. Limiting vegetable intake to one serving per day B. Limiting whole grains to three servings per week C. Providing cooked fruits such as prunes or apricots D. Including spicy foods in the diet to increase peristalsis

C. Providing cooked fruits such as prunes or apricots

A home health nurse is performing an assessment of a client's skin. The nurse, noting multiple threadlike lines, both straight and wavy, beneath the skin, recognizes the presence of scabies. Which of the following precautions should the nurse institute before completing the assessment of the client? A. Putting on a pair of gloves B. Donning a mask and gloves C. Putting on a gown and gloves D. Avoiding sitting on the client's furniture

C. Putting on a gown and gloves

A nurse is admitting a postoperative client from the postanesthesia care unit to the surgical nursing unit. Which of the following measures should the nurse take for the safety of the client? A. Asking the client to slide from the stretcher to the bed B. Quickly moving the client from the stretcher to the bed C. Putting the siderails up after moving the client from the stretcher D. Uncovering the client before making the transfer from the stretcher to the bed

C. Putting the siderails up after moving the client from the stretcher

A client with obsessive-compulsive disorder who continually cleans her room with paper towels becomes enraged with her roommate for throwing the package of paper towels into the waste basket, begins to yell, and slaps the roommate. Which action would the nurse take first? A. Restraining the client B. Filling out an incident report C. Removing both clients to safe locations D. Calling the hospital's risk-management department

C. Removing both clients to safe locations

A client is admitted to the psychiatric inpatient unit and suicide precautions are instituted. Which intervention should the nurse implement? A. Restricting visitors B. Placing the client in a private room and locking the bathroom door C. Removing perfume, shampoo, and other toiletries from the client's room D. Placing flowers brought to the client in a small glass vase and putting them in the client's room

C. Removing perfume, shampoo, and other toiletries from the client's room

The nurse is caring for a client who has been identified as a victim of physical abuse. Which action is the priority as the nurse plans care for the client? A. Notifying the caseworker of the situation B. Adhering to mandatory abuse reporting laws C. Removing the client from any immediate danger D. Obtaining treatment for the abusing family member

C. Removing the client from any immediate danger

A client with histoplasmosis has the following arterial blood gas (ABG) results: pH 7.30, PaCO2 58 mm Hg (7.72 kPa), PaO2 75 mm Hg (9.93 kPa), HCO3 26 mEq/L (26 mmol/L). Which acid-base disturbance does the nurse recognize in these results? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis

A nurse reviews the blood gas results of a client in respiratory distress. The pH is 7.32 and the PaCO2 is 50 mm Hg (6.65 kPa). Which acid-base imbalance does the nurse recognize in these findings? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis

A client with a urinary tract infection has been started on nitrofurantoin, a urinary antiseptic medication, and is taught about the foods that will maintain the urinary pH in the acid range. Which food does the nurse tell the client to eliminate from the diet while taking this medication? A. Prunes B. Oranges C. Rhubarb D. Cranberries

C. Rhubarb

A client who has sustained multiple fractures of the left leg is in skeletal traction. The nurse has obtained an overhead trapeze to improve the client's bed mobility. To which high-risk area must the nurse pay particular attention during assessment for indications of pressure and skin breakdown? A. Left heel B. Scapulae C. Right heel D. Back of the head

C. Right heel

A nurse has provided dietary instructions to a client with a new diagnosis of gout. Which menu suggestions by the client indicate to the nurse that the client needs additional instruction? Select all that apply. A. Carrots B. Tapioca C. Scallops D. Broccoli E. Chicken liver

C. Scallops E. Chicken liver

A woman is brought to the emergency department after an assault. She presents with complaints of dizziness, dyspnea, visual disturbance, and motor tension with hyperactivity. Which level of anxiety does the nurse recognize in the client's presentation? A. Mild B. Panic C. Severe D. Moderate

C. Severe

A nurse is assessing a newborn for fetal alcohol syndrome (FAS). Which finding would the nurse expect to note in the newborn? A. Greater-than-average length B. Higher-than-normal birth weight C. Short palpebral fissures and a flat midface D. Greater-than-average head circumference

C. Short palpebral fissures and a flat midface

A nurse is preparing to assess the function of a client's spinal accessory nerve. Which of the following actions does the nurse ask the client to take to aid assessment of this nerve? A. Smiling B. Clenching the teeth C. Shrugging the shoulders against the nurse's resistance D. Identifying by taste a substance placed on the back of the tongue

C. Shrugging the shoulders against the nurse's resistance

A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One hour later the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining. Which action should the nurse take first? A. Remove the IV B. Sit the client up in bed C. Shut off the IV infusion D. Slow the rate of infusion

C. Shut off the IV infusion

A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. A. Slow pulse B. Decreased urine output C. Skeletal muscle weakness D. Hyperactive bowel sounds E. Hyperactive deep tendon reflexes

C. Skeletal muscle weakness D. Hyperactive bowel sounds

A staff nurse caring for a client with a head injury notes that the client is restless and pulling at the intravenous (IV) line. The client's physician does not want to prescribe sedation, and the family has requested that the client not be restrained. Which action by the nurse is appropriate? A. Asking a family member to sit with the client B. Asking a nursing assistant to monitor the client C. Staying with the client and consulting with the nurse manager about the situation D. Telling the family that the application of wrist restraints is critical in preventing injury to the client

C. Staying with the client and consulting with the nurse manager about the situation

A sexually active married couple, discussing birth control methods with the nurse, express the need for a method that is convenient. Because the couple has told the nurse that family-planning goals have been met, which method of birth control does the nurse suggest? A. Diaphragm B. Spermicide C. Sterilization D. Male condom

C. Sterilization

A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs and symptoms of respiratory alkalosis does the nurse assess this client? A. Disorientation and dyspnea B. Drowsiness, headache, and tachypnea C. Tachypnea, dizziness, and paresthesias D. Dysrhythmias and decreased respiratory rate and depth

C. Tachypnea, dizziness, and paresthesias

A young adult client who is dying says to the nurse, "I keep asking my wife what I can do for her and our daughter before I die, but she refuses to tell me." Based on the client's statement, what is the appropriate nursing intervention? A. Teaching the client's wife to write down her thoughts and feelings and to read them to her husband B. Saying to the client, "It sounds to me like your wife is truly comfortable and doesn't want you to worry needlessly" C. Talking with both the client and his wife about the importance of expressing their feelings and how to do it in healthy ways D. Talking with all family members, including the daughter, about the importance of expressing their concerns and feelings to the dying client

C. Talking with both the client and his wife about the importance of expressing their feelings and how to do it in healthy ways

A nurse, charting the administration of medications to an assigned client at 9 pm, notes that atenolol (Tenormin) was prescribed to be administered at 9 am instead of 9 pm. The nurse checks the client's vital signs, completes an incident report, and calls the physician to report the error. The physician tells the nurse that an incident report is not needed but instructs her to monitor the client during the night for hypotension. What action should the nurse take? A. Notifying the nursing supervisor B. Tearing up and discarding the incident report C. Telling the physician that the error warrants the completion of an incident report D. Telling the nursing supervisor that the physician did not want an incident report completed and filed

C. Telling the physician that the error warrants the completion of an incident report

A nurse is assisting with disaster relief after a tornado. The nurse's goal with the overall community is to prevent as much injury and death resulting from the uncontrollable event as possible. Finding safe housing for survivors, providing support to families, organizing counseling sessions, and securing physical care when needed are all examples of which level of prevention? A. Initial B. Primary C. Tertiary D. Secondary

C. Tertiary

A nurse is providing information to a mother of a 1-year-old who has asked about bladder-training her child. The nurse should provide which information to the mother? A. That she may start bladder training at any time B. That her child is too young and that she should not yet be worrying about it C. That a child cannot begin to control urination until approximately the age of 24 months D. That bowel training should be started immediately and then begin bladder training in about 1 month

C. That a child cannot begin to control urination until approximately the age of 24 months

A client taking metronidazole for the treatment of trichomoniasis vaginalis calls the clinic nurse to express concern because her urine has turned dark in color. The nurse should provide which information to the client? A. To increase her fluid intake B. To discontinue the medication C. That darkening of the urine is a harmless side effect D. To report to the clinic to see the health care provider

C. That darkening of the urine is a harmless side effect

A mother of twin toddlers tells the nurse that she is concerned because she found her children involved in sex play and didn't know what to do. What should the nurse tell the mother? A. To separate her children during playtime B. That if the behavior continues, she will need to bring her children to a child psychologist C. That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity D. To tell her children that what they are doing is bad and that they will be punished if they are caught doing it again

C. That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity

During a client's yearly eye examination, the nurse checks the intraocular pressure. The nurse notes that the pressure in the right eye is 12 mm Hg and 19 mm Hg in the left. The nurse tells the client: A. That he has glaucoma in the left eye B. That he has glaucoma in the right eye C. That the intraocular pressure in both eyes is normal D. That he needs to increase his fluid intake, because the pressure in the right eye is low

C. That the intraocular pressure in both eyes is normal

A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig's disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-not-resuscitate (DNR) order. The nurse should tell the client that: A. Consent must be obtained from the family B. The health care provider makes the final decision about a DNR request C. The DNR request should be discussed with the physician, who will write the order D. Oral consent is sufficient and that his request will be honored by all healthcare providers

C. The DNR request should be discussed with the physician, who will write the order

A nurse provides instruction to a new nursing assistant regarding the application of a restraint to a client. The nurse watches as the nursing assistant applies the restraint. What observation tells the nurse that the nursing assistant is using correct procedure? A. The assistant applies a tie knot in the restraint strap. B. The assistant attaches the restraint straps securely to the siderails. C. The assistant applies the restraint so that the strap does not tighten when force is applied against it. D. The assistant secures the restraint in such a way that it is impossible to slip a finger between the restraint and the client's skin.

C. The assistant applies the restraint so that the strap does not tighten when force is applied against it.

A nurse is reading the chest x-ray report of a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. The nurse interprets that the tube is positioned above which anatomical area? A. The first tracheal cartilaginous ring B. The point where the larynx connects to the trachea C. The bifurcation of the right and left main stem bronchi D. The area connecting the oropharynx to the laryngopharynx

C. The bifurcation of the right and left main stem bronchi

An adult client undergoes various diagnostic tests to determine the pumping ability of the heart. The nurse notes that the results of these tests indicate that the client's cardiac output is 5 L/min. The nurse concludes that: A. The client has a low cardiac output B. The client has a high cardiac output C. The client has a normal cardiac output D. The client will need a blood transfusion

C. The client has a normal cardiac output

The nurse employed in an emergency department is assisting in caring for an adult client who is a victim of family violence. Which priority instruction does the nurse include in the discharge plan? A. Calling the police B. Self-defense classes C. The locations of shelters D. The importance of leaving the violent situation

C. The locations of shelters

A nurse is caring for an older client who has a bronchopulmonary infection. Why should the nurse monitor the client's ability to maintain a patent airway? A. The normal aging process increases the production of surfactant B. The normal aging process increases respiratory system compliance C. The normal aging process decreases an older client's ability to clear secretions D. The normal aging process decreases the number of alveoli and increases the function of those remaining

C. The normal aging process decreases an older client's ability to clear secretions

Which action by the nurse represents the ethical principle of beneficence? A. The nurse upholds a client's decision to refuse chemotherapy for lung cancer. B. The nurse follows a plan of care designed to relieve pain in a client with cancer. C. The nurse administers an immunization to a child even though it may cause discomfort. D. The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity.

C. The nurse administers an immunization to a child even though it may cause discomfort.

A nurse reviews a client's urinalysis report. Which finding does the nurse recognize as abnormal? A. pH of 6.0 B. An absence of protein C. The presence of ketones D. Specific gravity of 1.018

C. The presence of ketones

A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should provide which information to the client about the test? A. HIV infection has been confirmed B. The client probably has an opportunistic infection C. The test will need to be confirmed with the use of a Western blot D. A positive test is a normal result and does not mean that the client is infected with HIV

C. The test will need to be confirmed with the use of a Western blot

A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. What should the nurse tell the client? A. The test results are normal B. She has developed immunity to the rubella virus C. The test will need to be repeated during the pregnancy D. She must have been exposed to the rubella virus at some point in her life

C. The test will need to be repeated during the pregnancy

A nurse in the pediatrician's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which finding is noted? A. The infant turns to the side that is touched. B. The fingers curl tightly and the toes curl forward. C. The toes flare and the big toe is dorsiflexed. D. There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side.

C. The toes flare and the big toe is dorsiflexed.

An older adult client tells the nurse that she is tired during the day because she awakens frequently during the night. Which information should the nurse provide to the client? A. She should avoid napping during the day B. The only thing that will help is a sleeping pill C. This is a normal occurrence as a person gets older D. She needs to stay up later at night to prevent these awakenings

C. This is a normal occurrence as a person gets older

Contact precautions are initiated for a client with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse, providing instructions to a nursing assistant about caring for the client, tells the assistant: A. To transfer the client to a semiprivate room B. That gloves only are needed to care for the client C. To wear gloves and a gown when changing the client's bed linen. D. To wear a gown when caring for the client and remove the gown immediately after leaving the client's room

C. To wear gloves and a gown when changing the client's bed linen.

During a neurological assessment, the nurse asks the client to close the jaws tightly, after which the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of the: A. Trochlear nerve B. Abducens nerve C. Trigeminal nerve D. Oculomotor nerve

C. Trigeminal nerve

A nurse is teaching a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the deficit. The nurse tells the client to: A. Wear eyeglasses 24 hours a day B. Wear a patch on the affected eye C. Turn the head to scan the lost visual field D. Keep all objects in the impaired field of vision

C. Turn the head to scan the lost visual field

A nurse is caring for a client who has just returned from a cardiac catheterization through the right side of the groin. The client tells the nurse that he feels the urge to urinate. The nurse assists the client in using a urinal, but the client is unable to void. Which action should the nurse take to stimulate the client's micturition reflex? A. Helping the client stand B. Elevating the head of the bed 90 degrees C. Turning on the water in the sink in the client's room and allowing it to run D. Obtaining assistance to ambulate the client to the bathroom in the client's room

C. Turning on the water in the sink in the client's room and allowing it to run

A nurse is supervising a new nursing graduate in various procedures. Which of the following actions by the new nursing graduate constitutes a negligent act? A. Giving a verbal report to the nurse on the oncoming shift B. Checking neurological signs in a client with a head injury C. Using clean gloves to change a gastrostomy tube dressing D. Contacting a health care provider about a change in a client's blood pressure

C. Using clean gloves to change a gastrostomy tube dressing

A nurse in a health care provider's office has just made an appointment for a client to undergo an exercise stress test. The nurse, in providing pre-procedure teaching, should provide which information to the client? A. Wear sweatpants and a heavy sweatshirt B. Eat a small meal just before the procedure C. Wear comfortable rubber-soled shoes such as sneakers D. Avoid consuming caffeine for 30 minutes before the procedure

C. Wear comfortable rubber-soled shoes such as sneakers

A nurse is preparing a chemotherapy infusion to be administered to a client with a diagnosis of Hodgkin's disease. Which precaution should the nurse take while working with this intravenous (IV) infusion? A. Wearing gloves and a mask B. Wearing gloves and a gown C. Wearing gloves, a mask, and eye protection D. Wearing gloves, a mask, and a head covering

C. Wearing gloves, a mask, and eye protection

The psychiatrist notes that a client being admitted to the inpatient mental health unit uses avoidance and denial to cope with stress. Which positive stress response will the nurse plan to focus on when working with the client? A. Reframing B. Locus of control C.Problem-solving D. Use of social supports

C.Problem-solving

A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant being brought into the home. Which statement is the most appropriate response for the nurse to make to the client? A. "Don't be concerned; any 2-year-old would welcome a newborn." B. "If your 2-year-old becomes angry or jealous, you should have the child seen by a child psychologist." C. "A 2-year-old toddler will be more concerned about exploring the environment, so there's no reason to be concerned." D. "Even though a 2-year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth."

D. "Even though a 2-year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth."

A nurse is conducting the initial assessment of a child with rheumatic fever. Which question does the nurse ask the parents to elicit information specific to the development of the disease? A. "Has he had any loss of appetite?" B. "Has he complained of a backache recently?" C. "Has he been excessively tired or lethargic?" D. "Has he had a sore throat in the last few months?"

D. "Has he had a sore throat in the last few months?"

A schizophrenic client attending a support group held by a clinic nurse says to the nurse and the group, "I've been laid off from my job at the factory, and so have 300 other people, so I'll have to get a new job. For now, there's unemployment." Which statement by the nurse would be most therapeutic at this time? A. "It seems that the stock market is responsible for mass unemployment in our factory-based city." B. "I'm sorry to hear that you've lost your job. Why not make an appointment to come in and talk with me this week?" C. "How do people feel about this loss of employment? Does anyone in the group who experienced this have any advice?" D. "Have other people in the group been feeling the job crunch this week? When changes like this occur, it's best to increase the number of your appointments with me for a short time."

D. "Have other people in the group been feeling the job crunch this week? When changes like this occur, it's best to increase the number of your appointments with me for a short time."

During a nursing interview, a client says, "My daughter was murdered in her apartment, and her estranged husband called to tell me. I can't stop myself from wondering whether he killed her, but the police have ruled him out as a suspect." Which response by the nurse would be therapeutic? A. "Sounds like it." B. "It feels terrible to lose a daughter." C. "I agree. What do you want to bet he did it?" D. "Have you shared your concerns with the police?"

D. "Have you shared your concerns with the police?"

A 16-year-old client says, "My dad thinks I'm evil, but we get into fights because I let things build up. He never has any time for me because he's always glued to the TV. He doesn't even look at me when he talks." Which statement by the nurse encourages the client to use assertive behavior with his father? A. "So you're saying that you let your feelings build up and then you just explode?" B. "Have you tried standing in front of the television when your dad is watching it?" C. "What makes you feel that you have the right to fly off the handle just because you feel ignored?" D. "Have you tried saying that directly to your dad? For example, you could say, 'I notice that you watch television when I'm telling you things that are important to me.'"

D. "Have you tried saying that directly to your dad? For example, you could say, 'I notice that you watch television when I'm telling you things that are important to me.'"

A 12-year-old client who has been reported for drawing sexually explicit scenes in her textbooks during class says to the psychiatric nurse, "I just felt like it." Which response by the nurse would be therapeutic and aid assessment of abuse-related symptoms? A. "Well, a picture paints a thousand words." B. "You just felt like destroying your textbooks?" C. "Your parents and teachers are very concerned about your drawings." D. "I am concerned about you. Are you being or have you ever been abused?"

D. "I am concerned about you. Are you being or have you ever been abused?"

The family of a client who is being discharged after trying to kill himself with one of his father's guns asks for a family meeting with the nurse to discuss their son's situation. Which statement by the nurse would be the most therapeutic start to the meeting? A. "I must begin by saying that I am uncomfortable meeting without your son here to talk for himself." B. "Let's start by introducing ourselves and talking about what is most troubling to each of you about having your son home." C. "Why don't we all introduce ourselves and say what our relationship is to your son? I'll begin, because I'm the nurse who'll be seeing him after he comes home." D. "I am going to begin by talking in general terms about your son's return home and some of the things that might happen. I can suggest measures that might be helpful, and then you can ask questions."

D. "I am going to begin by talking in general terms about your son's return home and some of the things that might happen. I can suggest measures that might be helpful, and then you can ask questions."

A client says to the nurse, "I'm really phobic about flying, so my husband and I always drove or took the train everywhere. Now he's been offered a big job in Europe, and if I don't get over this and fly with him, he says we're done. I'll be left to bring up our three children by myself." Which statement by the nurse would be therapeutic? A. "No problem. You can be hypnotized to sleep through your trip." B. "I'm interested that it took his threat of leaving you to motivate you to seek help." C. "You seem more anxious and afraid of raising three children alone than of flying." D. "I can teach you strategies to help master your panic. An anti-anxiety medicine would also help you."

D. "I can teach you strategies to help master your panic. An anti-anxiety medicine would also help you."

A psychiatric nurse is playing a card game with a client in the day room. The client states to the nurse, "The voice in my head is telling me that you're cheating." Which response by the nurse is therapeutic? A. "Is the voice telling you to do anything?" B. "I don't believe that you are hearing voices." C. "It isn't possible for people to hear voices in their head." D. "I do not hear any voices. Has the voice said anything else?"

D. "I do not hear any voices. Has the voice said anything else?"

A nurse manager asks a nurse to work overtime because of a short-staffing problem. The nurse has made plans to do her Christmas shopping after work and does not want to work overtime. What is the most assertive response by the nurse to her nurse manager? A. "I'm not working overtime today." B. "You know how I hate to work overtime." C. "I will if you need me, but I am not happy about this." D. "I have plans after work and will not be able to work overtime."

D. "I have plans after work and will not be able to work overtime."

A manic client who tends to be manipulative says angrily, "You had better let me out of here, or I'm going to call my lawyer. My boss has good friends with the owners of this tin-pot place you call a 'mind holism respite.'" Which statement by the nurse would be most therapeutic? A. "When you can speak to me without yelling and being aggressive, I'll be happy to speak with you." B. "Just get your anger out with me, because we're not going to allow you be discharged until you calm down." C. "Do threats and name-calling usually work for you? Do people tend to listen to you and do as you order them to?" D. "I know that you feel that you're doing your very best right now, but you are yelling. Take some time out and some deep breaths, and I'll speak to you in half an hour."

D. "I know that you feel that you're doing your very best right now, but you are yelling. Take some time out and some deep breaths, and I'll speak to you in half an hour."

During a health assessment interview, the client tells the nurse that she has some vaginal drainage. The client is concerned that it may indicate a sexually transmitted infection (STI). Which statement should the nurse make to the client? A. "When was your last gynecological checkup?" B. "Have you been engaging in unprotected sexual intercourse?" C. "Don't worry about the discharge. Some vaginal discharge is normal." D. "I need some more information about the discharge. What color is it?"

D. "I need some more information about the discharge. What color is it?"

A nurse instructs a client with hypothyroidism about the dosage, method of administration, and side effects of levothyroxine sodium. Which statement by the client indicates an understanding of the nurse's instructions? A. "I should take the medication in the evening." B. "I can expect diarrhea, insomnia, and excessive sweating." C. "If I feel nervous or have tremors, I should only take half the dose." D. "I need to report any episodes of palpitations, chest pain, or dyspnea."

D. "I need to report any episodes of palpitations, chest pain, or dyspnea."

A nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction? A. "I should drink extra fluids during the summer." B. "I should wear cool, light clothing in warm weather." C. "I need to wear a hat with a wide brim when I go outdoors." D. "I need to wear additional antiperspirant and deodorant in warm weather."

D. "I need to wear additional antiperspirant and deodorant in warm weather."

A nurse provides instructions to a client who will be taking furosemide. Which statement by the client indicates to the nurse that the client needs additional instruction? A. "I need to sit or stand up slowly." B. "I need to maintain my fluid intake." C. "This medication will make me urinate." D. "I should expect to have ringing in my ears."

D. "I should expect to have ringing in my ears."

A nurse has taught the client with a herniated lumbar disk about proper body mechanics and other information about low back care. The nurse determines that the client needs further instruction if the client makes which statement? A. "I should bend at the knees to pick things up." B. "I need to increase the fiber and fluids in my diet." C. "I can strengthen my back muscles by swimming or walking." D. "I should get out of bed by sitting up straight and swinging my legs over the side of the bed."

D. "I should get out of bed by sitting up straight and swinging my legs over the side of the bed."

The mother of a child who is taking methylphenidate hydrochloride (Ritalin) tells the school nurse that she is administering an over-the-counter (OTC) cough syrup to her son. Which response by the nurse would be appropriate? A. "His cough could be a side effect of the Ritalin." B. "Your son should never take any medicine, even if it's OTC." C. "You may administer a small amount of OTC cough syrup without a problem, but not for more than 3 days." D. "I think that you should stop giving this medicine to your son until I can check its content with the pharmacy."

D. "I think that you should stop giving this medicine to your son until I can check its content with the pharmacy."

A nurse provides home care instructions to a client with a below-the-knee amputation (BKA) about residual limb and prosthesis care. Which statement by the client indicates a need for further instruction? A. "I should wear a sock over my stump." B. "I can wash my leg with a mild soap." C. "I need to check my leg for irritation every day." D. "I'll put lotion on my leg a few times a day."

