Finished line comprehensive A, B, C

A charge nurse is providing teaching for group of newly licensed nurse about grieving process. Which of the following information should the charge nurse include in the teaching?

Client might feel guilt over some aspect of their loss

A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following finding should the nurse identify as the priority?

Dysphagia

A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching ?

Eat 1g/kg of protein per day

Which of these actions should a nurse take prior to initiating prescribed antibiotic therapy for a client who has a urinary tract infection? a. Measure the body temperature. b. Cleanse the perineum. c. Weigh the client. d. Obtain a urine culture specimen.

d. Obtain a urine culture specimen.

A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching?

Establish a toileting schedule for the client

A nurse should place a child who is two hours post-tonsillectomy and adenoidectomy in which of these positions? a. Supine, flat. b. Orthopneic. c. Trendelenberg. d. Side-lying.

d. Side-lying.

4. A nurse is caring for a client who has type 2 diabetes mellitus and a blood glucose level of 60 mg/dL. For which of the following findings should the nurse monitor?

Fasting plasma glucose level

A nurse is caring for a client who has acute glomerulonephritis .Which of the following should the nurse expect ?

Hematuria - urinalysis will show red blood cells and protein, also reddish brown col colored urine

44. A nurse is reviewing the immunization records of a 9 year old child during a routine physical exam, which of the following should indicate to the nurse the child is not current with the minimum required immunization?

One MMR vaccine.

A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations?

Orthostatic hypotension

116. A nurse is reinforcing teaching for a client who has just started taking amitriptyline (Elavil). Which of the following should the nurse include as an adverse effect of this medication?

Orthostatic hypotension.

33. A nurse is collecting data from a client who presents to the clinic reporting vomiting. Which of the following findings indicate that the client is experiencing a fluid volume deficit?

Orthostatic hypotension.

90. A nurse is caring for a client who was recently diagnosed with paranoid schizophrenia and is taking risperidone (risperdal). Which of the following statements by the family indicates a need for further teaching?

Our son's symptoms will stop as soon as he begins his medications.

A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at the peripheral IV site. Which of the following actions should the nurse plan to take?

Please a warm moist compress on the site

74.A client who is participating in an anger management session explains that his recent behaviors are related to his job loss. Which of the following defense mechanisms is the client using?

Rationalization.

14. A nurse is reinforcing teaching about car seat safety to the parents of a newborn, The nurse should instruct the parents to place the car seat in a?

Rear-facing position in the back seat.

132. A nurse is reinforcing discharge teaching to a client who is prescribed propylthiuracil. for which of the following should the nurse instruct the client to monitor and report to the provider immediately?

d. Sore throat.

3. A nurse is discharging a client who was admitted for newly diagnosed type 2 diabetes mellitus. The client is independent and lives alone. Which of the following should be included in the discharge plan?

Refer the client to a diabetic support group.

137. A nurse is caring for a client in a mental health unit who is pacing back and forth and wringing his hands. Which of the following interventions should the nurse implement?

d. Take the client for a walk to the recreation room.

When assessing a client's risk of developing nosocomial infection, a nurse plans to determine potential entry portals, which include: a. the urinary meatus. b. vomitus. c. contaminated water. d. sexual intercourse.

a. the urinary meatus.

A nurse determines that the therapeutic effectiveness of magnesium sulfate (MgSO4) for client who has preeclampsia is achieved when there is increased: a. urinary output. b. blood pressure. c. respiratory rate. d. uterine movement.

a. urinary output.

Which of these items should a nurse removed from the food tray of a client who is on a sodium-restricted diet? a. Packet of a salt substitute. b. Grapefruit juice. c. Container of jelly. d. Ketchup.

d. Ketchup.

130. A nurse receives a verbal order for a client to receive a stat dose of meperidine (demerol) 100 mg PO. she administers the medication, charts the administration, and then realizes she has administered Phentoin (dilantin) 100 mg PO. After obtaining the client's vital signs, which of the following actions should the nurse take?

d. Notify the provider.

A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP?

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

A community health nurse receives a referral for a family home visit. Which of the following tasks should the nurse perform first?

Clarify the source of the referral

A nurse is reviewing the medical record of a client. The nurse should identify that the client is at risk for which of the following complication.

Dumping syndrome

A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect?

Heightened perceptual field

60. A nurse is caring for a client who is in active labor and is accompanied by her partner. The client and her partner tell the nurse they were unable to attend childbirth preparation classes. Which of the following responses by the nurse supports the partner's involvement during labor?

"Breathing with your partner will help her to relax during contractions."

A nurse is interviewing the partner of a client who was admitted in the manic phase of bipolar disorder. The partner states, "I don't know what to do. Everything has been happening so quickly." Which of the following responses by the nurse is therapeutic?

"Can you talk about what was happening with your partner at home?"

A nurse is teaching a client who has an ileostomy about the care of his stoma site. Which of the following statements by the client requires further teaching?

"I should change the stoma pouch every day"

A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?

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

103. A nurse is reinforcing teaching with a group of expectant parents regarding the proper use of car seat, Which of the following statements by a parent indicates an understanding of the teaching?

"I can place a rolled towel on each side of my newborn's head until he can hold his head up."

55. A nurse is collecting data from an adolescent client who is a victim of sexual abuse. The nurse recognizes the use of the defense mechanism of suppression when the client states.

"I guess I have to take some of the blame because of the way my friends and I dress."

5. A female client who is an abusive marriage has discusses with the nurse strategies to prevent this abuse. Which of the following client statements indicate an understanding of an appropriate strategy?

"I need to recognize the signs that my husband is becoming abusive." c. "I need to identify what triggers my husband's anger to prevent his abuse."

78.A nurse is reinforcing teaching to a group of adolescent males. Which of the following statements made by a student indicates a need for further teaching?

"I should perform a self-exam of my testes once a year."

A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identify as a manifestation of increased risk for child abuse?

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

A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching?

"I will avoid food and beverages that contain caffeine"

32.A nurse is providing anticipatory guidance to the parent of a 6-year old child, which of the following statements by the parent indicated an understanding of appropriate safety precautions for the child?

"I will encourage my child to wear a bicycle helmet whenever bike riding."

76.A nurse is reinforcing teaching to the parent of a child who has been prescribed ferrous sulfate (Feosol) in liquid form. Which of the following statements made by the parent indicates the teaching was effective?

"I will give the iron through a straw."

45.A nurse is reinforcing teaching with a new mother on facility security measure, which of the following statements by the mother indicates that the teaching was effective?

"I will have an identification band that matches the one my baby wears."

A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role?

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

A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks of gestation about managing diabetes during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

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

57. A nurse is providing home care to a client and is reinforcing teaching regarding home safety. Which of the following by the client indicates a need for further teaching?

"I will walk barefoot to prevent slipping." d. "I will check my smoke alarms once a month."

141. A nurse is collecting data for a client who has been receiving medroxyprogesterone acetate (Depo- Provera) for the past 6 months. Which of the following statements made by the client should be reported to the provider?

"I'm experiencing calf pain."

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?

Contractions

105. A nurse is caring for a client who is asking about the technique of effleurage and its use in labor and delivery. Which of the following responses should the nurse make regarding this technique?

"It is a light stroking of the skin during a uterine contraction."

19. A Client who is prescribed metoprolol (Lopressor) for hypertension tells the nurse, "I don't want to take this medication because it makes me tired all the time." Which of the following is the appropriate response?

"Let's talk with your doctor about other options."

18. A nurse is reinforcing teaching with a client about organ donation. Which of the following client statements indicated a need for further teaching?

"My doctor should decide if my organs will be donated."

111. A nurse is provider's office is reinforcing teaching to the parents of a school- age child who has an ankle sprain. The nurse should include which of the following statements in the teaching?

"Offer aspirin every 4 hours for discomfort." c. "elevate the affected extremity to a level higher than the heart."

114. A nurse is reinforcing teaching to the parents of an infant who has pavlik harness. Which of the following statements should the nurse include in the teaching?

"The harness promotes hip joint development."

108. A nurse is reinforcing teaching with a client regarding the use of guided imagery to relieve back pain. Which of the following statements made by the nurse is appropriate?

"Think about a pleasant memory as you visualize your pain floating away."

A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

"This type of seizure can be mistaken for daydreaming"

26. A nurse is caring for a client admitted with shortness of breath who will be undergoing arterial blood gas testing, which of the following client statements indicated an understanding of the purpose of drawing arterial blood gases?

"This will indicate how much acid is building up in my blood."

A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?

"What are the voices telling you?"

A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client?

"What high school did you graduate from"

A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching?

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

A nurse is providing a preoperative teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching?

"You should push the button before physical activity to allow maximum pain control"

43. A client's daughter calls the nurse requesting information about her mother's condition, the client's chart does not specify that information can be released to the daughter, which of the following is an appropriate response by the nurse?

"You will need to contact your mother directly about her condition."

A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?

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

58. A Client with emphysema asks the nurse why he has difficulty exhaling, Which of the following statements by the nurse is appropriate?

"Your windpipe is inflamed and constricted."

A nurse is preparing to witness a client's signature on a consent form for a colon resection. The nurse should recognize that which of the following information should be provided to the client by the provider before signing the form? (SATA)

- Explain the procedure - Expected outcome of the procedure - Potential complications - Possible alternative treatments

A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." which of the following responses by the nurse is appropriate? (SATA)

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

A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following action should nurse take? (SATA)

- Wear a lead apron when providing care - Limit visitors to 30 mins

A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care?

A client who received a Mantoux test 48 hours ago and has induration

A nurse enters a client's room and sees a small fire in the client's bathroom. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps)

1. Transport the client to another area of the nursing unit 2. Activate the facility's fire alarm system 3. Close all nearby windows and doors 4. Use the unit's fire extinguisher to attempt to put out the fire

A nurse is planning to administer ampicillin 100 mg/kg/day in divided doses every 12 hours to a newborn who weighs 4.34 kg(9.5 lbs). Available is ampicillin 125mg/ml. How many milliliters should the nurse administer per dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero)

1.7 mL per dose

77.A nurse is preparing to administer 0.9% sodium chloride 1,000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr?

150 mL/hr

146. A nurse is preparing to administer K+ gluconate (kaon) 60mEq PO in three equally divided doses. Available is K+ gluconate 20 mEq/15 mL. How many mL should the nurse administer with each dose?

15mL

A nurse is assessing a client who is at 36 weeks gestation. Which of the following findings should the nurse report to the provider ?

3+ deep tendon reflexes -preeclampsia

A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

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

56. A client is prescribed 2g of ampicillin, The pharmacy dispenses this medication in 500 mg tablets. Which of the following should the nurse give the client?

4 tablets.

161. A nurse receives report on four clients. The nurse should first collect data about the client who has.

A decreased level of consciousness and vomiting.

140. A nurse is preparing to irrigate a wound of a client who has methicillin- resistant Staphylococcus aureus (MRSA).The nurse should use which of the following personal protective equipment?

A face shield

151. A nurse is reinforcing teaching regarding the dietary intake needed to reduce the risk of neural tube defects with a client who is planning to become pregnant.

Cooked spinach

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

7.5%

A nurse on a surgical pediatric care unit receives report prior to providing care for a group of clients. Which of the following clients should the nurse assess first?

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

125. A nurse is providing change-of-shift report on four clients. Which of the following is most important for the nurse to include in the report?

A client had a blood glucose of 140mg/dL.

2. A nurse is working on a unit for clients with dementia. Which of the following client situations requires the nurse to write an incident report?

A client is found lying on the floor next to a chair

9. A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept?

A client who had a cesarean delivery 24hr ago.

49. A nurse in a long-term care facility has received a change-of-shift report on four clients. Which of the following clients should the nurse attend to first?

A client who has COPD and dementia and was agitated during the night shift.

A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?

A client who has a hip fracture and a new onset of tachypnea

A nurse on an acute unit has received change of shift report for 4 clients which of the following clients should the nurse assess first? Pain pallor pulselessness paresthesia

A client who has fractured left tibia and pallor in the affected extremity

A nurse on an antepartum unit is prioritizing care for multiple clients. Which of the following clients should the nurse see first?

A client who has preeclampsia and reports a persistent headache

A charge nurse on a medical surgical unit is assisting with the emergency responses plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current client should the nurse recommend for early discharge?

A client who is 1 day postoperative following a vertebroplasty

A charge nurse on a medical-surgical unit is planning assignments for a licensed practical nurse (LPN) who has been sent from the postpartum unit due to a staffing shortage for the shift. Which of the following client assignments should the nurse delegate to the LPN?

A client who is postoperative following a bowel resection with an NGT set to continuous suction

A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?

A client who is receiving heparin for deep vein thrombosis.

A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration?

A history of gastroesophageal reflux disease

15. A nurse is caring for a client and recognizes the client's rights to confidentiality have been breached in which of the following situations?

A hospital risk manager includes information from a client's medical record in

172. A woman who is postmenopausal presents to a clinic for a well-woman examination. She tells the nurse that she does not understand the need for a Pap test because she is no longer experiencing menses. Which of the following responses by the nurse is appropriate?

