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A client diagnosed with bipolar disorder is going home on a week-end pass. Which suggestions should give the client's family to help them prepare for the visit? 1. Discuss the importance of continuing the usual at-home activities 2. Encourage the family to plan daily activities to keep the client busy 3. Have friends and family visit the client at a welcome party. 4. Instruct family to monitor the client's choice of television programs.

1. Discuss the importance of continuing the usual at-home activities

The nurse is preparing to administer an infusion of amino acid-dextrose total parenteral nutrition (TPN) through a central venous catheter (CVC) line. Which action should the nurse implement first? a- Attached de IV tubing to the central line. b- Check the TPN solution for cloudiness c- Set the infusion PUMP at the prescribed rate. d- Prime the IV tubbing with the TPN solution.

Check the TPN solution for cloudiness

A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? a. Altered consciousness within the first 24 hours after injury. b. Cushing reflex and cerebral edema after 24 hours c. Fever, nuchal rigidity and opisthotonos within hours d. Headache and pupillary changes 48 hours after a head injury

a. Altered consciousness within the first 24 hours after injury.

In making client care assignment, which client is best to assign to the practical nurse (PN) working on the unit with the nurse? a. An immobile client receiving low molecular weight heparin q12 h. b. A client who is receiving a continuous infusion of heparin and gets out of bed BID c. A client who is being titrated off heparin infusion and started on PO warfarin (Coumadin) d. An ambulatory client receiving warfarin (Coumadin) with INR of 5 second.

a. An immobile client receiving low molecular weight heparin q12 h.

A male client with cancer is admired to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescription include radiation therapy. What action should the nurse implement? a. Ask the client about his expected goals for the hospitalization b. Explain the palliative care measures can be provided at home c. Notify do radiation department to withhold the treatment for now d. Determine if the client wishes to cancel further radiation treatment

a. Ask the client about his expected goals for the hospitalization

A young adult male who is being seen at the employee health care clinic for an annual assessment tell the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficulty indeed. Which response is best for the nurse to provide? a. Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed. b. Encourage the client to seek genetic counseling to determine his risk for mental illness. c. Informed the client that his mother schizophrenic has affected his psychological development. d. Tell the client that mental illness has a familial predisposition, so he should see a psychiatrist.

a. Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.

While the nurse is conducting a daily assessment of an older woman who resides in a long-term facility, the client begins to cry and tells the nurse that her family has stopped calling and visiting. What action should the nurse take first? a. Ask the client when a family member last visited her. b. Determine the client's orientation to time and space c. Review the client's record regarding social interactions d. Reassure the client of her family's love for her

a. Ask the client when a family member last visited her.

A client who had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement? a. Auscultate all quadrant of the abdomen. b. Perform a digital rectal exam c. Palpate the liver and spleen d. Obtain a hemoccult of the client's stool

a. Auscultate all quadrant of the abdomen.

A primigravida a 40-weeks gestation with preeclampsia is admitted after having a seizure in the hot tub at a midwife's birthing center. Based on documentation in the medical record, which action should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.) a. Continue to monitor the client's blood pressure hourly. b. Inform the healthcare provider of CBC results c. Update the nursery staff on the client's status d. Give a dose of calcium gluconate per preeclampsia protocol.

a. Continue to monitor the client's blood pressure hourly.

A young couple who has been unsuccessful in conceiving a child for over a year is seen in the family planning clinic. During an initial visit, which intervention is most important for the nurse to implement? a. Determine current sexual practice b. Prepare a female client for an ultrasound c. Request a sperm sample for ovulation d. Evaluate hormone levels on both clients

a. Determine current sexual practice

A client with persistent low back pain has received a prescription for electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond? a. Determine if the sensation feels uncomfortable. b. Decrease the strength of the electrical signals. c. Remove electrodes and observe for skin redness. d. Check the amount of gel coating on the electrodes.

a. Determine if the sensation feels uncomfortable.

A male client was transferred yesterday from the emergency department to the telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor alarms for ventricular tachycardia (VT), what action should the nurse take first? a. Determine the client's responsiveness and respirations b. Bring the crash cart to the room to defibrillate the client. c. Immediately initiate chest compressions. d. Notify the emergency response team

a. Determine the client's responsiveness and respirations

To prevent infection by auto contamination during the acute phase of recovery from multiple burns, which intervention is most important for the nurse to implement? a. Dress each wound separately. b. Avoid sharing equipment between multiple clients. c. Use gown, mask and gloves with dressing change. d. Implement protective isolation.

a. Dress each wound separately.

The nurse ask the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement? a. Examine the genitalia as the last part of the total exam. b. Use soothing statements to facilitate cooperation c. Allow the child to keep underpants on to examine genitalia d. Work slowly and methodically so not to stress the child

a. Examine the genitalia as the last part of the total exam.

A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? a. Explain that counseling will be provided to give her information about her cancer risk. b. Gather additional information about the client's family history for all types of cancer. c. Offer assurance that there are a variety of effective treatments for breast cancer. d. Provide information about survival rates for women who have this genetic mutation.

a. Explain that counseling will be provided to give her information about her cancer risk.

An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. What is the best response by the nurse? a. Explain that the client will start to lose consciousness and his body system will slow down b. Reassure the spouse that the healthcare provider will let her know when to call the children c. Offer to discuss the client's health status with each of the adult children d. Gather information regarding how long it will take for the children to arrive

a. Explain that the client will start to lose consciousness and his body system will slow down

In planning strategies to reduce a client's risk for complications following orthopedic surgery, the nurse recognizes which pathology as the underlying cause of osteomyelitis? a. Infectious process b. Metastatic process c. Autoimmune disorder d. Inflammatory disorder

a. Infectious process

After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? a. Initiate intravenous fluid as prescribed b. Notify the HCP of the need to reposition the catheter c. Remove the catheter and apply direct pressure for 5 minutes. d. Secure the catheter using aseptic technique

a. Initiate intravenous fluid as prescribed

A low-risk primigravida at 28-weeks gestation arrives for her regular antepartal clinic visit. Which assessment finding should the nurse consider within normal limits for this client? a. Pulse increase of 10 beats/minute b. Proteinuria c. Glucosuria d. Fundal height 0f 22 centimeters

a. Pulse increase of 10 beats/minute

At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation: a. Remove sequential compression devices. b. Apply PRN oxygen per nasal cannula. c. Administer a PRN dose of an antipyretic. d. Reinforce the surgical wound dressing.

a. Remove sequential compression devices.

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection would indicate to the nurse the client understands they prescribed diet? a. Roasted turkey canned vegetables b. Baked potatoes with skin raw carrots c. Pancakes whole-grain cereal's d. Roast pork fresh strawberries

a. Roasted turkey canned vegetables

A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse? a. The client has asymmetrical chest wall expansion b. The clients complain of pain at the insertion site c. The client chest's x-ray indicates decreased pleural effusion d. The client's arterial blood gases are pH 7.35, PaO2 85, Pa CO2 35, HCO3 26

a. The client has asymmetrical chest wall expansion

A client in septic shock has a double lumen central venous catheter with one liter of 0.9% Normal Saline Solution infusing at 1 ml/hour through one lumen and TPN infusing at 50 ml/ hr. through one port. The nurse prepared newly prescribed IV antibiotic that should take 45 mints to infuse. What intervention should the nurse implement? a. Use a secondary port of the Normal Saline solution to administer the antibiotic. b. Add the antibiotic to the TPN solution, and continue the normal saline solution. c. Stop the TPN infusion for the time needed to administer the prescribed antibiotic. d. Add the antibiotic to the Normal Saline solution and continue both infusions.

a. Use a secondary port of the Normal Saline solution to administer the antibiotic.