D. "I'll put lotion on my leg a few times a day."

A client who was recently admitted to the mental health unit has a history of paranoia. When the meal tray is delivered, the client refuses to eat and tells the nurse that someone is poisoning the food. Which statement by the nurse is appropriate? A. "Your food is not poisoned." B. "Why do you think the food is poisoned?" C. "There is no poison in the food. Here, I'll taste the food for you." D. "It must be frightening to you. Has something made you feel that your food is poisoned?"

D. "It must be frightening to you. Has something made you feel that your food is poisoned?"

A client says to the nurse, "I've started a journal because my health care provider suggested it, and I'm writing about the things that bother me each day. Sometimes I dictate my feelings and what happened during the day into a recorder and write them up before I go to bed — and, do you know, they seem silly to me then. Is this helping me?" Which response by the nurse would be appropriate? A. "I'm not certain that using a tape recorder will help you with the journal-keeping." B. "Well, I wonder about the dictation, because the writing is what helps reduce stress." C. "Well, it will take some time, but let's see how you're doing over a month. In the meantime, keep writing." D. "It seems that people who write in their journals and can share traumatic events improve their self-awareness."

D. "It seems that people who write in their journals and can share traumatic events improve their self-awareness."

A 56-year-old client says to the nurse, "I'm a guidance counselor at the middle school, and the kids like to come to see me for help, but I just found out from my wife that my 22-year-old daughter is a lesbian, and now I'm the one who needs advice. How am I supposed to accept that? She was the boy we didn't have, and I made a tomboy of her by taking her to baseball games with me. Is that why she's gay?" Which statement by the nurse would be therapeutic? A. "Are you prejudiced against lesbian and gay people?" B. "You're good at talking with middle schoolers, but how about young adults?" C. "How did your wife happen to tell you about this? Did your daughter ask her to tell you?" D. "It sounds like you and your daughter were very close but she kept her sexual orientation from you."

D. "It sounds like you and your daughter were very close but she kept her sexual orientation from you."

The nurse enters a client's room to administer a medication that has been prescribed by the health care provider. The client asks the nurse about the medication. Which response by the nurse is appropriate? A. "It's to help get rid of the swelling in your feet." B. "You need to discuss this medication with your physician." C. "I know that it's for fluid buildup, and I think you've taken it before." D. "It's called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in your diet."

D. "It's called furosemide (Lasix), and it will promote urination and rid your body of the excess fluid. It can cause an alteration in electrolyte levels, so we'll need to increase the potassium in your diet."

A client who is an attorney says to the clinic nurse, "I'm worried about my wife. She's been so distant and disorganized since our son died of leukemia 4 months ago. She never suggests that we go out or take our other children anywhere. Is this normal, or do I need to get her to a doctor?" Which statement by the nurse would be therapeutic? A. "Absolutely. It sounds as if she may be experiencing a severe depression." B. "To be safe, it would not hurt to have her see your family doctor, or maybe you have a member of the clergy she can talk to." C. "The reluctance to resume activities and overprotect your other children is a normal part of bereavement and will subside in 2 months." D. "It's normal, but by the end of a year you can expect that your wife is improving and able to redirect her energy. Have you expressed your concerns to her?"

D. "It's normal, but by the end of a year you can expect that your wife is improving and able to redirect her energy. Have you expressed your concerns to her?"

A client says to the nurse, "My doctor wants me to start keeping a journal every day about what's happening in my job." Which response by the nurse is appropriate? A. "You can erase your stresses by identifying things that set off negative physical experiences." B. "Well, it has always helped me to write down daily happenings and relate them to my stress level." C. "Yes, that is an excellent suggestion. You need to keep a meticulous diary of your day with all of the details." D. "Journal-keeping that identifies what seems to cause a strain in a person's life is a good way of improving one's health."

D. "Journal-keeping that identifies what seems to cause a strain in a person's life is a good way of improving one's health."

A client says to the nurse, "It's over for me — the whole thing is over." Which response by the nurse would be therapeutic? A. "What do you mean, 'The whole thing is over'?" B. "Over? Well, that sounds pretty drastic to me. Let's discuss this in the strictest confidence." C. "Can you tell me more about why it's over for you? I'll keep your thoughts strictly confidential." D. "Let's talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members."

D. "Let's talk more about your feeling that the whole thing is over for you. This is important, and I may need to share your feelings with other staff members."

On the initial visit to the mental health clinic, a client says to the nurse, "When I married my husband, more than 30 years ago, he was a big, handsome, competent professional who never wanted me to work and was so loving. Well, two kids later he's a slob who gambles and loses one job after another. Now I'm the breadwinner and he's content to be a shiftless town joke." Which statement by the nurse would be therapeutic? A. "You sound disgusted with your husband. Is this an accurate assessment? Why not divorce him?" B. "Can you tell me how long you have felt like this and how much longer you plan to continue this way?" C. "You seem to have changed your feelings about your husband completely. This didn't happen overnight, so why are you here now?" D. "Many things have happened to you and your husband. Sounds as if you've both been struggling for some time. Would you like to have him come in with you to talk with me about all of this?"

D. "Many things have happened to you and your husband. Sounds as if you've both been struggling for some time. Would you like to have him come in with you to talk with me about all of this?"

An alcoholic client says to the nurse, "I'm taking milk thistle, so I can drink all I want and never get cirrhosis." Which statement by the nurse would be therapeutic? A. "Milk thistle aside, you still need to stop using alcohol. You have a severe drinking problem." B. "If milk thistle is so effective, I wonder why the liquor industry isn't lobbying to put it in alcohol?" C. "Milk thistle is used in Europe this way, but research findings are limited, so I'd stop drinking if I had a problem like you do." D. "Milk thistle is an herbal extract. It does seem to prevent liver damage and stimulate liver cell regeneration, but it can't prevent damage to other organs, like your brain."

D. "Milk thistle is an herbal extract. It does seem to prevent liver damage and stimulate liver cell regeneration, but it can't prevent damage to other organs, like your brain."

A 68-year-old client whose husband died 2 months ago says to the nurse, "I'm having trouble sleeping lately, even though I don't nap in the daytime. I've been using warm milk without any results." Which statement by the nurse would be therapeutic? A. "So you've started having sleeping problems but no other problems?" B. "Perhaps you should join the grieving spouses group that meets on Monday nights." C. "Since you've lost your husband, have you experienced any other problems besides trouble sleeping?" D. "One of the things that I've found has helped others is a small snack with your warm milk before sleep and a moderate increase in walking during the day. Is that something you could try?"

D. "One of the things that I've found has helped others is a small snack with your warm milk before sleep and a moderate increase in walking during the day. Is that something you could try?"

A client says to the nurse, "My doctor says he thinks I'm ready to taper off my pain medication, but the new painkiller he prescribed doesn't relieve my pain the way the other pill did. I get pain when I try to do things." Which nursing response would be most supportive to the client? A. "Your health care providerhealth care provider feels that your body is physically ready to make the change in medication." B. "I think you need to listen to your health care provider health care providerwhen it comes to taking such strong medication." C. "Well, your health care provider is concerned that you will become physically dependent on the first painkiller." D. "Perhaps if I medicate you about a half-hour before you plan to start your daily activities, the medicine will be more effective."

D. "Perhaps if I medicate you about a half-hour before you plan to start your daily activities, the medicine will be more effective."

A client says to the nurse, "I've been following my diet and taking my medication. What else do you want to talk about today?" Which response would be most helpful during the working phase of the therapeutic alliance? A. "Sounds fine to me. Let's meet again in 6 months." B. "I don't believe that you have been following your diet, because you haven't lost any weight." C. "Well, you've talked about diet in your terms, but perhaps I should test you on specific things." D. "Some people have added exercise to diet and medication therapy and gotten positive results. Do you think that this would work for you?"

D. "Some people have added exercise to diet and medication therapy and gotten positive results. Do you think that this would work for you?"

A client whose husband died 2 months ago says to the nurse, "After church, I visit my husband's grave and talk to him. It comforts me, but my daughter thinks I'm morbid and crazy and is upset with me because I don't want to meet her for coffee after church like I used to." Which statement by the nurse would be therapeutic? A. "You need to stop your visits immediately, or your daughter will have you examined for a mental disorder." B. "Perhaps you could reduce your visits to his grave to once a month and meet your daughter for coffee like you used to." C. "I think your visits are perfectly normal. After all, you were married for a long time. You'll stop when the winter weather comes." D. "Sounds as if you have had difficulty letting your husband go from your life. What would happen if you visited his grave less frequently?"

D. "Sounds as if you have had difficulty letting your husband go from your life. What would happen if you visited his grave less frequently?"

A victim of sexual assault is being seen in the crisis center. The client states that she still feels "as though the assault just happened," even though it has been a few months since she was attacked. Which supportive statement should the nurse make to the client? A. "Things like this take time to get over." B. "Be realistic. Remember, the assault didn't just happen." C. "Why keep thinking about this? It'll only make matters worse." D. "Tell me more about why you feel like the assault just occurred."

D. "Tell me more about why you feel like the assault just occurred."

A client with an alcohol problem who has been sober for 8 months asks the nurse, "Do you think I should add individual therapy to my treatment plan?" Which response by the nurse would be therapeutic? A. "What do you think? What is the individual therapy all about?" B. "Are you feeling that you're vulnerable to a slip? If not, why complicate treatment further?" C. "Okay, what's going on with you? You had to be coerced into treatment, but now you seem to want the full monty." D. "The best time to add individual therapy seems to be after 2 to 5 years of sobriety. Individuals vary, though, and it may be that you are asking because you feel ready to work on your issues."

D. "The best time to add individual therapy seems to be after 2 to 5 years of sobriety. Individuals vary, though, and it may be that you are asking because you feel ready to work on your issues."

A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions? A. "I need to keep large toys out of the crib." B. "The drop side needs to be impossible for my infant to release." C. "Wood surfaces on the crib need to be free of splinters and cracks." D. "The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body."

D. "The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body."

The parents of an adopted child schedule an appointment at a psychiatric clinic, and when they arrive the nurse conducts an initial assessment. One of the parents says to the nurse, "We need to speak to a psychiatrist about our adopted daughter. Could you please get one for us?" Which intervention by the nurse would be therapeutic? A. "I'd like to accommodate you both, but he is busy right now and you will have to talk to me." B. "Do you feel that I am incompetent to talk with you? Everyone who comes here sees me first." C. "That is not the procedure here. If you can't work with the system, you're free to go elsewhere." D. "The doctors here feel that clients are best served when I conduct the initial assessment, after which the psychiatrist will see you with complete information."

D. "The doctors here feel that clients are best served when I conduct the initial assessment, after which the psychiatrist will see you with complete information."

A new mother asks the nurse, "I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?" Which statement should the nurse make in response to the mother? A. "Yes, your infant is protected from all infections." B. "If you breastfeed, your infant is protected from infection." C. "The transfer of your antibodies protects your infant until the infant is 12 months old." D. "The immune system of an infant is immature, and the infant is at risk for infection."

D. "The immune system of an infant is immature, and the infant is at risk for infection."

An alcoholic client who has been admitted to the mental health unit states to the nurse, "The judge made me come in here. My blood alcohol level was only 0.20% when the cop pulled me over in my car." Which statement by the nurse is most appropriate? A. "Did you ask the judge to clarify his decision to make you come here?" B. "This limit means that you had consumed enough alcohol to put you close to the legal intoxication level. You were lucky because you just missed that level." C. "Well, the legal limit is much less than that, so you avoided a drunken driving charge by coming here. Seems to me that the judge treated you pretty leniently by allowing you to take refuge here. Don't you agree?" D. "This level means that you consumed several drinks of alcohol and would be experiencing depressed motor function of the brain. You would have been staggering and clumsy and your judgment would have been impaired, but you seem to feel that the judge was unreasonable for sending you here."

D. "This level means that you consumed several drinks of alcohol and would be experiencing depressed motor function of the brain. You would have been staggering and clumsy and your judgment would have been impaired, but you seem to feel that the judge was unreasonable for sending you here."

A young woman who has been divorced twice says to the nurse, "I've decided not to date men ever again! It never works out for me. Now I'm left with two children to bring up." Which nursing response would be therapeutic? A. "Oh, me too. I always pick the worst kind of men, so I know just how you feel." B. "Divorce is more difficult for children. Maybe you should focus on them for now." C. "You've been unfortunate, but you seem to be focusing on yourself and what you have to do." D. "You talk about how the divorces affected you. Tell me how your children are dealing with the loss."

D. "You talk about how the divorces affected you. Tell me how your children are dealing with the loss."

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this! I'm the one who's dying." Which response by the nurse would be most therapeutic? A. "Have you shared your feelings with your family?" B. "Well, it sounds like you're being pretty pessimistic." C. "I think we should talk more about your anger with your family." D. "You're feeling angry that your family continues to hope for you to be cured."

D. "You're feeling angry that your family continues to hope for you to be cured."

A 45-year-old fireman says to the nurse, "I've worked at some fires recently that were just devastating, but last week was the worst. I carried this little girl from a fire — she was badly burned and lived just a few minutes after I brought her out, and she said to me, 'Tell my mom and Rudy I love them both very much.' Her mom told me that Rudy is their dog, and he just mopes around the house since the little girl died. I keep thinking about her and just don't know if I can go on." Which response by the nurse would be therapeutic? A. "Maybe you could help the mother find a home for Rudy, and then your troubling thoughts would go away." B. "Would you listen to yourself? You've seen firemen stress out before. What is your responsibility in all this?" C. "You've helped victims of some horrific fires lately, and yet you question your calling. Do you feel the need to resign?" D. "You're questioning your job because you're upset about the little girl you tried to save. Work stress can be treated and help you cope better. It is so important for you to seek treatment."

D. "You're questioning your job because you're upset about the little girl you tried to save. Work stress can be treated and help you cope better. It is so important for you to seek treatment."

A client who witnessed her husband being shot and killed in an incident of road rage says to the nurse, "It's been 3 months now, and I still can't drive my car without acting crazy. My sister says I grip the wheel like I'm glued to it. I can't merge with traffic until it's almost completely clear, and I'm parking a mile from in the mall when there's plenty of parking close to the building." Which statement by the nurse would be therapeutic? A. "I still grip the wheel when I merge with traffic, and I just wonder whether your sister needs to see me do it." B. "If I were you, I'd have trouble driving the car again. Driving a car and being the victim of road rage are two very different things, and you need therapy and time to heal." C. "Smart of you to take no chances. You should see the dents and dings on my car from mall parking. Does your sister depend on you for many things? It seems like she's pushing you too hard." D. "You're seeking help appropriately, and there are many things you can do to get comfortable behind the wheel again. You've returned to driving, but remember, you're still grieving. It's normal to still feel this way."

D. "You're seeking help appropriately, and there are many things you can do to get comfortable behind the wheel again. You've returned to driving, but remember, you're still grieving. It's normal to still feel this way."

A student calls the campus crisis hotline and tells the nurse, "I went out to a sorority party last week and drank too much. Someone raped me, but when I told my folks about it, they acted like it was my fault. I feel so dirty and used." Which statement by the nurse would be most therapeutic? A. "Would you come in to talk with me in the strictest confidence?" B. "I believe that you can feel a lot better about yourself. Won't you come in to see me tomorrow?" C. "Parents always feel that their daughters could never be raped. I could talk to them for you, if you'll let me." D. "You've had an awful experience, but it's not your fault that it happened. Can you come in and talk to me about it in more detail?"

D. "You've had an awful experience, but it's not your fault that it happened. Can you come in and talk to me about it in more detail?"

A client says to the nurse at the mental health clinic, "My husband and sister-in-law both have terminal illnesses, and my family thinks that because I'm a nurse I should be able to handle everything." Which nursing response would be therapeutic? A. "Are you saying you are overly involved and will need to emotionally distance yourself to be therapeutic for your family?" B. "Shame on them for expecting so much from you. Perhaps we need to schedule a family meeting so I can help you set them straight." C. "I'm sorry to hear that your loved ones are so ill. As a nurse, you should be able to assist them by using your professional expertise. Perhaps that's what your family expects from you." D. "You've seen your loved ones dealing with some troubling events recently. Sounds as if you feel that your family expects more from you than from others in the family because you're a nurse."

D. "You've seen your loved ones dealing with some troubling events recently. Sounds as if you feel that your family expects more from you than from others in the family because you're a nurse."

The slightly overweight mother of a morbidly obese 11-year-old girl says, "My family health care provider is wild over my daughter's weight gain. He says she's not eating correctly and is too sedentary, and now she's at risk for diabetes. He says the sugar in her blood was up this month. It's all my fault because I eat the wrong things, too, and I never get off the couch." Which statement by the nurse would be therapeutic in easing the client's self-blame? A. "Well, it seems very bleak to you, but your daughter is responsible for her eating and exercising, too." B. "What about her father? Isn't it partly his fault, too? I want to meet with you, him, and your daughter tomorrow." C. "It's all this fast food and TV-watching these days. If our kids aren't watching television, they're playing with their computers." D. "Your daughter has a serious problem, but there are many successful programs that you can join with her to lose weight and improve your overall lifestyle."

D. "Your daughter has a serious problem, but there are many successful programs that you can join with her to lose weight and improve your overall lifestyle."

A client with depression says to a nurse, "Why is my family meeting with you? Are you telling them about me?" Which response by the nurse would be therapeutic? A. "Have you talked with your family? What have they said to you about the meetings?" B. "I am committed to keeping everything you say to me confidential, so it is troubling when you accuse me of talking to your family." C. "You sound concerned that I would tell your family something about you even though you know that what we talk about is confidential." D. "Your family is learning about depression and how best to help you so that they can be supportive of you. We do not talk about you or anything confidential about you."

D. "Your family is learning about depression and how best to help you so that they can be supportive of you. We do not talk about you or anything confidential about you."

A client says to the nurse, "I'm worried about my husband. He's talking about ending it all since his law practice dropped off and his son by his late first wife died of a drug overdose — but he's too intelligent to hurt himself, isn't he?" Which response by the nurse is appropriate? A. "Yes, he's too intelligent to end it all." B. "I'm not sure. I don't know him that well." C. "Most people who talk about ending it all are just looking for attention." D. "Your husband is displaying behaviors that indicate a risk for self-harm."

D. "Your husband is displaying behaviors that indicate a risk for self-harm."

The parents of a 20-year-old who was killed while driving drunk say to the nurse, "We're so devastated, but we are also angry that she would drink and drive when we told her over and over not to." Which statement by the nurse would be therapeutic? A. "Young people don't always obey their parents." B. "Everyone feels guilt or anger when they lose a loved one." C. "Does anyone in the family have a drinking or drug problem?" D. "Your sadness over losing your daughter is mixed with anger at her driving while intoxicated."

D. "Your sadness over losing your daughter is mixed with anger at her driving while intoxicated."

A client whose adolescent son committed suicide by hanging himself in the family's garage says to the nurse, "The coroner just informed us that our son had AIDS." Which response to the client by the nurse is appropriate? A. "You didn't know that he had AIDS? How did he see the family health care provider without your knowing?" B. "Your poor son. How troubled he must have been. It's a shame he couldn't talk to you and get some help." C. "Your son had an autopsy because he committed suicide, but the coroner didn't have to tell you that he was ill." D. "Your son was keeping a very troubling diagnosis to himself. I am so sorry. No matter how close and loving children are to their parents, some children just aren't able to confide in their parents."

D. "Your son was keeping a very troubling diagnosis to himself. I am so sorry. No matter how close and loving children are to their parents, some children just aren't able to confide in their parents."

A pediatric nurse finds a hospitalized child unresponsive. A quick assessment reveals that the child is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR). How many chest compressions per minute does the nurse deliver? A. 15 B. 30 C. 50 D. 100

D. 100

A cleansing enema is prescribed for an adult client. The nurse understands that which is the maximal volume of fluid that can be administered? A. 250 mL B. 500 mL C. 750 mL D. 1000 mL

D. 1000 mL

A multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed? A. 6 weeks B. 8 weeks C. 12 weeks D. 16 weeks

D. 16 weeks

A nurse is administering a high cleansing enema. At what level above the client's hips should the nurse place the enema bag? A. 4 inches B. 8 inches C. 10 inches D. 18 inches

D. 18 inches

The nurse reviewing a client's record sees that the following medications are prescribed. Which medication should the nurse plan to administer first? Client Medications 1. Atorvastatin (Lipitor) 10 mg orally 2. Zolpidem (Ambien) 5 mg orally daily 3. Ferrous sulfate (Feosol) 1 tablet orally 4. Levothyroxine (Synthroid) 137 mg orally A. 1 B. 2 C. 3 D. 4

D. 4

A nurse responds to an external disaster that occurred in a large city when a building collapsed. Numerous victims require treatment. Which victim should the nurse attend to first? A. A victim who has died of multiple serious injuries B. A hysterical victim who has sustained a head injury C. An alert victim who has numerous bruises on the arms and legs D. A victim with a partial amputation of a leg who is bleeding profusely

D. A victim with a partial amputation of a leg who is bleeding profusely

A nurse is reviewing the laboratory results of a client receiving intravenous chemotherapy. Which laboratory finding prompts the nurse to initiate neutropenic precautions? A. A clotting time of 10 minutes B. An ammonia level of 20 mcg N/dL (14.6 μmol N/L) C. A platelet count of 100 × 103/μL (100× 109/L). D. A white blood cell (WBC) count of 2.0 × 103/μL (2.0 × 109/L).

D. A white blood cell (WBC) count of 2.0 × 103/μL (2.0 × 109/L).

A client complains that he feels as though his ear is blocked and tells the nurse that he has a history of cerumen impaction in the external ear. What should the nurse check for when inspecting the ears for cerumen impaction? A. Redness and swelling of the tympanic membrane B. An external auditory canal that is longer than normal C. The presence of edema in the external auditory canal D. A yellowish or brownish waxy material in the external auditory canal

D. A yellowish or brownish waxy material in the external auditory canal

A registered nurse (RN) is watching as a new licensed practical nurse (LPN) administer an intramuscular (IM) injection in a client's deltoid muscle. The RN determines that the LPN is performing the procedure correctly if the LPN: A. Administers the injection in the thigh B. Places the client in the Sims position C. Positions the client in a prone toe-in position D. Administers the injection 2 inches below the acromion process

D. Administers the injection 2 inches below the acromion process

A client arrives at the emergency department with reports of a headache, hives, itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour earlier and believes that he is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first? A. Administration of normal saline solution B. Administration of an intravenous (IV) glucocorticoid C. Administration of pain medication to relieve the client's headache D. Administration of a subcutaneous injection of epinephrine (Adrenalin)

D. Administration of a subcutaneous injection of epinephrine (Adrenalin)

A client has a serum sodium level of 151 mEq/L (151 mmol/L), and the nurse provides instruction regarding foods to avoid. Which menu choice by the client indicates to the nurse that the client needs further instruction? A. Fish B. Spinach C. Rhubarb D. American cheese

D. American cheese

A nurse attending a recertification course in basic life support (BLS) for healthcare professionals is practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the infant's pulse? A. Neck B. Wrist C. Behind the knee D. Antecubital fossa of the arm

D. Antecubital fossa of the arm

Performing an abdominal assessment, a nurse notes tenderness while lightly palpating a client's right lower quadrant. The nurse determines that this finding is most likely associated with which of the following anatomic structures? A. Liver B. Spleen C. Pancreas D. Appendix

D. Appendix

A nurse is assessing a newborn infant for jaundice. Which action should the nurse take to assess the infant for its presence? A. Squeeze the infant's nail beds B. Squeeze the infant's brachial area C. Apply pressure with a finger over the umbilical area D. Apply pressure with a finger on the infant's forehead

D. Apply pressure with a finger on the infant's forehead

A nurse has a prescription to get the client out of bed and into a chair on the first postoperative day after total knee replacement. Which action should the nurse take to protect the knee? A. Assisting the client into the chair, using a walker to minimize weight bearing on the affected leg B. Securely covering the surgical dressing with an elastic wrap and applying ice to the knee while the client is sitting C. Lifting the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place. D. Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is sitting

D. Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is sitting

A client who sustained a fracture of the left arm requires the application of a plaster cast. The nurse tells the client that the procedure for applying the cast involves: A. Administering a local anesthetic to the fractured arm B. Soaking the left arm in a warm-water bath for 2 hours before cast application C. Debriding any open wounds and applying antibiotic ointment before the cast material is applied D. Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material

D. Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material

The nurse is teaching assertiveness training to a client with anger-management issues. Which instruction would the nurse give for helping the client assertively confront someone? A. Emphasize how much you like the person but insist that the other person make the changes you need. B. Tell the person that the behavior has become intolerable for you and that the behavior must be changed immediately. C. Demonstrate that you understand how the other person feels but state that you still expect the other person to make the changes you need. D. Ask for private time to talk and point out the facts without being accusatory, then determine areas of mutual misunderstanding and request the changes you need.