A pap test can help with early detection of cervical cancer.

A nurse is performing assessments on newborns in the nursery. Which of the following findings should the nurse report to the provider?

A two day old newborn who has a respiratory rate of 70 (30 - 60 is normal)

28. A nurse is collecting data from a client who reports recent weight loss and a Chronic cough that is now producing blood-streaked sputum. For which of the following should the nurse expect the client to have diagnostic testing?

A. Lung Cancer B. Emphysema.

68.A nurse in a long-term care facility is reviewing a client's laboratory results, The client's potassium level is 5_8 mEq/L. Which of the following findings should the nurse expect?

Abdominal cramps.

122. A nurse is caring for an adolescent client who has anorexia nervosa. Which of the following findings should the nurse expect?

Absence of menses a. Elevated blood pressure.

A nursing planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?

Administer analgesics on a scheduled basis for the first 24 hr

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take?

Administer calcium gluconate IV Rationale: Calcium gluconate is given for magnesium sulfate toxicity. Always have an injectable form of calcium gluconate available when administering magnesium sulfate by IV.

A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate?

Administer enalapril 2.5 mg PO twice daily

A nurse is preparing an inservice for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching?

Administering potassium via IV bolus

48. A nurse is working on a mental health unit is reviewing policies for client seclusion. For which of the following is seclusion appropriate?

Aggressive behavior

173. A nurse in provider's office is talking on the phone with a parent of a school- age child who has varicella. The parent asks the nurse when the child can return to school. The nurse tells the parent the child is no longer contagious when

All vesicles have crusted over.

80.A nurse is caring for a client who is terminally ill and requires ongoing palliative care. Which of the following interventions is consistent with the goals of this type of care?

Allowing the family overnight visitation.

179. A nurse is planning client care for a shift. Which of the following should the nurse plan to delegate to an assistive personnel?

Ambulating a client receiving patient-controlled analgesia.

A nurse is caring for a client who is immobile which of the following interventions is appropriate to prevent contracture?

Apply an orthotic to the clients foot

A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child's dressing. Which of the following actions should the nurse take?

Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site.

109. A nurse is caring for an older adult client who is postoperative following a total hip replacement. The client is incontinent of stool and urine. To prevent skin breakdown, the nurse should?

Apply moisture-absorbing undergarments.

154. A mother of two small children tells the nurse, "I just don't know what to do about my cancer. I've seen three doctors, and each one recommended a different treatment options." appropriate response.

Arranging a conference with your providers is something I could assist you with.

107. A nurse is administering medication. A client states, "I know that the Inderal helps my blood pressure, but I don't like the way it makes me feel, I don't think I'll take it today." Which of the following actions should the nurse take?

Ask the client to describe what he is experiencing.

51. A nurse is assisting a client to move up in bed. Which of the following actions should the nurse take?

Ask the client to flex the hips and knees.

38.A nurse is reinforcing discharged teaching with the family of a client who has dependent personality disorder. Which of the following instructions should the nurse include in the teachings?

Assume responsibility for making the clients decisions

91 A nurse is caring for a newly postoperative client who has unilateral breath sounds and asymmetrical chest expansion. The nurse should recognize these findings are indicative of which of the following and should be reported to the provider?

Atelectasis.

A nurse is caring for a client who requests to ambulate in the hallway with his own clothing. The nurse is demonstrating which of the following ethical principles when respecting the client's decision to wear his own clothing ?

Autonomy Autonomy: The ability of the client to make personal decisions, even when those decisions might not be in the client's own best interest

64.A nurse is assisting with the care of a 36-year-old client who is at 1.6 weeks of gestation an is scheduled for an amniocentesis, The nurse recognizes that the client understands the amniocentesis is performed to identify

Chromosomal abnormalities.

34.A nurse is reinforcing teaching for a client undergoing radiation therapy to the neck. Which of the following should the nurse include?

Avoid exposing the neck to the cold

A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching?

Avoid hot tub while wearing the patch

A nurse in the emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority?

Below the knee amputation

A nurse is planning to administer Atenolol to a client. Which of the following should the nurse assess prior to administering the medication?

Blood pressure

A nurse is assessing a newborn who has patent ductus arteriosus. Which of the following findings should the nurse except?

Bounding pulse

A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection?

Clamp the catheter distal to the injection port

30.A nurse in a long-term care facility nuts that the assistive personnel lack knowledge of blood glucose monitoring, The nurse should bring this observation to the attention of which of the following personnel?

Charge Nurse.

117. A nurse in a long-term care facility is caring for a client who uses a continuous positive airway pressure (CPAP) machine at night for sleep apnea. The client reports daytime sleepiness. Which of the following actions should the nurse take first?

Check for proper fit of the mask on the CPAP machine. D. Provide activities during the day to stimulate the client.

176. A nurse is implementing a bladder training program for a client after a cerebrovascular accident. Which of the following interventions by the nurse is appropriate for the client?

Check for residual urine after voiding.

143. A nurse in a long-term care facility is caring for a client who has spinal cord injury. The client is demonstrating manifestations of autonomic dysreflexia. Which of the following actions should the nurse take first?

Check the client for bladder distention d. Loosen the client's clothing.

104. A nurse is preparing to apply a pulse oximeter to a client's finger. Which of the following actions should the nurse take before applying the sensor?

Check the client's capillary refill.

A nurse in an emergency department is caring for a toddler who has burns following a house fire. Which of the following actions should the nurse take first ?

Check the mouth for smooth and smoky breath - airway obstruction via foreign body

A nurse in a provider's office is reviewing the laboratory results of a group of clients. The nurse should identify that which of the following sexually transmitted infectious disease that should be reported to the state health department?

Chlamydia

1. A nurse is caring for a group of clients, which of the following can be assigned to an assistive personnel?

Collecting a stool specimen two tests for occult blood

A nurse is caring for a client who has end-stage liver disease and is undergoing a paracentesis. Which of the following actions should the nurse take to evaluate effectiveness of the procedure?

Compare the client's current weight with preprocedure weight.

A nurse is conducting an initial assessment of a client and noticed a discrepancy between the clients current IV infusion and the information received during the shift report. Which of the following actions should the nurse take?

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

A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?

Consume food high in bran fiber

12.A nurse is preparing a client for surgery. The client tells the nurse that he is concerned about the safety of a large sum of money in his wallet. Which of the following actions is appropriate for the nurse to take?

Contact security personnel to place the money in the facility safe.

A nurse is caring for a client who is at 41 week of gestation and is receiving oxytocin for labor induction. The nurse notes early deceleration on the fetal heart rate monitor . Which of the following nursing actions should the nurse take ?

Continue the monitor the fetal heart rate (Not a problem- absent or late are a problem)

A nurse is assessing a client's respirations which of the following actions should the nurse take?

Count respirations for 1 minute if the rhythm is irregular

40. A nurse is caring for a client who is 2 days postoperative following a partial bowel resection. The client reports that the "felt something pop" when he sneezed, The nurse observes an evisceration, After calling for assistance, which of the following actions should the nurse take first?

Cover the wound with sterile saline-soaked gauze

164. A nurse is caring for a client receiving PRBCs. The following finding should the nurse recognize as indicative of excess fluid volume?

Crackles in the lung Bases.

166. A nurse is collecting data from a female client who wishes to begin oral contraception. Which of the following is a contraindication to the use of oral contraceptives?

Current use of nicotine.

159. A nurse is collecting data from a client who is pregnant and has hypermesis gravidarum. Which of the following finding should the nurse expect?

Decreased blood pressure.

79.An infant is admitted to a pediatric unit following a motor-vehicle crash with a subsequent head injury. For which of the following should the nurse monitor to identify increased intracranial pressure?

Decreased motor response.

177. A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?

Dependent edema

6. A charge nurse in a long-term care facility is preparing to administer noon insulin to a client. The nurse observes that the assistive personnel (AP) has no documented the client's blood glucose level. Which of the following actions should the charge nurse take first?

Determine if the AP has completed the assignment.

46. A nurse is reinforcing teaching with a client who is at 10 weeks gestation and has a medical history of mild hypertension. The nurse should remind the client to call the clinic if she?

Develops edema of the ankles.

96. A nurse observes a client who has Alzheimer's disease and is experiencing aphasia. Which of the following behaviors should the nurse expect?

Difficulty understanding spoken words.

87. A nurse is collecting data from a client at an urgent care clinic. The client tells the nurse that she hasn't been able to sleep since the death of her father 2 days ago. Which of the following is the nurse's priority action?

Discuss coping skills that have worked for the client previously.

A nurse is working in acute care mental health facility is assessing a client who has schizophrenia. Which of the following findings should the nurse expect?

Disorganized speech

20. A nurse is preparing to administer an IM injection to a client. To reduce the risk of needle stick injury, the nurse should?

Dispose of the used needle immediately in a puncture-proof sharps container.

73.A nurse in a long term care facility is planning to perform hygiene care for a newly admitted male client with Parkinson's disease who is ambulatory. Which of the following is an appropriate statement by the nurse prior to starting routine care?

Do you usually take your bath in the morning or in the evening?

A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following should the actions the nurse take?

Document the client's condition every 15 minutes

A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include.

Document the client's conditions every 15 minutes

A nurse is preparing to catheterize a toddler for a urine culture. Which of the following is an appropriate action for the nurse to take?

Don sterile gloves prior to the procedure.

A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?

Eat a light snack before bedtime

70.A nurse is caring for a client who is receiving IV therapy, The nurse suspects fluid infiltration, Which of the following findings should the nurse expect at the insertion site?

Edema.

22.A client who is 24 hour postoperative suddenly develops chest pain, dyspnea, anxiety, diaphoresis, and cough. Which of the following actions should the nurse take first?

Elevate the head of the client's bed.

A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago. Which of the following findings should the nurse expect?

Elevated temperature

63. A nurse caring for the mother of a newborn finds the client crying in her room, the client tells the nurse, "I don't think I can handle caring for a baby." Which of the following nursing interventions is appropriate?

Encourage the client to share her feelings

A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?

Encourage the client to take frequent rest periods

A nurse is caring for a client who has heart failure and is receiving a continuous IV infusion of low dose dopamine. Which of the following findings is the highest priority?

Erythema 5 cm (2in) above the IV site

127. A nurse discovers a fire in the trash can of a client's room. Which of the following actions should the nurse take first?

Escort the client to a secure area.

A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following effects should the nurse include ?

Excessive sweating

A nurse is caring for a client who is dissatisfied with the care from the provider and decides to leave the facility against medical advice. After notifying the provider, which of the following actions is appropriate for the nurse to take?

Explain the risks of leaving

84.A nurse is observing a client who is in the manic phase of bipolar disorder. The client states, "Don't need to eat today. Where's the money? Time to write that speech." The nurse should document this as which of the following?

Flight of ideas.

A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take?

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

121. A nurse is caring for a toddler who is admitted to the pediatric unit and is 2 hr postoperative following a tonsillectomy. Which of the following findings is a sign of hemorrhage?

Frequent swallowing

39.A nurse is reinforcing teaching with school staff about streptococcal infection of the pharynx, the nurse should instruct the staff that the period of contagion for children who have this infection is which of the following?

From onset of symptoms until 24hrs of antibiotic therapy.

10.A nurse in a provider's office is collecting data from a parent of an infant who is being screened for cystic fibrosis. Which of the following supports a diagnosis of cystic fibrosis?

Frothy stools.

17. A nurse is caring for a full-term newborn who was circumcised 6 hours ago, which of the following findings indicates that the newborn is experiencing pain?

Furrowed Brow

A nurse is planning to administer vancomycin IV to a client. Which of the following actions should the nurse take to reduce the risk of an adverse reaction to the vancomycin?

Give the dose over 60 min

A nurse is caring for a client who is insulin dependent and is undergoing tests to determine if his blood glucose is being adequately controlled. The nurse should identify that which of the following laboratory values is the best indicator of adequate blood glucose control?

HbA1c 6.5%

A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching?

HbA1c level less than 7%

81.A nurse in an inpatient psychiatric unit is a caring for a client who was raised in an Asian culture. Which of the following communication techniques demonstrates cultural sensitivity?

Holding eye contact for brief instances.

A nurse is caring for a client who has end stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for her father. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?

Hypertension

A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use?

Hypertension

175. A nurse should monitor a client who is taking Lasix for which of the following adverse effects?

Hypokalemia.

A nurse is assessing a client who had heart failure is taking furosemide. Which of the following findings should the nurse monitor ?

Hyponatremia- loop diuretic (Lasix) - wherever water goes sodium and potassium will follow

A nurse is assessing a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following findings should the nurse recognize as a result of magnesium sulfate toxicity?

Hyporeflexia

153. A nurse is reinforcing teaching regarding home care with a client who is scheduled for discharge following a coronary artery bypass graft. understands teaching?

I can begin my cardiac rehabilitation program within the week.

A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?