A client is discharged with automated peritoneal dialysis (PD) to be used nightly...which instructions should the nurse include? a. Wash hands before cleaning exit site b. Keep the head of the bed flat at night c. Feel for a thrill and a distal pulse nightly d. Do not get up if fluid is left in the abdomen

a. Wash hands before cleaning exit site

A female client with severe renal impairment is receiving enoxaparin (lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider? a. creatinine clearance 25 mL/ minute b. calcium 9 mg/dl c. hemoglobin 12 grams/dl d. partial thromboplastin time (PTT) 30 seconds

a. creatinine clearance 25 mL/ minute

The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be referred to the health care provider immediately? a. headache, photophobia, and nuchal rigidity b. high fever, skin rash, and a productive cough c. nausea, vomiting, and poor skin turgor d. malaise, fever, and stiff, swollen joints

a. headache, photophobia, and nuchal rigidity

After receiving the Braden scale findings of residents at a long-term facility, the charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize the skin care for which client? a. An older adult who is unable to communicate elimination needs. b. An older man whose sheets are damped each time he is turned. c. A woman with osteoporosis who is unable to bear weight. d. A poorly nourished client who requires liquid supplement. An older man whose sheets are damped each time he is turned.

b. An older man whose sheets are damped each time he is turned.

The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide? a. Perform CPT after meals to increase appetite and improve food intake. b. CPT should be performed more frequently, but at least an hour before meals. c. Stop using CPT during the daytime until the child has regained an appetite. d. Perform CPT only in the morning, but increase frequency when appetite improves.

b. CPT should be performed more frequently, but at least an hour before meals.

The nurse is changing a client's IV tubing and closes the roller clamp on the new tubing setup when the bag of solution is....which action should the nurse take to ensure adequate filling of the drip chamber? a. Lower the IV bag to a flat surface b. Compress the drip chamber c. Open the roller clamp d. Squeeze the bag of IV solution

b. Compress the drip chamber

A mother runs into the emergency department with s toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first? a. Call poison control emergency number. b. Determine type of chemical exposure. c. Obtain equipment for gastric lavage. d. Assess child for altered sensorium.

b. Determine type of chemical exposure.

During a routine clinic visit, an older female adult tells the nurse that she is concerned that the flu season is coming soon, but is reluctant to obtain the vaccination. What action should the nurse take first? a. Determine when the client last had an influenza vaccination. b. Discuss the concerns expressed by the client about the vaccination. c. Ask about any recent exposure to persons with the flu or other viruses. d. Review the informed consent form for the vaccination with the client.

b. Discuss the concerns expressed by the client about the vaccination.

Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity a. Range of Motion b. Distal pulse intensity c. Extremity sensation d. Presence of exudate

b. Distal pulse intensity

A female client presents in the Emergency Department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask? a. Does she know the person who raped her? b. Has she taken a bath since the raped occurred? c. Is the place where she lived a safe place? d. Did she report the rape to the police Department?

b. Has she taken a bath since the raped occurred?

A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? a. Sed rate (ESR) b. Hemoglobin c. Calcium d. Osmolality.

b. Hemoglobin

During a well-baby, 6-month visit, a mother tells the nurse that her infant has had fewer ear infections than her 10-year-old daughter. The nurse should explain that which vaccine is likely to have made the difference in the siblings' incidence of otitis media? a. Varicella Virus Vaccine Live b. Hemophilic Influenza Type B (HiB) vaccine c. Pneumococcal vaccine d. Palivizumab vaccine for RSV

b. Hemophilic Influenza Type B (HiB) vaccine

A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider? a. Pain scale rating at 9 on a 0-10 scale b. Last menstrual period was 7 weeks ago c. Reports white curdy vaginal discharge d. History of irritable bowel syndrome IBS

b. Last menstrual period was 7 weeks ago

A client with Alzheimer's disease falls in the bathroom. The nurse notifies the charge nurse and completes a fall follow-up assessment. What assessment finding warrants immediate intervention by the nurse? a. Urinary incontinence b. Left forearm hematoma c. Disorientation to surroundings d. Dislodge intravenous site

b. Left forearm hematoma

A client who had an emergency appendectomy is being mechanically ventilated, and soft wrist restrain are in place to prevent self extubation. Which outcome is most important for the nurse to include in the client's plan of care? a. Understand pain management scale b. Maintain effective breathing patterns c. Absence of ventilator associated pneumonia d. No injuries refer to soft restrains occur

b. Maintain effective breathing patterns

A nurse is planning discharge care for a male client with metastatic cancer. The client tells the nurse that he plans to return to work despite pain, fatigue, and impending death. Which goals is most important to include in this client's plan of care? a. Implements decisions about future hospices services within the next 3 months. b. Maintaining pain level below 4 when implementing outpatient pain clinic strategies. c. Request home health care if independence become compromised for 5 days. d. Arranges for short term counseling stressors impact work schedule for 2 weeks.

b. Maintaining pain level below 4 when implementing outpatient pain clinic strategies.

Which intervention should the nurse include in the plan of care for a client with leukocytosis? a. Avoid intramuscular injections b. Monitor temperature regularly c. Assess skin for petechiae or bruising d. Implement protective isolation measures

b. Monitor temperature regularly

The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. What expected outcome has the highest priority for this client? a. Identifies 2 treatments for constipation due to immobility. b. Names 3 home safety hazards to be resolve immediately. c. State 4 risk factors for the development of osteoporosis. d. Lists 5 calcium-rich foods to be added to her daily diet.

b. Names 3 home safety hazards to be resolve immediately.

The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating? a. A paced rhythm with 100% capture after pacemaker replacement b. Normal sinus rhythm and complaining of chest pain c. Atrial fibrillation with congestive heart failure and complaining of fatigue d. Sinus tachycardia 3 days after a myocardial infarction

b. Normal sinus rhythm and complaining of chest pain

The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate do you effectiveness of the teaching? a. Ask the adolescent to describe his level of comfort with injecting himself with insulin. b. Observe him as he demonstrates self-injection technique in another diabetic adolescent c. Have the adolescent list the procedural steps for safe insulin administration. d. Review his glycosylated hemoglobin level 3 months after the teaching session.

b. Observe him as he demonstrates self-injection technique in another diabetic adolescent

A client with pneumonia has an IV of lactated ringer's solution infusing at 30ml/hr current labor....sodium level of 155 mEq/L, a serum potassium level of 4mEq/L.... what nursing intervention is most important? a.Provide a high-potassium snack, such as bananas. b. Obtain a prescription to increase the IV rate c. Administer the next scheduled dose of antibiotic d. Review the report of the most recent chest x-ray.

b. Obtain a prescription to increase the IV rate

The nurse is assessing a postpartum client who is 36 hours post-delivery. Which finding should the nurse report to the healthcare provider? a. White blood count of 19,000 mm3 b. Oral temperature of 100.6 F c. Fundus deviated to the right side d. Breasts are firm when palpated

b. Oral temperature of 100.6 F

The nurse has received funding to design a health promotion project for AfricanAmerican women who are at risk for developing breast cancer. Which resource is most important in designing this program? a. A listing of African-American women so live in the community b. Participation of community leaders in planning the program c. Morbidity data for breast cancer in women of all races d. Technical assistance to produce a video on breast self-examination.

b. Participation of community leaders in planning the program

A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? a. Abnormal responses for cranial nerves I and II b. Persistent coughing while drinking c. Unilateral facial drooping d. Inappropriate or exaggerated mood swings

b. Persistent coughing while drinking

In assessing a pressure ulcer on a client's hip, which action should the nurse include? a. Determine the degree of elasticity surrounding the lesion b. Photograph the lesion with a ruler placed next to the lesion c. Stage the depth of the ulcer using the Braden numeric scale d. Use a gloved finger to palpate for tunneling around the lesion

b. Photograph the lesion with a ruler placed next to the lesion

A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client? a. Chew food slowly and thoroughly before attempting to swallow b. Plan volume-controlled evenly-space meal thorough the day c. Sip fluid slowly with each meal and between meals d. Eliminate or reduce intake fatty and gas forming food

b. Plan volume-controlled evenly-space meal thorough the day

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? a. Replace the IV site with a smaller gauge. b. Redress the abdominal incision c. Leave the lights on in the room at night. d. Apply soft bilateral wrist restraints.

b. Redress the abdominal incision

To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented? a. Confirm that all the staff nurses are being assigned to equal number of clients. b. Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. c. Assign each staff nurse a turn unit charge nurse on a regular, rotating basis. d. Analyze the amount of overtime needed by the nursing staff to complete assignments.

b. Review the staff nurse job description to ensure that it is clear, accurate, and recurrent.