D. Ask for private time to talk and point out the facts without being accusatory, then determine areas of mutual misunderstanding and request the changes you need.

A nurse sees another nurse changing an intravenous (IV) solution because the wrong solution is infusing into the client. The nurse who changed the IV solution does not report the error. What should the nurse who observed the error do first? A. Call the client's health care provider B. Document the error in the client's chart C. Report the nurse who changed the IV solution D. Ask the nurse whether she intends to report the error

D. Ask the nurse whether she intends to report the error

A nurse performing a neurological examination is testing the cochlear portion of the acoustic nerve (cranial nerve VIII). Which of the following actions does the nurse take to test this nerve? A. Asking the client to raise his or her eyebrows and looking for symmetry B. Asking the client to clench the teeth, then palpating the masseter muscles just above the mandibular angle C. Asking the client to close the eyes and then identify light and sharp touch with a cotton ball and a pin on both sides of the face D. Asking the client to close his or her eyes and then indicate when a ticking watch is heard as the nurse brings the watch closer to the client's ear

D. Asking the client to close his or her eyes and then indicate when a ticking watch is heard as the nurse brings the watch closer to the client's ear

A nurse has a prescription to collect a 24-hour urine specimen from a client. Which measure should the nurse take during this procedure? A. Keeping the specimen at room temperature B. Saving the first urine specimen collected at the start time C. Discarding the last voided specimen at the end of the collection time D. Asking the client to void, discarding the specimen, and noting the start time

D. Asking the client to void, discarding the specimen, and noting the start time

The nurse instructs a unlicensed assistive personnel (UAP) that a client who is recovering from a myocardial infarction requires a complete bed bath. The nurse would intervene if the nurse observed the UAP doing which? A. Washing the client's feet B. Washing the client's chest C. Giving the client a back rub D. Asking the client to wash his arms

D. Asking the client to wash his arms

A nurse is performing sterile wound irrigation for an assigned client. A nursing assistant enters the client's room and tells the nurse that a physician has telephoned and has asked to speak to the nurse. What is the appropriate action by the nurse? A. Asking the nursing assistant to take a message B. Covering the client and answering the telephone call C. Finishing the wound irrigation while the physician waits on the telephone D. Asking the nursing assistant to obtain a telephone number from the physician so that the nurse may return the call after the wound irrigation is complete

D. Asking the nursing assistant to obtain a telephone number from the physician so that the nurse may return the call after the wound irrigation is complete

A nurse asks an unlicensed assistive personnel (UAP) to provide afternoon care to a client. The nurse expects that the UAP will take which action? A. Give the client a complete bed bath B. Ask the client whether he would like to wash his face C. Give the client a back massage and prepare the client for sleep D. Assist the client in washing his hands and face and performing mouth care, offering a bedpan or urinal, and straightening the bed linens

D. Assist the client in washing his hands and face and performing mouth care, offering a bedpan or urinal, and straightening the bed linens

A nurse gathering subjective data from a client during a health assessment plans to ask the client about the medical history of the client's extended family. About which family members should the nurse ask the client? A.Spouse and spouse's parents B. Foster children and their parents C. Spouse's children from a previous marriage D. Aunts, uncles, grandparents, and cousins

D. Aunts, uncles, grandparents, and cousins

A client who experienced the sudden onset of respiratory distress has been intubated with an endotracheal tube. After the tube is placed in the trachea, the nurse should take which immediate action? A. Tape the tube in place B. Send the client for a chest x-ray C. Note how far the tube has been inserted D. Auscultate both lungs for the presence of breath sounds

D. Auscultate both lungs for the presence of breath sounds

The mother of a 2-year-old tells the nurse that she is very concerned about her child because he has developed "a will of his own" and "acts as if he can control others." The nurse provides information to the mother to alleviate her concern, recalling that, according to Erikson, a toddler is confronting which developmental task? A. Initiative versus guilt B. Trust versus mistrust C. Industry versus inferiority D. Autonomy versus doubt and shame

D. Autonomy versus doubt and shame

A client requires a partial bed bath. The nurse, giving instructions to an unlicensed assistive personnel (UAP) about the bath, tells the UAP to take which action? A. Just wash the client's hands and face B. Provide mouth care and perineal care only C. Let the client decide what she wants washed D. Bathe the client's body parts that, if left unbathed, would give rise to discomfort or odor

D. Bathe the client's body parts that, if left unbathed, would give rise to discomfort or odor

A client requests the use of an alternative or complementary therapy to help control pain and asks about the use of guided imagery. The nurse responds by telling the client that in this technique, the clientwill experience which? A. Become totally unaware of pain B. Ignore the pain by focusing on the alternate activity C. Alter pain perception though the influence of positive suggestion D. Become less aware of pain by creating and then concentrating on a mental image

D. Become less aware of pain by creating and then concentrating on a mental image

The home care nurse makes a new-baby visit to a young husband and wife. The visit takes two-and-a-half hours because the parents are so detailed in giving information and asking questions of the nurse. Which intervention by the nurse would be therapeutic? A. Ordering a follow-up visit to the family pediatrician and mental health clinical specialist B. Informing all home care nurses to schedule their visits to the couple as their last visit of the day C. Having the home care office secretary call the nurse's cell phone 20 minutes after starting the visit to expedite the nurse's departure D. Blocking out more time for the next visit and scheduling a follow-up visit as soon as possible to assess how they are coping and gauge their level of anxiety

D. Blocking out more time for the next visit and scheduling a follow-up visit as soon as possible to assess how they are coping and gauge their level of anxiety

A client with heart failure is being given furosemide and digoxin. The client calls the nurse and complains of anorexia and nausea. Which action should the nurse take first? A. Administer an antiemetic B. Administer the daily dose of digoxin C. Discontinue the morning dose of furosemide D. Check the result of laboratory testing for potassium on the sample drawn 3 hours ago

D. Check the result of laboratory testing for potassium on the sample drawn 3 hours ago

A registered nurse is in charge of the emergency department (ED) during the night shift. A client arrives at the ED for treatment after a sexual assault. The nurse has never cared for anyone who has been raped. To determine the necessary actions in regard to this client's injury, the nurse should: A. Ask a licensed practical nurse B. Call the nurse in charge of the day shift C. Ask the police officers who brought the client to the ED D. Check the unit policy for the protocol for the care of clients who have been sexually assaulted

D. Check the unit policy for the protocol for the care of clients who have been sexually assaulted

A client has just returned to the nursing unit after bronchoscopy. To which intervention should the nurse give priority? A. Ambulating the client B. Administering pain medication C. Encouraging copious fluid intake D. Checking for the return of the gag reflex

D. Checking for the return of the gag reflex

Buck extension traction is applied to the right leg of a client who sustained a right hip fracture. Which intervention should the nurse include in the plan of care? A. Assessing the pin sites at least every 8 hours B. Removing the traction weights to provide skin care C. Applying lanolin to the skin of the right leg once per shift D. Checking the skin integrity of the right leg at least every 8 hours

D. Checking the skin integrity of the right leg at least every 8 hours

A nurse is reviewing the healthcare record of a client who has just undergone an examination of the internal genitalia. Which of the following documented findings indicates an abnormality? A. The cervix is pink. B. The cervix is midline. C. The cervix is about 1 inch in diameter. D. Clear secretions with a foul odor are noted on the cervix.

D. Clear secretions with a foul odor are noted on the cervix.

A nurse is making an initial home visit to a client with chronic obstructive pulmonary disease who was recently discharged from the hospital. Which type of database does the nurse use to obtain information from the client? A. Episodic B. Follow-up C. Emergency D. Complete

D. Complete

A case manager is serving on a community task force on violence in schools. The members of the task force are planning to develop interventions to help prevent violence. According to the nursing process, the first activity that the nurse would suggest to the task force is: A. Teaching schoolchildren about the dangers of school violence B. Looking at what other communities are doing about school violence C. Distributing fliers that identify the causes of school violence to families in the community D. Conducting a community survey to assess community perceptions regarding school violence

D. Conducting a community survey to assess community perceptions regarding school violence

A nurse who has been employed in a hospital for 8 weeks is consistently taking extended lunch breaks. The nurse's behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse manager to deal with this situation? A. Ignoring the situation B. Asking other staff members to cover for the nurse C. Documenting the problem in the nurse's personnel file D. Confronting the nurse to discuss the behavior and initiate problem-solving measures

D. Confronting the nurse to discuss the behavior and initiate problem-solving measures

In which situation is the nurse upholding the ethical principle of fidelity? A. Allowing a client to decide when to receive daily hygiene care B. Inserting a 19-gauge intravenous catheter into a client requiring a blood transfusion C. Providing complete information regarding treatment options to a client with newly diagnosed cancer D. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan

D. Contacting the health care provider about the client's request to incorporate complementary therapies for pain into the treatment plan

The nurse is caring for a hospitalized client with an alcohol abuse disorder. In reviewing the client's discharge outcomes, the most positive outcome is that the client states that he or she will perform which action? A. Learn to play tennis B. Take a painting class C. Start an exercise program D. Continue to attend Alcoholics Anonymous meetings

D. Continue to attend Alcoholics Anonymous meetings

A client who has undergone abdominal surgery calls the nurse and reports that she just felt "something give way" in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action? A. Document the findings B. Contact the health care provider C. Place the client in a supine position with the legs flat D. Cover the abdominal wound with a sterile dressing moistened with sterile saline solution

D. Cover the abdominal wound with a sterile dressing moistened with sterile saline solution

A nurse is performing a throat assessment on an assigned client. On asking the client to stick his tongue out, the nurse notes that it protrudes in the midline. Which of the following cranial nerves is the nurse testing? A. Cranial nerve X B. Cranial nerve V C. Cranial nerve IX D. Cranial nerve XII

D. Cranial nerve XII

A mother brings her 18-month-old child to the clinic to receive the next scheduled vaccine. The child has previously received the following vaccines: three doses of the hepatitis B vaccine (at birth and 1 and 6 months of age); three doses of the diphtheria/tetanus/acellular pertussis (DTaP) vaccine (at 2, 4, and 6 months of age); four doses ofHaemophilus influenzae type b (Hib) conjugate vaccine (at 2, 4, 6, and 12 months of age); three doses of inactivated poliovirus vaccine (IPV) (at 2, 4, and 6 months of age); one dose of measles/mumps/rubella vaccine (MMR) (at 12 months of age); varicella zoster vaccine at 12 months of age; and four doses of pneumococcal vaccine (at 2, 4, 6, and 12 months of age). After reviewing the child's immunization record, which scheduled vaccine does the nurse prepare to administer? A. Hib B. IPV C. MMR D. DTaP

D. DTaP

A nurse is admitting a client with a diagnosis of hypothermia to the hospital. Which signs does the nurse anticipate that this client will exhibit? A. Increased heart rate and increased blood pressure B. Increased heart rate and decreased blood pressure C. Decreased heart rate and increased blood pressure D. Decreased heart rate and decreased blood pressure

D. Decreased heart rate and decreased blood pressure

A nurse manager tells the nursing staff that the agency's disaster preparedness plan will be distributed to all employees for review. The nurse manager states that the plan is an important component of disaster readiness because it primarily: A. Identifies the location of healthcare supplies B. Identifies the types of disasters that may occur C. Aids determination of how victims will be triaged D. Describes a formal plan of action for the coordination of a response

D. Describes a formal plan of action for the coordination of a response

A Mexican-American client with epilepsy is being seen at the clinic for an initial examination. What is the primary purpose of including cultural information in the health assessment? A. Confirm the medical diagnosis B. Make accurate nursing diagnoses C. Identify any hereditary traits related to the epilepsy D. Determine what the client believes has caused the epilepsy

D. Determine what the client believes has caused the epilepsy

The nurse sees a nursing assistant talking in an unusually loud voice to a client with delirium. Which action should the nurse take? A. Informing the client that everything is all right B. Speaking to the nursing assistant immediately, while in the client's room, to solve the problem C. Explaining to the nursing assistant that yelling in the client's room is tolerated only if the client is talking loudly D. Determining that the client is safe, calmly asking the nursing assistant to join you outside the room, and informing the nursing assistant of the observation

D. Determining that the client is safe, calmly asking the nursing assistant to join you outside the room, and informing the nursing assistant of the observation

A community health nurse working in a school setting is concerned because parents are not participating in health activities designed to promote child safety. In this situation, the most appropriate initial action is: A. Implementing a child safety program B. Planning a focused child safety program C. Performing an analysis of health problems related to child safety D. Determining the appropriateness of the planned health activity

D. Determining the appropriateness of the planned health activity

A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. Which action should the nurse take first? A. Call a code B. Contact the health care provider C. Administer a bronchodilator D. Disconnect the suction source from the catheter

D. Disconnect the suction source from the catheter

A home health nurse is visiting a client with tuberculosis (TB). Which action by the client tells the nurse that the client understands the necessary respiratory precautions to be taken at home? A. Staying secluded in the bedroom B. Wearing an oxygen mask at all times C. Keeping the house closed up to minimize the spread of disease D. Disposing of contaminated tissues in a container with a leak-proof bag

D. Disposing of contaminated tissues in a container with a leak-proof bag

A nurse performing a physical assessment of a 12-month-old infant notes that the infant's head circumference is the same as the chest circumference. Based on this finding, what should the nurse do? A. Suspect the presence of hydrocephalus B. Suggest to the pediatrician that a skull x-ray be performed C. Tell the mother that the infant is growing faster than expected D. Document these measurements in the infant's health-care record

D. Document these measurements in the infant's health-care record

A nurse is assisting a new nursing graduate with organizational skills in delivering client care. The nurse determines that the new nursing graduate needs assistance with time management if he: A. Allows time for unexpected tasks B. Prioritizes client needs and daily tasks C. Gathers supplies before beginning a task D. Documents task completion and client information at the end of the day

D. Documents task completion and client information at the end of the day

A client receives cefazolin sodium (Ancef) by way of the intravenous route. During the infusion, the client begins exhibiting signs of an allergic reaction. The client states that his skin is itchy, and the nurse notes that the skin is warm and flushed, with a red rash on the arms, chest, and back. The nurse immediately discontinues the medication, further assesses the client, contacts the physician, and begins to document the reaction in an incident report. The nurse most accurately documents which of the following? A. The client had an allergy to cefazolin sodium. B. The health care provider was notified because a rash developed while the client was receiving cefazolin sodium. C. The client is apparently allergic to cefazolin sodium, as indicated by warm, flushed skin and a rash on the arms, chest, and back. D. During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified.

D. During an infusion of cefazolin sodium, the client complained that his skin was itchy. The client's skin was warm and flushed, with a red rash on the arms, chest, and back. The health care provider was notified.

A client is scheduled to undergo computerized tomography (CT) with contrast for evaluation of an abdominal mass. The nurse should provide the client with which information about the test? A. The test may be painful B. The test takes 2 to 3 hours C. Food and fluids are not allowed for 4 hours after the test D. Dye is injected and may cause a warm flushing sensation

D. Dye is injected and may cause a warm flushing sensation

A client who has received sodium bicarbonate in large amounts is at risk for metabolic alkalosis. For which signs and symptoms does the nurse assess this client? A. Disorientation and dyspnea B. Drowsiness, headache, and tachypnea C. Tachypnea, dizziness, and paresthesias D. Dysrhythmias and decreased respiratory rate and depth

D. Dysrhythmias and decreased respiratory rate and depth

A client is found to have viral hepatitis, and the nurse provides home care instructions to the client. The nurse should tell the client to: A. Maintain strict bed rest B. Limit the intake of alcohol C. Take acetaminophen for discomfort D. Eat small frequent meals that are low in fat and protein and high in carbohydrates

D. Eat small frequent meals that are low in fat and protein and high in carbohydrates

On assessing a client's skin, the nurse notes the presence of several large red-blue and purple areas on the client's body that do not blanch when pressure is applied. The nurse documents this finding as: A. Psoriasis B. Anasarca C. Petechiae D. Ecchymosis

D. Ecchymosis

A healthcare provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication? A. Insert a Foley catheter in the client B. Prepare the client for insertion of a central IV line C. Administer the medication with the use of a macrodrip IV tubing set D. Ensure that the medication is diluted in an appropriate amount of normal saline solution

D. Ensure that the medication is diluted in an appropriate amount of normal saline solution

A client complains that her skin is redder than normal. The nurse assesses the client's skin, documents hyperemia, and explains to the client that this condition is caused by which? A. Contraction of the underlying blood vessels B. A reduced amount of bilirubin in the blood C. Diminished perfusion of the surrounding tissues D. Excess blood in the dilated superficial capillaries

D. Excess blood in the dilated superficial capillaries

A nurse is providing discharge instructions to a client after outpatient surgery for cataract removal. The nurse determines that the client needs additional instructions if the client indicates that he will: A. Limit activity for 24 hours B. Take acetaminophen for discomfort C. Leave the eye patch in place until he has been seen by the health care provider D. Expect to experience pain, nausea, and vomiting after the procedure

D. Expect to experience pain, nausea, and vomiting after the procedure

A single mother whose only son died 2 months ago says to the nurse, "I've been bothered at work with thoughts of my son. Suddenly I'll think of something awful I said to him years ago or some punishment I gave him because he'd been bad." Which plan should the nurse include in caregiving? A. Scheduling the client for an appointment with the psychiatrist, because this is a pathological manifestation. B. Calling the health care provider to report that the client is a high risk for suicide and increasing the frequency of visits with the client. C. Seeking emergency certification for the psychiatric inpatient unit at the community hospital because of high lethality concerns and visiting the client daily. D. Explaining that bereaved persons often describe intrusive thoughts of negative experiences with the deceased and then increasing the frequency of nurse-client visits.

D. Explaining that bereaved persons often describe intrusive thoughts of negative experiences with the deceased and then increasing the frequency of nurse-client visits.

A nurse is providing instructions to an unlicensed assistive personnel (UAP) about effective measures for communicating with a hearing-impaired client. The nurse instructs the UAP to: A. Raise his voice when talking to the client B. Talk directly into the client's impaired ear C. Be cordial and smile when talking to the client D. Face the client when talking, keeping the hands away from the mouth

D. Face the client when talking, keeping the hands away from the mouth

A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope at the: A. Second left interspace B. Second right interspace C. Left lower sternal border D. Fifth left interspace at the midclavicular line

D. Fifth left interspace at the midclavicular line

A nurse has delegated several nursing tasks to staff members. The nurse's primary responsibility after delegation of the tasks is: A. Documenting completion of each task B. Assigning any tasks that were not completed to the next nursing shift C. Allowing each staff member to make judgments when performing the tasks D. Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task.

D. Following up with each staff member regarding the performance of the task and the outcomes related to implementation of the task.

Betaxolol eye drops have been prescribed for the treatment of a client's glaucoma. The nurse tells the client to return to the clinic for follow-up for which purpose? A. To have weight checked B. To give a sample for urinalysis C. To have the blood glucose level checked D. For measurement of blood pressure and apical pulse

D. For measurement of blood pressure and apical pulse

A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. The nurse should take which most appropriate action? A. Recheck the score in 5 minutes B. Initiate cardiopulmonary resuscitation C. Provide no action except to support the infant's spontaneous efforts D. Gently stimulate the infant by rubbing his back while administering oxygen

D. Gently stimulate the infant by rubbing his back while administering oxygen

The mother of a 9-month-old infant calls the nurse at the pediatrician's office, tells the nurse that her infant is teething, and asks what can be done to relieve the infant's discomfort. What should the nurse instruct the mother to do? A. Schedule an appointment with a dentist for a dental evaluation B. Rub the infant's gums with baby aspirin that has been dissolved in water C. Obtain an over-the-counter (OTC) topical medication for gum-pain relief D. Give the infant cool liquids or a Popsicle and hard foods such as dry toast

D. Give the infant cool liquids or a Popsicle and hard foods such as dry toast

A client in labor complains of back discomfort. Which position will best aid in relieving the discomfort? A. Prone B. Supine C. Standing D. Hands and knees

D. Hands and knees

A nurse notes documentation in a client's medical record indicating that the client is experiencing oliguria. On the basis of this notation, the nurse determines which about the client when planning care? A. Is unable to produce urine B. Is voiding large amounts of urine C. Has difficulty with leakage of urine D. Has a diminished capacity to form urine

D. Has a diminished capacity to form urine

A client tells the nurse that during the past 2 weeks her urine output has been greater than usual. The nurse, gathering subjective data from the client, should most appropriately ask the client about which? A. Has she been regularly exercising B. Has she been experiencing headaches C. Has she been having heavy menstrual cycles D. Has she been drinking an excessive amount of coffee

D. Has she been drinking an excessive amount of coffee

The nurse is supervising an unlicensed assistive personnel (UAP)in caring for a client who has just undergone lumbar spinal fusion after herniation of a lumbar disc. Which action by the UAP while repositioning the client would cause the nurse to intervene? A. Keeping the head of the bed flat B. Placing pillows beneath the full length of the legs C. Using a log-rolling technique for repositioning D. Having the client assist by using the overhead trapeze

D. Having the client assist by using the overhead trapeze

A client is receiving intermittent bolus feedings by way of a nasogastric tube. In which position should the nurse place the client once the feeding is complete? A. Supine B. Head of bed flat C. Left lateral position D. Head of bed elevated 30 to 45 degrees

D. Head of bed elevated 30 to 45 degrees

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. Based on this finding, what does the nurse determine? A. The results are negative B. The client needs to receive the hepatitis B series of vaccines C. The results indicate that the mother does not have hepatitis B D. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth

D. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth

A schizophrenic client is admitted to the inpatient psychiatric unit. The client is exhibiting clang associations, word salad, and loose associations. Which problem does the nurse recognize that the client is experiencing? A. Defensive coping B. Inability to cope effectively C. Sensory perception alterations D. Inability to communicate effectively

D. Inability to communicate effectively

The nurse is working with an older client who has been hospitalized and the client's family to formulate a plan for discharge. In guiding the discussion with the client and family, which living arrangement should the nurse understand most older persons prefer? A. Alone B. With their children C. In long-term care facilities D. Independently but close to their children

D. Independently but close to their children

A client is going to receive instruction in biofeedback technique to lower his stress level. The client asks the nurse to describe this technique. What should the nurse tell the client? A. It is a technique that trains the mind to elicit a relaxation response B. It is the purposeful use of one's imagination to achieve relaxation and control C. It involves learning to contract and relax muscles in a systematic way and may be combined with breathing exercises D. It is a therapeutic modality that enables an individual to monitor skin temperature, muscle activity, heart rate, blood pressure, and other bodily functions, then learn to control these physiologic responses to stressful or challenging events

D. It is a therapeutic modality that enables an individual to monitor skin temperature, muscle activity, heart rate, blood pressure, and other bodily functions, then learn to control these physiologic responses to stressful or challenging events

A nursing student is assigned to work in the emergency department to assist victims after a tornado. The student says to the nurse in charge, "I don't know how to help these parents. Their son was just decapitated by a flying piece of glass, and they won't leave him. They did mention that they are Catholic." Which intervention does the nurse suggest for inclusion in a plan of immediate care for the family? A. Telling the student not to disturb the family until the end of shift B. Calling their family priest immediately to come help them to let their son go C. Asking the emergency department health care provider to join the student in requesting that the family let the nursing staff care for their son D. Joining the family and, after they have been able to be with their son for some time, helping them relinquish their son's body to the nurses