I can resume activities, such as sewing.

142. A nurse is reinforcing teaching with a new mother regarding the use of breast milk. Which of the following statements by the mother indicates an understanding of the teaching?

I can store my breast milk in the freezer for up to 6 months.

A nurse in a prenatal Clinic is teaching a client about non pharmacological pain management during labor. Which of the following statements by the client indicates an understanding of the teaching?

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

A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?

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

147. A nurse is reinforcing teaching to a client who has GERD and is prescribed raintidine (Zantac). Which of the following indicates an understanding of the teaching?

I have to remain upright for 1 hours after taking the medication.

75.A nurse is reinforcing teaching with a new mother of a full-term newborn about breastfeeding. The newborn is 5 days old. Which of the following statements by the mother indicates an understanding of the teaching?

I should have my baby latch on to my nipple and areola during feeding."

148, A nurse is reinforcing teaching with a client diagnosed with diabetes mellitus requiring insulin injections. Which of the following statements made by the client indicates understanding of the teaching?

I should remove bubbles from the syringe before injecting my insulin.

A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis. Which of the following statements indicates that the client understands the teaching?

I should urinate before the test

A nurse is providing discharge teaching about circumcision care to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

I will change my baby's diaper at least every 4 hours

A nurse is teaching a client how to perform kegel exercises. Which of the following client statements indicates understanding of the teaching?

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

A nurse is teaching a client who has a newly documented latex allergy. Which of the following statements by the clients indicates an understanding of the teaching?

I will remove bananas from my diet

120. A nurse is reinforcing teaching with a client who is undergoing chemotherapy to treat laryngeal cancer and has developed mucositis. Which of the following client statements indicates an understanding of the teaching?

I will rinse my mouth with room-temperature saline solution.

72.A nurse is reinforcing discharge instructions regarding umbilical cord care to the mother of a newborn. Which of the following statements by the mother indicates the teaching was effective?

I will wait until the cord falls off to give my baby a tub bath.

25. A nurse is reinforcing discharge teaching to a client following a gastrectomy, to prevent dumping syndrome, which of the following foods should the nurse instruct the client to avoid?

Ice Cream

A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first?

Identify environmental hazards in the home

41. A nurse is caring for a client who is in balanced skeletal traction for a leg fracture. Which of the following should the nurse expect to be included in the care plan?

Increase counter traction every 24 hr. d. Inspect the ropes, knots, and pulleys every 8 hrs

A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?

Increase in frequency of swallowing (may indicate bleeding)

A nurse is administering an analgesic to a client who has a chest tube . The provider is preparing to discontinue the chest tube before the medication has taken effect. Which of the following actions should the nurse take first ?

Inform the provider of the time of the last does of pain medication

A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken affect. Which of the following actions should the nurse prepare to take first?

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

A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention?

Iniang IV 1uid resuscitaon - they are at risk for hypovolemic shock d/t 3rd spacing

A nurse is caring for a child who has sickle cell anemia and experiencing vaso- constrictive crisis. Which of the following actions should the nurse include in the plan of care?

Initiate IV fluid replacement

A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take ?

Initiate seizure precautions

126. A nurse is caring for a client who has an order for NPH insulin (Humulin N) 10 units and regulate insulin (humulin R) 15 units SQ. Which of the following actions should the nurse perform first?

Inject 10 units of air into the NPH insulin vial.

53. A nurse is reinforcing teaching to a first-time mother about toddler safety, the nurse should recognize the client's understanding of the teaching when the client states, "I will?

Install gates at the top and bottom of the stairs."

A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse?

Instruct the client on the use of esophageal speech (I think)

A nurse is planning care for a client who is scheduled to have a paracentesis. Which of the following actions should the nurse include in the plan of care?

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

82.A nurse is caring for a client who has an order for a 12-lead ECG. Which of the following actions should the nurse take?

Instruct the client to take slow, deep breaths.

59.A nurse is caring for a client who was admitted 12 hours ago and is experiencing acute alcohol withdrawal, which of the following is an expected finding for the client?

Irritability.

A nurse is planning discharge teaching about cord care for the parents of a newborn which of the following instructions should the nurse plan to include in the teaching?

Keep the cord stump dry until it falls off Rationale: cord usually falls out within 7 to 10 days. Clean with soap and water. Cord is expected to turn black and dry

102. A nurse is caring for a client who has esophageal cancer. A gastrostomy tube is in place and the client is receiving continuous tube feedings. Which of the following actions should the nurse take?

Keep the head of the bed elevated at least 30 degrees.

A nurse is assessing a 24-month-old toddler during a well-child visit. Which of the following developmental tasks should the toddler be able to perform?

Kick a ball forward

50. A nurse is applying a condom catheter to a male client who is incontinent which of the following is an appropriate technique to use?

Leave space between the tip of the penis and the end of the condom catheter.

A nurse is assessing a client's pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?

Left ventricular failure

A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information?

Level of consciousness. (priority)- decreased LOC can mean less o2 going to the brain ?

174. A nurse is collecting data from a client who is in her third trimester of pregnancy during a routine prenatal visit to the provider's office. The client reports she feels dizzy, has clammy skin, and becomes pale while lying down. The nurse should tell the client that when she feels this way, she should do which of the following?

Lie on her left side.

A nurse is assessing a client who is prescribed valproic acid. Which of the following laboratory tests should the nurse monitor?

Liver function test

98. A nurse is caring for a client experiencing alcohol withdrawal. Which of the following medications should the nurse anticipate administering?

Lorazepam (Ativan)

A nurse is transcribing new medication prescriptions for a group of clients. For which of the following prescriptions should the nurse contact the provider for clarification?

Lorazepam 0.5 mg PO one tablet daily

A nurse is assessing a client who requests an oral contraceptive. Which of the following findings in the client's medical history should the nurse identify as a contraindication for the use of a combination oral contraceptive?

Migraines with aura

A nurse is caring for a client following a stroke. The client has right-sided weakness and facial drooping. Which of the following nursing actions is the priority?

Maintain NPO status for client(ABC)

128. A client has a large, deep ulcer on her right hip. The primary care provider has prescribed a woman vacuum to be applied. Which of the following is an appropriate nursing action?

Maintain hyfrophillic material deep into the ulcer.

66.A nurse is caring for a client who is 12hr postpartum. The nurse observes an increase in vaginal bleeding. Which of the following actions should the nurse plan to take first?

Massage the fundus. d. Obtains the client's vital signs.

A nurse is caring for a client who is in active labor and notes the FHR baselines has been 100/min for the past 15 min. The nurse should the identify which of the following conditions as a possible cause of fetal bradycardia?

Maternal hypoglycemia

A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan?

Measure the client's urine output every hour. - monitor for toxicity.

149. A client newly diagnosed with bipolar disorder asks the nurse, "How long will I have to take lithium?" Which of the following is an appropriate response by the nurse?

Medication is usually continued for 6 months after symptoms subside.

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?

Minimize noise in the newborn environment

A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?

Monitor the child's cardiac status

47.A nurse is caring for a client who has been placed in restraints. Which of the following is appropriate?

Monitor the client's skin integrity on a regular schedule.

A nurse is caring for a client following a cardiac catheterization through the left groin. Which of the following actions should the nurse take?

Monitor the dorsalis pedis pulse every 15 minutes (because circulation)

A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a soft, turbulent sound between beats at the left midclavicular line in the fifth intercostal space. Which of the following is an appropriate documentation of the findings?

Murmur at the mitral area

69. A nurse is collecting data during a well-child visit of a 12-month-old infant which of the following statements made by the parent indicates a need for further evaluation?

My child can't go from a lying to a sitting position."

A nurse is obtaining a nutritional health history on a client who reports problems with constipation. Which of the following should the nurse identify as a cause of constipation?

New prescription for an iron supplement

65. A nurse is caring for client who is requesting assistance with smoking cessation. For which of the following medications should the nurse anticipate having to reinforce teaching?

Nicotinic Acid (niacin)

16.A nurse is caring for a client who had a femoral-popliteal bypass graft 2 days ago. When monitoring peripheral pulses, the nurse is unable to locate a pulse on the affected leg. Which of the following actions should the nurse take?

Notify the charge nurse of the finding.

A client who is pregnant voice her concern that her 3y/o son will feel left out once the newborn arrives. Which of the following statements by the nurse is appropriate?

Offer your son a gift when the baby receives one

118. A nurse is caring for a client in the provider's office who has is experiencing an episode of acute asthma. The nurse should administer which of the following medications?

Traimcinolone (Azmacort)

180. A nurse is assisting with the admission of an adolescent client who is suspected of having bacterial meningitis. Which of the following findings should the nurse expect?

Nuchal rigidity

165. A nurse is caring for a client who was placed in a cast 12 hr ago due to a fractured left tibia. Which of the following findings is the highest priority?

Numbness in the left foot.

27. A nurse manager is seeking ways to increase cost-effectiveness on the unit. In which of the following client care situations should the nurse manager intervene?

Nurse discards a bottle of sterile saline after it has been open for 24 hours

23.A nurse is caring for a 17-year old client who is admitted for an emergency appendectomy. Which of the following is an appropriate action by the nurse in obtaining informed consent?

Obtain verbal consent from the client while waiting for the parents to arrive. b. Witness the signature of the client's parent when he arrives. c. Have the client's older sibling give consent if a parent is not available. d. Delay the procedure if the provider cannot contact the parents.

A nurse is caring for a client who has depression and is experiencing loss of appetite. Which of the following actions should the nurse take?

Offer high-calorie, high protein snacks to the client

97. A nurse in a long-term care facility is caring for an older adult client who has a history of hypertension. Which of the following is indicative of transient ischemic attacks?

Pain radiating down the left arm c. sudden loss of vision in one eye.

A nurse is assessing a client who is 2 hrs postpartum for uterine atony. Which of the following action should the nurse take?

Palpate the client's fundus

A newly licensed nurse is reviewing the role of a nurse in disaster planning. Which of the following is an activity a nurse should engage in to assist in disaster preparedness?

Participate in community drills and mock events

A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel?

Perform chest compressions during cardiac resuscitation

A nurse is assigning tasks to assistive personnel(AP). Which of the following tasks should the nurse assign to the AP?

Perform post mortem care

A nurse is orienting a newly licensed nurse while caring for clients who are in labor. Which of the following pain management strategies by the newly licensed nurse requires intervention?

Placing a transcutaneous electrical nerve stimulation (TENS) unit on a client's abdomen

A nurse is preparing a change of shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report?

Platelets 100,000/mm3 (150,000-300,00 risk for bleeding)

A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?

Perform the procedure twice a day

37. A nurse is caring for a client who has hepatitis B, When caring for the client, which of the following actions places the nurse at highest risk for acquiring hepatitis B?

Performing oral hygiene

11.When caring for an assigned group of clients, the nurse should wear gloves when

Performing oral hygiene.

A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which of the following findings should the nurse identify as a contraindication for heat therapy?

Peripheral neuropathy

A nurse is reviewing the laboratory findings of a client who is receiving IV infusion of insulin. The client's lab findings reveal a potassium level of 5.5 mEq/L, BUN of 15 mg/dL, and a creatinine level of 1 mg/dL. Which of the following interventions is appropriate for the nurse to take?

Place a cardiac monitor on the client

88. A nurse is planning care for a client who is 6 hours postoperative following a right knee arthroplasty. Which of the following interventions should the nurse include in the client's care plan?

Place a pillow under the client's surgical knee.

158. A nurse is caring for a postoperative client who has a midline abdominal incision and notes dehiscence of the wound edges with protrusion of internal organs. Which of the following actions should the nurse take?

Place pressure on the abdomen. d. Cover the wound with a sterile saline dressing.

54. A nurse is preparing a sterile field to perform a dressing change, which of the following actions should the nurse take?

Place sterile objects at least 2.5 cm (1 inch) from the edge of the sterile field.

139, A nurse is caring for a client who is in bed and experiencing a toni-clonic seizure. Which of the following actions should the nurse take?

Place the bed in the lowest position.

A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

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

124. A nurse is admitting a client with active tuberculosis. Which of the following is an appropriate nursing intervention?

Place the client in a room that is ventilated to the outside.

150 A nurse in the birthing unit is assisting with the care of a client who is at 38 weeks gestation and has bring red vaginal bleeding but denies pain?

Placenta previa.

A nurse is providing teaching about the use of crutches using a three-point gait to a client who has tibia fracture. Which of the following actions by the client indicates an understanding of the teaching?

Positioning both hands on the grips with his elbows slightly flexed

A nurse is reviewing the laboratory levels of a client who is having elective surgery. Which of the following levels should the nurse report to the provider?

Potassium 3.2 mEq/L

A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery?

Potassium 5.2 mEq/L

A nurse is teaching dietary guidelines to a client who has celiac disease which of the following food choices is appropriate for the client?

Potato pancakes

A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement?

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

A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding?

Prealbumin 10 mcg/dl (normal: 16-40)

A nurse is completing an admission assess for a client who has narcissistic personality disorder. Which of the findings should the nurse expect?