An adult client present to the clinic with large draining ulcers on both lower legs that are characteristics of Kaposi's sarcoma lesions. The client is accompanied by two family member. Which action should the nurse take? a. Ask family member to wear gloves when touching the patient b. Send family to the waiting area while the client's history is taking c. Obtain a blood sample to determine is the client is HIV positive d. Complete the head to toes assessment to identify other sign of HIV

b. Send family to the waiting area while the client's history is taking

A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the car about 50 feet away. What action should the nurse take first? a. Examine the victim's body surfaces for arterial bleeding b. Stabilize the victim's neck and roll over to evaluate his status c. Return to the car to call emergency response 911 for help d. Open the airway and initiate resuscitative measures

b. Stabilize the victim's neck and roll over to evaluate his status

A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. What action I the treatment plan should the nurse implement? a. Tell the client to drive over the bridge until fear is manageable b. Teach client to listen to music or audio books while driving c. Encourage client to have spouse drive in stressful places. d. Recommend that the client avoid driving over the bridge.

b. Teach client to listen to music or audio books while driving

One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in the clients plan of care a. Encourage Progressive active range of motion b. Teach need for dietary and supplementary vitamin D3 c. Explain the need for skin exposure to sunlight without sunscreen d. Instruct the client to use of muscle strengthening exercises

b. Teach need for dietary and supplementary vitamin D3

The fire alarm goes off while the charge nurse is receiving the shift report. What action should the charge nurse implement first? a. Instruct the client's family member to stay in the visitor waiting area until further notice b. Tell the staff to keep all clients and visitors in the client rooms with the doors closed. c. Direct the nursing staff to evacuate the clients using the stairs in a calm and orderly manner. d. Call the hospital operator to determine if the is indeed a real emergency or a fire drill.

b. Tell the staff to keep all clients and visitors in the client rooms with the doors closed.

The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide? a. High salt can damage the lining of the blood vessels b. Too much salt can cause the kidneys to retain fluid c. Excessive salt can cause blood vessels to constrict d. Salt can cause information inside the blood vessels

b. Too much salt can cause the kidneys to retain fluid

An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? a. Rebound abdominal tenderness b. nausea and projectile vomit c. rib pain with deep inspiration d. diminished bilateral breath sounds

b. nausea and projectile vomit

When five family members arrive at the hospital, they all begin asking the nurse questions regarding the prognosis of their critically ill mother. What intervention should the nurse implement first? a- Include the family in client's care b- Request the chaplain's presence c- Ask the family to identify a specific spokesperson d- Page the healthcare provider to speak with family.

c- Ask the family to identify a specific spokesperson

The nurse is triaging victims of a tornado at an emergency shelter. An adult woman who has been wandering and crying comes to the nurse. What action should the nurse take? a- Check the client's temperature, blood sugar, and urine output. b- Transport the client for laboratory client for laboratory test and electrocardiogram (EKG) c- Delegate care of the crying client to an unlicensed assistant d- Send the client to the shelter's nutrient center to obtain water and food.

c- Delegate care of the crying client to an unlicensed assistant

The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms? a- Fruity breath odor b- Polyphagia c- Diaphoresis d- Polydipsia

c- Diaphoresis

The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse's immediate attention? a. A young adult with Crohn's disease who reports having diarrheal stools b. An older adult with type 2 diabetes whose breakfast tray arrives 20 minutes late. c. A 10-year-old who is receiving chemotherapy and the infusion pump is beeping. d. A teenager who reports continued pain 30 minutes after receiving an oral analgesic.

c. A 10-year-old who is receiving chemotherapy and the infusion pump is beeping.

On a busy day, one hour after the shift report is completed, the charge nurse learns that a female staff nurse who lives one hour away from the hospital forgot her prescription eye glasses at home. What action should the charge nurse take? a. Encourage the nurse purchase the reading glasses in the hospital gift shop b. Request another nurse to assist the staff nurse with her documentation c. Ask the nurse to return home and get her prescription eyeglasses for work. d. Tell the staff nurse to take a day off and change her weekly work schedule.

c. Ask the nurse to return home and get her prescription eyeglasses for work.

A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? a. Review the heart rhythm on cardiac monitors b. Check urinary catheter for obstruction c. Auscultated bilateral breath sounds d. Give PRN dose of lorazepam (Ativan)

c. Auscultated bilateral breath sounds

A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse? a. Low-grade fever, headache, and malaise for the past 72 hours b. Unable to bear weight on the left foot, with the swelling and bruising c. Chest discomfort one hour after consuming a large, spicy meal d. One-inch bleeding laceration on the chain of the crying five-year-old

c. Chest discomfort one hour after consuming a large, spicy meal

Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? a. Ensure that the knot can be quickly released. b. Tie the knot with a double turn or square knot. c. Move the ties so the restraints are secured to the side rails. d. Ensure that the restraints are snug against the client's wrist.

a. Ensure that the knot can be quickly released.

After receiving the first dose of penicillin, the client begins wheezing and has trouble breathing. The nurse notifies the healthcare provider immediately and received several prescriptions. Which medication prescription should the nurse administer first? a. Epinephrine Injection, USP IV b. Diphenhydramine IV c. Albuterol (Ventolin) inhaler d. Methylprednisolone IV

a. Epinephrine Injection, USP IV

In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the nurse include in the plan of care? a. Evaluate closet proximal pulse. b. Asses skin elasticity of the stump. c. Observe for swelling around the stump. d. Note amount color of wound drainage.

a. Evaluate closet proximal pulse.

While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? a. Serum albumin b. Creatinine level c. Culture for sensitive organisms. d. Serum blood glucose (BG) level

c. Culture for sensitive organisms.

The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant. Which action should the nurse include? a. Select a 22 gauge 1 ½ inch (3.8 cm) needle for the intramuscular injection b. Administer into the deltoid muscle while the parent holds the infant securely c. Divide the medication into two injections with volumes under 1ml d. Use a quick dart-like motion to inject into the dorsogluteal site.

c. Divide the medication into two injections with volumes under 1ml

The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider? a. Decreased white blood cell count b. Pruritus and muscle aches c. Elevated liver function tests d. Vomiting and diarrhea

c. Elevated liver function tests

A female client is extremely anxious after being informed that her mammogram was abnormal and needs to be repeated. Client is tearful and tells the nurse her mother died of breast cancer. What action should the nurse take? a. Provide the client with information about treatment options for breast cancer. b. Reassure the client that the final diagnosis has not been made. c. Encourage the client to continue expressing her fears and concerns. d. Suggest to the client that she seek a second opinion.

c. Encourage the client to continue expressing her fears and concerns.

Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first? a. Prepared both client's medication and take to them at once b. Determine when each client last received pain medication. c. Evaluate both client's pain using a standardized pain scale d. Provide non-pharmacologic pain management interventions.

c. Evaluate both client's pain using a standardized pain scale

The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam? a. Determine the client's level of emotional functioning' b. Assess functional ability of the primary support system. c. Evaluate the client's mood, cognition and orientation. d. Review the client's pattern of adaptive coping skill

c. Evaluate the client's mood, cognition and orientation.

A client with C-6 spinal cord injury rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or "goosebumps". The nurse should asses for which trigger? a. Loud hallway noise. b. Fever c. Full bladder d. Frequent cough.

c. Full bladder

The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective? a. These warts are caused by a fungus b. Early treatment is very effective c. I need to have regular pap smears d. I will clean my hot tub better

c. I need to have regular pap smears

When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? a. Massage the uterus to decrease atony b. Check for a distended bladder c. Increase intravenous infusion d. Review the hemoglobin to determined hemorrhage

c. Increase intravenous infusion

What action should the school nurse implement to provide secondary prevention to a school-age children? a. Collaborate with a science teacher to prepare a health lesson b. Prepare a presentation on how to prevent the spread of lice c. Initiate a hearing and vision screening program for first-graders d. Observe a person with type 1 diabetes self-administer a dose of insulin

c. Initiate a hearing and vision screening program for first-graders

If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding? a. The intravenous fluid replacement contains a hypertonic solution of sodium chloride b. Urinary and Gastrointestinal fluid loss reduce blood viscosity and stimulate thirst c. Insensible loss of body fluids contributes to the hemoconcentration of serum solutes d. Hypothalamic resetting of core body temperature causes vasodilation to reduce body heat

c. Insensible loss of body fluids contributes to the hemoconcentration of serum solutes

While changing a client's chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take? a. Apply a pressure dressing around the chest tube insertion site. b. Assess the client for allergies to topical cleaning agents. c. Measure the area of swelling and crackling. d. Administer an oral antihistamine per PRN protocol.

c. Measure the area of swelling and crackling.

Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse? a. Diarrhea and flatulence b. Abdominal cramps c. Muscle pain d. Altered taste

c. Muscle pain

After receiving report, the nurse can most safely plan to assess which client last? The client with... a. A rectal tube draining clear, pale red liquid drainage b. A distended abdomen and no drainage from the nasogastric tube c. No postoperative drainage in the Jackson-Pratt drain with the bulb compressed d. Dark red drainage on a postoperative dressing, but no drainage in the Hemovac®.

c. No postoperative drainage in the Jackson-Pratt drain with the bulb compressed

A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 F. he is drooling and becoming increasingly more restless. What action should the nurse take first? a. Put a cold cloth on his head and administer acetaminophen. b. Listen to lung sounds and place him in a mist tent. c. Notify the healthcare provider and obtain a tracheostomy tray d. Assist the child to lie down and examine his throat.

c. Notify the healthcare provider and obtain a tracheostomy tray

Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. What action should the nurse take? a. Reposition the transdermal patch to the client's trunk. b. Remove the transdermal patch until the vomiting subsides. c. Notify the healthcare provider of the vomiting. d. Explain that this is a side effect of the medication in the patch.

c. Notify the healthcare provider of the vomiting.

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? a. Evaluate the client's ability to use an incentive spirometer b. Monitor the amount of drainage from the client's incision c. Observe both lower extremities for redness and swelling d. Palpate all peripheral pulse points for volume and strength

c. Observe both lower extremities for redness and swelling

A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? a. Collect a clean catch urine specimen. b. Instruct the client to empty the bladder. c. Obtain vital signs and breath sounds. d. No specific nursing action is required

c. Obtain vital signs and breath sounds.

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned? a. Empty the urinary drainage bag b. Feed the client a snack c. Offer the client oral fluids d. Assess the breath sounds

c. Offer the client oral fluids

A native-American male client diagnosed with pneumonia, states that in addition to his prescribed medical treatment of IV antibiotics he wishes to have a spiritual cleaning performed. Which outcome statement indicates that the best plan of care was followed? a. Identifies his ethnocentric values and behaviors b. States an understanding of the medical treatment c. Participated actively in all treatments regimens d. Expresses a desire for cultural assimilation

c. Participated actively in all treatments regimens

The nurse is demonstrating correct transfer procedures to the unlicensed assisted personnel (UAP) working on a rehabilitation unit. The UAPs ask the nurse how to safely move a physically disabled client from the wheelchair to a bed. What action should the nurse recommended? a. Hold the client at arm's length while transferring to better distribute the body weight. b. Apply the gait belt around the client's waits once standing position has been assumed. c. Place a client's locked wheelchair on the client's strong side next to the bed. d. Pull the client into position by reaching from the opposite side of the bed.

c. Place a client's locked wheelchair on the client's strong side next to the bed.

A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three times daily two months ago. Which finding provides the best indication that the medication regimen is effective? a. The nurse note that no pills remain in the prescription bottle. b. The client serum Depakote level is 125 mcg/ml c. The family reports a great reduction in client's maniac behavior d. The client denies any occurrence of suicidal ideation.

c. The family reports a great reduction in client's maniac behavior

A client who is experiencing musculoskeletal pain receives a prescription for ketorolac 15mg IM q6 hours. The medication is depended in a 39mg/ml pre-filled syringe. Which action should the nurse implement when giving the medication? a. Administer the entire pre-filled syringe deep in the dorsogluteal site. b. Use a separate syringe to remove 15mg from the pre-filled syringe and give in the back of the arm. c. Waste 0.5 ml from the pre-filled syringe and inject the medication in the ventrogluteal site. d. Call the healthcare provider to request a prescription change to match the dispensed 30mg dose.

c. Waste 0.5 ml from the pre-filled syringe and inject the medication in the ventrogluteal site.

When teaching a group of school-age children how to reduce the risk of Lyme disease which instruction should the camp nurse include a. Wash hands frequently b. Avoid drinking lake water c. Wear long sleeves and pants d. Do not share personal products

c. Wear long sleeves and pants

The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation? a. Tell the UAP to offer more choices during the personal care to prevent anxiety b. Meet with the UAP later to role model more assertive communication techniques c. Assume care of the client to ensure that effective communication is maintained. d. Affirm that the UAP is using and effective strategy to reduce the client's anxiety.

d. Affirm that the UAP is using and effective strategy to reduce the client's anxiety.

The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignments is best for the nurse to give this nurse? a. Transfer a client to another unit b. Monitor the central telemetry c. Perform the admission d. Assist cardiac nurses with their assignments

d. Assist cardiac nurses with their assignments

The nurse identifies an electrolyte imbalance, an elevated pulse rate, and elevated BP for a client with chronic kidney disease. Which is the most important action for the nurse to take? a. Monitor daily sodium intake. b. Record usual eating patterns. c. Measure ankle circumference. d. Auscultate for irregular heart rate.

d. Auscultate for irregular heart rate.

The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan? a. Limit intake fatty foods for one month after surgery. b. Notify the healthcare provider if edema occurs. c. Increase activity and exercise gradually, as tolerated. d. Avoid crowds for first two months after surgery.

d. Avoid crowds for first two months after surgery.