D. Joining the family and, after they have been able to be with their son for some time, helping them relinquish their son's body to the nurses

The nurse plans outcomes for a client who is being treated for psychosis. Which step would be included during the stable or discharge phase of treatment? A. Evaluation of neurological status B. Use of directive communications with the client C. Administration of acute psychotropic medications D. Keeping the client active with hobbies, exercise, and work

D. Keeping the client active with hobbies, exercise, and work

A nurse performing a physical examination is assessing the client for costovertebral angle tenderness. When the nurse percusses the area, the client complains of sharp pain. The nurse interprets this finding as most indicative of: A. Liver enlargement B. Ovarian infection C. Spleen enlargement D. Kidney inflammation

D. Kidney inflammation

A nurse is preparing a female client for a rectal examination. Into which position does the nurse assist the client? A. Supine B. Standing C. Lithotomy D. Left lateral

D. Left lateral

A nurse is caring for a client who has undergone resection of an abdominal aortic aneurysm (AAA). Which action should the nurse implement to prevent graft occlusion? A. Monitoring urine output B. Monitoring bowel sounds C. Checking pedal pulses distal to the graft site D. Limiting elevation of the head of the bed to 45 degrees

D. Limiting elevation of the head of the bed to 45 degrees

A nurse is preparing to listen to the breath sounds of a client. The nurse should: A. Ask the client to lie prone B. Ask the client to breathe in and out through the nose C. Hold the bell of the stethoscope lightly against the chest D. Listen for at least one full respiration in each location on the chest

D. Listen for at least one full respiration in each location on the chest

A nurse is preparing to assist the physician in performing an internal gynecological examination of a client. In which of the following positions does the nurse place the client for this examination? A. Prone B. Left side-lying C. Sims D. Lithotomy

D. Lithotomy

A nurse is performing a skin and peripheral vascular assessment on a client in later adulthood. Which observation should the nurse expect to note as an age-related finding? A. Thin, ridged toenails B. Thick skin on the lower legs C. Bounding dorsalis pedis pulse D. Loss of hair on the lower legs

D. Loss of hair on the lower legs

A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first? A. Check the client's blood pressure B. Check the oxygen saturation level C. Have the client take some deep breaths D. Lower the head of the bed slowly until the dizziness is relieved

D. Lower the head of the bed slowly until the dizziness is relieved

A nurse is providing dietary instructions to a client with tuberculosis. Which foods would the nurse specifically instruct the client to include more of in the daily diet? A. Rice and fish B. Eggs and bacon C. Cereals and broccoli D. Meats and citrus fruits

D. Meats and citrus fruits

Immediately after delivery, the nurse assesses the woman's uterine fundus. At what location does the nurse expect to be able to palpate the fundus? A. In the pelvic cavity B. 2 cm above the umbilicus C. At the level of the umbilicus D. Midway between the symphysis pubis and umbilicus

D. Midway between the symphysis pubis and umbilicus

Mastitis is diagnosed in a client who recently gave birth. The nurse tells the woman that: A. Wearing a bra will increase the discomfort B. Antibiotics are not usually used to treat this disorder C. Breastfeeding must be discontinued until the condition resolves D. Moist heat will increase circulation and may be used before the breasts are emptied

D. Moist heat will increase circulation and may be used before the breasts are emptied

A nurse is preparing a plan of care for a client with a diagnosis of cancer who is receiving morphine sulfate for pain. Which action does the nurse identify as a priority in the plan of care for this client? A. Monitoring urine output B. Encouraging increased fluids C. Monitoring the client's temperature D. Monitoring the client's respiratory rate

D. Monitoring the client's respiratory rate

At a health screening clinic, a nurse is educating a young woman about breast self-examination (BSE). The nurse determines that the client demonstrates understanding when she states that: A. BSE must be performed every other month B. BSE is performed on the day menstruation begins C. Monthly BSE is the only way to ensure early detection of breast cancer D. Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down

D. Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down

The nurse observes that a client is pacing back and forth. The nurse asks the client how she is feeling, and the client responds by telling the nurse that she feels "out of control!" Which intervention is most appropriate initially to maintain a safe environment? A. Restraining the client B. Placing the client in seclusion C. Continuing to monitor the client D. Moving the client to a quiet room and talking about her feelings

D. Moving the client to a quiet room and talking about her feelings

Clomiphene (Clomid, Serophene) is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication. What should the nurse tell the couple? A. The couple should engage in coitus once a week during treatment B. The health care provider should be notified immediately if breast engorgement occurs C. If the oral tablets are not successful, the medication will be administered intravenously D. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies

D. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies

A client in the postanesthesia care unit has an as-needed prescription for ondansetron. Which occurrence would prompt the nurse to administer this medication to the client? A. Paralytic ileus B. Incisional pain C. Urine retention D. Nausea and vomiting

D. Nausea and vomiting

A client complains of feeling fatigued because of the need to get up several times during the night to urinate. The nurse documents that the client is experiencing which problem? A. Anuria B. Oliguria C. Polyuria D. Nocturia

D. Nocturia

A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing? A. Justice B. Fidelity C. Autonomy D. Nonmaleficence

D. Nonmaleficence

A nurse notes that a client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. How should the nurse interpret this data? A. Normal near vision B. Normal central vision C. Normal peripheral vision D. Normal ocular movements

D. Normal ocular movements

The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit? A. Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift B. Checking the crash cart to ensure that all needed supplies are readily available should an emergency arise C. Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed D. Obtaining the assigned medical record from the hospital's medical record room to review documentation made during a client's hospital stay

D. Obtaining the assigned medical record from the hospital's medical record room to review documentation made during a client's hospital stay

A client recovering from surgery has a large abdominal wound. Which food, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing? A. Steak B. Veal C. Cheese D. Oranges

D. Oranges

A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next? A. Calling the health care provider B. Calling the respiratory therapist C. Rechecking the pulse oximetry reading D. Oxygenating the client with 100% oxygen

D. Oxygenating the client with 100% oxygen

A nurse preparing to examine a client's eyes plans to perform a confrontation test. The nurse tells the client that this test measures: A. Near vision B. Color vision C. Distant vision D. Peripheral vision

D. Peripheral vision

The nurse plans to wear this protective mask (see figure) when caring for clients with certain disorders. What are these disorders? Select all that apply. A. Scabies B. Hepatitis A C. Tuberculosis D. Pharyngeal diphtheria E. Streptococcal pharyngitis F. Meningococcal pneumonia

D. Pharyngeal diphtheria E. Streptococcal pharyngitis F. Meningococcal pneumonia

A nurse is teaching a pregnant client about nutrition and food sources that are high in folic acid. Which food item does the nurse tell the client contains the highest amount of folic acid? A. Lettuce B. Oranges C. Broccoli D. Pinto beans

D. Pinto beans

A nurse is preparing for intershift report when an unlicensed assistive personnel (UAP) pulls an emergency call light in a client's room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first? A. Call the health care provider B. Check the hourly urine output C. Check the IV site for infiltration D. Place the client in a modified Trendelenburg position

D. Place the client in a modified Trendelenburg position

A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve? A. Asking the client to stick out his or her tongue and watching the client for tremors B. Touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex C. Depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says "ah." D. Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands

D. Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands

A client is admitted to the medical-surgical unit of a hospital, and suicide precautions are taken until the client can be admitted to the psychiatric unit. Which nursing intervention should the nurse implement? A. Placing the client in a private room and locking the client's closets and bathroom B. Placing the client in a private room and removing all knives and glass from the client's meal tray C. Allowing the client to go out on pass as long as the client is accompanied by a responsible adult D. Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping an arm's distance from the client at all times

D. Placing the client in a semiprivate room, providing plastic utensils for eating, and keeping an arm's distance from the client at all times

Which of the following situations is an example of the use of evidence-based practice in the delivery of client care? A. Encouraging a client who has had a stroke to consume thin liquids and foods B. Blowing on a fingerstick site to dry it after cleaning the site with an alcohol swab C. Immediately picking up a dislodged radiation implant with gloved hands and placing it in a lead container D. Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin

D. Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin

A community health nurse is asked to assist in developing a community disaster plan. The nurse determines that this responsibility is a component of which disaster management phase identified by the Federal Emergency Management Agency (FEMA)? A. Response B. Recovery C. Mitigation D. Preparedness

D. Preparedness

A nurse is telling a pregnant client about the signs that must be reported to the health care provider or nurse-midwife. The nurse tells the client that the health care provider or nurse-midwife should be contacted if which occurs? A. Morning sickness B. Breast tenderness C.Urinary frequency D. Puffiness of the face

D. Puffiness of the face

A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is most important? A. Administering a sedative B. Encouraging fluid intake C. Administering an oral preparation of radiopaque dye D. Questioning the client about allergies to iodine or shellfish

D. Questioning the client about allergies to iodine or shellfish

A nurse conducting a peripheral vascular assessment performs the Allen test. The nurse understands that this test is used to determine the patency of the: A. Capillaries B. Pedal pulses C. Femoral arteries D. Radial and ulnar arteries

D. Radial and ulnar arteries

The mother of a 9 year old child who is 5 feet 1 inch in height asks a nurse about car safety seats. What should the nurse tell the mother to use? A. Front booster seat B. Rear convertible seat C. Forward-facing car seat D. Rear seat using lap and shoulder seat belts

D. Rear seat using lap and shoulder seat belts

A client has a prescription for short-term therapy with enoxaparin . The nurse explains to the client that this medication is being prescribed for which purpose? A. Prevent pain B. Relieve back spasms C. Increase the client's energy level D. Reduce the risk of deep vein thrombosis

D. Reduce the risk of deep vein thrombosis

A client has been told to apply cold packs to a knee injury, and the client asks the nurse how this will help the injury. The nurse hould provide the clent with which information about a cold pack? A. Reduces muscle tension B. Dilates the blood vessels C. Promotes muscle relaxation D. Reduces blood flow to the extremity

D. Reduces blood flow to the extremity

A nurse manager notes that an employee is constantly calling in sick. Which action should the nurse manager take initially to handle this problem? A. Reporting the employee to administration B. Documenting the employee's behavior in the personnel file C. Telling the employee that she will be fired if she calls in sick again D. Reminding the employee of the employment standards of the agency

D. Reminding the employee of the employment standards of the agency

A nurse employed in a physician's office hears a client in the waiting room call out, "Help! Fire!" The nurse rushes to the waiting room and finds that the wastebasket is on fire. The nurse immediately: A. Confines the fire B. Extinguishes the fire C. Activates the fire alarm D. Removes the clients from the waiting room

D. Removes the clients from the waiting room

A client has the following arterial blood gas (ABG) results: pH 7.51, PaCO231 mm Hg (4.12 kPa), PaO2 94 mm Hg (12.45 kPa), HCO3 24 mEq/L (24 mmol/L). Which acid-base disturbance does the nurse recognize in these results? A .Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

D. Respiratory alkalosis

A nurse in the newborn nursery is monitoring a neonate born to a mother with diabetes mellitus. For which finding does the nurse monitor the neonatemost closely? A. Hypercalcemia B. Hyperglycemia C. Hypobilirubinemia D. Respiratory distress syndrome

D. Respiratory distress syndrome

A client with terminal cancer is receiving a continuous intravenous infusion of morphine sulfate. On assessment of the client, what does the nurse check first? A. Pulse B. Urine output C. Temperature D. Respiratory status

D. Respiratory status

A nursing staff member approaches a nurse manager and announces that another nurse is not using alcohol swabs to clean the intravenous port when administering intravenous push medications. What is the appropriate way for the nurse manager to handle this situation? A. Telling the nurse that it is inappropriate to report other nurses B. Providing an in-service educational session on aseptic technique for everyone on the nursing unit C. Informing the nurse who reported the occurrence that intravenous ports do not need to be cleaned with alcohol before medication administration D. Reviewing the skills checklist of the nurse who is not using aseptic technique to determine whether the nurse has ever performed this skill and had her technique validated

D. Reviewing the skills checklist of the nurse who is not using aseptic technique to determine whether the nurse has ever performed this skill and had her technique validated

A nurse is auscultating for vesicular breath sounds in a client. Of which quality would the nurse expect these normal breath sounds to be? A. Harsh B. Hollow C. Tubular D. Rustling

D. Rustling

A client in a mental health unit gets into a fight with another client over the use of the public telephone on the unit. The client is accused of making two telephone calls and staying on the telephone for 1 hour. Which intervention by the nurse would be most therapeutic? A. Taking telephone privileges away from both clients for the day and giving them time-outs in their rooms B. Saying to the clients, "Okay, this is the last straw. Neither of you may use the telephone until tomorrow, and then only with a nurse timing you." C. Saying to the clients, "Go to your rooms, both of you. I don't want to hear anything more about the telephone on this unit for at least 2 hours." D. Saying to the clients, "You may each use the phone for 10 minutes. I will time the calls for both of you. Do you both agree to abide by my decision?"

D. Saying to the clients, "You may each use the phone for 10 minutes. I will time the calls for both of you. Do you both agree to abide by my decision?"

A homeless client with an antisocial disorder is brought to the emergency department by the police after disturbing customers in a department store. The client says to the nurse, "I need to be hospitalized. It's getting cold out, and I need a warm bed. If you don't get me into a hospital, I'll jump off a bridge." Which nursing intervention would be therapeutic? A. Sending the client to the psychiatric hospital intake center immediately for evaluation B. Asking the police to pick the client up and arrest him for vagrancy, as they should have done immediately C. Discharging the client with a follow-up appointment for the next day and guaranteeing him a hospital bed if he shows up D. Sending the client to a shelter that will provide temporary housing if he signs a contract agreeing not to attempt suicide

D. Sending the client to a shelter that will provide temporary housing if he signs a contract agreeing not to attempt suicide

A nurse notices a paranoid stare during a conversation with a client. The client then begins to fidget and gets up to pace around the room. Which action by the nurse would be beneficial? A. Allowing the client to pace B. Escorting the client to a quiet room C. Changing the conversation to a less threatening subject D. Sharing the observation with the client and helping the client recognize and acknowledge his or her feelings

D. Sharing the observation with the client and helping the client recognize and acknowledge his or her feelings

A nurse is caring for a hospitalized child with a diagnosis of Kawasaki disease. During the subacute phase, the nurse monitors the child closely for: A. Bleeding B. A high fever C. Failure to thrive D. Signs of congestive heart failure (CHF)

D. Signs of congestive heart failure (CHF)

A nurse is examining the peripheral vision of a client using the confrontation test. How should the nurse carry out this procedure? A. Asks the client to discriminate numbers on a chart composed of colored dots B. Darkens the room and asks the client to identify colored blocks and shapes that appear in the visual field C. Has both the client and nurse cover the right eye, stare at each other's uncovered eye, and bring a small object into the visual field, then repeat the test with the left eye D. Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field

D. Sits at eye level with the client, covers one eye, and has the client cover the eye directly opposite the nurse's, after which each stares at the other's uncovered eye and the nurse brings a small object into the visual field

A client with a history of multiple somatic complaints involving several organ systems has no evidence of organic pathologic conditions. It is important for the nurse planning care for this client to understand that the client is afflicted with which disorder? A. Paranoia B. Depression C. Schizophrenia D. Somatization disorder

D. Somatization disorder

The nurse is trying to deescalate aggressive behavior exhibited by a client with schizophrenia. Which nursing action would be contraindicated in this situation? A. Being assertive with the client B. Negotiating options with the client C. Maintaining a nonaggressive posture D. Standing close to the client and telling the client that the behavior is unacceptable

D. Standing close to the client and telling the client that the behavior is unacceptable

A nurse is assisting a client with a closed chest tube drainage system in bathing. As the nurse is turning the client onto his side, the chest tube is disconnected. What should the nurse do first? A. Call the health care provider B. Clamp the chest tube with a Kelly clamp C. Instruct the client to inhale and hold his breath D. Submerge the end of the chest tube in a bottle of sterile water

D. Submerge the end of the chest tube in a bottle of sterile water

The nurse is preparing to change the solution bag and intravenous tubing of a client receiving total parenteral nutrition (TPN) through a left subclavian central venous line. Which essential action does the nurse ask the client to perform just before switching the tubing? A. Turn the head to the left B. Turn the head to the right C. Exhale slowly and evenly D. Take a deep breath and hold it

D. Take a deep breath and hold it

The nursing instructor enters a classroom to begin class and finds two students yelling and physically assaulting each other. Which intervention by the instructor would be most appropriate? A. Walking out of the classroom and asking the secretary to call security, then telling all of the students to leave and go to the nursing laboratory B. Getting the class to leave with her and sending everyone to the nursing laboratory, then calling security to the classroom and reentering to observe what is happening with the two students. C. Telling the class, "Take a break. I'll come and get you to restart class as soon as I can," then closing the classroom door, refusing to let anyone else in, and asking a passing instructor to get security D. Telling the class to go to the nursing laboratory at once, then asking a student to tell the nursing secretary to have security come to the classroom, and asking the students who are fighting to stop fighting and take their seats

D. Telling the class to go to the nursing laboratory at once, then asking a student to tell the nursing secretary to have security come to the classroom, and asking the students who are fighting to stop fighting and take their seats

A client who has sustained a myocardial infarction is scheduled to have an echocardiogram. Which measure should the nurse take before the procedure? A. Imposing nothing-by-mouth (NPO) status for 4 hours B. Asking the client to sign an informed consent form C. Asking the client about a history of allergy to iodine or shellfish D. Telling the client that the procedure is painless and takes 30 to 60 minutes to complete

D. Telling the client that the procedure is painless and takes 30 to 60 minutes to complete

A woman has been scheduled for a routine mammogram. The nurse should provide the client with which information about the test? A. That mammography takes about 1 hour B. Not to eat or drink on the morning of the test C. That there is no discomfort associated with the procedure D. That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test

D. That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test

A nurse provides home care instructions to a client after a scleral buckling procedure. The nurse should tell the client: A. To maintain strict bedrest for 48 hours B. To expect bloody drainage on the eye dressing C. That vision will be perfectly clear immediately after surgery D. That redness and swelling of the eyelids and conjunctiva are expected

D. That redness and swelling of the eyelids and conjunctiva are expected

A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. What should the nurse tell the client? A. The procedure takes about 2 hours B. She will be positioned on her back for the procedure C. A probe coated with gel will be inserted into the vagina D. That she may need to drink fluids before the test and may not void until the test has been completed

D. That she may need to drink fluids before the test and may not void until the test has been completed

A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what should the nurse assessfirst? A. The client's vital signs B. The amount of drainage C. The client's lung sounds D. The chest tube connections

D. The chest tube connections

The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse should tell the mother that which observation is a sign of physical readiness? A. The child has been walking for 2 years. B. The child can eat using a fork and knife. C. The child no longer has temper tantrums. D. The child can remove his or her own clothing.

D. The child can remove his or her own clothing.

A client about to undergo surgery is instructed in postoperative pain relief measures is asked whether he would like to use a patient-controlled analgesia (PCA) pump. The client asks the nurse to describe the pump. Which information should the nurse provide to the client? A. The PCA pump eliminates the need for an intravenous (IV) line B. The client will be able to deliver his own dose of medication every 4 hours C. The client's spouse will be able to administer medication for the client D. The client administers his own medication by pressing a control button

D. The client administers his own medication by pressing a control button

The nurse caring for a schizophrenic client is assessing the client's ability to control distorted thought processes. Which finding indicates a positive outcome? A. The client is able to identify when hallucinations or delusions are real. B. The client can describe in detail the frequency and context of the hallucinatory and delusional behavior. C. The client can describe the hallucinations and delusions in detail and is able to interact with others and share in their delusional systems. D. The client can identify the recurrence of hallucinations, can refrain from responding to them, and reports a significant decrease in the incidence of hallucinations.

D. The client can identify the recurrence of hallucinations, can refrain from responding to them, and reports a significant decrease in the incidence of hallucinations.

The nurse is reading the medical record of a client who has a diagnosis of moderate anxiety and notes that the health care provider has documented that the client exhibits eustress. Based on this information, which finding would the nurse expect to encounter while assessing the client? A. The client complains of fatigue. B. The client complains of feeling drained. C. The client complains of feeling anxious. D. The client engages in purposeful movement.

D. The client engages in purposeful movement.

The nurse is collecting data from a client in crisis and assessing the potential for self-harm. Which finding indicates that the client is at high risk for suicide? A. The client is impulsive. B. The client is disorganized. C. The client has a history of suicide attempts. D. The client has an immediate plan for a suicide attempt.

D. The client has an immediate plan for a suicide attempt.

A nurse reviews the health history of a client who will be seeing the health care provider to obtain a prescription for a combination oral contraceptive (estrogen and progestin). Which finding in the health history would cause the nurse to determine that use of a combination oral contraceptive is contraindicated? A. The client has hyperlipidemia. B. The client has type 2 diabetes mellitus. C. The client is being treated for hypertension. D. The client has been treated for breast cancer.

D. The client has been treated for breast cancer.

The nurse collects data from an older client and monitors him for signs of abuse. Which psychosocial factor does the nurse recognize as placing the client at risk for abuse? A. The client lives alone. B. The client is independent. C. The client shows signs and symptoms of depression. D. The client is completely dependent on family members for food and medicine.

D. The client is completely dependent on family members for food and medicine.

The nurse working in the emergency department is performing an initial assessment on a client, and notes many physical injuries. The nurse suspects family-related violence. Which finding is specific to this type of violence? A. The client lives in an assisted living facility. B. The client is financially dependent on him or herself. C. The client relies on neighbors and friends for transportation to and from appointments. D. The client lives with one of their children and requires extensive assistance with activities of daily living.

D. The client lives with one of their children and requires extensive assistance with activities of daily living.

A nurse provides information to a client who is scheduled for cardiac catheterization to rule out coronary occlusion. The nurse should provide which information to the client? A. The procedure is performed in the operating room B. It is necessary to lie quietly on a hard x-ray table for about 4 hours C. The room is bright and well lit, and it is best to keep the eyes closed D. The client may have feelings of warmth or flushing during the procedure

D. The client may have feelings of warmth or flushing during the procedure

A client comes to the mental health clinic after losing all of his personal belongings in a hurricane. The client tells the nurse that the loss of his possessions is his fault because he didn't prepare for the storm. The nurse determines that the client is coping ineffectively and develops goals with the client. Which goal is the least realistic? A. The client will identify effective coping skills. B. The client will develop and use adaptive coping patterns. C. The client will express and share his feelings about this crisis. D. The client will stop blaming himself for the loss of his belongings.

D. The client will stop blaming himself for the loss of his belongings.

A client who has been referred for group therapy asks the nurse about the therapy. The nurse tells the client that this type of therapy is focused on which purpose? A. Social skills training B. Social functioning in groups C. Cognitive behavioral therapy D. The development of interpersonal skills, resolution of family problems, and effective use of community support

D. The development of interpersonal skills, resolution of family problems, and effective use of community support

A nurse is providing information to the mother of an 18-month-old about bowel training. The nurse should provide the mother with which information? A. The child should be able to control defecation at the age of 18 months B. The child will let you know when she is ready to begin bowel training C. Girls usually achieve the neuromuscular development necessary for controlling defecation much sooner than boys do D. The neuromuscular development needed to control defecation does not take develop until 2 to 3 years of age

D. The neuromuscular development needed to control defecation does not take develop until 2 to 3 years of age

During a laboratory training session, the nurse is watching as a nursing assistant repositions a client. Which observation tells the nurse that further training is necessary? A. The nursing assistant positions himself close to the client. B. The nursing assistant keeps his neck, back, pelvis, and feet aligned. C. The nursing assistant encourages the client to assist as much as possible. D. The nursing assistant keeps his knees straight and his feet close together.

D. The nursing assistant keeps his knees straight and his feet close together.

A nursing instructor is observing a nursing student who is practicing the use of standard precautions in the nursing laboratory. Which of the following observations by the instructor indicates a need for further teaching? A. The nursing student changes gloves between tasks and procedures. B. The nursing student washes hands before making contact with the client. C. The nursing student wears a gown to change the bed of an incontinent client. D. The nursing student washes her hands before glove removal after emptying a Foley bag.