Preoccupied with aging

A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

Previous violent behavior Risk factors also include: past history of aggression, poor impulse control, and violence. Comorbidity that leads to acts of violence (psychotic delusions, command hallucinations, violent angry reactions with cognitive disorders).

A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around the wrists. Which of the following actions should the nurse take to address the suspicions of elder abuse?

Privately interview the client about her condition.

A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings should the nurse report to the provider?

Protruding Hemorrhoids

A public health nurse working in a rural area is developing a program to improve health for the local population. Which of the following actions should the nurse plan to take?

Provide anticipatory guidance classes to parents through public schools

157. A nurse is caring for a client who is in labor and has requested an alternative birthing plan. The client is experiencing back pain. Which of the following nursing actions is most effective?

Provide sacral counter pressure using the fist or ball of the hand.

83.A newly admitted client tells the nurse that he does not have an advance directive. Which of the following is the appropriate action for the nurse to take?

Provide the client with written information about advance directives.

92. A nurse is planning care for a client with delirium. Which of the following should the nurse recognize as interfering with the client's recovery?

Providing the client with activities that vary daily.

110. A client comes to the clinic with reports to nasal congestion. Which of the following medications should the nurse anticipate that the primary care provider will prescribe?

Pseudoephedrine (Sudafed)

67.A nurse is caring for a client with diabetes mellitus who has an order for daily morning insulin before breakfast. The client refuses his blood glucose check at 0700. Which of the following actions should the nurse take?

Reinforce client teaching.

52.A nurse is supervising an assistive personnel (AP). During the morning meal, the nurse observes the AP accidentally spill a cup of coffee on a client. Which of the following actions should the nurse take?

Reinforce safe meal setup techniques.

61. A nurse is planning tracheostomy care for a client in a long-term care facility. Which of the following actions should the nurse plan to take first?

Remove the tracheostomy inner cannula.

A nurse is obtaining a medical history from a client who has new diagnosis of type 2 diabetes mellitus. The nurse should report which of the following conditions is a contraindication for the use of metformin?

Renal insufficiency

160. A nurse is caring for a postoperative client and obtains a pulse oximeter reading of 89%. Which of the following interventions should the nurse take first?

Repeat the test on another finger.

A client's partner tells a staff nurse that he overhears laboratory staff discussing the result of the clients biopsy report while on the elevator. Which of the following actions should the nurse take?

Report the information to the charge nurse

8. A nurse smells alcohol on the breath of an assistive personnel CAP) during report. Which of the following actions should the nurse take?

Report the situation to the nurse manager.

A nurse is admitting a client who is 1 week postpartum and reports excessive vaginal bleeding, The nurse does not speak the same language as the client . The client partner and a 10 year old child are accompanying her. Which of the following actions should the nurse take to gather the clients information?

Request a female translator interpreter through the facility

A nurse is caring for a client who has COPD and is 5kg (11lb) below her ideal body weight. The client experiences shortness of breath when eating. Which of the following actions should the nurse take?

Request non gas forming foods from the dietary department

A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (SATA)

Tremors Diaphoresis Inability to concentrate

144. A nurse is caring for a toddler who was admitted for pneumonia. Which of the following findings has the highest priority?

Respiratory rate of 36/min

89. A nurse in pediatric clinic is reviewing the history of a 11-year-old child. Which of the following immunizations should the nurse anticipate administering?

Rotavirus c. meningococcal conjugate

A nurse is assessing a client Telemetry strip. Which of the following findings should the nurse report to the provider?

ST segment elevations (Remember this could possibly lead to infarctions)

A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the following clinical manifestations is an expected finding for this client?

Scratchy, high pitched sound upon chest auscultation

The nurse is caring for a client who has histrionic personality disorder. Which of the following findings should the nurse expect?

Seductive Behavior

A nurse is providing teaching to a client who is to undergo a cardiac catheterization. Which of the following findings is expected during the procedure?

Sensation of skin warmth

A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse should expect the client to have an increase in which of the following laboratory values?

Serum glucose level- increased

A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client?

Serum potassium- diuretic that retains potassium= hyperkalemic risk

A nurse is obtaining a client's medical history before initiating 1000 ml of 0.9% NaCl with 20 mEq/L KCl IV to correct hypokalemia. Which of the following findings is a contraindication to the client receiving this IV solution?

Severe renal impairment. (Stage IV Kidney Disease)

112. A nurse is caring for a client with a closed head injury. Which of the following findings should indicate to the nurse a need for further data collection? A. Inappropriate words when speaking.

Sharp sensation when touched with safety pin point.

A nurse is providing discharge instructions to a client who has a new prescription for haloperidol which of the following adverse effects should the nurse instruct the client to report to the provider?

Shuffling gait →A/E EPS: is an indication of parkinsonism and should be reported

100. A nurse is planning a health-promotion program for high school students. Which of the following facts about cigarette smoking is likely to be most effective in changing the adolescents' attitudes towards smoking?

Smoking causes unattractive stains on the teeth and hands.

99. A nurse is caring for a client who has borderline personality disorder. The client states, "I look forward to seeing you in the morning because the night nurse treats me badly." Which of the following behaviors is the client likely demonstrating?

Splitting

115. A nurse is caring for a client in a mental health inpatient facility who reports auditory and visual hallucinations. Which of the following should the nurse recognize as indicating the client is most in need of intervention?

States he is being told to hit his roommate.

71.A nurse is caring for a client who is newly diagnosed with type 1 diabetes mellitus. The nurse should recognize that the client needs a referral for diabetic education when the client?

States that he will treat hypoglycemic reactions with 15 g of carbohydrates.

13.A nurse is caring for a client who is receiving heparin. Which of the following is the appropriate route of administration?

Subcutaneously.

A nurse is caring for an infant who has gastroenteritis. Which of the following assessments should the nurse report to the provider?

Sunken fontanels and dry mucous membranes

A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?

Swelling of the face

155. A nurse is reinforcing discharge instructions for an older adult client regarding management of hypertension. Which of the following should the nurse instruct the client to do when evaluating for the presence of orthostatic hypotension?

Take a blood pressure reading while sitting and another one 2 min later while standing.

A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following is appropriate for this client?

Tape stockinet over monitoring device and cords

A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? Primary - before it happens Secondary - screening Tertiary - already happened

Teach parenting skills to families at risk for abuse

A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of non-blanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

Teach the client to shift his weight every 15 min while sitting (cannot do this because he is paraplegic)

169. A nurse finds a client's wife crying in the hallway. she states, "I just don't know how I am going to go on after he is gone." Which of the following is an appropriate response by the nurse?

Tell me more about how are you feeling.

A nurse is delegating tasks to an assistive personnel group of clients. Which of the following statements should the nurse make?

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

24. A nurse has delegated care to an assistive personnel. At the end of the shift, the Ap asks the nurse to enter data for her because the AP has forgotten her password and needs to leave, Which of the following actions should the nurse take?

Tell the AP to contact the IT department for charting assistance

95. A nurse is taking the vital signs of an adult client who has just been transferred from the PACU to the clinical unit. Which of the following findings should the nurse recognize as the most significant?

Temperature 36 C (96.8 F)

A home health nurse is preparing to assess a client who reports tingling around the mouth and laxative use at least once daily. Which of the following assessments should the nurse perform first?

Test the client for Trousseau's sign

170. A nurse is caring for a client whose previous blood pressure reading have been within the expected reference range. The client's current blood pressure reading is suddenly elevated above the expected range. Which of the following factors can contribute to a false high blood pressure reading?

The blood pressure cuff is too small for the client's arm.

A nurse is assessing a client following a ischemic stroke. Which of the following findings is the priority for the nurse to report to the provider?

The client coughs after swallowing

A nurse is developing an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder?

The client exhibits impulsive behavior

A nurse is developing an in service about personality disorders Which of the following information should the nurse include when discussing borderline personality disorder?

The client exhibits impulsive behavior - spending money giving away money or possessions

A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings is a potential contraindication for using lavender?

The client has a history of asthma

36. A nurse is reinforcing teaching with the parents of a 4-month-old infant during a home visit. Which of the following findings in the infant's room indicates a need for further teaching?

The infant is lying in the crib with a stuffed animal

A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination?

The client is showing evidence of phenytoin toxicity

21.A Nurse is contributing to the discharge plan for a client following surgery. Which of the following findings indicate the need for an interdisciplinary care conference?

The client requires assistance to pay for dressing supplies.

119. A nurse is assisting with the care of a client who is receiving IV therapy of 0.9% sodium chloride. The client received 200mL more than prescribed in 1 hr because the infusion pump was set incorrectly. Data collection reveals that the client is stable. This incident does not meet the criteria of malpractice because?

The client was not harmed as a result of the incident.

A nurse in a PACU is transferring care of a client to a nurse on the medical surgical unit. Which of the following statements should the nurse include in the hand off report ?

The estimated blood loss was 250 milliliters

A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

The estimated blood loss was 250 milliliters.

93. A nurse is caring for a client who has paranoid schizophrenia and believes that she is being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?

The psychiatric staff are not FBI. They are here to help you.

156. A nurse is reinforcing teaching with a client who is scheduled to undergo a fiberoptic bronchoscopy. Which of the following client statements indicates an understanding of the procedure?

They will look into my lungs with a lighted tube to determine my problem.

152, The parent of a 3-year-old child tells the nurse that he is concerned because his daughter has begun playing with an imaginary friend. Which of the following is an appropriate response by the nurse?

This is a common behavior for children of this age.

113. A nurse is reinforcing teaching with the parents of a 1-year-old infant regarding appropriate play activities for this age group. Which of the following activities should the nurse include?

This is an appropriate toy for a 12-month-old infant. Beads that are too large to pass through a toilet paper tube do not present a choking hazard. This toy would provide visual and tactile stimulation for a 1-year-old infant

A nurse is providing teaching to the parents of a newborn about genetic screening. Which of the following statements should the nurse include in the teaching?

This test should be performed after you baby is 24 hours old

A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client's ability to eliminate urine from the bladder is restored?

Two voids of 150 mL each over the past 2 hours= 2 x 30 = 60 mls

178. A nurse is reinforcing teaching to an adult client who is prescribe Lipitor. The nurse should advise the client that which of the following is an adverse effect of this medication and should be reported to the provider?

Unexplained muscle pain

106. A nurse is administering hydromorphone (Dilaudid) to a client who is experiencing postoprerative pain. Which of the following is an adverse effect of this medication?

Urinary Retention.

A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects?

Urinary retention

162. A clinic nurse is reviewing laboratory values for a client who is at 34 weeks of gestation. Which of the following laboratory values should the nurse report to the provider?

Urine protein 3+

42.A nurse is using contact precautions while caring for a toddler. Which of the following actions should the nurse take?

Use a designated stethoscope for the toddler

145. A nurse is reinforcing teaching for a client regarding various forms of contraception. The nurse should recognize that the client understands the instructions if she says, "I will?

Use a spermicide with condoms to increase the effectiveness."

A nurse is preparing to administer three medications to a client who is receiving continuous enteral tube feeding through an NG tube. Which of the following actions is appropriate for the nurse to take?

Use a syringe to allow the medications to Flow by gravity

A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?

Use an albuterol inhaler

A nurse is teaching a newly licensed nurse about therapeutic techniques to use when leading a group on a mental health unit. which of the following group facilitation techniques should the nurse include in the teaching?

Use modeling to help the clients improve their interpersonal skills

A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco?

Use of tobacco decreases the level of athletic ability

29.A nurse is caring for an older adult client with a decreased level of consciousness. Which of the following is an appropriate intervention related to the client's mouth care?

Uses a sponge toothette to cleanse the inside of the mouth.

A nurse is observing a newly licensed nurse who is administering Total parenteral Nutrition tpn to a client. Which of the following actions by the newly licensed nurse indicates a need for the nurse to intervene?

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

94. A nurse is monitoring a client who is in labor. Which of the following findings needs further evaluation?

Uterine contractions lasting 100 to 120 seconds.

7. A client is scheduled for an outpatient colonoscopy+ which of the following actions is a nursing responsibility in the informed consent process?

Verify that there is a signed and witnesses consent form in the client's chart.

A nurse should assess a child who has diabetes mellitus (type 1) for symptoms of hyperglycemia, which include: a. flushed skin and thirst. b. irritability and hunger. c. sweating and jitteriness. d. lethargy and tremors

a. flushed skin and thirst.

131, A nurse is administering medication to a client. Which of the following actions is appropriate for the nurse to take?

Verify with another nurse when calculating a new dose of medication.

101. A nurse is caring for a school-age child whose family adheres to a vegan diet in the home, The nurse should recognize the child is at risk for deficiency of which of the following?

Vitamin D

A nurse is caring for a client who has pernicious anemia, Which of the following laboratory values should the nurse evaluate effectiveness of the treatment ?

Vitamin b12 level

A nurse is reviewing the medical record of a client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine ?