The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? a. Express feelings of sadness and loneliness b. Neglects personal hygiene and has no appetite c. Lacks interest in the activity of the family and friends d. Begin to show signs of improvement in affect

d. Begin to show signs of improvement in affect

After a routine physical examination, the healthcare admits a woman with a history of Systemic Lupus Erythematous (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse? a. Dark, rust-colored urine b. Urine output 300 ml/hr c. Joint and muscle aches d. Blood pressure 170/98

d. Blood pressure 170/98

A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual nutritional status? a. A 24-hour diet history b. History of a recent weight loss c. Status of current petite d. Condition of hair, nails, and skin

d. Condition of hair, nails, and skin

The nurse is preparing an intravenous (IV) fluid infusion using an IV pump. Within 30 seconds of turning on the machine, the pump's alarm beeps "occlusion". What action should the nurse implement first? a. Flush the vein with 3 ml of sterile normal saline. b. Assess the IV catheter insertion site for infiltration. c. Verify the threading of the tubing through the IV pump. d. Determine if the clamp on the IV tubing is released

d. Determine if the clamp on the IV tubing is released

The nurse assigned unlicensed assistive personnel (UAP) to apply antiembolism stockings to a client. The nurse and UAP enters the room, the nurse observes the stockings that were applying by the UAP. The UAP states that the client requested application of the stockings as seen on the picture, for increased comfort. What action should the nurse take? a. Ask the client if the stocking feel comfortable. b. Supervise the UAP in the removal of the stockings. c. Place a cover over the client's toes to keep them warm. d. Discussed effective use of the stockings with the client and UAP

d. Discussed effective use of the stockings with the client and UAP

A client with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend to this client? a. Cheddar cheese and crackers. b. Carrot and celery sticks. c. Beef bologna sausage slices. d. Dry roasted almonds.

d. Dry roasted almonds.

The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history? a. Genetically inherited disorders of family members b. Length and frequency of the client's tobacco use. c. Ingestion of selfish or fish oil capsules daily. d. Frequency of laxative use for chronic constipation

d. Frequency of laxative use for chronic constipation

Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse emphasize concerning the installation of the antipyrine/ benzocaine otic solution? a. Place the dropper on the upper outer ear canal and instill the medication slowly. b. Warm the medication in the microwave for 10 seconds before instilling. c. Keep the medication refrigerated between administrations. d. Have the child lie with the ear up for one to two minutes after installation.

d. Have the child lie with the ear up for one to two minutes after installation.

The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using medela haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple's elongated tip in the back of the oral cavity. What instructions should the nurse provide the mother about feedings? a. Squeeze the nipple base to introduce milk into the mouth b. Position the baby in the left lateral position after feeding c. Alternate milk with water during feeding d. Hold the newborn in an upright position

d. Hold the newborn in an upright position

The nurse walks into a client's room and notices bright red blood on the sheets and on the floor by the IV pole. Which action should the nurse take first? a. Clean up the spilled blood to reduce infection transmission. b. Notify the healthcare provider that the client appears to be bleeding. c. Apply direct pressure to the client's IV site. d. Identify the source and amount of bleeding.

d. Identify the source and amount of bleeding.

The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next? a. Remove the catheter and insert into urethral opening b. Observe for urine flow and then inflate the balloon. c. Insert the catheter further and observe for discomfort. d. Leave the catheter in place and obtain a sterile catheter.

d. Leave the catheter in place and obtain a sterile catheter.

While assisting a client who recently had a hip replacement into a bed pan, the nurse notices that there is a small amount of bloody drainage on the surgical dressing, the client's skin is warm to the touch, and there is a strong odor from the urine. Which action should the nurse take? a. Obtain a urine sample from the bed pan b. Remove dressing and assess surgical site c. Insert an indwelling urinary catheter d. Measure the client's oral temperature

d. Measure the client's oral temperature

The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention? a. Lip smacking and frequent eye blinking b. Shuffling gait and stooped posture c. Rocks back and forth in the chair d. Muscle spasms of the back and neck

d. Muscle spasms of the back and neck

A client with myasthenia Gravis (MG) is receiving immunosuppressive therapy. Review recent laboratory test results show that the client's serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important? a. Check the visual difficulties b. Note most recent hemoglobin level c. Assessed for he and Hand joint pain d. Observe rhythm on telemetry monitor

d. Observe rhythm on telemetry monitor

The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and threaty. What action should the nurse take? a. Document that an accurate oxygen saturation reading cannot be obtained b. Elevate to client's hands for five minutes prior to obtaining a reading from the finger c. Increase the oxygen based on the clients breathing patterns and lung sounds d. Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading

d. Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading

An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar...in addition to the client's glucose, which laboratory value is most important for the nurse to monitor? a. Urine ketones b. Urine albumin c. Serum protein d. Serum potassium

d. Serum potassium

A male client reports to the clinic nurse that he has been feeling well and is often "dizzy" his blood pressure is elevated. Based on this findings, this client is at a greatest risk for which pathophysiological condition? a. Pulmonary hypertension b. Left ventricular hypertrophy c. Renal failure d. Stroke

d. Stroke

A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5 ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump. With intervention should the nurse implement? a. Irrigate the indwelling urinary catheter. b. Prepare the client for external pacing. c. Obtain capillary blood glucose measurement. d. Titrate the dopamine infusion to raise the BP.

d. Titrate the dopamine infusion to raise the BP.

A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complain of difficulty breathing. The nurse determine the client is tachypneic with absent breath sounds in the client's right lungs fields. Which additional finding indicates that the client has developed a tension pneumothorax? a. Continuous bubbling in the water seal chamber b. Decrease bright red blood drainage c. Tachypnea and difficulty breathing d. Tracheal deviation toward the left lung.

d. Tracheal deviation toward the left lung.

The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan? a. Reposition the infant every 2 hours. b. Perform diaper changes under the light. c. Feed the infant every 4 hours. d. Cover with a receiving blanket.

a. Reposition the infant every 2 hours.

Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider? a. Sudden dysphagia b. Blurred visual field c. Gradual weakness d. Profuse diarrhea

a. Sudden dysphagia

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival? a. Hypoglycemia b. Fluid balance c. Heat loss d. Bleeding tendencies

c. Heat loss

When assessing a 6-month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant? a. Crying b. Straining on stool c. Vomiting d. Sitting upright.

d. Sitting upright.

The leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas, what action should the nurse take? a. Remove the heating pads and place a soft blanket over the client's leg and feet. b. Advise the UAP to observe the client's skin while the heating pads are in place. c. Elevate the client's feet on a pillow and monitor the client's pedal pulses frequently. d. Instruct the UAP to reposition the heating pads to the sides of the legs and feet.

a. Remove the heating pads and place a soft blanket over the client's leg and feet.

A 6 -years-old who has asthma is demonstrating a prolonged expiratory phase and wheezing, and has 35% personal best peak expiratory flow rate (PEFR). Based on these finding, which action should the nurse implement first? a. Administer a prescribed bronchodilator. b. Report finding to the healthcare provider. c. Encourage the child to cough and deep breath d. Determine what trigger precipitated this attack.

a. Administer a prescribed bronchodilator.

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? a. Allopurinol (Zyloprim) b. Aspirin, low dose c. Furosemide (lasix) d. Enalapril (vasote)

a. Allopurinol (Zyloprim)

An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran one year ago, his spouse states that the client no longer runs, bur sits and watches television most of the day. Which is most important for the nurse to include in this client's plan of care for today? a. Assist client in identifying goals for the day. b. Encourage client to participate for one hour in a team sport. c. Schedule client for a group that focuses on self-esteem. d. Help client to develop a list of daily affirmations.

a. Assist client in identifying goals for the day.