D. The nursing student washes her hands before glove removal after emptying a Foley bag.

A client arrives in the emergency department in a crisis state. The client demonstrates signs of profound anxiety and is unable to focus on anything but the object of the crisis and the impact on herself. The nurse plans to focus the initial assessment on which client factor? A. Sources of support B. The object of the crisis C. The client's coping mechanisms D. The physical condition of the client

D. The physical condition of the client

A 30-year-old client says to the nurse, "I want to die. I think about it a lot, but I don't know how in the world to do it." Based on the client's statement, what does the nurse determine? A. There is no suicide risk B. There is a minimal suicide risk C. Suicide has been attempted unsuccessfully D. The risk for suicide exists and continued assessment is needed

D. The risk for suicide exists and continued assessment is needed

A nurse is conducting a psychosocial assessment of a young adult. Which observations would lead the nurse to determine that the client is demonstrating a sign of emotional health? Select all that apply. A. The young adult is sensitive to criticism. B. The young adult verbalizes unrealistic fears. C. The young adult verbalizes disappointment with life. D. The young adult verbalizes satisfaction with friendships. E. The young adult has a sense of meaning and direction in life.

D. The young adult verbalizes satisfaction with friendship. E. The young adult has a sense of meaning and direction in life.

A client with newly diagnosed angina pectoris has taken 2 sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client complains of a headache. What should the nurse tell the client? A. This is an indication that the medication should not be used again B. Headache indicates medication tolerance, and the dosage must be increased C. This may be an allergic reaction to the nitroglycerin, and the health care provider must be notified D. This is an expected side effect of the nitroglycerin, and the client can relieve it by taking acetaminophen

D. This is an expected side effect of the nitroglycerin, and the client can relieve it by taking acetaminophen

A nurse is changing the central line dressing of a client receiving total parenteral nutrition (TPN). The nurse notes moisture under the dressing covering the catheter insertion site. What should the nurse assess next? A. Temperature B. Time of the last dressing change C. Expiration date on the infusion bag D. Tightness of the tubing connections

D. Tightness of the tubing connections

A nurse is providing post-procedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should provide the client with which information? A. To resume full activity the next day B. Not to eat or drink anything until the next morning C. To keep the shoulder completely immobilized for the rest of the day D. To report to the health care provider the development of fever or redness and heat at the site

D. To report to the health care provider the development of fever or redness and heat at the site

Zidovudine (is prescribed for an adult client with HIV infection. The nurse should provide which instruction to the client about the medication? A. That the medication must be taken with milk B. That aspirin can be taken to treat headache C. To discontinue the medication if nausea occurs D. To space the doses evenly around the clock

D. To space the doses evenly around the clock

A nurse answers the call bell of a client who has been fitted with an internal cervical radiation implant, and the client states that she thinks that the implant has fallen out. The nurse checks the client and sees the implant lying in the bed. Which action should the nurse take first? A. Calling the health care provider B. Reinserting the implant into the client's vagina C. Picking up the implant with gloved hands and placing it in sterile water D. Using long-handled forceps to place the implant in a lead container

D. Using long-handled forceps to place the implant in a lead container

A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. What should the nurse tell the clients? A. It is best to do grocery shopping and other errands late in the day B. They must stay in the house and ask a neighbor or family member to run their errands C. Drinking eight 8-oz glasses of fluid each day will reduce the risk of contracting influenza D. Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses

D. Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses

A furious and aggressive client is put in restraints and told that the restraints will be removed once the she regains control. At which time is removal of the restraints by the nurse appropriate? A. When medication that has been administered has taken effect B. When the client apologizes and tells the nurse that it will never happen again C. When the nurse explores with the client the reasons for the angry and aggressive behavior D. When no acts of aggression are observed in the hour following the release of two extremity restraints

D. When no acts of aggression are observed in the hour following the release of two extremity restraints

The client is the wife of a former workaholic who now has not worked in years, refusing to get a job or help with chores around the house. The man watches television and snacks all day. The client tells the nurse that her husband now weighs more than 300 lb and expects her to support him. The client states, "I keep saying everything will be fine. It will be if he keeps up these bad health habits, because they'll kill him, and then I would be free and wouldn't have to deal with his obnoxious behavior." Which negative stress response does the nurse recognize in the client's behavior? A. Blaming B. Daydreaming C. Problem- solving D. Wishful thinking

D. Wishful thinking

A home care nurse is instructing a client in the use of ice packs to treat an eye injury. The nurse instructs the client to: A. Place the ice pack directly on the eye B. Avoid the use of commercially prepared ice bags C. Keep the ice pack on the eye continuously for 24 hours D. Wrap a plastic bag filled with ice in a pillowcase and place it on the eye

D. Wrap a plastic bag filled with ice in a pillowcase and place it on the eye

A nurse helps a young adult conduct a personal lifestyle assessment. Why should the nurse carefully review the assessment with the young adult? A. Young adults ignore their risk for a serious illness B. Young adults are unable to afford health insurance C. Young adults are exposed to hazardous substances D. Young adults ignore physical symptoms and postpone seeking health care

D. Young adults ignore physical symptoms and postpone seeking health care

The nurse determines that the client is exhibiting signs of a hemolytic transfusion reaction while receiving a blood transfusion. The nurse should perform these actions in which priority order? Arrange the actions in the order that they should be performed. All options must be used.

The correct order is: Documenting the findings Obtaining vital signs/oxygen saturation Hanging an IV bag of normal saline solution (NS) at a keep-vein-open (KVO) rate Notifying the health care provider Stopping the infusion of blood

A nurse hears someone calling, "Help! My bed is on fire!" On entering the room, the nurse finds a client trying to beat out the flames with a pillow. Place in order of priority the actions that the nurse should take:

The correct order is: Removing the client from the room Pulling the nearest fire alarm Closing the door to the room Running to get the nearest fire extinguisher

Place in order of priority the actions that the nurse should take to perform hand-washing procedure.

The correct order is: Wet the hands and wrists, keeping the hands lower than the elbows. Obtain 3 to 5 mL of soap from the dispenser. Wash all surfaces for 15 to 30 seconds. Rinse the hands and wrists. Dry the hands. Turn off the water faucet.

The serum theophylline level of a client who is taking the medication (Theo-24) is 16 mcg/mL. On the basis of this result, the nurse should take which action initially? A. Document the normal value on the chart B. Call the health care provider immediately C. Call the rapid response team to help with the emergency D. Call the pharmacy to alert the pharmacist regarding the client's theophylline level

A. Document the normal value on the chart

A nurse administers a tap water enema to an adult client who is constipated. The client defecates a scant amount of brown fecal matter, which the nurse interprets as a poor result. The nurse should take which action? A. Document the results B. Administer a second tap water enema C. Add soap suds to the enema bag and repeat the enema D. Administer a Fleet enema, then a tap water irrigation

A. Document the results

A nurse performing a genital examination of a male client notes that the skin of the penis and scrotum is wrinkled. On the basis of this finding, the nurse: A. Documents the normal finding B. Checks for penile discharge, because this finding indicates infection C. Palpates for a mass in the scrotum, because wrinkling indicates the presence of one D. Obtains additional subjective data from the client, focusing on the scrotal abnormality

A. Documents the normal finding

A nurse suspects that a client has a distended bladder. On percussing the client's bladder, which finding does the nurse expects to note if the bladder is full? A. Dull sounds B. Hyperresonance sounds C. Hypoactive bowel sounds D. An absence of bowel sounds

A. Dull sounds

A nurse is preparing to measure a client's calf circumference. The nurse performs this procedure by: A. Placing a tape measure around the widest point of the lower leg B. Measuring 2 inches above the knee and placing the tape measure around the client's leg at this point C. Measuring 2 inches above the ankle and placing the tape measure around the client's leg at this point D. Measuring 2 inches below the patella and placing the tape measure around the client's leg at this point

A. Placing a tape measure around the widest point of the lower leg

A nurse is instructing a client about the foods that will acidify the urine and inhibit the growth of microorganisms. Which foods does the nurse tell the client are most likely to acidify the urine? Select all that apply. A. Plums B. Prunes C. Apples D. Broccoli E. Cabbage F. Cranberries

A. Plums B. Prunes F. Cranberries

A nurse checks the residual volume from a client's nasogastric tube feeding before administering an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before administering the prescribed 100 mL of formula to the client? A. Pour the residual volume into the nasogastric tube through a syringe with the plunger removed B. Discard the residual volume properly and record it as output on the client's fluid balance record C. Dilute the residual volume with water and inject it into the nasogastric tube, applying pressure on the plunger D. Mix the residual volume with the formula and pour it into the nasogastric tube, using a syringe without a plunger

A. Pour the residual volume into the nasogastric tube through a syringe with the plunger removed

The registered nurse has accepted a new position as case manager in a hospital. Which responsibilities are part of the nurse's new role? Select all that apply. A. Evaluating and updating the plan of care as needed B. Prescribing treatments specific to the client's needs C. Assessing the client's needs for home supplies and equipment D. Coordinating consultations and referrals to facilitate discharge E. Establishing a safe and cost-effective plan of care with the client

A. Evaluating and updating the plan of care as needed C. Assessing the client's needs for home supplies and equipment D. Coordinating consultations and referrals to facilitate discharge E. Establishing a safe and cost-effective plan of care with the client

A health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospital's stoma nurse to visit the client and assist the client with care of the colostomy. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client because of his: A. Expert power B. Reward power C. Referent power D. Coercive power

A. Expert power

Metoprolol has been prescribed for a client with hypertension. For which common side effects of the medication does the nurse monitor the client?Select all that apply. A. Fatigue B. Dry eyes C. Weakness D. Impotence E. Nightmares

A. Fatigue C. Weakness D. Impotence

Carbamazepine is prescribed for a client with trigeminal neuralgia. Which side/adverse effects does the nurse instruct the client to report to the health care provider? Select all that apply. A. Fever B. Nausea C. Headache D. Sore throat E. Mouth sores

A. Fever D. Sore throat E. Mouth sores

A nurse is palpating a client's sinus areas. Which sensation does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal? A. Firm pressure B. Pain behind the eyes C. Pain during palpation D. Pressure producing an acute headache

A. Firm pressure

An unlicensed assistive personnel (UAP) is providing morning care to a client with a fractured leg who is in skeletal traction. The nurse determines that the UAP needs instruction regarding the guidelines for client bathing if the UAP is implementing which action? A. Giving the client a complete bed bath B. Pulling the room curtains around the bathing area C. Turning up the thermostat in the client's room for the bath D. Keeping the side rails (per agency policy)up while away from the client

A. Giving the client a complete bed bath

A nurse is developing a bowel-training program for a client after a stroke. Which interventions are appropriate for inclusion in the plan? Select all that apply. A. Providing privacy and time for defecation B. Assisting the client into a sitting position C. Limiting the amount of fiber in the client's diet D. Providing a cool drink before defecation time E. Initiating defecation measures every day at the same time F. Administering a cathartic suppository a half-hour before defecation time

A. Providing privacy and time for defecation B. Assisting the client into a sitting position E. Initiating defecation measures every day at the same time F. Administering a cathartic suppository a half-hour before defecation time

A nurse is using an otoscope to inspect the ears of an adult client. Which action does the nurse take before inserting the otoscope? A. Pulling the pinna up and back B. Pulling the pinna down and forward C. Tipping the client's head down and toward the examiner D. Tipping the client's head down and away from the examiner

A. Pulling the pinna up and back

A nurse is caring for a client who has lost a significant amount of blood as a result of complications during a surgical procedure. Which parameter does the nurse recognize as the earliest indication of new decreases in fluid volume? A. Pulse rate B. Blood pressure C. Pulmonary artery systolic pressure D. Pulmonary artery end-diastolic pressure

A. Pulse rate

A nurse has just hung a transfusion of packed red blood cells and stayed with the client for the appropriate amount of time. Before leaving the room, the nurse tells the client that it is most important to immediately report which specific signs if it occurs? Select all that apply. A. Rash B. Chills C. Fatigue D. Backache E.Tiredness

A. Rash B. Chills D. Backache

A nurse assessing a client in the fourth stage of labor notes that the uterine fundus is firmly contracted and is midline at the level of the umbilicus. On the basis of this finding, the nurse most appropriately: A. Records the findings B. Massages the fundus C. Contacts the health care provider D. Helps the mother void

A. Records the findings

A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson's theory of psychosocial development, what should the nurse tell the group about the infants? A. Rely on the fact that their needs will be met B. Need to tolerate a great deal of frustration and discomfort to develop a healthy personality C. Must have needs ignored for short periods to develop a healthy personality D. Need to experience frustration, so it is best to allow an infant to cry for a while before meeting his or her needs

A. Rely on the fact that their needs will be met

A client is admitted to the psychiatric unit after a serious suicide attempt involving a drug overdose. What is the priority nursing intervention? A. Remain with the client at all times B. Request that a family member remain with the client at all times C. Remove the client's clothing and dress the client in a hospital gown D. Place the client in a seclusion room from which all potentially dangerous articles have been removed

A. Remain with the client at all times

A nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the nurse should take which action first? A. Remove the IV catheter B. Slow the rate of infusion C. Notify the health care provider D. Check for loose catheter connections

A. Remove the IV catheter

A client rings the call bell and complains of pain at the site of an IV infusion. The nurse assesses the site and determines that phlebitis has developed. Which actions should the nurse take? Select all that apply. A. Removing the IV catheter at that site B. Applying warm, moist compresses to the IV site C. Notifying the health care provider about the finding D. Encouraging the client to scrub the site while in the shower E. Starting a new IV line in a proximal portion of the same vein

A. Removing the IV catheter at that site B. Applying warm, moist compresses to the IV site C. Notifying the health care provider about the finding

A nurse provides dietary instructions to the mother of a child with celiac disease. Which food does the nurse tell the mother to include in the child's diet? A. Rice B. Wheat cereal C. Rye crackers D. Oatmeal biscuits

A. Rice

A nurse is providing dietary instructions to a client taking spironolactone. Which foods does the nurse instruct the client are acceptable to consume?Select all that apply. A. Rice B. Cereal C. Carrots D. Bananas E.Citrus fruits

A. Rice B. Cereal C. Carrots

A nurse provides dietary instructions to a client with cholecystitis. Which menu selection by the client indicates to the nurse that the client understands the instructions? A. Roast turkey with a baked potato B. Fruit plate with fresh whipped cream C. Fried chicken with macaroni and cheese D. Barbecued spare ribs with buttered noodles

A. Roast turkey with a baked potato

Which actions should the nurse take in the event of an accidental poisoning? Select all that apply. A. Saving vomitus for laboratory analysis B. Placing the client in the supine position C. Determining the type and amount of substance ingested D. Removing any visible materials from the nose and mouth E. Inducing vomiting if a household cleaner has been ingested F. Assessing the client's airway patency, breathing, and circulation

A. Saving vomitus for laboratory analysis C. Determining the type and amount of substance ingested D. Removing any visible materials from the nose and mouth F. Assessing the client's airway patency, breathing, and circulation

The charge nurse on the 11 pm-to-7 am shift is gathering the nursing staff together to listen to the 3-to-11 pm intershift report. The charge nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol intoxication. Which is the most appropriateaction for the charge nurse to take? A. Send the staff member home B. Ask the staff member how much alcohol she has consumed C. Tell the staff member that she is not allowed to administer medications D. Ask the staff member to rest in the nurses' lounge until the effects of the alcohol wear off

A. Send the staff member home

A 17-year-old client arrives at the clinic and asks to be examined because she believes that she has contracted a sexually transmitted infection. In regard to informed consent, the nurse tells the client that: A. She will need to sign an informed consent form B. Her mother or father will need to be contacted for permission to treat her C. Anyone over the age of 18 years may sign a consent form for her treatment D. A consent form is not needed if the problem is a sexually transmitted infection

A. She will need to sign an informed consent form

A community health nurse is providing information to local residents about the transmission of anthrax. Through which body systems does the nurse tell the residents that anthrax can be contracted? Select all that apply. A. Skin B. Lung C. Immune D. Urinary E. Lymphatic F. Gastrointestinal

A. Skin Correct B. Lungs Correct F. Gastrointestinal Correct

A schizophrenic client says, "I feel like I'm rotting away inside and all of my organs are rusting." Which type of delusion does the nurse identify in the client's statement? A. Somatic B. Jealousy C. Persecution D. Idea of reference

A. Somatic

The nurse is instructing a client with hypertension about foods that are low in sodium. Which menu selections by the client indicate to the nurse that the client understands what has been taught? Select all that apply. A. Spaghetti with fresh tomatoes B. Boiled lobster with baked potato C. Grilled chicken with turnip greens D. Instant hot cereal with bacon E. Tomato soup with a ham sandwich

A. Spaghetti with fresh tomatoes C. Grilled chicken with turnip greens

A nurse is monitoring a woman who is receiving oxytocin (Pitocin) to induce labor. Which action should the nurse, on suddenly noting the presence of late decelerations on the fetal heart rate (FHR) monitor, take first? A. Stopping the oxytocin infusion B. Notifying the nurse-midwife or health care provider C. Checking the woman's blood pressure and pulse D. Increasing the intravenous (IV) rate of the nonadditive solution

A. Stopping the oxytocin infusion

A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz. The nurse notes that the infant now weighs 13 lb. Which action should the nurse take? A. Tell the mother that the infant's weight is increasing as expected B. Tell the mother to decrease the daily number of feedings because the weight gain is excessive C. Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizes D. Tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate

A. Tell the mother that the infant's weight is increasing as expected

A nurse performs a nonstress test on a pregnant client. The nurse determines that the results are nonreactive if which finding is noted on the electronic monitoring recording strip? A. Absence of accelerations after fetal movement B. Accelerations without fetal movement with fetal heart rate (FHR) increases of 15 beats per minute for 15 seconds C. Acceleration of the FHR by 25 to 30 beats per minute for at least 15 seconds in response to fetal movement D. Two fetal heart accelerations within a 20-minute period, peaking at 15 beats per minute above baseline and lasting 15 seconds from baseline to baseline

A. Absence of accelerations after fetal movement

A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department of an area hospital is advised to prepare for causalities. Which action should the nurse manager who receives the telephone call regarding this warning take first? A. Activating the agency disaster plan B. Supplying the triage rooms with additional equipment C. Increasing the number of nursing staff for the day on which the hurricane is expected D. Calling the hospital maintenance department to secure the building against the storm

A. Activating the agency disaster plan

A client with schizophrenia has been taking an antipsychotic medication for 2 months. For which adverse effect should the nurse monitor the client closely? A. Akathisia B. Pelvic thrusts C. Athetoid limbs D. Protruding tongue

A. Akathisia

Which client does the nurse recognize as being at the greatest risk for injury resulting from the use of heat or cold application? A. An older client B. A client with renal calculi C. A client with osteoporosis D. A client with rheumatoid arthritis

A. An older client

A client in the third trimester of pregnancy is experiencing painless vaginal bleeding, and placenta previa is suspected. For which intervention does the nurse prepare the client? A. An ultrasound examination B. Internal fetal monitoring C. Administration of oxytocin (Pitocin) D. A manual (digital) pelvic examination

A. An ultrasound examination

A nurse performing an assessment of a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. How should the nurse document this finding? A. Anasarca B. Ecchymosis C. Unilateral edema D. Increased vascularity of the skin tissue

A. Anasarca

A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate? A. Applying an ice pack to the perineum B. Contacting the nurse-midwife or health care provider C. Administering an intravenous (IV) opioid analgesic D. Assisting the woman in taking a warm sitz bath

A. Applying an ice pack to the perineum

A licensed practical nurse (LPN) tells the registered nurse (RN) that she administered acetaminophen (Tylenol) to a client by way of the rectal route rather than the prescribed oral route because the client was extremely nauseated. The RN most appropriately: A. Asks the LPN to complete and file an incident report B. Asks the LPN to check the client in 30 minutes to see whether the nausea has subsided C. Tells the LPN that she made a sound judgment in administering the medication by way of the rectal route D. Instructs the LPN to write "pr" (per rectum) on the medication record next to the time at which the medication was administered

A. Asks the LPN to complete and file an incident report

A 16-year-old girl visits the women's health clinic to obtain information about birth control because she is sexually active and wants to avoid pregnancy. The nurse who is interviewing the client should first: A. Assess the client's knowledge of available birth control methods B. Inform the client that birth control methods cannot be discussed unless the client's boyfriend is present C. Tell the client that for her age and lifestyle, birth control pills would be the easiest method of contraception D. Give the client written material about various birth control methods and ask her to read them and to call if she has any questions

A. Assess the client's knowledge of available birth control methods

A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client? A. Assess the patency of the airway B. Check tubes and drains for patency C. Check the dressing for bleeding D. Assess the vital signs to compare them with preoperative measurements

A. Assess the patency of the airway

A client arrives in the emergency department for treatment of a surface injury sustained when sand blew into the eye. Which action does the nurse take first? A. Assessing the client's vision B. Placing ice on the eye C. Removing the sand particles D. Irrigating the eye with sterile saline solution

A. Assessing the client's vision

A home care nurse is visiting an older client who has been recovering from a mild brain attack (stroke) affecting her left side. The client lives alone but receives regular assistance from her daughter and son, who both live within 10 miles. Which of the following actions should the nurse take to assess the client's safety risk? Select all that apply. A. Assessing the client's visual acuity B. Observing the client's gait and posture C. Evaluating the client's muscle strength D. Looking for any hazards in the home environment E. Asking a family member to move in with the client until her recovery is complete F. Requesting that the client transfer to an assisted living environment for at least 1 month

A. Assessing the client's visual acuity B. Observing the client's gait and posture C. Evaluating the client's muscle strength D. Looking for any hazards in the home environment

A nurse performing a neurological assessment is preparing to assess the optic nerve. The nurse performs this examination by: A. Assessing visual acuity B. Inspecting the eyelids for ptosis C. Assessing pupil constriction D. Assessing ocular movements

A. Assessing visual acuity

A nurse is planning client assignments for the day. Which of the following assignments is the least appropriate for the nursing assistant? A. Assisting a client with dysphagia in eating B. Providing hygiene to a client with dementia C. Ambulating a client with Parkinson's disease D. Assisting a client with an above-the-knee amputation in showering

A. Assisting a client with dysphagia in eating

A client with liver cancer who is undergoing chemotherapy tells the nurse that some foods on the meal tray taste bitter. Which food does the nurse suggest that the client eliminate from the diet, knowing that it is most likely to taste bitter to the client? A. Beef B. Custard C. Potatoes D. Cantaloupe

A. Beef

A nurse enters a client's room and finds the client unconscious. The nurse quickly performs an assessment and determines that the client is not breathing. Which action does the nurse take first? A. Beginning chest compressions B. Checking the client's pulse oximetry reading C. Placing an oxygen mask on the client D. Counting the client's carotid pulse for 15 seconds

A. Beginning chest compressions

A client who has undergone renal biopsy complains of pain, radiating to the front of the abdomen, at the biopsy site. For which finding should the nurse assess the client? A. Bleeding B. Renal colic C. Infection at the site D. Increased temperature

A. Bleeding

A nurse in a daycare setting is planning play activities for 2- and 3-year-old children. Which toy is most appropriate for these activities? A. Blocks and push-pull toys B. Finger paints and card games C. Simple board games and puzzles D. Videos and cutting-and-pasting toys

A. Blocks and push-pull toys

A nurse discontinues an infusion of a unit of blood after the client experiences a transfusion reaction. Once the incident has been documented appropriately, where does the nurse send the blood transfusion bag? A. Blood bank B. Risk management C. Microbiology laboratory D. Infection-control department

A. Blood bank

Calcitriol is prescribed for a client with hypocalcemia. Which foods does the nurse, knowing that they may interfere with calcium absorption, instruct the client to limit in the diet? Select all that apply. A. Bran B. Milk C. Clams D. Spinach E. Orange juice

A. Bran D. Spinach

A nurse, monitoring a client in the fourth stage of labor, checks the client's vital signs every 15 minutes. The nurse notes that the client's pulse rate has increased from 70 to 100 beats per minute. Based on this finding, which priority action should the nurse take? A. Checking the client's uterine fundus B. Notifying the nurse-midwife immediately C. Documenting the vital signs in the client's medical record D. Continuing to check the client's vital signs every 15 minutes

A. Checking the client's uterine fundus

A client is receiving total parenteral nutrition (TPN) with fat emulsion (lipids) piggybacked to the TPN solution. For which signs of an adverse reaction to the fat emulsion should the nurse monitor the client? Select all that apply. A. Chills B. Pallor C. Headache D. Chest and back pain E. Nausea and vomiting F. Subnormal temperature

A. Chills C. Headache D. Chest and back pain E. Nausea and vomiting

A nurse is administering an enema to a client. While the enema solution is being instilled, the client complains of abdominal cramping. Which action should the nurse take? A. Clamp the enema bag tubing B. Remove the enema tube and allow the client to rest C. Stop the instillation and allow the client to expel the solution D. Raise the enema bag to quickly finish instillation of the solution

A. Clamp the enema bag tubing

A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve? A. Coffee B. A tuning fork C. A wisp of cotton D. An ophthalmoscope

A. Coffee

The nurse provides instructions to a client who is beginning therapy with oral theophylline. The nurse recognizes that the client understands the instructions when the client states to limit consumption of which items? A. Coffee, cola, and chocolate B. Oysters, lobster, and shrimp C. Apples, oranges, and pineapple D. Cottage cheese, cream cheese, and dairy creamers

A. Coffee, cola, and chocolate

Which of the following actions are in keeping with the principles of standard precautions? Select all that apply. A. Handwashing between client contacts B. Cleaning of blood spills with soap and warm water C. Discarding needles in puncture-resistant containers D. Handwashing before removal of a pair of soiled gloves E. Wearing a face shield as a part of the protective garb during a wound irrigation F. Wearing a gown and gloves when changing the linens on the bed of a client with a draining lesion of the leg

A. Handwashing between client contacts C. Discarding needles in puncture-resistant containers E. Wearing a face shield as a part of the protective garb during a wound irrigation F. Wearing a gown and gloves when changing the linens on the bed of a client with a draining lesion of the leg

A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding? A. Document the findings. B. Check the client's temperature. C. Report the findings to the nurse-midwife. D. Obtain a sample of the amniotic fluid for laboratory analysis.