WBC count 2,900 /mm3 (Agrunlocytosis - 4,800-15,000 normal range)

31. A nurse is reinforcing discharge teaching for a client admitted with an acute myocardial infarction, which of the following activities is appropriate for the client to participate in during the first two weeks following discharge?

Walking.

62. A nurse in a provider's office is reinforcing teaching with the parents of a school-age child who has an active case of pediculosis capitis, which of the following should be included in the teaching?

Wash the bed linens in hot water. d. Clean the child's toys with 1:10 bleach solution.

A case manager is meeting with a client who asks about using alternative therapies to manage her rheumatoid arthritis. Which of the following statements should the nurse make?

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

A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?

We should establish our roles in the initial session.

A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?

Weak femoral pulses

A nurse is preparing to apply a transdermal nicotine patch for a client. Which of the following actions should the nurse take?

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

A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication?

Whole grain bread

A 36-week-pregnant woman awakens to find she is having profuse, red vaginal bleeding. A nurse should prepare the woman to have an immediate sonogram to determine the: a. location of the placenta. b. uterine response to labor. c. the fetus's current weight. d. condition of the uterine vascular bed.

a. location of the placenta.

35.A nurse is caring for a client who is receiving warfarin (Coumadin) for deep vein thrombosis. The nurse observed that the client's INR is 3.8. Which of the following actions should the nurse take?

Withhold the ordered dose of the medication

A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make?

You have the right to decide who receives information

163. A client who has inoperable cancer tells the nurse that she does not want to pursue the recommended treatment. She asks if the provider can force her to have the treatment. appropriate response.

You have the right to refuse the recommended treatment plan.

A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate?

You may breastfeed unless your nipples are cracked or bleeding.

A doctor prescribes liquid oral iron medication for a 4-year-old child. Which of these questions should a nurse ask the child's mother to determine if the medication is being administered correctly? a. "Are you using a straw to administer the medicine?" b. "Has your child been urinating more frequently?" c. "Have you increased your child's milk intake each day?" d. "Is there a change in the color of your child's skin?"

a. "Are you using a straw to administer the medicine?"

A nurse is preparing a client for a vaginal examination. Which of these statements should the nurse make? a. "Go into the bathroom and empty your bladder." b. "Cleanse your perineal area with betadine solution." c. "Hold your breath while the speculum remains in place." d. "Push down as the doctor inserts the speculum."

a. "Go into the bathroom and empty your bladder."

A client who has a history of asthma develops an acute asthma attack. Which of these questions should a nurse ask when assessing the etiology of this attack? a. "Have you eaten any new foods recently?" b. "How many hours did you sleep last night?" c. "Are you exercising every day?" d. "Have you reduced your fluid intake recently?"

a. "Have you eaten any new foods recently?"

134. A nurse is caring for a client who has heart failure and is taking furosemide (lasix). Which of the following statements made by the client indicates a need for the nurse to intervene?

a. "I have to sleep sitting up."

Which of these statements, if made by a client who is taking a diuretic, should a nurse recognize as indicative of the need for additional instructions? a. "I take all of my medications at bedtime so I don't forget them." b. "I eat one or two bananas every day." c. "I weigh myself every day in the morning." d. "I will call my doctor if I have muscle weakness."

a. "I take all of my medications at bedtime so I don't forget them."

Which of these instructions should a nurse give to a client when collecting a sputum specimen? a. "Take a deep breath, then cough and spit into this container." b. "Gargle with antiseptic mouthwash before you spit into this container. c. "Spit whatever sputum you have in your mouth into this container." d. "Drink some fluids to loosen your secretions and the spit into this container."

a. "Take a deep breath, then cough and spit into this container."

A client has the following order for regular insulin (Humulin R) on a sliding scale: Blood sugar 150-180 mg: Give 2 units regular insulin. Blood sugar 181-200 mg: Give 4 units regular insulin. Blood sugar 201-220 mg: Give 6 units of regular insulin. Blood sugar above 220 mg: Call MD. At 11 A.M., a nurse obtains a finger stick glucose of 198 mg. The only syringe is a three milliliter one. Regular insulin is available as 100 units per milliliter. How many milliliters should the nurse administer? a. 0.04 b. 0.4 c. 4 d. 40

a. 0.04

Which of these techniques should a nurse use to assess for correct placement of a nasogastric tube prior to administering a feeding? a. Aspirate 10 mL contents and measure the pH. b. Slowly inject 50 mL of saline and observe for resistance. c. Inject 20 mL of water and listen for gurgling sounds. d. Observe for bubbles after submerging the end of the tube in a cup of water.

a. Aspirate 10 mL contents and measure the pH.

A nurse inadvertently administers an incorrect medication to a client. Which of these actions should the nurse take first? a. Assess the client. b. Notify the physician. c. Contact the nurse manager. d. Complete an incident report.

a. Assess the client.

Which of these menus, if chosen by a parent of a child who has celiac disease, would indicate to a nurse that the parent understands the teaching about a gluten-free diet? a. Broiled steak, baked potato, and spinach. b. Pork chop, egg noodles, and green peas. c. Fried chicken, white roll, and mixed vegetables. d. Baked macaroni with cheddar cheese and corn.

a. Broiled steak, baked potato, and spinach.

Which of these foods should a nurse suggest that a client who is diagnosed with iron-deficiency anemia choose for dinner? a. Cooked dry beans, green leafy vegetables, and dried fruits. b. Raw cabbage, tomato juice, and cantaloupe. c. Fresh fish, peanut butter, and oatmeal. d. Cheddar cheese, enriched bread, and yellow vegetables.

a. Cooked dry beans, green leafy vegetables, and dried fruits.

85. A nurse is reinforcing dietary teaching to a client who has end-stage renal failure. Which of the following instructions should the nurse include in the teaching?

a. Decrease calcium intake. c. Decease sodium intake.

A client who is on the inpatient psychiatric unit has a history of violence. Which of these actions should a nurse take if the client is agitated? a. Encourage the client to verbalize feelings. b. Lock the client in a secluded room. c. Ask the other clients to give feedback regarding the client's behavior. d. Ignore the client's inappropriate behavior

a. Encourage the client to verbalize feelings.

Which of these measures should an emergency room nurse include when speaking with a family experiencing the loss of an infant from Sudden Infant Death Syndrome (SIDS)? a. Explaining to the parents how SIDS could have been predicted. b. Discouraging the parents from viewing the infant's body. c. Encouraging the parents to take the opportunity to say goodbye. d. Interviewing the parents in-depth about the circumstances of the infants death.

a. Explaining to the parents how SIDS could have been predicted.

136. A nurse is caring for a client who is 2 days postoperative. The client has a prescription for acetaminophen 300mg with codeine 30 mg (Tylenol #3), 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently gave the client 2 tablets. Which of the following is the proper place to document this error?

a. Incident report

An elderly client is at increased risk of developing drug toxicity to prescribed medications due to declining hepatic and renal functioning. Which of these strategies should a nurse plan to decrease this risk? a. Increasing the time interval between medication doses. b. Limiting the client's oral fluid intake. c. Administering the medications with meals. d. Encouraging the client to void every three to four hours.

a. Increasing the time interval between medication doses.

A 22-year-old college student has a heart rate that is 48/minute and regular during a routine physical examination. Which of these questions should a nurse consider when analyzing this heart rate a. Is this student an athlete? b. Does this student smoke? c. How much alcohol does this student drink? d. Is this student feeling anxious?

a. Is this student an athlete?

Which of these interventions should plan for a child who is receiving chelation therapy for lead poisoning? a. Keeping an accurate record of intake and output. b. Instituting measures to prevent skeletal fractures. c. Maintaining isolation precautions. d. Maintaining strict bed rest.

a. Keeping an accurate record of intake and output.

A 15-year-old child who has type I diabetes mellitus receives an injection of regular insulin 5 units and isophane (NPH) insulin 15 units subcutaneously at 7:00 A.M. before eating breakfast. At 10:30 A.M., the child tells the school nurse, "I am sweating and feel weak." Which of these actions should the nurse take first? a. Measure the blood sugar. b. Determine what the child ate for breakfast. c. Give a simple carbohydrate. d. Contact the physician.

a. Measure the blood sugar.

Which of these actions should a nurse take initially if a client who is diagnosed with diabetes mellitus develops tremors and ataxia? a. Measure the client's blood sugar level. b. Administer a concentrated form glucose to the client. c. Administer a prn dose of insulin. d. Measure the client's urine for ketones.

a. Measure the client's blood sugar level

Which of these preventative measures should a nurse manager in a long-term care facility plan to institute to decrease clients' risks for falls? a. Monitoring clients frequently for evidence of activity intolerance. b. Placing all client personal items in the bedside drawers. c. Raising the side rails for all clients who have memory impairment. d. Maintaining all client beds in the highest position.

a. Monitoring clients frequently for evidence of activity intolerance.

Which of these strategies should a nurse plan for a client who is manic and has lost 30 pounds? a. Nutritious finger foods. b. Low-protein diets. c. Limiting fluids in between meals. d. Daily weights.

a. Nutritious finger foods.

Which of these assessments should a nurse make of a client who had a knee replacement this morning? a. Pain. b. Signs of infection. c. Bowel movement frequency. d. Range of motion.

a. Pain.

Which of these laboratory test results should a nurse monitor for a client who is receiving intravenous heparin therapy at a rate of 1,500 units per hour for the treatment of an acute pulmonary embolism? a. Partial thromboplastin time. b. Clot retraction time. c. Platelet levels. d. Bleeding time.

a. Partial thromboplastin time.

Which of these client care situations has the greatest potential for presenting an ethical dilemma for a nurse? a. Participating in pregnancy termination procedures. b. Counseling a client who is terminally ill with AIDS. c. Discussing contraception options with adolescents. d. Caring for a client who is from a different culture than the nurse.

a. Participating in pregnancy termination procedures.

A client's urine output is 500 mL in 24 hours. Which of these actions should a nurse take? a. Report the findings to the physician. b. Obtain an order for a diuretic. c. Encourage the client to limit fluid intake. d. Record the finding and continue to monitor the client.

a. Report the findings to the physician.

Which of these assessments is the priority for a client who sustained second-degree burns of the face and neck? a. Respiratory status. b. Renal function. c. Level of pain. d. Signs of infection

a. Respiratory status.

A client says to a nurse, "I am Alexander the Great. I am a world leader and must return to my kingdom. I am not taking any medications. I do not want anyone to come near me. I need to protect myself if they do." Which of these problems should the nurse focus on first? a. Risk for violence. b. Delusions of grandeur. c. Disturbed personal identity. d. Risk for noncompliance.

a. Risk for violence.

A 75-year-old client who is newly admitted to a long-term care facility has all these nursing diagnoses. Which one is the priority? a. Risk of injury. b. Anxiety. c. Sleep pattern disturbance. d. Chronic.

a. Risk of injury.

Which of these manifestations, if reported by a client who is 10-weeks-pregnant, supports the diagnosis of ruptured tubal pregnancy. a. Sharp unilateral abdominal pain. b. Uncontrollable vomiting. c. Marked abdominal distention. d. Profuse vaginal bleeding.

a. Sharp unilateral abdominal pain.

Which of these assignments, if delegated to unlicensed assistive personnel (UAP) by a nurse, is appropriate? a. The UAP is assigned to measure a client's intake and output. b. The UAP is assigned to assess a client's lung sounds. c. The UAP is assigned to teach a client about diet restrictions. d. The UAP is assigned to change a client's postoperative wound dressing.

a. The UAP is assigned to measure a client's intake and output.

A nurse is obtaining the health history of a client who is admitted for surgical repair of an inguinal hernia. Which of these factors should the nurse recognize as having the greatest impact on the outcome of the surgery? a. The client takes several acetylsalicylic acid (Aspirin) tablets daily for knee pain. b. The client drinks one glass of beer every evening with dinner. c. The client had a knee replacement six months prior to this admission. d. The client is allergic to all penicillin-type antibiotics.

a. The client takes several acetylsalicylic acid (Aspirin) tablets daily for knee pain.

Which of these manifestations, if assessed in a client who is two-hours postoperative after abdominal surgery, should a nurse report immediately? a. Vomiting and a pulse rate of 106/minute. b. Respiratory rate of 12/minute and urine dribbling. c. Blood pressure of 100/60 mm Hg and wound discomfort. d. Urine output of 100 mL/hr and flushed skin.

a. Vomiting and a pulse rate of 106/minute.

123. A nurse has administered cephalexin (Keflex) to a client. Which of the following is the earliest indicator of an anaphylactic reaction?

a. Wheezes b. Hypotension

A nurse should assist a pregnant client who is in the first trimester to achieve the developmental task of this stage of pregnancy, which is: a. accepting the fact that she is pregnant. b. accepting the fact that the fetus is a separate being. c. accepting that she will soon deliver the child. d. accepting that her body image has changed.

a. accepting the fact that she is pregnant.