A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs q2 hours. Which finding should the nurse report immediately to the healthcare provider? a. Confusion and tremors b. Yellowing and itching of skin. c. Abdominal pain and vomiting d. Anorexia and abdominal distention

a. Confusion and tremors

A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? a. Instructions about how much fluid the child should drink daily b. information about non-pharmaceutical pain reliever measures c. Referral for social services for the child and family d. Signs of addiction to opioid and medications

a. Instructions about how much fluid the child should drink daily

An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest that the client is experiencing increased intracranial pressure (ICP)? a. Lethargy b. Decorticate posturing c. Fixed dilated pupil d. Clear drainage from the ear.

a. Lethargy

A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain? a. Level of consciousness b. Percussion of abdomen c. Serum electrolytes d. Blood glucose.

a. Level of consciousness

A young adult female college student visits the health clinic in early winter to obtain birth control pills. The clinic nurse asks if the student has received an influenza vaccination. The student stated she did not receive vaccination because she has asthma. How should the nurse respond? a. Offer to provide the influenza vaccination to the student while she is at the clinic b. Encourage the student to obtain a vaccination prior to the next influenza season. c. Confirm that a history of asthma can increase risks associated with the vaccine. d. Advise the student that the nasal spray vaccine reduces side effects for people with asthma.

a. Offer to provide the influenza vaccination to the student while she is at the clinic

A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? a. Prepare the skin for procedure. b. Identify client's pulse points c. Witness consent for procedure d. Check telemetry monitoring

a. Prepare the skin for procedure.

While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute, respirations 18 breaths/minute, and blood pressure 90/60. Which intervention should the nurse implement first? a. Raise the client's legs and feet b. Administer 250 ml saline bolus c. Decrease blood flow from dialyzer d. Stop the hemodialysis procedure.

a. Raise the client's legs and feet

A client who had a below the knee amputation is experiencing severe phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful? a. Research indicates that mirror therapy is effective in reducing phantom limb pain b. You can try mirror therapy, but do not expect to complete elimination of the pain c. Transcutaneous electrical nerve stimulators (TENS) have been found to be more effective d. Where did you learn about the use of mirror therapy in treating in treating phantom limb pain?

a. Research indicates that mirror therapy is effective in reducing phantom limb pain

The nurse is assisting a new mother with infant feeding. Which information should the nurse provide that is most likely to result in a decrease milk supply for the mother who is breastfeeding? a. Supplemental feedings with formula b. Maternal diet high in protein c. Maternal intake of increased oral fluid d. Breastfeeding every 2 or 3 hours.

a. Supplemental feedings with formula

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanations should the nurse provide? a. This hernia is a normal variation that resolves without treatment. b. Restrictive clothing will be adequate to help the hernia go away. c. An abdominal binder can be worn daily to reduce the protrusion. d. The quarter should be secured with an elastic bandage wrap.

a. This hernia is a normal variation that resolves without treatment.

Following and gunshot wound, an adult client a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is not type AB negative blood currently available. Which intervention should the nurse implement? a. Transfuse Type A negative blood until type AB negative is available. b. Recheck the client's hemoglobin, blood type and Rh factor. c. Administer normal saline solution until type AB negative is available d. Obtain additional consent for administration of type A negative blood

a. Transfuse Type A negative blood until type AB negative is available.

When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? a. Withhold food and fluid intake. b. Initiate IV fluid replacement. c. Administer antiemetic as needed. d. Evaluate intake and output ratio.

a. Withhold food and fluid intake.

A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take? a. Ask a chemotherapy-certified nurse to administer the Zofran b. Administer the Zofran after flushing the saline lock with saline c. Hold the scheduled dose of Zofran until the client awakens d. Awaken the client to assess the need for administration of the Zofran.

b. Administer the Zofran after flushing the saline lock with saline

A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take? a. Provide a bedtime snack to be eaten before taking the medication. b. Administer the medication as prescribed with a glass of water c. Contact the prescriber about changing the time of administration. d. Check the client's blood pressure prior to administering the med.

b. Administer the medication as prescribed with a glass of water

A new member joins the nursing team spreads books on the table, puts items on two chairs, and sits on a third chair. The members of the group are forced to move closer and remove their possessions from the table what action should the nurse leader take? a. Move to welcome and accommodate a new person b. Ask the new person to move belonging to accommodate others c. Tell the new person to move belongings because of limited space d. Bring in additional chairs so that all staff members can be seated

b. Ask the new person to move belonging to accommodate others

An adult who is 5 feet 5 inches (165.1 cm) tall and weighs 90 lb. (40.8 Kg) is admitted with a diagnosis of chronic anorexia. The client receives a regular diet for 2 days, and the client's medical records indicates that 100% of the diet provided has been consumed. However the client's weight on the third day morning after admission is 89 lb. (40.4 Kg). What action should the nurse implement? a. Examine the client's room for hidden food. b. Assign staff to monitor what the client eats. c. Ask the client if the food provided is being eaten or discarded. d. Provide the client with a high calorie diet.

b. Assign staff to monitor what the client eats.

The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching? a. Do not read without direct lighting for 6 weeks. b. Avoid straining at stool, bending, or lifting heavy objects. c. Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic ointment. d. Limit exposure to sunlight during the first 2 weeks when the cornea is healing.

b. Avoid straining at stool, bending, or lifting heavy objects.

The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension? a. Tomato soup, grilled cheese sandwich, pickles, skim milk, and lemon meringue pie. b. Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie. c. Grilled steak, baked potato with sour cream, green beans, coffee and raisin cream pie. d. Beed stir fry, fried rice, egg drop soup, diet coke and pumpkin pie. Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie

b. Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie.

A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client's serum laboratory values requires intervention by the nurse? a. Total calcium 9 mg/dl (2.25 mmol/L SI) b. Creatinine 4 mg/dl (354 micromol/L SI) c. Phosphate 4 mg/dl (1.293 mmol/L SI) d. Fasting glucose 95 mg/dl (5.3 mmol/L SI)

b. Creatinine 4 mg/dl (354 micromol/L SI)

In assessing a client at 34-weeks' gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28%, a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up? a. Elevated thyroid hormone level. b. Hematocrit of 28%. c. Heart rate of 92 beats per minute. d. Systolic murmur.

b. Hematocrit of 28%.

An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week "I'm trying to start a new business and "I'm too busy to eat". The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority? a. Hygiene-self-care deficit b. Imbalance nutrition c. Disturbed sleep pattern d. Self-neglect

b. Imbalance nutrition

An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding, which action is required? a. Report the results to the healthcare provider. b. Increase ventilator rate. c. Administer a dose of sodium carbonate. d. Decrease the flow rate of oxygen.

b. Increase ventilator rate.

What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? a. Assess the client's ability to use a numeric pain scale b. Initiate the dosage lockout mechanism on the PCA pump c. Instruct the client to use the medication before the pain become severe d. Assess the abdomen for bowel sounds

b. Initiate the dosage lockout mechanism on the PCA pump

When providing diet teaching for a client with cholecystitis, which types of food choices the nurse recommend to the client? a. High protein b. Low fat c. Low sodium d. High carbohydrate.

b. Low fat

A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse? a. Jaundice skin tone b. Muffled heart sounds c. Pitting peripheral edema d. Bilateral scleral edema

b. Muffled heart sounds

An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement? a. Observe neck for jugular vein distention b. Notify healthcare provider to prepare for pericardiocentesis c. Asses for paradoxical blood pressure d. Monitor oxygen saturation (Sp02) via continuous pulse oximetry

b. Notify healthcare provider to prepare for pericardiocentesis

After the risk and benefits of having a cardiac catheterization are reviewed by the healthcare provider, an older adult with unstable angina is scheduled for the procedure. When the nurse presents the consent form for signature, the client asks how the wires will keep a heart heating during the procedure. What action should the nurse take? a. Explain the procedure again in detail and clarify any misconceptions. b. Notify the healthcare provider of the client's lack of understanding. c. Call the client's next of kin and have them provide verbal consent. d. Postpone the procedure until the client understands the risk and benefits.

b. Notify the healthcare provider of the client's lack of understanding.