A. Document the findings.

The nurse provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information? A. "I need to avoid eating fried or greasy foods." B. "I need to be sure to drink adequate fluids with my meals." C. "I should eat five or six small meals a day rather than three full meals." D. "I should keep dry crackers at my bedside and eat them before I get out of bed in the morning."

B. "I need to be sure to drink adequate fluids with my meals."

A home health nurse teaches a client about home modifications to reduce the risk of falls. Which statements by the client indicate a need for further teaching? Select all that apply. A. "I need to use night lights." B. "I need to remove my wall-to-wall carpeting." C. "I need to get handrails put up in the bathroom." D. "I need to use the staircase handrails when I go up the stairs." E. "I should walk barefoot as much as possible so that I'll know about any wet spots on the floor."

B. "I need to remove my wall-to-wall carpeting." E. "I should walk barefoot as much as possible so that I'll know about any wet spots on the floor."

A nurse provides instructions to a client with chronic obstructive pulmonary disease (COPD) about the positions that are most effective in alleviating dyspnea. Which statement by the client indicates a need for further instruction? A. "I should sit up in my recliner." B. "I should lie on my right side in bed." C. "I should sit on the side of my bed and lean on the overbed table." D. "I should stand with my back and hips against the wall and my shoulders bent slightly forward."

B. "I should lie on my right side in bed."

The nurse teaches a client with gastroesophageal reflux disease (GERD) about measures to prevent reflux during sleep. The nurse determines that the client needs additional instructions if the client states: A. "I should take an antacid at bedtime." B. "I should sleep flat on my right side." C "The histamine antagonist will help me." D. "I should avoid eating in the 3 hours before bedtime."

B. "I should sleep flat on my right side."

A client with schizophrenia who has been taking an antipsychotic medication calls the clinic nurse and says, "I need to cancel my appointment with the psychiatrist again, because I still have this awful sore throat. It's so bad that my mouth has a sore." How does the nurse respond to the client? A. "I wouldn't be upset. It happens when you aren't drinking enough water." B. "I think you need to come in for blood work today, because this may be an adverse effect of your medicine." C. "Do you remember when you started this medication? Your psychiatrist told you how important it is to keep your appointments with him." D. "You probably have a simple flu, but it might help if you gargle with some antiseptic mouthwash every 2 hours or so and drink plenty of water."

B. "I think you need to come in for blood work today, because this may be an adverse effect of your medicine."

Warfarin sodium has been prescribed, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary? A. "I won't play football anymore." B. "I won't take any over-the-counter medications except aspirin." C. "I'll use an electric shaver until the doctor stops the Coumadin prescription." D. "I'll buy one of those medication alert tags that tells people I'm taking an anticoagulant."

B. "I won't take any over-the-counter medications except aspirin."

A nurse is describing the procedure for testicular self-examination (TSE) to a male client. Which statement should the nurse make to the client? A. "A good time to examine the testicles is just before you take a shower." B. "If you notice an enlarged testicle or a lump, you need to notify the physician." C. "The testicle is egg-shaped and movable. It feels firm and has a lumpy consistency." D. "Perform a testicular exam at least every 2 months to detect early signs of testicular cancer."

B. "If you notice an enlarged testicle or a lump, you need to notify the physician."

A survivor of a nightclub fire that killed more than 100 people says to the nurse, "It should have been me. How come I got out and they didn't?" Which response by the nurse is appropriate? A. "I don't know what to say. It was a terrible fire. I'm so sorry this happened." B. "It seems that you're blaming yourself for something that was beyond your control." C. "It seems to me that you're making this all about you when many people died in that fire." D. "You should be thankful that you're a survivor. The victims and their families lost, not you."

B. "It seems that you're blaming yourself for something that was beyond your control."

During a mental health intake interview, a young adult client who lives with his family rent free says, "I'm tired of not being able to offer my friends a beer just because my folks don't believe in taking a drink socially." Which nursing response would be therapeutic? A. "Well, I guess you could move out and live on your own if you wanted to." B. "It seems that your parents expect you to follow their rules when you live under their roof." C. "You tell me you live rent free, yet you expect the same privileges as an adult who supports the household?" D. "Well, if you directly discussed your concerns with them, I guess it's a case of 'When in Rome, do as the Romans do.'"

B. "It seems that your parents expect you to follow their rules when you live under their roof."

A nurse is obtaining assessment data from an older client about sleep patterns. The client reports that she has been awakening during the night, awakens early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. Based on the data, which action should the nurse take? A. Report the findings to the health care provider B. Document the findings in the medical record C. Ask the health care provider for a prescription for a nighttime sedative D. Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours

B. Document the findings in the medical record

A client has just returned to the nursing unit after computerized tomography (CT) with contrast medium. Which action should the nurse plan to take as part of routine after-care for this client? A. Administering a laxative B. Encouraging fluid intake C. Maintaining the client on strict bed rest D. Holding all medications for at least 2 hours

B. Encouraging fluid intake

The nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. Which action should the nurse take? A. Tape the wedding band in place B. Explain to the client why the wedding band must be removed C. Ask the client whether she would like to remove the wedding band or wear it to surgery D. Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgery

B. Explain to the client why the wedding band must be removed

A married couple is attending a hospital program about in vitro fertilization. During the program, a crew from a local television station arrives to film the proceedings because the station is publicizing a series on hospital services. The nurse conducting the program should: A. Allow the television crew to videotape the program B. Explain to the television crew that videotaping is not allowed C. Ask the television crew to interview the individuals attending the program individually D. Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization

B. Explain to the television crew that videotaping is not allowed

A nurse performing a cranial nerve assessment is testing the function of the oculomotor, trochlear, and abducens nerves. Which of the following parameters does the nurse check to determine the function of these nerves? A. Tongue symmetry B. Eye movements C. Facial symmetry D. Corneal reflex

B. Eye movements

During a neurological assessment, the nurse asks the client to puff out both cheeks. Which cranial nerve is the nurse assessing? A. Vagus B. Facial C. Abducens D. Oculomotor

B. Facial

A client who was given a diagnosis of hypertension 3 months ago is at the clinic for a checkup. Which type of database does the nurse use in performing an assessment? A. Emergency B. Follow-up C. Complete (total) D. Problem-centered

B. Follow-up

A nurse manager discusses staff empowerment with the nursing team. The nurse manager explains that staff empowerment: A. Allows the staff to make every decision regarding employee scheduling B. Fosters the growth of others so that they are less dependent on the leader C. Means that the staff has the power to reprimand and punish any individual who is not meeting the standards of care delivery D. Indicates that the nurse leader will make decisions regarding the nursing unit and expects that the staff will comply with the changes

B. Fosters the growth of others so that they are less dependent on the leader

A nurse reviewing the healthcare record of a client notes documentation of grade 4 muscle strength. The nurse understands that this indicates: A. Full range of motion (ROM) with gravity B. Full ROM against gravity with some resistance C. Full ROM with gravity eliminated (passive motion) D. Full ROM against gravity with full resistance

B. Full ROM against gravity with some resistance

A nurse is assigned to care for a client with an infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator that requires frequent suctioning. While gathering the needed supplies before entering the client's room, which necessary protective items does the nurse obtain? Select all that apply. A. Mask B. Gown C. Gloves D. Face shield E. Shoe protectors

B. Gown C. Gloves D. Face shield

An ambulatory care nurse is providing home care instructions to the mother of a child who had a tonsillectomy. The nurse determines that the motherneeds further instruction if she indicates that she will: A. Avoid giving citrus juices to her child B. Have her child use a straw to make drinking easier C. Give acetaminophen (Tylenol) to her child for discomfort D. Give her child extra fluids to relieve a foul odor from the mouth

B. Have her child use a straw to make drinking easier

The nurse brings a meal tray to a psychotic client in his hospital room. The client refuses the meal and says, "I'm not eating any more poisoned food while I'm vacationing here. I'm starting on a fast to stay healthy and alive." Which nursing intervention would be most appropriate initially? A. Taking the tray away and canceling all meals until further notice B. Having the client eat with other clients in the community dining room C. Eating some of the food from the client's tray to prove that it isn't poisoned D. Telling the client that the psychiatrist will be called for a prescription for a tube feeding

B. Having the client eat with other clients in the community dining room

Diverticulitis has been diagnosed in a client who has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet, during the asymptomatic period? A. Low in fat B. High in fiber C. Low in residue D. High in carbohydrates

B. High in fiber

A client and her newborn have undergone human immunodeficiency virus (HIV) testing, and the results for both clients are positive. The news is devastating, and the mother is crying. What is the appropriate nursing action at this time? A. Describe the stages of and treatments for HIV B. Listen quietly while the mother talks and cries C. Discuss with the mother how she might have gotten HIV D. Call an HIV counselor and make an appointment for the woman

B. Listen quietly while the mother talks and cries

A nurse has administered a dose of furosemide to a client with diminished urine output. The nurse expects the urine output to increase once the medication has had time to exert an effect on which structure in the kidney? A. Distal tubule B. Loop of Henle C. Collecting duct D. Proximal tubule

B. Loop of Henle

A client is receiving intravenous bleomycin sulfate. During administration of the chemotherapy, nursing assessment is the priority? A. Heart rate B. Lung sounds C. Peripheral pulses D. Level of consciousness

B. Lung sounds

A nurse is caring for a client with cirrhosis. As part of the teaching regarding dietary means of minimizing the effects of the disorder, the nurse educates the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase the intake of which foods? Select all that apply. A. Milk B. Peanuts C. Chicken D. Broccoli E. Asparagus F. Whole-grain cereals

B. Peanuts E. Asparagus F. Whole-grain cereals

A nurse is preparing to assess a client for the presence of the Tinel sign. Which action does the nurse take to elicit this sign? A. Testing the strength of each muscle joint B. Percussing at the location of the median nerve C. Checking for repetitive movements in the joints D. Asking the client to hold the hands back to back while flexing the wrist 90 degrees

B. Percussing at the location of the median nerve

A client has just undergone a renal biopsy. Which intervention should the nurse include in the post-procedure plan of care? A. Restricting fluid intake for the first 24 hours B. Periodically testing the urine for occult blood C. Avoiding the administration of opioid analgesics D. Having the client ambulate in the room and hall for short distances

B. Periodically testing the urine for occult blood

A nurse has admitted a client with a diagnosis of tuberculosis (TB) to the nursing unit. Which finding that confirms the diagnosis does the nurse expect to see documented in the client's record? A. Night sweats and a low-grade fever B. Positive result on an acid-fast bacillus smear C. Cough and expectoration of mucopurulent sputum D. A tuberculin skin test result that indicates 5 mm of redness

B. Positive result on an acid-fast bacillus smear

A nurse planning care for her assigned clients understands that the purpose of the hospital's standards of care is to: A. Identify methods of treatment B. Provide direction for the practice of nursing C. Provide direction for care on the basis of the client's diagnosis D. Identify new care methods on the basis of current medical research

B. Provide direction for the practice of nursing

Which step should be included in the care of a 13-year-old hospitalized child who has been abused? A. Encouraging the child to avoid the abuser B. Providing a caring environment that fosters the development of trust C. Teaching the child to make intelligent choices when confronted with an abusive situation D. Having the child identify the abuser if that person should visit while the child is hospitalized

B. Providing a caring environment that fosters the development of trust

The nurse coordinates the use of hospice care to visit a dying client who will be going home with his family. Which is a function of hospice services that the nurse should tell the family? A. Helping the client focus completely on his physical health B. Providing bereavement support to the family after the client's death C. Helping the family stop the client's efforts to go out at night with his friends D. Working with the client to sustain hope by talking of recent research breakthroughs regarding his illness

B. Providing bereavement support to the family after the client's death

According to Erik Erikson's developmental theory, which is a developmental task of the middle adult? A. Redefining self-perception and capacity for intimacy B. Providing guidance during interactions with his children C. Verbalizing readiness to assume parental responsibilities D. Making decisions concerning career, marriage, and parenthood

B. Providing guidance during interactions with his children

The safety department is providing a yearly educational session on fire safety and the use of fire extinguishers. A nurse is asked to demonstrate the use of a fire extinguisher after the session. The nurse demonstrates appropriate use of the fire extinguisher by first: A. Aiming at the base of the fire B. Pulling the pin on the fire extinguisher C. Squeezing the handle of the extinguisher D. Sweeping from the top to the bottom of the fire with the extinguisher

B. Pulling the pin on the fire extinguisher

A client with a peripheral intravenous (IV) line in place has a new prescription for infusion of total parenteral nutrition (TPN), a solution containing 25% glucose. Which action should be taken by the nurse? A. Hanging the IV solution as prescribed B. Questioning the health care provider about the prescription C. Diluting the solution with sterile water to half-strength D. Hanging the IV solution but setting the infusion at just half the prescribed rate

B. Questioning the health care provider about the prescription

The nurse administers a dose of ramipril (Altace) 2.5 mg to a client at 9 am. While documenting administration of the medication, the nurse discovers that 1.25 mg, not 2.5 mg, was the prescribed dose. The nurse assesses the client, completes an incident report, and notifies the physician and nursing supervisor of the error. What statement does the nurse add to the client's record? A. An incident report was completed and filed. B. Ramipril (Altace) 2.5 mg was administered at 9 am. C. Twice the amount of the prescribed ramipril was administered at 9 am. D. Client's blood pressure was 128/82 mm Hg after the administration of the incorrect dose of ramipril.

B. Ramipril (Altace) 2.5 mg was administered at 9 am.

A client is scheduled for a barium swallow (esophagography) in 2 days. The nurse, providing preprocedure instructions, should tell the client to implement which measure? A. Eat a regular supper and breakfast B. Remove all metal and jewelry before the test C. Expect diarrhea for a few days after the procedure D. Take all oral medications as scheduled with milk on the day of the test

B. Remove all metal and jewelry before the test

The nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. Which action is the most appropriate for the nurse to take? A. Contact the client's health care provider B. Report the incident to the nursing supervisor C. Tell the client that the nurse did the right thing in giving the enema D. Confront the nurse who gave the enema and tell the nurse that she is going to be charged with battery

B. Report the incident to the nursing supervisor

How does a client who has lost a spouse show that she is successfully completing the tasks of mourning? Select all that apply. A. Relating that its better "he went first" B. Reporting that sleeping alone is so hard now C. Purchasing a smaller car she is comfortable driving D. Placing a picture of her husband on the bedside stand E. Heard explaining to family that illness "took" her husband

B. Reporting that sleeping alone is so hard now C. Purchasing a smaller car she is comfortable driving D. Placing a picture of her husband on the bedside stand

A nurse is providing home care instructions to a client with Parkinson disease about measures to avoid rigidity and to overcome tremor and bradykinesia. The nurse tells the client to: A. Sit in soft, deep chairs B. Rock back and forth to start movement C. Exercise in the evening to combat fatigue D. Perform tasks with only the hand that has the tremor

B. Rock back and forth to start movement

A client who experiences frequent episodes of chest pain is admitted to the hospital for cardiac monitoring. The client suddenly complains of chest pain, and the nurse obtains a 12-lead electrocardiogram (ECG). Which finding would the nurse expect to note in the event of an ischemic episode? A. Peaked T waves B. ST-segment depression C. Widened QRS complex D. An isolated premature ventricular contraction (PVC)

B. ST-segment depression

The nursing instructor asks a student to name an example of false imprisonment. Which situation reflects a violation of this client right? A. Performing a procedure without consent B. Telling the client that he or she may not leave the hospital C. Threatening to give a client a medication against his or her will D. Observing the provision of care to the client without the client's permission

B. Telling the client that he or she may not leave the hospital

A nurse provides instructions to a female client regarding the procedure for collecting a midstream urine specimen. What should the nurse tell the client? A. That she should douche before collecting the specimen B. That she should cleanse the perineum from front to back C. That she should collect the urine in the cup as soon as the urine flow begins D. That she should collect the specimen at bedtime and bring it to the laboratory the next morning

B. That she should cleanse the perineum from front to back

A nurse is performing a voice test. To carry out this procedure correctly, the nurse asks the client to repeat which kind of words? A. Spoken in a soft tone of voice by the nurse about 5 feet in front of the client B. Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested C. Spoken by the nurse from the client's side in a normal tone of voice about 10 feet from the ear being tested D. Whispered at a distance of 20 feet by the nurse while he or she is standing in front of the client

B. Whispered by the nurse from the client's side at a distance of 1 to 2 feet from the ear being tested

A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client's personal care items: A. Within the client's reach on the left side B. Within the client's reach on the right side C. Just out of the client's reach on the left side D. Just out of the client's reach on the right side

B. Within the client's reach on the right side

A 35-year-old female client asks the clinic nurse when she should begin to have yearly mammograms. What does the nurse tell the client? A. Yearly mammograms are recommended starting at age 25. B. Yearly mammograms are recommended starting at age 40. C. Yearly mammograms are not necessary unless there is a family history of breast cancer. D. Yearly mammograms are recommended starting at the age of 20 and continuing until menopause begins.

B. Yearly mammograms are recommended starting at age 40.

A nurse has taught a client with a new colostomy about measures to control stool odor in the ostomy drainage bag. Which foods listed on the client's shopping list indicate to the nurse that the client has understood the information? Select all that apply. A. Eggs B. Yogurt C. Parsley D. Broccoli E. Cucumbers F. Cranberry juice

B. Yogurt C. Parsley F. Cranberry juice

A nurse provides information to a pregnant client with hemorrhoids about measures that will alleviate her discomfort. Which actions does the nurse tell the client to take? Select all that apply. A. Sleep lying on her back B. Shower daily but avoid sitting in a bathtub C. Apply cool compresses to the hemorrhoids D. Contact the nurse-midwife if any bleeding occurs E. Elevate her hips on a pillow when resting or during sleep

C. Apply cool compresses to the hemorrhoids E. Elevate her hips on a pillow when resting or during sleep

A client who has just undergone a skin biopsy is listening to discharge instructions from the nurse. The nurse determines that the client needs further teachingif the client indicates that he plans to do what as part of aftercare? A. Use the antibiotic ointment as prescribed B. Return in 7 days to have the sutures removed C. Apply cool compresses to the site twice a day for 20 minutes D. Call the health care provider if excessive drainage from the wound occurs

C. Apply cool compresses to the site twice a day for 20 minutes

A nurse receives a telephone call from a neighbor, who says that her child was just hit in the eye with a swing. The nurse rushes to the neighbor's house and notes that the child has sustained a contusion of the eye. The nurse advises the child's mother to immediately: A. Call an ambulance B. Call an optometrist C. Apply ice to the affected eye D. Irrigate the eye with cool water

C. Apply ice to the affected eye

A client with an infection is receiving antibiotics by way of intramuscular (IM) injection. The client is also receiving subcutaneous (SC) injections of heparin. Which precaution does the nurse understand is most appropriate to help ensure the safety of this client? A. Doubling the dose of anticoagulant B. Applying a pressure bandage to the site after each IM injection C. Applying prolonged pressure to the sites of the IM and SC sites D. Decreasing the sizes of the needles used for the IM and SC injections

C. Applying prolonged pressure to the sites of the IM and SC sites

A client is receiving a continuous IV infusion of heparin for the treatment of deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) level is 88 seconds (88 seconds). The client's baseline before the initiation of therapy was 30 seconds (30 seconds). Which action does the nurse anticipate is needed? A. Shutting off the heparin infusion B. Increasing the rate of the heparin infusion C. Decreasing the rate of the heparin infusion D. Leaving the rate of the heparin infusion as is

C. Decreasing the rate of the heparin infusion

A nurse performing an eye examination uses an ophthalmoscope to best visualize which area? A. Iris B. Cornea C. Optic disc D. Conjunctiva

C. Optic disc

A female client asks a nurse about the advantages of using a female condom. Which should the nurse tell the client? A. It can be used along with a male condom B. That it is 100% safe in preventing pregnancy C. That it offers protection against sexually transmitted infections (STIs) D. That it does not have to be discarded after use and can be used several times before a new one must be obtained

C. That it offers protection against sexually transmitted infections (STIs)

A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if she performs which action? A. Washes the diaper area first B. Washes the infant's chest first C. Uncovers only the body part being washed D. Uses a cotton-tipped swab to carefully clean inside the infant's nose

C. Uncovers only the body part being washed

A nurse is watching as an unlicensed assistive personnel (UAP) measure the blood pressure (BP) of a hypertensive client. Which actions on the part of the UAP would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply. A. Measuring the BP after the client has sat quietly for 5 minutes B. Having the client sit with the arm bared and supported at heart level C. Used a cuff with a rubber bladder that encircles at least 60% of the limb D. Measuring the BP after the client reports that he just drank a cup of coffee E. Allowing the client to talk as the blood pressure is being measured

C. Used a cuff with a rubber bladder that encircles at least 60% of the limb D. Measuring the BP after the client reports that he just drank a cup of coffee

The nurse employed in a mental health unit is reviewing the work schedule. At what time does the nurse expect that additional client safety precautions will be provided? A. Day shift B. Weekdays C. Weekends D. 7 to 10 a.m.

C. Weekends

A client says to the nurse, "I don't do anything right. I'm such a loser." What is the appropriate response? A. "Everything will get better." B. "You don't do anything right?" C. "You do things right all the time." D. "You are not a loser; you are sick.

B. "You don't do anything right?"

A female client who has undergone placement of a sealed radiation implant asks the nurse whether she can take a walk around the nursing unit. How should the nurse respond to the client's request? A. "Short walks are OK." B. "You need to stay in your room for now." C. "Yes, it's fine to take a walk around the nursing unit." D. "Do you think that a walk around the unit will tire you out?"