When determining the duration of a uterine contraction, a nurse should measure the contraction from the: a. beginning of one contraction to the end of that contraction. b. end of one contraction to the beginning of the next contraction. c. beginning of one contraction to the beginning of the next contraction. d. strongest point of one contraction to the strongest point of the next contraction.

a. beginning of one contraction to the end of that contraction.

A newborn is placed under fluorescent light as part of the treatment for physiologic jaundice. During the duration of the newborn's treatment, a nurse should: a. cover the newborn's closed eyes with patches. b. measure the newborn's pulse and respirations every two hours. c. keep the newborn under the light at all times, even during the feedings. d. notify the physician if the newborns stools become greenish yellow.

a. cover the newborn's closed eyes with patches.

A client is admitted for opiate detoxification for the fifth time. Which of these statements, if made by a staff member, indicates a biased view of the client? a. "I feel so frustrated when clients are re-admitted." b. "Addicts relapse because they don't try hard enough." c. "I think this client needs to consider long-term placement after detoxification." d. "The team really needs to discuss this client's treatment plan."

b. "Addicts relapse because they don't try hard enough."

When a client who has a diagnosis of depression is taking a monoamine oxidase (MAO) inhibitor, which of these dieatry instructions should a nurse give to the client? a. "Increase your intake of foods that are high in vitamin C, such as oranges." b. "Avoid foods that contain tyramine, such as aged cheeses." c. "Increase your intake of foods high in tryptophan, such as fish." d. "Restrict foods high in sodium, such as canned soups."

b. "Avoid foods that contain tyramine, such as aged cheeses."

Which of these instructions should a nurse include in the plan of care for a 32-week gestation client who had an amniocentesis today? a. "Drink at least six glasses of fluids during the next six hours after the test." b. "Call the clinic if you experience any abdominal cramps." c. "Don't be concerned if you have some vaginal spotting in the next 12 hours." d. "When you get home, stay on bed-rest for the next 48 hours."

b. "Call the clinic if you experience any abdominal cramps."

A client who has insulin-dependent diabetes mellitus asks a nurse, "What should I do when I feel nervous, sweaty, and hungry?" The nurse should give the client which of these instructions? a. "Lie down and rest." b. "Eat a carbohydrate snack." c. "Take your prn dose of insulin." d. "Add a slice of bread to your next meal."

b. "Eat a carbohydrate snack."

Which of these statements, if made by a nurse, is non-therapeutic because it disregards a client's feelings and concerns? a. "You appear anxious and tense." b. "Everything will be okay." c. "I notice you're biting your nails." d. "I'm not sure I understand what you're saying."

b. "Everything will be okay."

Which of these statements, if made by a client who has chronic obstructive pulmonary disease, indicates improvement? a. "I hope to attend my grandson's graduation next month." b. "I can now walk one more block than I could last month." c. "I take several quick breaths when I begin to cough." d. "I do my breathing exercises in the evening after I eat dinner."

b. "I can now walk one more block than I could last month."

Which of these client reports should a nurse recognize as suggestive of hypothyroidism? a. "My hands shake whenever I reach for anything." b. "I feel cold and tired all the time." c. "I sweat whenever I walk more than one block." d. "My head aches each evening."

b. "I feel cold and tired all the time."

Which of these statements, if made by a nursing student prior to a sterile dressing change, is correct? a. "I understand that if objects touch other objects on the sterile field they are considered contaminated." b. "I understand that sterile objects that are below my waist are considered contaminated." c. "I understand that all objects in the sterile field must be dry." d. "I understand that contaminated objects can be used if rinsed with an antimicrobial solution."

b. "I understand that sterile objects that are below my waist are considered contaminated."

Which of these statements, if made by a client who had a total hip replacement, would indicate a correct understanding of the postoperative instructions? a. "I will stoop carefully to pick up items from the floor." b. "I will use a raised toilet seat in the bathroom." c. "I will bend forward when tying my shoes." d. "I will put my leg through the full range of motion each day."

b. "I will use a raised toilet seat in the bathroom."

Which of these assignments, if made by a nurse to a nursing assistant, indicates that the nurse needs additional instructions regarding the principles of delegation? a. "Please bathe the client in room 12, and then bring the client to the dining room for breakfast by 9 A.M." b. "Please bathe the client in room 10, administer a back rub, and then evaluate if the back rub eased the pts. discomfort." c. "Please measure the intake and output for the client's in rooms 8. 9. and 10, and record each on the I&O sheets by 2 P.M." d. "Please toilet the clients in rooms 11, 12, and 13 mid-morning and after lunch."

b. "Please bathe the client in room 10, administer a back rub, and then evaluate if the back rub eased the pts. discomfort."

When assessing a group of children, a nurse should recognize which child is at increased risk of developing acute glomerulonephritis? a. A 3-year-old who has multiple urinary tract anomalies. b. A 4-year-old who had a streptococcal infection a week ago. c. A 5-year-old who has recurrent enuresis at night. d. A 6-year-old who had chicken pox infection two weeks ago.

b. A 4-year-old who had a streptococcal infection a week ago.

A licensed practical nurse (LPN) is assigned to care for all of these clients. Which client should the nurse assess first? a. A client who is eight-hours postoperative after a hip replacement. b. A client who is drowsy after falling out a third story window. c. A client who is four hours post-colonoscopy and polyp removal. d. A client who is dysphasic after a transient ischemic attack.

b. A client who is drowsy after falling out a third story window.

A child is brought to the clinical for serum lead screening because of ingestion of lead-based paint. Which of these manifestations, if present in the child, would indicate early signs of lead toxicity? a. Convulsive seizures. b. Behavior changes. c. Bleeding tendencies. d. Low-grade fever.

b. Behavior changes.

A nurse should recognize that a client's selection of which of these foods demonstrates a correct understanding of a high-fiber diet for colon cancer prevention? a. Corn muffin. b. Bran flakes. c. Raising muffin. d. Green salad.

b. Bran flakes.

Which of these outcome criteria is appropriate for a client who has a nursing diagnosis of ineffective airway clearance? a. Absence of wheezing throughout the lung fields. b. Clear lung sounds on auscultation. c. Pulse oximetry level of 80%. d. Frequent coughing throughout the day

b. Clear lung sounds on auscultation.

An 8-month-old infant is admitted to the hospital because of failure to thrive. Which of these actions should a nurse plan? a. Limit the parents' interactions with the infant. b. Consistently assign the care of the infant to the same staff. c. Rotate assignments so that all staff can evaluate the infant. d. Limit the infant's activity until the cause of the problem is identified.

b. Consistently assign the care of the infant to the same staff.

Which of these actions should a nurse take prior to assisting an elderly client to shave his face? a. Have the client sign a consent form. b. Determine what medications the client takes. c. Soften the client's skin by applying lotion. d. Cleanse the face with a bactericidal solution.

b. Determine what medications the client takes.

A client has been admitted with acute pancreatitis. Which of these laboratory test results supports this diagnosis? a. Elevated serum potassium level. b. Elevated serum amylase level. c. Elevated serum sodium level. d. Elevated serum creatinine level.

b. Elevated serum amylase level.

Which of these instructions should be included in the teaching plan for the parents of a 10-month-old infant who is admitted to the hospital for failure to thrive? a. Advise the mother to make sure the infant drinks the entire bottle at each feeding. b. Encourage the mother to feed the infant slowly in a quiet environment. c. Teach the mother to position the infant on the abdomen following feedings. d. Instruct the mother to play actively with the infant during bottle feedings.

b. Encourage the mother to feed the infant slowly in a quiet environment.

A nurse charts on all assigned clients at 2:00 P.M. The nurse then remembers something that happened at 9:00 A.M. to a client who was not charted. Which of these actions should the nurse take? a. Include the 9:00 A.M. scenario in the shift report. b. Enter the scenario after the original 2:00 P.M. charting and mark it as a "late entry". c. Put the information in the margin and indicate the accurate time placement by drawing an arrow. d. Draw a line through the previous charting with "error" and then re-record everything, including the new information.

b. Enter the scenario after the original 2:00 P.M. charting and mark it as a "late entry".

138. A nurse is reinforcing teaching about levothyroxine (synthroid) to a client has hypothyroidism. Which of the following should the nurse instruct the client to expect?

b. Increased energy c. weight loss.

Which of these changes in the assessment data of a child who has congestive heart failure should a nurse recognize as indicative of a therapeutic response to prescribed medication therapy? a. Increased weight. b. Increased urine output. c. Increased respiratory rate. d. Increased heart size.

b. Increased urine output.

Which of these actions should a nurse include to enhance the effectiveness of client teaching sessions? a. Include all content in one session so as not to overwhelm the client. b. Initially demonstrate and explain the procedure to the client. c. Avoid repetition of content. d. Include all clients on the unit in the sessions.

b. Initially demonstrate and explain the procedure to the client.

Which of the following manifestations should a nurse recognize as suggestive of right-sided heart failure? a. Cool extremities and frothy sputum. b. Jugular vein distention and pedal edema. c. Orthopnea and frequent cough at night. d. Weight loss and lower calf pains.

b. Jugular vein distention and pedal edema.

When a newborn is 48 hours old, a nurse notes that the child is jaundiced. The nurse should recognize which of these conditions as a probable cause of the newborn's jaundice? a. Dehydration. b. Liver immaturity. c. ABO incompatibility. d. Gallbladder immaturity.

b. Liver immaturity.

A young healthy adult, who has been exercising in hot weather, has fatigue, loss of appetite, and lightheadedness. Which of these assessments should a nurse make? a. Determine the client's preferred diet. b. Measure the client's body temperature. c. Auscultate the lungs. d. Ascertain the client's typical sleep pattern.

b. Measure the client's body temperature.

A nurse is planning to interview a client who speaks limited English. Which of these strategies should the nurse include? a. Smile frequently during the interview interview to reduce the client's anxiety. b. Observe the client for indicators of confusion or not understanding questions. c. Maintain constant eye contact throughout the interview. d. Keep the interview short to decrease the client's fatigue.

b. Observe the client for indicators of confusion or not understanding questions.

86. A nurse is assisting with the admission of a client who attempted suicide. When the nurse processes the client's belongings, which of the following items should the nurse remove from the client's suitcase?

b. Perfume d. Emery Boards.

A nurse should recognize which of these signs is a probably sign of pregnancy? a. Frequency of urination. b. Positive pregnancy test. c. Nausea in the morning. d. Abdominal distention.

b. Positive pregnancy test.

Which of these measures should a nurse include when planning care for a school-aged child during a sickle cell crisis episode? a. Monitoring for signs of bleeding. b. Providing pain relief. c. Administering cool sponge baths to reduce fevers. d. Offering a high calorie diet.

b. Providing pain relief.

When auscultating the lungs of a woman who is admitted for severe pregnancy-induced hypertension, a nurse notes the presence of crackles and moist respirations. These assessment findings most likely indicate which of these complications? a. A convulsion is imminent. b. Pulmonary edema has developed. c. Bilateral lobar pneumonia is present. d. Respiratory failure is evident.

b. Pulmonary edema has developed.

A client has been in bed for the past three days. Which of these measures should a nurse include before assisting the client out of bed? a. Having the client drink a glass of water. b. Raising the head of the bed. c. Flexing the client's knees. d. Assessing the lung sounds.

b. Raising the head of the bed.

Which of these rationales explains the purpose of nasogastric tube with suction for a client who had abdominal surgery a. Prevention of gastric decompression. b. Removal of secretions from the stomach. c. Provision of postoperative nutrition. d. Promotion of abdominal distention.

b. Removal of secretions from the stomach.

A nurse obtains these vital signs on an adult client. Which finding should the nurse follow-up first? a. Heart rate, 60/minute and regular. b. Respiration, 30/minute and deep. c. Temperature, 97.1 °F (36.2 °C) d. Blood pressure, 136/86 mm Hg

b. Respiration, 30/minute and deep.

Which of these manifestations should a nurse expect to observe in a client who is diagnosed with paranoid schizophrenia? a. Regression. b. Suspiciousness. c. Catatonia. d. Hyperactivity

b. Suspiciousness.

Which of these manifestations should a nurse expect to observe in a 3-month-old infant who is diagnosed with dehydration? a. Hyperreflexia. b. Tachycardia. c. Bradypnea. d. Agitation.

b. Tachycardia.

A client who has a head injury is drowsy and lethargic, and has clear nasal discharge. Which of these actions should a nurse take? a. Obtain a specimen of the drainage for culture and sensitivity. b. Test the drainage for glucose. c. Cover the nares with sterile gauze. d. Cleanse the nostrils with sterile saline solution.

b. Test the drainage for glucose.

Which assessment information should a nurse obtain first when a pregnant woman and her husband arrive at the Labor and Delivery Unit? a. Whether the couple attended birthing classes. b. The frequency and intensity of labor contractions. c. The number of previous pregnancies and outcomes. d. The amount and time of the client's last food intake.

b. The frequency and intensity of labor contractions.

Which of these actions best demonstrates cultural sensitivity by a nurse? a. The nurse talks in a slow-paced speech. b. The nurse asks clients about their beliefs and practices toward pregnancy. c. The nurse uses charts and diagrams when teaching pregnant clients. d. The nurse can speak several different languages.

b. The nurse asks clients about their beliefs and practices toward pregnancy.