53- A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client's plan of care? a. Determine client's level current blood alcohol level. b. Observe for changes in level of consciousness. c. Involve the client's family in healthcare decisions. d. Provide grief counseling for client and his family.

b. Observe for changes in level of consciousness.

An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement? a. Obtain a urine specimen for culture and sensitivity b. Palpate the client's suprapubic area for distention c. Advise the client to maintain a voiding diary for one week d. Instruct in effective technique to cleanse the glans penis

b. Palpate the client's suprapubic area for distention

An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse's response should be based on which information about assistive devices? a. They can contribute to increased dependency b. They decrease the risk for joint trauma c. They promote muscle strength d. They diminish range of motion ability.

b. They decrease the risk for joint trauma

Which client should the nurse assess frequently because of the risk for overflow incontinence? A client a. Who is bedfast, with increased serum BUN and creatinine levels b. Who is confused and frequently forgets to go to the bathroom c. With hematuria and decreasing hemoglobin and hematocrit levels d. Who has a history of frequent urinary tract infections.

b. Who is confused and frequently forgets to go to the bathroom

A female nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the nurse has asked administration to allow her to return to work. When the nurse administrator approaches the charge nurse with the impaired nurse request, which action is best for the charge nurse to take? a. Since treatment is completed, assign the nurse to the route RN responsibilities b. Ask to meet with impaired nurse's therapist before allowing her back on the unit. c. Allow the impaired nurse to return to work and monitor medication administration d. Meet with staff to assess their feelings about the impaired nurse's return to the unit.

c. Allow the impaired nurse to return to work and monitor medication administration

When should intimate partner violence (IPV) screening occur? a. As soon as the clinician suspects a problem b. Only when a client presents with an unexplained injury c. As a routine part of each healthcare encounter d. Once the clinician confirms a history of abuse

c. As a routine part of each healthcare encounter

A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5pound weight gain. Which intervention the nurse implement? a. Arrange transport for admission to the hospital. b. Insert saline lock for IV diuretic therapy. c. Assess compliance with routine prescriptions. d. Instruct the client to monitor daily caloric intake.

c. Assess compliance with routine prescriptions.

A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement? a. discontinue the magnesium sulfate immediately b. Decrease the client's iv rate to 50 ml per hour c. Continue with the plan of care for this client d. Change the client's to NPO status

c. Continue with the plan of care for this client

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? a. Conversion of the client's PPD test from negative to positive. b. Length of time of the exposure to tuberculosis. c. Current diagnosis of hepatitis B. d. History of intravenous drug abuse.

c. Current diagnosis of hepatitis B.

A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and which action should the nurse implement next? a. Report the incident to the local child protective services. b. Find a home health agency that specializes in brain injuries. c. Determine the mother's basic skill level in providing care. d. Consult the ethics committee to determine how to proceed.

c. Determine the mother's basic skill level in providing care.

In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management? a. Prepare the client to independently treat their disease process b. Reduce healthcare costs related to diabetic complications c. Enable clients to become active participating in controlling the disease process d. Increase client's knowledge of the diabetic disease process and treatment options.

c. Enable clients to become active participating in controlling the disease process

A male client's laboratory results include a platelet count of 105,000/ mm3 Based on this finding the nurse should include which action in the client's plan of care? a. Cluster care to conserve energy b. Initiate contact isolation c. Encourage him to use an electric razor d. Asses him for adventitious lung sounds

c. Encourage him to use an electric razor

A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement? a. Evaluate postural blood pressure measurements b. Obtain specimen for uranalysis c. Encourage popsicles and fluids of choice d. Assess bowel sounds in all quadrants

c. Encourage popsicles and fluids of choice

During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN) a. Encourage the woman at risk for cancer to obtain colonoscopy. b. Present a class of breast-self examination c. Prepare a woman for a bone density screening d. Explain the follow-up need it for a client with prehypertension.

c. Prepare a woman for a bone density screening

A client with emphysema is being discharged from the hospital. The nurse enters the client's room to complete discharge teaching. The client reports feeling a little short of breath and is anxious about going home. What is the best course of action? a. Postpone discharge instructions at this time and offer to contact the client by phone in a few days b. Invite the client to return to the unit for discharge teaching in a few days, when there is less anxiety c. Provide only necessary information in short, simple explanations with written instructions to take home d. Give detailed instructions speaking slowly and clearly while looking directly at the client when speaking

c. Provide only necessary information in short, simple explanations with written instructions to take home

A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administered to prevent the development of Wernicke's syndrome? a. Lorazepam (Ativan) b. Famotidine (Pepcid) c. Thiamine (Vitamin B1) d. Atenolol (Tenormin)

c. Thiamine (Vitamin B1)

The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is: a. Two days postoperative bladder surgery with continuous bladder irrigation infusing. b. One day postoperative laparoscopic cholecystectomy requesting pain medication. c. Three days postoperative colon resection receiving transfusion of packed RBCs. d. Preoperative, in buck's traction, and scheduled for hip arthroplasty within the next 12 hours.

c. Three days postoperative colon resection receiving transfusion of packed RBCs.

A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly? a. "I have a hard time inhaling and holding my breath after I squeeze the inhaler, but I do my best" b. "I never use the inhaler unless I am feeling really short of breath" c. I always shake the inhaler several times before I start" d. "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, bit it goes away"

d. "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, bit it goes away"

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first? a. A young man with schizophrenia who wants to stop taking his medication b. The mother of a child who was involved in a physical fight at school today. c. A client diagnosed with depression who is experiencing sexual dysfunction. d. A family member of a client with dementia who has been missing for five hours

d. A family member of a client with dementia who has been missing for five hours

While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side-table. The client is currently receiving at 2 litters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement? a. Assist the client to lie back in bed b. Call for an Ambu resuscitating bag c. Increase oxygen to 6 litters/minute d. Administer a nebulizer Treatment

d. Administer a nebulizer Treatment

A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that he is "starving" because he has had no "real food" since before the surgery. Prior to advancing his diet, which intervention should the nurse implement? a. Discontinue intravenous therapy b. Obtain a prescription for a diet change c. Assess for abdominal distention and tenderness. d. Auscultate bowel sounds in all four quadrants

d. Auscultate bowel sounds in all four quadrants

A client with angina pectoris is being discharge from the hospital. What instruction should the nurse plan to include in this discharge teaching? a. Engage in physical exercise immediately after eating to help decrease cholesterol levels. b. Walk briskly in cold weather to increase cardiac output c. Keep nitroglycerin in a light-colored plastic bottle and readily available. d. Avoid all isometric exercises but walk regularly. Avoid all isometric exercises, but walk regularly

d. Avoid all isometric exercises but walk regularly.

When administering an immunization in an adult client, the nurse palpates and administer the injection one inch below the acromion process into the center of the muscle mass. The nurse should document that the vaccine was administered at what site? a. Rectus femenis b. Ventrogluteous c. Vastus lateralis d. Deltoid

d. Deltoid

A nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. What information is most important for the nurse to include? a. Swaddle the infant in a blanket for sleeping b. Place the infant in a prone position whenever possible c. Prop that the infant's crib matter is firm d. Ensure that the infant's crib mattress is firm.

d. Ensure that the infant's crib mattress is firm.

A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? a. Patch one eye. b. Reorient often. c. Range of motion. d. Evaluate swallow

d. Evaluate swallow

A clinical trial is recommended for a client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond? a. Ask the client with her children present if she fully understands the decision she has made. b. Discuss success of clinical trials and ask the client to consider participating for one month. c. Explain to the family that they must accept their mother's decision. d. Explore the client's decision to refuse treatment and offer support

d. Explore the client's decision to refuse treatment and offer support

At 40 week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take? a. Encourage the client to turn on her left side. b. Place a pillow under the client's head and knees. c. Explain to the client that her position is not safe. d. Place a wedge under the client's right hip.

d. Place a wedge under the client's right hip.