B. "You need to stay in your room for now."

A young adult asks the nurse about the normal cholesterol level. The nurse tells the client that the total cholesterol level should be maintained at less than which value? A. 140 mg/dL (<3.64 mmol/L) B. 200 mg/dL (<5.2 mmol/L) C. 250 mg/dL (<6.5 mmol/L) D. 300 mg/dL (<7.8 mmol/L)

B. 200 mg/dL (<5.2 mmol/L)

Oxygen by way of nasal cannula has been prescribed for a client with emphysema. The nurse checks the health care provider's prescriptions to ensure that the prescribed flow is not greater than which liter (L) per minute (min)? A. 1 L/min B. 3 L/min C. 4 L/min D. 6 L/min

B. 3 L/min

Blood is drawn from a male client with suspected uric acid calculi for a serum uric acid determination. Which value does the nurse recognize as a normal uric acid level? A. 1.7 mg/dL (101.2 μmol/L) B. 4.4 mg/dL (262 μmol/L) C. 8.9 mg/dL (529.9 μmol/L) D. 12.8 mg/dL (762.1 μmol/L

B. 4.4 mg/dL (262 μmol/L)

A nurse, newly employed by a home health agency, is told that the organization's decision-making process is centralized. The nurse determines that this means that the authority to make decisions is vested in: A. Every employee B. A few individuals, such as the board of directors C. All nursing employees, pharmacists, and hospital physicians D. Many individuals, with decisions filtering down to the individual employee

B. A few individuals, such as the board of directors

A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mEq/L (0.5 mmol/L). Which assessment findings does the nurse expect to note? Select all that apply. A. Hypotension B. Abdominal distention C. Trousseau sign D . Skeletal muscle weakness E. Decreased deep tendon reflexes

B. Abdominal distention C. Trousseau sign

A nurse is assessing the motor development of a 24-month-old child. Which activities would the nurse expect the mother to report that the child can perform? Select all that apply. A. Put on and tie his shoes B. Align two or more blocks C. Dress himself appropriately D. Go to the bathroom without help E. Turn the pages of a book one at a time

B. Align two or more blocks E. Turn the pages of a book one at a time

An industrial nurse at a large factory provides information to the employees in the mailroom and shipping department about the signs of skin (cutaneous) anthrax. For which early sign of cutaneous anthrax does the nurse tell the employees to check their skin? A. An open ulcer B. An itchy bump C. A weeping blister D. A black skin area of skin

B. An itchy bump

The nurse is preparing client assignments for the day. Which client should the nurse assign to a nursing assistant? A. A client scheduled for a liver biopsy B. An unconscious client who requires oral care C. A client who has just undergone cardiac catheterization D. A client who is getting up to ambulate for the first time after surgery

B. An unconscious client who requires oral care

A clear liquid diet has been prescribed for client who has just undergone surgery. Which foods should the nurse offer to the client? Select all that apply. A. Custard B. Apple juice C. Orange juice D. Chicken broth E. Orange gelatin F. Vanilla ice cream

B. Apple juice D. Chicken broth E. Orange gelatin

A stapedectomy is performed on a client with otosclerosis. During the preparations for discharge, which home care instruction does the nurse give the client? A. Expect excessive ear drainage for about 2 weeks. B. Avoid rapidly moving the head and bending over for at least 3 weeks. C. Rinse the ear canal at least twice a day to clear out any excess drainage. D. It is all right to shower as long as the ear dressing is changed immediately after the shower

B. Avoid rapidly moving the head and bending over for at least 3 weeks.

The home care nurse makes a visit to a client with a diagnosis of depression. The nurse finds the client unconscious on the floor, with an empty bottle of a prescribed tricyclic antidepressant lying near the client. What action must the nurse take immediately? A. Inducing vomiting B. Calling an ambulance C. Administering syrup of ipecac D. Counting the pills remaining in the bottle

B. Calling an ambulance

The nurse and an unlicensed assistive personnel (UAP)enter a client's room to provide care and find the client lying on the floor. Which action should the nurse take first? A. Ask the nursing assistant to complete an incident report B. Check the client's level of consciousness and vital signs C. Ask the nursing assistant to assist in getting the client back to bed D. Contact the unit secretary on the intercom and ask that the client's health care provider be called

B. Check the client's level of consciousness and vital signs

A client with atrial fibrillation has been placed on warfarin sodium. As part of the instructions for the medication, which foods does the nurse tell the client are acceptable to eat? Select all that apply. A. Lettuce B. Cherries C. Broccoli D. Cabbage E. Potatoes

B. Cherries E. Potatoes F. Spaghetti

A home care nurse visits a client who lives in a small apartment to perform an admission assessment. During the home safety assessment, the client asks the nurse whether it is safe to use a space heater. What is the appropriate response by the nurse? A. "A space heater should never be used in an apartment." B. "A space heater can be used as long as it is kept at a low setting at all times." C. "A space heater can be used as long as it is kept in the bedroom at night in case a fire occurs." D. "A space heater can be used as long as it's placed at least 3 feet from anything that may ignite."

D. "A space heater can be used as long as it's placed at least 3 feet from anything that may ignite."

A nurse has provided instructions to a mother regarding the use of safety seats in car travel for her newborn infant. Which statement by the mother indicates understanding of the instructions? A. "I'll put the baby's car seat in the front seat, facing forward and reclined a little." B. "I'll put the baby's car seat in the front seat, facing backward and reclined a little." C. "I'll put the baby's car seat in the middle back seat, facing forward and reclined a little." D. "I'll put the baby's car seat in the middle back seat, facing backward and reclined a little."

D. "I'll put the baby's car seat in the middle back seat, facing backward and reclined a little."

A nurse is instructing a client in the first trimester of pregnancy about nutrition. Which statement by the client indicates the need for further instruction? A. "I need to eat foods high in calcium." B. "How I eat can affect my baby's growth." C. "I need to take vitamins throughout my pregnancy." D. "My risk for malnourishment is much higher while I'm pregnant."

D. "My risk for malnourishment is much higher while I'm pregnant."

A client's baseline vital signs are temperature 98° F oral, pulse 74 beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever of 103° F. Which respiratory rate would the nurse anticipate as part of the body's response to the change in client status? A. 12 breaths/min B. 16 breaths/min C. 18 breaths/min D. 22 breaths/min

D. 22 breaths/min

The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client. Which compression-ventilation ratio is correct? A. 15:1 B. 15:2 C. 20:2 D. 30:2

D. 30:2

A client admitted to the hospital with a diagnosis of acute pancreatitis has blood drawn for several serum laboratory tests. Which serum amylase value, noted by the nurse reviewing the results, would be expected in this client at this time? A. 48 units/L (0.816 μkat/L) B. 97 units/L (1.649 μkat/L) C. 150 units/L (2.55 μkat/L) D. 395 units/L (6.715 μkat/L)

D. 395 units/L (6.715 μkat/L)

A nurse is reviewing the findings of a physical examination that have been documented in a client's record. Which piece of information does the nurse recognize as objective data? A. The client is allergic to strawberries. B. The last menstrual period was 30 days ago. C. The client takes acetaminophen (Tylenol) for headaches. D. A 1 × 2-inch scar is present on the lower right portion of the abdomen.

D. A 1 × 2-inch scar is present on the lower right portion of the abdomen.

A nurse leading an educational session about terrorism for members of the community is discussing anthrax. Which of the following pieces of information should the nurse provide to the group attending the session? Select all that apply. A. Anthrax is never fatal. B. No vaccine to prevent anthrax is available. C. Anthrax can be transmitted from person to person. D. A blood test is available for the detection of anthrax. E. One way that anthrax can be contracted is through the skin.

D. A blood test is available for the detection of anthrax. E. One way that anthrax can be contracted is through the skin.

A nurse is making initial rounds on a group of assigned clients. Which client should the nurse see first? A. A client receiving total parenteral nutrition (TPN) at a rate of 50 mL/hr for the last 24 hours B. A client receiving TPN at a rate of 50 mL/hr whose temp was 99° F on the previous shift C. A client receiving TPN at a rate of 100 mL/hr who has complained of needing frequent trips to the bathroom to void D. A client whose TPN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating

D. A client whose TPN solution was decreased to a rate of 25 mL/hr who is now complaining of weakness, headache, and sweating

A registered nurse (RN) is planning assignments for five clients on the nursing unit. The team includes a licensed practical nurse (LPN) and a nursing assistant. Which clients should the nurse assign to the LPN? Select all that apply. A. A client who is confused and requires assistance with a shower B. A client requiring a bed bath and frequent ambulation with a cane C. A client who must be accompanied to physical therapy twice during the shift D. A client with a colostomy who requires reinforcement regarding the procedure for irrigation E A client with diabetes mellitus who requires the administration of regular insulin in accordance with a sliding dosage scale every 4 hours

D. A client with a colostomy who requires reinforcement regarding the procedure for irrigation E A client with diabetes mellitus who requires the administration of regular insulin in accordance with a sliding dosage scale every 4 hours

A nurse is assigned to care for four clients. Which client should the nurse assess first? A. A client scheduled for a colonoscopy B. A client preparing for discharge after surgery C. A client requiring a tube feeding through a gastrostomy tube D. A client with a tracheostomy who is receiving humidified oxygen by way of a tracheostomy mask

D. A client with a tracheostomy who is receiving humidified oxygen by way of a tracheostomy mask

A nurse is working in the emergency department. Which client should be assessed first? A. A client with new-onset dizziness B. A client admitted with a recent ear injury C. A client who has been experiencing nausea and vomiting for 12 hours D. A client with new-onset atrial fibrillation with a rate of 118 beats/min

D. A client with new-onset atrial fibrillation with a rate of 118 beats/min

A nurse, planning play activities for a hospitalized school-age child, uses Erikson's theory of psychosocial development to select an appropriate activity. The nurse should select an activity that will assist is developing which psychosocial stage? A. Initiative B. Autonomy C.A sense of trust D. A sense of industry

D. A sense of industry

A nurse assessing a client's eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding? A. Myopia B. Hyperopia C. Photophobia D. Accommodation

D. Accommodation

A nurse is preparing a list of measures that will help promote sleep. Which measures that would be included on the list? Select all that apply. A. Exercise just before bedtime. B. Drink a glass of wine at bedtime. C. Drink a cup of black tea before bedtime. D. Adjust the room temperature to a comfortable level. E. Eliminate lights, noise, and other environmental distractions. F. Get up at the same time each day and avoid naps during the day.

D. Adjust the room temperature to a comfortable level. E. Eliminate lights, noise, and other environmental distractions. F. Get up at the same time each day and avoid naps during the day.

An emergency department (ED) nurse receives a telephone call from emergency medical services and is told that a client who has sustained severe burns of the face and upper arms is being transported to the ED. Which action does the nurse, preparing for the arrival of the client, plan to implement first? A. Inserting a Foley catheter B. Initiating an intravenous (IV) line C. Cleansing the burn wound D. Administering 100% humidified oxygen

D. Administering 100% humidified oxygen

A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily? A. Placing the tube in warm water B. Hyperextending the head while inserting the tube C. Removing the tube if any resistance to insertion is met D. Asking the client to swallow as the tube is being advanced

D. Asking the client to swallow as the tube is being advanced

A nurse is obtaining subjective data from the mother of a child admitted to the hospital with a diagnosis of intussusception. Which occurrence does the nurse expect the mother to report? A. Scleral jaundice B. Projectile vomiting C. Hard, pale stools D. Bloody mucus stools and diarrhea

D. Bloody mucus stools and diarrhea

A nurse reviewing the physical assessment findings in a client's healthcare record notes documentation that the Phalen test caused numbness and burning. Which disorder does the nurse, on the basis of this finding, conclude that the client has? A. Scoliosis B. Bone deformity C. Heberden nodules D. Carpal tunnel syndrome

D. Carpal tunnel syndrome

An adolescent client asks the nurse questions about the transmission of the Epstein-Barr virus (infectious mononucleosis). By which route should the nurse tell the client that the disease is transmitted? A. Fecal-oral B. Airborne particles C. Respiratory droplets D. Close intimate contact

D. Close intimate contact

A client with HIV infection has been started on therapy with zidovudine. The nurse tells the client to report to the laboratory in 3 months for testing to detect adverse effects of the therapy. Which laboratory test is most important to monitor for this client? A. Creatinine B. Serum potassium C. Blood urea nitrogen (BUN) D. Complete blood count (CBC)

D. Complete blood count (CBC)

A nurse monitoring a client in labor notes this fetal heart rate pattern (refer to figure) on the electronic fetal monitoring strip. Which is the most appropriate nursing action? A. Stop the oxytocin (Pitocin) infusion B. Notify the nurse-midwife or health care provider C. Administer oxygen with a face mask at 8 to 10 L/min D. Continue to monitor the client and fetal heart rate patterns

D. Continue to monitor the client and fetal heart rate patterns

A nurse is monitoring a client who is in the active phase of labor and has been experiencing contractions that are coordinated but weak. Which assessment finding indicates to the nurse that the client may be experiencing hypotonic contractions? A. Fetal hypoxia B. Discomfort with each contraction C. Increased frequency and longer duration of contractions D. Contractions that can be indented easily with fingertip pressure at their peak

D. Contractions that can be indented easily with fingertip pressure at their peak

A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. What is the immediate nursing action? A. Reinsert the chest tube B. Contact the health care provider C. Transfer the client back to bed D. Cover the insertion site with a sterile occlusive dressing

D. Cover the insertion site with a sterile occlusive dressing

A nurse inspecting a client's throat touches the posterior wall with a tongue blade and elicits the gag reflex. The nurse documents normal function of which nerve? A. Cranial nerve V B. Cranial nerve XII C. Cranial nerves I and II D. Cranial nerves IX and X

D. Cranial nerves IX and X

The nurse is preparing a plan of care for an older client with a diagnosis of depression. In preparing the plan, which should the nurse recall? A. Older clients do not commit suicide B. Depression in an older person is never treatable C. Depression in an older person will not cause physical manifestations D. Indications of dementia may be present in an older client with depression

D. Indications of dementia may be present in an older client with depression

A resident of a long-term care facility who has Alzheimer's disease becomes agitated when a group of children comes to sing and dance at the facility and tries to take one of the children to her room. Which piece of information should the nurse use when approaching the client about this behavior? A. This resident is a dangerous individual. B. Individuals with Alzheimer's disease are likely to be child molesters. C. This resident probably had an unfortunate experience while singing and dancing in his own youth. D. Individuals with Alzheimer's disease have difficulty tolerating excessive stimulation and changes in routine.

D. Individuals with Alzheimer's disease have difficulty tolerating excessive stimulation and changes in routine.

A ventilator's low exhaled volume (low-pressure) alarm sounds, and the nurse rushes to the client's room and quickly assesses the client. The client appears to be having respiratory difficulty. The nurse should first: A. Call a code B. Suction the client C. Call the anesthesiologist D. Manually ventilate the client, using a resuscitation bag

D. Manually ventilate the client, using a resuscitation bag

A nurse is assessing a client with AIDS for signs of Pneumocystis jiroveci infection. Which sign of the infection is the earliest manifestation? A. Fever B. Dyspnea at rest C. Dyspnea on exertion D. Nonproductive cough

D. Nonproductive cough

A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client's neck primarily for which reason? A. It is unnecessary to use both hands B. Feeling dual pulsations may lead to an incorrect measurement C. Palpating both carotid pulses simultaneously could occlude the trachea D. Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop

D. Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop

A nurse performing a respiratory assessment of a client plans to assess tactile (vocal) fremitus. The nurse performs this assessment by: A. Palpating for symmetric chest expansion B. Auscultating the breath sounds over the trachea and larynx C. Auscultating the breath sounds over the peripheral lung fields D. Palpating the thorax, comparing vibrations from side to side as the client repeats the word "ninety-nine"

D. Palpating the thorax, comparing vibrations from side to side as the client repeats the word "ninety-nine"

A nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign. The nurse reads the client's record and interprets this sign as indicating which? A. A thinning of the cervix B. A positive sign of pregnancy C. That cervical softening is present D. That the cervix was seen to be violet

D. That the cervix was seen to be violet

A home health nurse has been called to the home of an older postoperative cardiovascular client by the client's son. The son tells the nurse, "We're using a hospital bed here at home, but my mother has fallen out of bed three times." Which observation by the nurse reflects an increased risk of this client's falling out of bed? A. The client's bed is in a low position. B. The client is oriented to person, place, and time. C. The caregiver uses the overbed table for feedings. D. The caregiver leaves both siderails down while the client is in bed.

D. The caregiver leaves both siderails down while the client is in bed.

A client has made an appointment to for her annual Papanicolaou test (a.k.a. Pap smear). The nurse who schedules the appointment should provide which information to the client? A. Vaginal douching is required an hour before the test B. Spicy foods should not be eaten on the day of the test C. The test has absolutely no discomfort associated with it D. The test cannot be performed while the client is menstruating

D. The test cannot be performed while the client is menstruating

A client with a leg fracture who has been placed in skeletal traction is transported to the orthopedic unit after surgery. Which finding would indicate the need to contact the orthopedic specialist? A. The traction knots are intact. B. The traction weights are hanging freely. C. The clamps on the traction frame are tight. D. The traction ropes are unable to move over the pulleys.

D. The traction ropes are unable to move over the pulleys.

The health care provider prescribes 2000 mL of 5% dextrose and normal saline 0.45% for infusion over 24 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

1.21

The health care provider prescribes 1000 mL of 5% dextrose in water to be infused over 8 hours. The drop factor is 15 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

1.31

A nurse is preparing to care for a hospitalized teenage girl who is in skeletal traction. The nurse plans care knowing that the most likely primary concern of the teenager is which? A. Body image B. Obtaining adequate nutrition C. Keeping up with schoolwork D. Obtaining adequate rest and sleep

A. Body image

A nurse is teaching a client with an ileostomy about foods that could result in the production of liquid stools. Which food that just arrived on the client's meal tray should the nurse discourage the client from eating? A. Bran B. Pasta C. Boiled rice D. Low-fat cheese

A. Bran

Codeine sulfate is prescribed for a client with severe back pain. Which parameters does the nurse monitor while the client is taking this medication?Select all that apply. 1. Volume of urine output 2. Strength of peripheral pulses 3. Ability to move the extremities 4. Frequency of bowel movements 5. Color, motion, and sensation of extremities

1. Volume of urine output 4. Frequency of bowel movements

The health care provider's prescription reads, "Phenytoin 0.1 g by mouth twice daily." The medication label indicates that the bottle contains 100-mg capsules. How many capsules does the nurse prepare for administration of one dose?

1.1

A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test? A. "I didn't shampoo my hair." B. "I ate breakfast this morning." C. "I didn't take my anticonvulsant today." D. "It was hard not to drink coffee this morning, but I knew that I couldn't, so I didn't."

A. "I didn't shampoo my hair."

A nurse is assessing a fetal heart rate (FHR) and notes accelerations from the baseline rate when the fetus is moving. How should the nurse interpret this finding? A. A reassuring sign B. A nonreassuring sign C. An indication of fetal distress D. An indication of the need to contact the health care provider

A. A reassuring sign

A nurse performing an abdominal assessment is preparing to auscultate for bowel sounds. The nurse: A. Begins in the right lower quadrant B. Uses the bell end of the stethoscope C. Holds the stethoscope firmly and deeply against the skin D. Listens for at least 1 minute before deciding that bowel sounds are absent

A. Begins in the right lower quadrant

A sedated client is being transported to the radiology department on a stretcher. Which type of restraint should the nurse suggest applying to help ensure the client's safety? A. Belt B. Wrist C. Elbow D. Mitten

A. Belt

A nurse has taught a client taking a methylxanthine bronchodilator about beverages that must be avoided. Which beverage choices by the client indicate to the nurse that the client needs further education? Select all that apply. A. Cocoa B. Coffee C. Lemonade D. Orange juice E. Chocolate milk

A. Cocoa B. Coffee E. Chocolate milk

A home care nurse visits a pregnant client with a diagnosis of mild preeclampsia. During the assessment, the client tells the nurse that she has had an upset stomach and pain in the epigastric area. The nurse most appropriately: A. Contacts the client's health care provider B. Tells the client to avoid lying flat C. Instructs the client to eat a small portion of food every 2 to 3 hours D. Administers an antacid to the client and tell her to take a dose every 6 hours

A. Contacts the client's health care provider

A nurse has a prescription to apply a Holter monitor to a client for continuous cardiac monitoring for a 24-hour period. What steps should the nurse take to initiate this prescription? Select all that apply. A. Giving the client a device holder to wear around the waist B. Giving the client a diary in which to record activity and symptoms C. Telling the client to rest as much as possible during the next 24 hours D. Instructing the client to enclose the monitor in plastic wrap before taking a bath E. Telling the client that occasional slight shocks from the monitor will be felt but that they are harmless

A. Giving the client a device holder to wear around the waist B. Giving the client a diary in which to record activity and symptoms

A client is pregnant for the sixth time. She tells the nurse that she has had three elective first-trimester abortions and that she has a son who was born at 40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In calculating the gravidity and para (parity), what does the nurse determine? A. Gravida 6, para 2 B. Gravida 2, para 6 C. Gravida 2, para 2 D. Gravida 3, para 6

A. Gravida 6, para 2

A nurse performing a physical examination is preparing to auscultate the client's bowel sounds. The client tells the nurse that he ate lunch just 45 minutes ago. On the basis of this information, which finding does the nurse expect to note? A. Gurgling sounds B. Hypoactive sounds C. Low-pitched sounds D. An absence of sounds

A. Gurgling sounds

A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon's office? Select all that apply. A. Hematocrit 30% (0.30) B. Sodium 141 mEq/L (141 mmol/L) C. Hemoglobin 8.9 g/dL (89 g/L) D. Platelets 210× 103/μL (210 × 109/L) E. Serum creatinine 0.8 mg/dL (70 μmol/L)

A. Hematocrit 30% (0.30)

A nurse notes that the site of a client's peripheral IV catheter is reddened, warm, painful, and slightly edematous in the area of the insertion site. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client has experienced which problem? A. Phlebitis of the vein B. Infiltration of the IV line C. Hypersensitivity to the IV solution D. An allergic reaction to the IV catheter material

A. Phlebitis of the vein

A nurse is repositioning a client who has returned to the nursing unit after internal fixation of a fractured right hip. The nurse should use which for repositioning? A. Pillow to keep the right leg abducted while turning the client B. Rolled bath blanket to prevent abduction while turning the client C. Trochanter roll to keep the right leg adducted while turning the client D. Rolled bath blanket to prevent external rotation while turning the client

A. Pillow to keep the right leg abducted while turning the client

A client is severely injured, sustaining a full-thickness circumferential burn to the left leg, after passing out as a result of drinking alcohol and falling into a fire while on a camping trip. In report, the nurse is told that the client has just signed consent for amputation of the limb and that the procedure is scheduled for tomorrow. While caring for the client, the nurse notes that the client is upset and withdrawn. What is the most appropriate nursing action at this time? A. Reflecting back to the client that he appears upset B. Letting the client have some time alone to grieve the impending loss of the limb C. Reminding the client that the injury was a result of alcohol abuse and referring him for counseling D. Informing the health care provider of the client's depression and requesting medication to assist the client in coping with the diagnosis

A. Reflecting back to the client that he appears upset

A nurse is assessing a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the insertion site. What should the nurse dofirst? A. Remove the IV B. Apply a warm compress C. Check for blood return D. Measure the area of infiltration

A. Remove the IV

The nurse reviews the nursing care plan of a client being seen in the mental health clinic and notes that the client is experiencing dysfunctional grieving after losing his spouse. Which is the appropriate outcome for the treatment plan for this client? A. The client plans to attend a community grief group. B. The client reports that he is trying to use coping strategies. C. The client verbalizes an absolute need to spend time with friends. D. The client verbalizes the relationship between significant loss and depression.