Which of these actions should a nurse perform prior to a client's scheduled hemodialysis? a. Administer prophylactic antibiotics. b. Weigh the client. c. Give the client normal saline solution to drink. d. Measure the urine specific gravity.

b. Weigh the client.

When caring for a client who is receiving oxygen therapy via nasal cannula, a nurse should instruct the client: a. to inhale through the mouth. b. to breathe through the nose. c. to hold the catheter when coughing. d. to take quick, shallow breaths

b. to breathe through the nose.

Which of these discharge instructions should a nurse include for a client who has a ruptured tympanic membrane that occurred during a fall? a. "No showers or washing of the hair for the next month." b. "Avoid yawning or holding your head down." c. "Do not allow any water to enter the ear until healing is confirmed by direct visualization." d. "Avoid swallowing and coughing until your ear has healed."

c. "Do not allow any water to enter the ear until healing is confirmed by direct visualization."

Thrombophlebitis is a complication that may result due to surgery. Which of these actions should a nurse take in the operating room to prevent this complication from occurring? a. Gatch the knee of the bed. b. Administer anticoagulants preoperatively. c. Apply sequential compression devices. d. Maintain the legs in a dependent position.

c. Apply sequential compression devices.

A nurse has been discussing the nutritional needs of children with a group of parents in a clinic. Which of these statements, if made by the parent of a 2-year-old child, should the nurse follow up? a. "I give my child slices of cheese as an afternoon snack." b. "I give my child a cup of skim milk as an afternoon snack." c. "I give my child some popcorn as an afternoon snack." d. "I give my child some yogurt as an afternoon snack."

c. "I give my child some popcorn as an afternoon snack."

Which of the statements if made by a client who is take furosemide (Lasix), supports a nursing diagnosis of knowledge deficit? a. "This medication will increase the amount and frequency of my urination." b. "This medication must be taken, even on days when I fell well." c. "I will need to add more salt to my diet because this medication will increase its excretion." d. "I should change my position slowly to avoid dizziness related to this medication."

c. "I will need to add more salt to my diet because this medication will increase its excretion."

A woman is treated in the emergency room for a broken arm and multiple facial bruises caused by her spouse. Which of these statements, if made by a nurse, is therapeutic? a. "You should leave this relationship now or you will be sorry." b. "Are you aware that women who remain in abusive relationships eventually are killed?" c. "This type of abuse typically recurs after a period of remorse by the abuser." d. "Can you think of what you did to cause this abuse?"

c. "This type of abuse typically recurs after a period of remorse by the abuser."

A physician has ordered 100 mg of Amoxicillin po for a child. The available liquid amoxicillin is 250 mg/5 mL. How many milliliters should a nurse administer? a. 1.0 b. 1.5. c. 2.0 d. 2.5

c. 2.0

When discussing weigh gain during pregnancy, a nurse should recommend that the total weight gain for a pregnant client who is at ideal body weight for her height is: a. at least 15 pounds. b. 15 to 20 pounds. c. 25 to 35 pounds. d. at least 45 pounds.

c. 25 to 35 pounds.

A nurse takes the weight of a normal 2-year-old child who comes in to the pediatric clinic for a well-child visit. If the child weighted 7 lbs, 2 oz. at birth, how much should the nurse expect the child to weight at this visit? a. 14 lbs, 2 oz. b. 18 lbs, 6 oz. c. 28 lbs, 8 oz. d. 45 lbs, 10 oz.

c. 28 lbs, 8 oz.

A licensed practical nurse (LPN) is assigned to care for all of these clients. Which client should the nurse assess first? a. A 25-year-old client who is terminally ill with metastatic testicular cancer. b. A 37-year-old client who has second-degree burns on both feet. c. A 49-year-old client who has an acute myocardial infarction related to cocaine ingestion. d. A 68-year-old client who is bed bound related to severe Parkinson's disease.

c. A 49-year-old client who has an acute myocardial infarction related to cocaine ingestion.

Each of these clients has impaired mobility related to knee surgery. Which client should a nurse assess first? a. A 20-year-old who has a sports-related injury. b. A 37-year-old who reports limited mobility. c. A 59-year-old who has a history of hypertension. d. A 70-year-old who has bilateral cataracts.

c. A 59-year-old who has a history of hypertension.

A nurse should question an order for a potassium chloride intravenous infusion for which of these clients? a. A client who has hypoxia. b. A client who is obese. c. A client who has anuria. d. A client who is congested.

c. A client who has anuria.

Which of these behaviors, if taken by a staff nurse on a psychiatric unit, indicates a correct understanding of therapeutic techniques? a. A nurse smiles when speaking with clients who are manic. b. A nurse uses touch to communicate concern with a depressed client. c. A nurse sets consistent limits with manipulative clients. d. A nurse shares own anxiety reduction techniques with a client who has panic attacks.

c. A nurse sets consistent limits with manipulative clients.

Which of these women, each of whom is in labor, should a nurse recognize as in need of immediate attention? a. A woman who is having contractions every 6 to 8 minutes of mild to moderate intensity. b. A woman who is receiving oxytocin augmentation and who has contractions lasting 60 to 70 seconds. c. A woman who is in the active phase of labor and who insists she needs to use the bedpan to have a bowel movement. d. A woman whose uterine contractions frequency is every two to give minutes.

c. A woman who is in the active phase of labor and who insists she needs to use the bedpan to have a bowel movement.

Which of these nursing measures is the priority for a child who has hemophilia and who sustains a leg injury? a. Ensuring adequate hydration for the child. b. Soaking the child's injured leg in warm water. c. Administering the missing factor VIII to the child. d. Transfusing one unit of whole blood to the child.

c. Administering the missing factor VIII to the child.

A client has persistent paranoid delusions that the food on the unit is poisoned. Which of these measures should a nurse include in the client's care plan? a. Explaining that staff does not poison clients. b. Focusing on how the hospital staff helps clients. c. Allowing the client to eat food from sealed containers. d. Telling the client that not eating the food that is served will result in privilege restrictions.

c. Allowing the client to eat food from sealed containers.

Which of these measures should a nurse include when planning care for an 88-year-old client who is admitted to the hospital with pneumonia? a. Restricting visitors to the client's immediate family members. b. Limiting the client care activities to no more than five minutes each. c. Allowing the client to perform self-care as tolerated. d. Providing the client with a non-stimulating environment.

c. Allowing the client to perform self-care as tolerated.

Which of these tasks should a licensed practical nurse (LPN) delegate to a nursing assistant? a. Checking the 11 A.M. blood sugar for a client who has ketoacidosis. b. Measuring the pulse oximetry level for a client who has status asthmaticus. c. Ambulating a client who had a hip replacement three days ago. d. Changing the dressing for a client who had wound debridement last week.

c. Ambulating a client who had a hip replacement three days ago.

All of these clients are on bed rest. Which one is the most at risk to develop skin breakdown? a. An 82-year-old client who bathes once a week. b. An 83-year-old client who applies powder after drying the skin. c. An 84-year-old client who has been NPO for four days. d. An 85-year-old client who has coronary artery disease.

c. An 84-year-old client who has been NPO for four days.

A child who has cystic fibrosis is receiving pancrelipase (Pancrease MT) with meals and snacks. To determine if the desired effects of the Pancrease are achieved, a nurse should consider which of these questions? a. Is the child's blood sugar level within normal limits? b. Has the child's appetite improved with the medications? c. Are the child's stools of normal consistency? d. Does the child report increased belching and flatus?

c. Are the child's stools of normal consistency?

A client is eight hours postoperative after a transurethral resection of the prostate (TURP). Which of these observations, if noted by a nurse, indicates a complication? a. Hourly urine output of 90 mL. b. Reports of bladder spasms. c. BP 92/60 mm Hg, pulse rate 118/minute. d. Pink-tinged urine output.

c. BP 92/60 mm Hg, pulse rate 118/minute.

Which of these assessment findings, if present in a 4-month-old infant who has severe diarrhea, should a nurse recognize as suggestive that the infant is dehydrated? a. Bulging anterior fontanel. b. Pulse rate of 120/minute. c. Decreased urine output. d. Cyanosis of the mucus membrane.

c. Decreased urine output.

Which of these symptoms should a nurse expect to assess in a client who develops hypoglycemia? a. Fruity breath odor. b. Polyuria. c. Diaphoresis. d. Flushed skin

c. Diaphoresis.

Which of these lunch selections, if made by a client who has congestive heart failure, should a nurse recognize as indicative of a need for additional instructions? a. Cottage cheese with fresh fruit salad, whole wheat bread, and herbal tea. b. Baked chicken with brown rice, mixed green salad, and iced coffee. c. Egg salad sandwich with mayonnaise, pickles, and seltzer water. d. Beef tenderloin, carrots, mashed potatoes, and a baked apple.

c. Egg salad sandwich with mayonnaise, pickles, and seltzer water.

Which of these nursing measures is appropriate for a client who has recurrent renal calculi? a. Weighing the client daily before breakfast. b. Measuring the blood pressure every four hours. c. Encouraging a daily intake of three liters of fluids. d. Testing the urine for protein each shift

c. Encouraging a daily intake of three liters of fluids.

Which of these techniques should a nurse plan to use with a client who is delusional? a. Explore the delusion so the client will know it is false. b. Explain clearly why the client's belief is incorrect. c. Focus on reality-based topics. d. Avoid speaking with the client when he/she is delusional.

c. Focus on reality-based topics.

A nurse should recognize that which of these occupations increases a person's risk of developing hepatitis B? a. Sanitation worker. b. Nursery school teacher. c. Hemodialysis nurse. d. Fish market sales person

c. Hemodialysis nurse.

Which of these nursing diagnoses is the priority for a young adult client who has first-degree burns of the legs and smoke inhalation from a fire in the home? a. Pain. b. Risk for infection. c. Impaired gas exchange. d. Body image disturbance.

c. Impaired gas exchange.

Which of these tasks is appropriate for a nurse to delegate to a nursing assistant in an acute care unit? a. Feeding a client who was admitted with a stroke yesterday. b. Ambulating a client who was admitted with a myocardial infarction yesterday. c. Measure the blood pressure of a client who was admitted with an asthma attack yesterday. d. Suctioning the tracheostomy that was performed on a client yesterday

c. Measure the blood pressure of a client who was admitted with an asthma attack yesterday.

Which of these actions, if taken by a nursing assistant, should a nurse recognize as increasing the client's risk of developing a nosocomial infection? a. Wearing non-sterile gloves while emptying the Foley drainage bag. b. Taping a paper bag to the side rail for tissue disposal. c. Placing the Foley catheter drainage bag on the bed while transferring the client. d. Using the same cuff to measure the blood pressures of all the clients on the unit.

c. Placing the Foley catheter drainage bag on the bed while transferring the client.

Which of these assessments is the priority for a client who is admitted with recurrent depression? a. Previous episodes of depression. b. Compliance with prescribed medications. c. Presence of a suicide plan. d. Problems with communication.

c. Presence of a suicide plan.

Which of these outcomes should a nurse focus on for a client who had a bronchoscopy two hours ago? a. Preventing hemorrhage. b. Preventing pneumonia. c. Preventing aspiration. d. Preventing dehydration.

c. Preventing aspiration.

A client who is receiving radiation therapy has a nursing diagnosis of imbalanced nutrition: less than body requirements related to diminished taste perception and nausea. Which of these additional nursing diagnoses should a nurse consider for the client? a. Risk for aspiration. b. Ineffective protection. c. Risk for deficient fluid volume. d. Altered tissue perfusion.

c. Risk for deficient fluid volume.

Which of these nursing diagnosis is the priority for a client who is one-hour post-op after extensive abdominal surgery? a. Risk for impaired physical mobility. b. Risk for deficient fluid volume. c. Risk for ineffective airway clearance. d. Risk for infection.

c. Risk for ineffective airway clearance.

An elderly client who is receiving a blood transfusion develops a rapid bounding pulse and an elevated blood pressure. Which of these actions should a nurse take? a. Add a 5% dextrose solution to the line. b. Raise the head of the bed. c. Stop the transfusion. d. Measure the client's temperature.

c. Stop the transfusion.

Which of these factors should a nurse consider when delegating tasks to unlicensed assistive personnel (UAP)? a. The UAP's relationship with clients. b. The UAP's willingness to perform tasks. c. The UAP's previous experiences on the unit. d. The UAP's duration of employment on the unit.

c. The UAP's previous experiences on the unit.

Which of these assessments is the initial priority of a client who is one-hour postoperative after an exploratory laparotomy? a. The appearance of the client's surgical incision. b. The client's level consciousness. c. The adequacy of the client's respiratory function. d. The client's fluid and electrolyte status.

c. The adequacy of the client's respiratory function.