A. The client plans to attend a community grief group.

A home care nurse has been assigned a client who has been discharged home with a prescription for total parenteral nutrition (TPN). Which parameters does the nurse plan to check at each visit as a means of identifying complications of the TPN therapy? Select all that apply. A. Weight B. Glucose test C. Temperature D. Peripheral pulses E. Hemoglobin and hematocrit

A. Weight B. Glucose test C. Temperature

A nurse preparing to perform an abdominal assessment asks the client to void and then assists the client into a supine position. Which primary finding does the nurse expect to note on percussing all four quadrants of the abdominal cavity? A. Dullness B. Tympany C. Borborygmus D. Hyperresonance

B. Tympany

A health care provider is about to perform paracentesis on a client with abdominal ascites. Into which position would the nurse assist the client? A. Supine B. Upright C. Left side-lying D. Right side-lying

B. Upright

An older client is extremely anxious after admission, having never been hospitalized before. To help provide a safe environment and minimize the stress of hospitalization on the client, what does the nurse plan to do? Select all that apply. A. Keep visitors to a minimum B. Acknowledge the client's feelings C. Provide information about hospital routines D. Put the client in a room far from the nurses' station E. Keep the door open and the room lights on at all times F. Allow the client to have as many choices regarding his care as possible

B. Acknowledge the client's feelings C. Provide information about hospital routines F. Allow the client to have as many choices regarding his care as possible

A client has just been admitted to the mental health unit with a diagnosis of obsessive-compulsive disorder. The nurse observes the client for compulsive behavior involving which repetative element? A. Fears B. Actions C. Thoughts D. Delusions

B. Actions

A pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. What should the nurse tell the client? A. Complementary alternative therapies should not be used during pregnancy B. Devices that apply pressure alone are available over the counter C. The health care provider or nurse-midwife needs to provide a prescription for acupressure D. It is all right to try any type of complementary alternative therapy to relieve the nausea

B. Devices that apply pressure alone are available over the counter

The nursing staff in an emergency department is reviewing and updating the disaster preparedness plan. The staff members, discussing ways to help prevent the transmission of smallpox, know that this infection is transmitted by which route? A. Enteric B. Inhalation C. Gastrointestinal D. Through open wounds

B. Inhalation

A nurse provides instructions to a client about preventing injury while using crutches. The nurse tells the client to avoid resting the underside of the arm on the crutch pad, mainly because it could result in which problem? A. Skin breakdown B. Injury to the nerves C. An abnormal stance D. A fall and further injury

B. Injury to the nerves

A nurse is inserting an indwelling urinary catheter into a female client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. At this point, the nurse should take which action? A. Immediately inflate the balloon B. Insert the catheter 2.5 to 5 cm and inflate the balloon C. Wait until the urine flow stops and inflate the balloon D. Insert the catheter until resistance is met and inflate the balloon

B. Insert the catheter 2.5 to 5 cm and inflate the balloon

A nurse is monitoring a client's fluid balance. Which 24-hour intake and output totals indicates to the nurse that the client has the proper fluid balance? A. Intake 1600 mL, output 800 mL B. Intake 1500 mL, output 1400 mL C. Intake 2400 mL, output 2900 mL D. Intake 3000 mL, output 2400 mL

B. Intake 1500 mL, output 1400 mL

A nurse is evaluating the client's use of a cane for left-sided weakness. The nurse determines that the client needs further teaching if the client is observed doing what? A. Holds the cane on the right side B. Moves the cane when the right leg is moved C. Leans on the cane when the right leg moves forward D. Keeps the cane 6 inches out to the side of the right foot

B. Moves the cane when the right leg is moved

A nurse, preparing a sterile field on which to perform a dressing change, places the sterile drape on the overbed table. Which of these actions on the part of the nurse indicate correct understanding of the principles of aseptic technique? Select all that apply. A. Holding the pair of sterile forceps below waist level area B. Positioning the sterile field so that it remains in full view C. Reaching across the sterile field to pick up a sterile gauze D. Leaving the room to obtain a bottle of sterile normal saline solution E. Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand F. Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves

B. Positioning the sterile field so that it remains in full view E. Picking up a pair of sterile scissors from the sterile field with a sterile gloved hand F. Pouring sterile wound cleansing solution into a sterile cup before donning sterile gloves

A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client? A. Supine B. Semi-Fowler C. On the side that has undergone surgery D. Prone on the side that has undergone surgery

B. Semi-Fowler

A nurse is monitoring a client who is receiving a continuous intravenous infusion of morphine sulfate. Which finding should cause the nurse to contact the health care provider? A. Temperature of 97.6° F B. Urine output of 30 mL/hr C. Blood pressure of 100/60 mm Hg D. Respiratory rate of 10 breaths/min

D. Respiratory rate of 10 breaths/min

A client with heart failure and hypertension who has been admitted to the hospital is unable to make own selections from the menu. Which meal does the nurse select for the client's supper on the day of admission? A. Smoked ham, fresh carrots, boiled potato B. Hot dog in a bun, sauerkraut, baked beans C Turkey, baked potato, salad with oil and vinegar D. Shrimp, baked potato, salad with blue cheese dressing

C Turkey, baked potato, salad with oil and vinegar

A client has just undergone insertion of a central venous catheter by the health care provider at the bedside. Which result would the nurse be sure to check before initiating infusion of the IV solution that the health care provider has prescribed? A. Serum osmolality B. Serum electrolytes C. Portable chest x-ray D. Intake and output record

C. Portable chest x-ray

A serum phenytoin determination is prescribed for a client with a seizure disorder who is taking phenytoin. Which result indicates that the prescribed dose of phenytoin is therapeutic? A. 3 mcg/mL B. 8 mcg/mL C. 16 mcg/mL D. 28 mcg/mL

C. 16 mcg/mL

A nurse arrives at the scene of a code and begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on the chest to a depth of: A. 1 inch B. 1½ inches C. 2 inches D. 4 inches

C. 2 inches

A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives to the unit, the nurse first: A. Weighs the child B. Takes the child's temperature C. Attaches the child to a pulse oximeter D. Administers the prescribed antibiotic

C. Attaches the child to a pulse oximeter

A nurse performing a neurological assessment of an adult client asks the client to identify various odors. In this technique, which cranial nerve is the nurse assessing? A. Optic B. Abducens C. Olfactory D. Hypoglossal

C. Olfactory

An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse who receives the report of the client's laboratory work that the client's hematocrit is normal? A. 10% ( 0.10) B. 22% ( 0.22) C. 30% ( 0.30) D. 43% ( 0.43)

D. 43% ( 0.43)

An adult client tells the clinic nurse that he is susceptible to middle ear infections. About which risk factor related to infection of the ears does the nurse question this client? A. Loud music B. Use of power tools C. Occupational noise D. Exposure to cigarette smoke

D. Exposure to cigarette smoke

A nurse is preparing a client for the insertion of a central intravenous line into the subclavian vein by the health care provider. The nurse gathers the equipment, places it at the bedside, and prepares to assist the health care provider with the procedure. As further preparation for the procedure, the nurse places the client in which position? A. Flat on the left side B. In the prone position C. In the supine position D. In a slight Trendelenburg position

D. In a slight Trendelenburg position

A nurse is monitoring a client with deep vein thrombosis (DVT) for signs of pulmonary embolism. For which sign of DVT, the most common, does the nurse assess the client? A. Cough B. Hemoptysis C. Diaphoresis D. Pleuritic chest pain

D. Pleuritic chest pain

A nurse is preparing to auscultate for the presence of bowel sounds in a client who has just undergone surgery. The nurse places the stethoscope in which abdominal quadrant first? A. Left upper quadrant B. Left lower quadrant C. Right upper quadrant D. Right lower quadrant

D. Right lower quadrant

A client is scheduled to undergo electroconvulsive therapy (ECT). Which client concern is of the highest priority? A. Fear B. Anxiety C. Distorted body image D. Risk for impaired breathing

D. Risk for impaired breathing

The health care provider's prescription for an adult client reads, "Potassium chloride 15 mEq by mouth." The label on the medication bottle reads, "20 mEq potassium chloride/15 mL." How many milliliters of KCl does the nurse prepare to ensure administration of the correct dose of medication? (Round to the nearest whole number.)

1.11

The health care provider's prescription reads, "Clindamycin phosphate 0.3 g in 50 mL NS, to be administered IV over 30 minutes." The medication label reads, "Clindamycin phosphate 150 mg/mL." How many milliliters of medication does the nurse prepare to ensure that the correct dose is administered?

1.2

The health care provider prescribes 1000 mL of normal saline 0.45% for infusion over 8 hours. The drop factor is 10 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

1.21

The health care provider prescribes 1000 mL of 5% dextrose in water, to be infused over 24 hours. The drop factor is 60 gtt/mL. At how many drops per minute does the nurse set the flow rate? (Round to the nearest whole number).

1.42

The nurse is providing information to a group of nursing staff members about caring for suicidal clients. What should the nurse tell the group? A. Discussing suicide with a client is not harmful B. Those clients who talk about suicide never actually try it C. Depressed clients are the only people who commit suicide D. When a person makes suicide threats, the only thing the person wants is attention

A. Discussing suicide with a client is not harmful

A client with a history of lung disease is at risk for respiratory acidosis. For which signs and symptoms does the nurse assess this client? A. Disorientation and dyspnea B. Drowsiness, headache, and tachypnea C. Tachypnea, dizziness, and paresthesias D. Dysrhythmias and decreased respiratory rate and depth

A. Disorientation and dyspnea

A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats per minute. Which action should the nurse take? A. Document the findings B. Notify the health care provider of the finding C. Wait 15 minutes and then recheck the FHR D. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time

A. Document the findings

A nurse performing a neurological assessment of a client in later adulthood notes that the client has tremors of the hands. Based on this finding, which action should the nurse take? A. Document the findings B. Notify the health care provider immediately C. Obtain a prescription for a muscle relaxant D. Ask the health care provider about referring the client to a neurological specialist

A. Document the findings

A nurse provides dietary instructions to a client with iron-deficiency anemia. Which foods does the nurse recommend to the client? Select all that apply. A. Lentils B. Raisins C. Pineapple D. Egg whites E. Kidney beans F. Refined white bread

A. Lentils B. Raisins E. Kidney beans

An amniocentesis is scheduled for a pregnant client who is in the third trimester of pregnancy. The nurse tells the client that the most common indication for amniocentesis during the third trimester is which? A. Determination of fetal lung maturity B. Checking the amniotic fluid for intrauterine infection C. Checking the fetal cells for chromosomal abnormalities D. Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid

A. Determination of fetal lung maturity

A nurse is assessing a 12-month-old child with iron-deficiency anemia. Which finding does the nurse expect to note in this child? A. Lethargy B. Bradycardia C. Hyperactivity D. Reddened cheeks

A. Lethargy

A nurse preparing to perform a sterile dressing change notes that the covering of a package of sterile 4 × 4 gauze pads has a small tear. Which action should the nurse take? A. Discarding the package B. Using the gauze pads, because the tear was small C. Examining the gauze pads and using them as long as they appear untouched D. Discarding the gauze pad closest to the outside of the package and using the others

A. Discarding the package

A nurse is preparing a disaster preparedness checklist, identifying emergency plans and supplies that will be needed in the event of a disaster, for a community group. Which instructions should be included on the list? Select all that apply. A. Have a first aid kit available. B. Have a firearm or other weapon available. C. Plan a meeting place for family members. D. Obtain a 1-day supply of water (1 gallon per person). E. Have an adequate supply of prescription medications. F. Have a battery-operated radio and a flashlight and batteries available.

A. Have a first aid kit available. C. Plan a meeting place for family members. E. Have an adequate supply of prescription medications. F. Have a battery-operated radio and a flashlight and batteries available.

The nurse determines that a client whose son died in a car accident is at risk for self-harm. Which intervention is most appropriate initially? A. Making a "no suicide" contract with the client B. Telling the client that anger should be suppressed C. Providing a peaceful place for the client to meditate D. Helping the client control expression of his feelings

A. Making a "no suicide" contract with the client

A nurse, assigned to care for a hospitalized child who is 8 years old, plans care, taking into account Erik Erikson's theory of psychosocial development. According to Erikson's theory, which task represents the primary developmental task of this child? A. Mastering useful skills and tools B. Gaining independence from parents C. Developing a sense of trust in the world D. Developing a sense of control over self and body functions

A. Mastering useful skills and tools

A client is brought to the emergency department by a neighbor. The client is lethargic and has a fruity odor on the breath. The client's arterial blood gas (ABG) results are pH 7.25, PaCO234 mm Hg (4.52 kPa), PaO2 86 mm Hg (11.3 kPa), HCO3 14 mEq/L (14 mmol/L). Which acid-base disturbance does the nurse recognize in these results? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis

A client with type 1 diabetes mellitus has a blood glucose level of 620 mg/dL (34.4 mmol/L). After the nurse calls the health care provider to report the finding and monitors the client closely for which condition? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis

A nurse is caring for a client with diarrhea. For which acid-base disorder does the nurse assess the client? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis

A nurse is caring for a client with histoplasmosis who is receiving intravenous amphotericin B . What should the nurse do while the medication is being administered? A. Monitor the client's urine output B. Monitor the client for hypothermia C. Check the client's neurological status D. Check the client's blood glucose level

A. Monitor the client's urine output

A nurse is developing a plan of care for a client, hospitalized with heart failure, who has a history of Parkinson disease and is taking benztropine mesylate daily. Which intervention does the nurse identify as a priority in the plan? A. Monitoring intake and output Correct B. Monitoring the client's pupillary response C. Placing the client in a right side-lying position D. Checking the client's hemoglobin level daily

A. Monitoring intake and output

A nurse is reading the medical record of a client receiving haloperidol. The nurse notes that the health care provider has documented that the client is experiencing signs of akathisia. On the basis of the health care provider's note, which clinical manifestation would the nurse expect to find during assessment of the client? A. Motor restlessness B. Puffing of the cheeks C. Puckering of the mouth D. Protrusion of the tongue

A. Motor restlessness

A nurse is preparing to screen a client's vision with the use of a Snellen chart. Which action should the nurse take? A. Tests the right eye, then tests the left eye, and finally tests both eyes together B. Assesses both eyes together, then assesses the right and left eyes separately C. Asks the client to stand 40 feet from the chart and read the largest line on the chart D. Asks the client to stand 40 feet from the chart and read the line that can be read 200 feet away by someone with unimpaired vision

A. Tests the right eye, then tests the left eye, and finally tests both eyes together

A nurse is reading the history and physical examination findings of an older client who has just been admitted to the hospital. Which findings documented in the history indicate an increased risk for accidents? Select all that apply. A. The client's range of motion is limited. B. Transmission of hot impulses is delayed. C. The client's peripheral vision is decreased. D. The client complaints of frequent nocturia. E. High-frequency hearing tones are perceptible. F. Voluntary and autonomic reflexes are slowed.

A. The client's range of motion is limited. B. Transmission of hot impulses is delayed. C. The client's peripheral vision is decreased D. The client complaints of frequent nocturia. F. Voluntary and autonomic reflexes are slowed.

Which of the following statements reflect the principles of sterile technique? Select all that apply. A. The edge of a sterile field and a border 1 inch inward is unsterile. B. If a package is not labeled as sterile, it should be considered unsterile. C. Sterile objects that come in contact with unsterile objects are to be considered contaminated. D. Any part of a sterile field that hangs below the top of the table is sterile as long as it is not touched. E. When a sterile field becomes wet, it remains sterile as long as the items on the field are not touched. F. Items in a sterile package must be used immediately once the package has been opened; otherwise they are considered contaminated.

A. The edge of a sterile field and a border 1 inch inward is unsterile. B. If a package is not labeled as sterile, it should be considered unsterile. C. Sterile objects that come in contact with unsterile objects are to be considered contaminated F. Items in a sterile package must be used immediately once the package has been opened; otherwise they are considered contaminated.

A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2 oz about car safety. What should the nurse tell the mother? A. To secure the infant in the middle of the back seat in a rear-facing infant safety seat B. To place the infant in a booster seat in the front seat of the car with the shoulder and lap belts secured around the infant C. That it is acceptable to place the infant in the front seat in a rear-facing infant safety seat as long as the car has passenger-side air bags D. That because of the infant's weight it is acceptable to hold the infant as long as the mother and infant are sitting in the middle of the back seat of the car

A. To secure the infant in the middle of the back seat in a rear-facing infant safety seat

A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the health care provider? Select all that apply. A. Unequal chest expansion B. Pulse rate of 82 beats/min C. Respiratory rate of 22 breaths/min D. Diminished breath sounds in the right lung E. Complaints of discomfort at the needle insertion site

A. Unequal chest expansion

A nurse employed on a medical care unit is administering medications. She tells a client that she is going to administer his furosemide (Lasix) through his intravenous (IV) line. The client tells the nurse that he takes this medication orally at home every day and is concerned that it is being administered by way of a different route. The nurse should take which most appropriate action? A. Verifying the physician's prescription B. Sitting and talking to the client to alleviate his concern C. Explaining to the client that the oral route will not permit the medication to exert an adequate effect D. Letting the client know that most medications are administered by way of the IV route when a client is hospitalized

A. Verifying the physician's prescription

A nurse develops a nursing care plan for a client with a sealed radiation implant. Which stipulation does the nurse include in the plan? A. Visitors must be limited to one half-hour per day. B. Visitors must remain at least 2 feet from the client. C. A dosimeter badge must be placed on the client's bedside stand. D. The client may be maintained in a semiprivate room as long as the client uses a commode.

A. Visitors must be limited to one half-hour per day.

A nurse performing a skin assessment notes that the client's skin is very dry. How should the nurse document this finding? A. Xerosis B. Pruritus C. Seborrhea D. Actinic keratoses

A. Xerosis

A 62-year-old woman says, "Since my husband retired, 4 months ago, he's started playing golf 24/7, so after rearing our children alone while my workaholic husband ran his business I'm suddenly a golf widow." Which response by the nurse is appropriate? A. "Do other people call you a golf widow?" B. "Have you shared your feelings with your husband?" C. "'When you can't beat 'em, join 'em' — that's what I always say. Why not play golf with him?" D. "Some women wish they had your problem. My mother keeps complaining that Dad is always messing around in the house, driving her nuts."

B. "Have you shared your feelings with your husband?"

An older female client asks a nurse why her hair has turned gray. Which response is most appropriate for the nurse to make to the client? A. "It is caused by hereditary factors." B. "A loss of melanin occurs in the normal aging process." C. "The skin on the scalp becomes thin, causing moisture to escape." D. "The number of sweat glands and blood vessels decreases in the normal aging process."

B. "A loss of melanin occurs in the normal aging process."

A schizophrenic client says to the nurse, "I keep getting these thoughts and hearing voices. They worry and consume me so that I can't always stop myself like my health care provider told me to." Which intervention would the nurse suggest as a distraction technique? A. "Pretend that you're on the phone and talk to the voices." B. "Have you tried to count back from 100 or listen to music?" C. "The next time this happens, try telling the voices to go away." D. "Tell the voices that you will only listen to them just before you watch television at 8:30 in the evening."

B. "Have you tried to count back from 100 or listen to music?"

Blood for arterial blood gas determinations is drawn on a client with pneumonia, and testing reveals a pH of 7.45, PaCO2 of 30 mm Hg (3.99 kPa)., and HCO3 of 19 mEq/L (19 mmol/L). The nurse interprets these results as indicative of which disorder? A. Compensated metabolic acidosis B. Compensated respiratory alkalosis C. Uncompensated metabolic alkalosis D. Uncompensated respiratory acidosis

B. Compensated respiratory alkalosis

Which statement made by a client with anorexia nervosa would indicate to the nurse that treatment has been effective? A. "I no longer have to lose weight." B. "I won't starve myself anymore." C. "I'll eat until I don't feel hungry." D. "I went out to lunch today with my cousin."

D. "I went out to lunch today with my cousin."

A nurse provides information to a client about the importance of consuming fluids every day. If the client has no renal or cardiac disease or any other disorder requiring fluid alterations, how many milliliters of fluid should the nurse recommend that the client consume each day? A. 500 to 1000 mL B. 1000 to 1500 mL C. 1500 to 2000 mL D. 2000 to 2500 mL

D. 2000 to 2500 mL

A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect related specifically to the site of irradiation does the nurse tell the client to expect? A. Diarrhea B. Dyspnea C. Headache D. Dysphagia

D. Dysphagia

A teenage client returns to the gynecological (GYN) clinic for a follow-up visit after diagnosis and initial treatment of a sexually transmitted infection (STI). Which statement by the client indicates the need for further teaching? A. "I finished all the antibiotic, just like you said." B. "I know you won't tell my parents that I'm sick." C. "I always make sure my boyfriend uses a condom." D. "My boyfriend doesn't have to come in for treatment."

D. "My boyfriend doesn't have to come in for treatment."

A client with major depression says to the nurse, "I should have died. I've always been a failure." Which response by the nurse is therapeutic? A. "I see a lot of positive things in you." B. "You still have a great deal to live for." C. "Feeling like a failure is part of your illness." D. "You've been feeling like a failure for some time now?"

D. "You've been feeling like a failure for some time now?"

A 45-year-old client says to the nurse, "Since I left my wife and children, I can hardly make ends meet between child support and trying to support myself. I don't know why I bother going to work when my wife and kids take just about everything I make." Which nursing statement would be therapeutic? A. "I wonder why you left your wife and children." B. "What would you expect your wife and children to do? They didn't leave you." C. "You seem to be very angry about carrying out your responsibility to your children." D. "Do you feel that child support is designed to help children, not punish spouses who leave?"

D. "Do you feel that child support is designed to help children, not punish spouses who leave?"

A client with rheumatoid arthritis is taking high doses of acetylsalicylic acid. While assessing the client for aspirin toxicity, which question should the nurse ask the client? A. "Are you constipated?" B. "Are you having any diarrhea?" C. "Do you have any double vision?" D. "Do you have any ringing in the ears?"

D. "Do you have any ringing in the ears?"

During a physical assessment, the client tells the nurse that he is having difficulty swallowing medications and food. The nurse gathers additional subjective data and documents that the client is experiencing: A. Pyrosis B. Anorexia C. Eructation D. Dysphagia

D. Dysphagia

A recently widowed client says, "I lived my whole life for my husband and children. Now he's dead and my daughter and son have each married and moved across the country. They hardly ever call or visit. It's just that there's really nothing much for me to do." Which response by the nurse to the client is appropriate? A. "Your children seem very distant. They hardly ever call?" B. "Are you thinking of hurting yourself just because you're alone?" C. "You're feeling pretty useless right now, but I wonder if you've taken enough time to grieve?" D. "You seem to be identifying some issues in your life that are troubling, and you sound very down right now."

D. "You seem to be identifying some issues in your life that are troubling, and you sound very down right now."

A nurse is caring for a child with newly diagnosed type 1 diabetes mellitus who is receiving insulin. The child suddenly exhibits tachycardia and beings to sweat and tremble, and the nurse determines that the child is experiencing a hypoglycemic reaction. The nurse would immediately give the child: A. A sugar cube B. A teaspoon of sugar C . ½ cup of diet cola D. ½ cup of fruit juice

D. ½ cup of fruit juice

The nurse is developing a plan of care for a client who recently received a diagnosis of acquired immunodeficiency syndrome and is experiencing difficulty adjusting to the illness. Which action is an inappropriate intervention for this client? A. Monitoring the client for signs of self-harm B. Helping the client verbalize concerns related to fear C. Assisting the client with problem-solving and decision-making E. Discouraging social networking to prevent the spread of infection

E. Discouraging social networking to prevent the spread of infection

A nurse on the day shift is assigned to care for four clients. List the clients in order of priority for nurse.

The correct order is: A client with asthma who had shortness of breath during the night A client scheduled to have a chest x-ray at 9 am A client scheduled for an echocardiogram at 10 am A client with pneumonia who is scheduled for discharge home

A nurse on the day shift receives her client assignments for the day. List the clients in order of their priority for assessment.

The correct order is: A client with heart failure whose condition has been stable since the administration of furosemide (Lasix) A client with gastroenteritis and diarrhea A client with suspected gallbladder disease who is scheduled for an ultrasound of the abdomen A client with a herniated disc who is scheduled to be discharged today

A nurse working the 7 am-to-3 pm shift is assigned to care for four clients. List the clients in order of priority for the nurse.

The correct order is: A client with pneumonia who is receiving oxygen A client with diabetes mellitus who requires the administration of NPH insulin before breakfast A client with a wound requiring dressing changes at 10 am and 2 pm A client preparing for discharge after surgery

A nurse is assisting a nurse-midwife in performing an amniotomy. After the procedure, the nurse should perform the following actions. Arrange the actions in the order that they should be performed. All options must be used.

The correct order is: Assess the fetal heart rate Assess the color, odor, and other characteristics of the amniotic fluid Check the woman's heart rate and blood pressure Assist the woman in cleaning the perineal area Ask the woman about the need to void

A nurse who is preparing to leave the room of a client who is under airborne precautions needs to remove the following protective items: gloves, gown, mask, and goggles. Place in order of priority the items that need to be removed.

The correct order is: Gloves Goggles Gown Mask