A 12-month-old child is playing with the father. Which of these behaviors indicates that the child is demonstrating object permanence? a. The child transfers a toy to the other hand when given another one. b. The child returns a block to the same spot on the table. c. The child looks for a toy that the father has hidden under the table. d. The child recognizes that a ball of clay is the same when flattened out.

c. The child looks for a toy that the father has hidden under the table.

While giving a bath to a client, a nurse notices that the client's back appear reddened. Which of these interpretations and additional assessments should the nurse make? a. The client's skin is sensitive to touch; lightly rub the client's chest area. b. The client has decreased circulation; palpate the peripheral pulses. c. The client is showing signs of pressure; press on the skin and observe for a return of color. d. The client is allergic to the soap; check the extremities for discoloration.

c. The client is showing signs of pressure; press on the skin and observe for a return of color.

A nurse assesses a client who is scheduled for a total abdominal hysterectomy at 10:00 A.M. WHich of the factors should the nurse recognize as most likely to influence the outcome of the surgery? a. The client has voided two times since 5:00 A.M. b. The client is not able to demonstrate leg exercises because of osteoarthritis. c. The client takes one acetylsalicylic acid (baby Aspirin) daily. d. The client reports mouth dryness.

c. The client takes one acetylsalicylic acid (baby Aspirin) daily.

A nurse is monitoring a client who had a cystoscopy six hours ago. The nurse should inform the physician of which these manifestations? a. The client has pink-tinged urine. b. The client reports burning on urination. c. The client's white blood cell count is 15,000 mm3. d. The client appears drowsy

c. The client's white blood cell count is 15,000 mm3.

Which of these observations of a student nurse's behavior while interacting with a client who is crying indicates a correct understanding of therapeutic communication? a. The student maintains continuous eye contact with the client. b. The student places one arm around the client's shoulder? c. The student sits quietly next to the client. d. The student leaves the room to provide privacy for the client.

c. The student sits quietly next to the client.

A client who had a coronary artery bypass graft four days ago suddenly develops sinus tachycardia and reports shortness of breath and dizziness. Which of these interpretations and actions should a nurse take? a. This is an expected occurrence following bypass surgery; continue to monitor the client. b. This indicates normalization of the blood pressure; hold all anti-hypertensive medications. c. This may be an early sign of heart failure; notify the physician. d. This indicates hypoxia; administer oxygen at 5/L per minute.

c. This may be an early sign of heart failure; notify the physician.

Which of these laboratory test results is more important for a nurse to assess for a client who reports chest pain? a. WBC count. b. PTT level. c. Troponin level. d. Hemoglobin.

c. Troponin level.

A nurse is caring for a client with burns and in reverse isolation. Which measures should the nurse include? a. Wearing disposable gloves when chaging the dressings. b. Having the client wear goggles when staff is in the room. c. Wearing a gown, mask, and gloves when providing care to the client. d. Disposing of the client's soiled laundry in a red bag.

c. Wearing a gown, mask, and gloves when providing care to the client.

A client diagnosed with type 1 diabetes mellitus has a glycosylated hemoglobin A1c of 4.2%. A nurse should interpret this to mean that the client has: a. had a period of sustained hyperglycemia. b. been non-compliant with home management. c. been in relatively good diabetic control. d. eaten a high carbohydrate snack just prior to testing.

c. been in relatively good diabetic control.

The mother of a 2-month-old tells a nurse that the baby is consuming six ounces of plain commercial formula seven times a day, plus one ounce of cereal in the morning and at bedtime. Based on this information, the nurse should conclude that the baby's diet is: a. too high in calories. b. too high in iron content. c. deficient in calcium. d. insufficient for the baby's age and weight.

c. deficient in calcium.

When caring for a client who has hepatitis B, a nurse should wear: a. gloves when administering oral medications to the client. b. a gown when changing the client's position. c. gloves when removing the intravenous cannula. d. a gown when emptying the client's used bath water.

c. gloves when removing the intravenous cannula.

A nurse should explain to a primigravida that urine tests will be done at each prenatal visit throughout the pregnancy to measure: a. specific gravity and pregnancy hormones. b. culture and white blood cell count. c. glucose and protein. d. bacteria and red blood cell count.

c. glucose and protein.

A client has shortness of breath when lying down and usually assumes an upright or sitting position in order to breathe more comfortably. A nurse should document this observation as: a. dyspnea. b. bradypnea. c. orthopnea. d. apnea.

c. orthopnea.

Which of these instructions should a nurse include in the discharge teaching for a client who has diabetes mellitus? a. "Soak your feet in hot water once a day." b. "Cut your toenails in an oval shape weekly." c. "Avoid using any soap on your feet." d. "Apply lotion to your feet each day."

d. "Apply lotion to your feet each day."

135. A nurse is reinforcing teaching to a client who has a new prescription for transdermal nitroglycerin (Nitro-Dur). Which of the following statements indicates the client understands the teaching?

d. "I will leave the patch on for 12 to 14 hours each day."

133, A nurse is reinforcing foot care to a client with diabetes mellitus. Which of the following clients' statements indicate to the nurse a need for further teaching?

d. "I will soak my feet in warm water every night."

A nurse should recognize that a client who has chronic obstructive pulmonary disease (COPD), needs additional instructions if the client makes which of these statements? a. "I will try to take slow, deep breaths when I feel short of breath." b. "I will use the albuterol (Proventil) nebulizer before I eat. c. "I will drink most of my fluids between meals." d. "I will turn up the oxygen flow rate if I have difficulty breathing."

d. "I will turn up the oxygen flow rate if I have difficulty breathing."

A client, who is newly diagnosed with cancer says to anurse, "I suppose I need to complete all unfinished business as soon as possible." Which of these responses is appropriate? a. "Yes, you should do this immediately. b. "Don't you think you should stay focused on your treatment for now? c. "Exactly what things are you talking about?" d. "It sounds like you are concerned with your diagnosis."

d. "It sounds like you are concerned with your diagnosis."

Which of these instructions should a nurse give to a client who has venous insufficiency regarding the use of elastic stockings (TEDs)? a. "Bunch the TEDs up and pull them on like socks." b. "Lower the TEDs to your ankles if your legs ache." c. "Keep the TEDs on at all times." d. "Put the TEDs on before you get up in the morning."

d. "Put the TEDs on before you get up in the morning."

Which of the instructions should a nurse include in the teaching for a pt. who had removal of a cataract in the left eye? a. "Forcefully cough and take deep breaths every two hours to keep your airway clear." b. "Perform the prescribed eye exercises each day to strengthen your eye muscles." c. "Rinse your eyes with saline each morning to prevent postoperative infection." d. "Take the prescribed stool softener to avoid increasing intraocular pressure."

d. "Take the prescribed stool softener to avoid increasing intraocular pressure."

Which of these recommendations should a nurse make when teaching a client who is to start taking oral prednisone (Deltasone)? a. "Take this medicine at bedtime, on an empty stomach." b. "Take this medicine with a hot beverage in the evening." c. "Take this medicine in the morning, one hour before breakfast." d. "Take this medicine in the morning with food or milk."

d. "Take this medicine in the morning with food or milk."

A client who has a breast tumor says to a nurse, "I am so anxious. Why did I have to get sick now?" Which of these responses, if made by the nurse, is therapeutic? a. "You will need to find someone to talk over your fears on a regular basis." b. "What do you think is making you feel so anxious now?" c. "Are you aware that there are newer, more effective treatments for breast cancer?" d. "Tell me more about your concerns."

d. "Tell me more about your concerns."

A nurse plans to assess a client's recent memory. Which of these questions should the nurse include? a. "Who is your closest friend?" b. "What was the name of the school you attended?" c. "What day were you admitted to the unit?" d. "What did you have for breakfast?"

d. "What did you have for breakfast?"

A client tells a nurse, "I am so scared about the interview tomorrow. I just know I will say the wrong thing and not get the job." Which of these responses, if made by the nurse, will create a communication barrier? a. "Would you like to practice the interview?" b. "Have you thought about some possible questions that may be asked in the interview?" c. "Tell me more about your concerns." d. "You need to relax, and everything will be fine."

d. "You need to relax, and everything will be fine."

Which of the following clients should a nurse recognize is most likely to develop diabetic ketoacidosis? a. A 23-year-old who has type 1 diabetes mellitus and is being treated for a tooth abscess. b. A 31-year-old gestational diabetic who has occasional bout of nausea. c. A 55-year-old who has type 2 diabetes mellitus and is adjusting well to the lifestyle changes. d. A 72-year-old who has type 2 diabetes mellitus and is managed with diet and exercise.

d. A 72-year-old who has type 2 diabetes mellitus and is managed with diet and exercise.

A nurse has received a report on these assigned clients. Which client should the nurse follow-up first? a. A client, admitted with acute diverticulitis, who has a white blood cell count (WBC) of 10,000 mm3. b. A client, admitted with acute pancreatitis, who has a fasting serum glucose of 130 mg/dL today, and had a reading of 160 mg/dL yesterday. c. A client, admitted with hepatitis, who has jaundice and tea-colored urine. d. A client who is currently receiving cancer chemotherapy and who has a white blood cell count of 500 mm3 today.

d. A client who is currently receiving cancer chemotherapy and who has a white blood cell count of 500 mm3 today.

Which of these clients is at the highest risk of developing osteoporosis? a. An obese African American adolescent who does not exercise. b. A pregnant Asian client who is a vegetarian. c. A middle-aged Native-American male who is quadriplegic. d. A thin, elderly Caucasian female who lives alone.

d. A thin, elderly Caucasian female who lives alone.

A client who has Parkinson's disease has been identified as being at risk for falls. Which of these actions by a nurse is most likely to reduce the client's risk of falling a. Monitor the client's blood pressure after ambulation. b. Ensure the client wears socks when ambulating. c. Encourage frequent weight-bearing exercise. d. Assign an assistant to remain with the client when ambulating.

d. Assign an assistant to remain with the client when ambulating.

An adolescent has a nursing diagnosis of fatigue related to inadequate intake of iron-rich foods. Selection of which of these lunches by the client indicates a correct understanding of foods high in iron content? a. Peanut butter and jam sandwich. b. Chicken nuggets with rice. c. Tuna salad sandwich. d. Beefburger with cheese.

d. Beefburger with cheese.

A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding and take which of these actions? a. Suction the nasogastric tube. b. Flush the tube with 30 mL of sterile water. c. Remove the nasogastric tube. d. Check the residual volume.

d. Check the residual volume.

Which of these postoperative complications in the first hour after surgery requires immediate intervention? a. Serous draining on the dressing. b. Swelling of an extremity under a cast. c. Vomiting. d. Dehiscence of a wound.

d. Dehiscence of a wound.

129. A nurse is reinforcing teaching to a client who has been taking dig 0.25 mg PO daily for 6 months, which of the following indicates a need for further teaching?

d. I will call my provider if I experience a yellow tinge to my vision.

A nurse reviews a client's prenatal record and notes that the client's last menstrual period (LMP) was on September 18th. Using the Naegele's rule, the nurse should calculate that the client's expected date of delivery (EDD) will be: a. May 11th. b. May 25th. c. June 11th. d. June 25th.

d. June 25th.

Which of these actions, if taken by a nurse who is transferring a client from the bed to the chair, is correct? a. The bed is raised to a comfortable working height for the nurse. b. The wheelchair is placed perpendicular to the bed. c. The nurse stands behind the client during the transfer. d. The nurse supports the client in an upright standing position for a few moments.

d. The nurse supports the client in an upright standing position for a few moments.

Which of these assessment findings, if present in a primigravida, indicates that the client is experiencing true labor? a. The pains are felt in the lower abdomen, back, and groin. b. The Braxton-Hicks contractions have become stronger and more frequent. c. There is an increased amount of white mucus discharge. d. There is a progressive increase in effacement and cervical dilatation.

d. There is a progressive increase in effacement and cervical dilatation.

A nurse in a prenatal clinic performs Leopold's maneuvers on a client who is 8-months-pregnant primarily to: a. turn the fetus in the uterus. b. ease the fetus into the true pelvis. c. assessment of the location of the placenta. d. determine the fetal presentation

d. determine the fetal presentation

When interacting with a client who is paranoid, a nurse should: a. use touch to place the client at ease. b. maintain a caring facial expression. c. stand close to the client. d. maintain a professional attitude towards the client.

d. maintain a professional attitude towards the client.

A nurse is monitoring a client who is taking acetylsalicylic acid (Aspirin) 975 mg daily for adverse effects, which include: a. loss of joint mobility. b. increased serum calcium levels. c. increasing heart failure. d. occult blood in the stools.

d. occult blood in the stools.

a home health nurse is caring for an adult client who reports, "I keep coughing when I try to swallow my food, but not at other times." Which of the following actions should the nurse take?

initiate a consultation with a speech→ language pathologist; swallow eval

171. A nurse is caring for a client who is experiencing respiratory acidosis. The nurse should expect which of the following serum pH levels?

pH 7.30

167. A nurse is monitoring a client who is receiving a unit of packed red blood cells (PRBCs). The nurse recognizes an allergic reaction when the client reports.

urticaria.