When entering a client's room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next? a. Prepare to administer atropine 0.4 mg IVP b. Gather emergency tracheostomy equipment c. Prepare to administer lidocaine at 100 mg IVP d. Place cardiac monitor leads on the client's chest.

d. Place cardiac monitor leads on the client's chest.

When assessing the surgical dressing of a client who had abdominal surgery the previous day, the nurse observes that a small amount of drainage is present on the dressing and the wound's Hemovac suction device is empty with the plug open. How should the nurse respond? a. Replace the dressing and remove the drainage device b. Reposition the drainage device and keep the plug open c. Notify the healthcare provider that the drain is not working d. Recompress the wound suction device and secure to plug

d. Recompress the wound suction device and secure to plug

An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? a. Limit the intake of high calorie foods. b. Eat meals at the same time daily. c. Maintain a low protein diet. d. Restrict daily fluid intake. Restrict daily fluid intake.

d. Restrict daily fluid intake.

Following an outbreak of measles involving 5 students in an elementary school, which action is most important for the school nurse to take? a. Review the immunization records of all children in the elementary school b. Report the measles outbreak to all community health organizations c. Schedule a mobile public health vehicle to offer measles inoculations to unvaccinated children. d. Restrict unvaccinated children from attending school until measles outbreak is resolved.

d. Restrict unvaccinated children from attending school until measles outbreak is resolved.

Which information is more important for the nurse to obtain when determining a client's risk for (OSAS)? a- Body mass index b- Level of consciousness c- Self-description of pain d- Breath sounds

a- Body mass index

A client with end-stage liver failure is declared brain dead. The family wants to discontinue feeding and donate any viable organs. Which action should the nurse take? a- Contact the regional organ procurement agency b- Convene a multidisciplinary care conference c- Explain that client may not be an organ donor candidate d- Discontinue feeding and fluids per the family's request.

a- Contact the regional organ procurement agency

One day following a total knee replacement, a male client tells the nurse that he is unable to transfer because it is too painful. What action should the nurse implement? a- Encourage use of analgesics before position change b- Assess anxiety about transferring to commode chair c- Assist client during transfer on the first two days d- Review use of assistive devices for weight bearing.

a- Encourage use of analgesics before position change

The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client's cardiopulmonary stability during the blood transfusion? a- Increase the oxygen flow via nasal cannula if dyspnea is present. b- Place in a Trendelenburg position to increase cerebral blood flow c- Monitor capillary glucose measurements hourly during transfusion. d- Encourage increased intake of oral fluid to improve skin turgor.

a- Increase the oxygen flow via nasal cannula if dyspnea is present.

A client whose wrists are sutured from a recent suicide attempt is been transferred from a medical unit. Which nursing diagnosis is of the highest priority? a- Risk for self-directed violence related to impulsive actions b- Risk for violence related to feeling of guilt and failure c- Low self-esteem related to feeling of loss of control d- Ineffective coping related to violent actions towards self.

a- Risk for self-directed violence related to impulsive actions

A school-aged child was recently diagnosed with celiac disease. Which instruction should the nurse give the classroom teacher? a- The child should avoid eating homemade cookies and cupcakes during parties. b- No products containing any form of peanuts should be allowed in the classroom c- Report a runny nose or head cold to the nurse immediately for further revaluation. d- Avoiding direct contact sports and games will reduce the child's risk of bruising.

a- The child should avoid eating homemade cookies and cupcakes during parties.

A client with a serum sodium level of 125 meq/mL should benefit most from the administration of which intravenous solution? a. 0.9% sodium chloride solution (normal saline) b. 0.45% sodium chloride solution (half normal saline) c. 10% Dextrose in 0.45% sodium chloride d. 5% dextrose in 0.2% sodium chloride

a. 0.9% sodium chloride solution (normal saline)

The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan? a. Monitor for an elevated temperature b. Measure the abdominal girth daily c. Report the onset of sclera jaundice d. Keep a record of daily urinary output

a. Monitor for an elevated temperature

A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes Mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client's plan of care? a. Monitor the client's cardiac activity via telemetry. b. Maintain venous access with an infusion of normal saline. c. Assess glucose via fingerstick q4 to 6 hours. d. Evaluate hourly urine output for return of normal renal function

a. Monitor the client's cardiac activity via telemetry.

The nurse notes an increase in serosanguinous drainage from the abdominal surgical wound from an obese client. What action should the nurse implement? a. Observe the wound for dehiscence b. Teach the client to splint the incision while coughing c. Assess the skin surrounding the wound for maceration d. Obtain a culture of the wound drainage.

a. Observe the wound for dehiscence

An adult client with schizophrenia begin treatment three days ago with the Antipsychotic risperidone. The client also received prescription for trazodone as needed for sleep and clonazepam as needed for severe anxiety. When the client reports difficulty with swallowing, what action should the nurse take? a. Obtain a prescription for an anticholinergic medication b. Determine how many hours declined slept last night c. Administer the PRN prescription for severe anxiety d. Watch the thyroid cartilage move while the client swallows

a. Obtain a prescription for an anticholinergic medication

A client on a long-term mental health unit repeatedly takes own pulse regardless of the circumstance. What action should the nurse implement? a. Overlook the client's behavior. b. Distract client to interfere with the ritual. c. Ask why the client checks the pulse. d. Hold client's hand to stop the behavior.

a. Overlook the client's behavior.

An older male who is admitted for end stage of chronic obstructive pulmonary disease (COPD) tells the nurse .... The client provides the nurse with a living will and DNR. What action should the nurse implement? a- Inform the family of the client whishes b- Obtain a prescription for DNR c- Clergy consultation d- Ask the patient why he made this choice

b- Obtain a prescription for DNR

The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse? a- Opening the package b- Picking up the second glove c- Picking up the first glove d- Positioning of the table

b- Picking up the second glove

A client who is recently diagnosed with type 2 diabetes mellitus (DM) ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM? a- Immune antibodies attack pancreatic beta cells resulting in no insulin b- The body cells develop resistance to the action of insulin. c- Body organs produce less insulin and more glucagon d- The liver produces excess glucose in response to excess glycotrophic hormones

b- The body cells develop resistance to the action of insulin.

The nurse is conducting health assessments. Which assessment finding increases a 56 year-old woman's risk for developing osteoporosis? a. Body mass index of (BMI) of 31 b. 20 pack-year history of cigarette smoking c. Birth control pill usage until age 45 d. Diabetes mellitus in family history

b. 20 pack-year history of cigarette smoking

The psychiatric nurse is talking to a newly admitted client when a male client diagnosed with antisocial behavior intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" how should the nurse respond to this client? a. Put his behavior on extinction and continue talking with the newly admitted. b. Inform him that the nurse is busy admitting a new client and will talk to him later. c. Encourage him to go to the nurse's station and talk with another nurse. d. Introduce him to the newly admitted client and ask him to him to join in the conversation.

b. Inform him that the nurse is busy admitting a new client and will talk to him later.

The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN? a. A 64-year-old client who had a total hip replacement the previous day. b. A 75-year-old client with renal calculi who requires urine straining. c. An adolescent with multiple contusions due to a fall that occurred 2 days ago. d. A 30-year-old depressed client who admits to suicide ideation.

d. A 30-year-old depressed client who admits to suicide ideation.

A nurse working on an endocrine unit should see which client first? a. An adolescent male with diabetes who is arguing about his insulin dose. b. An older client with Addison's disease whose current blood sugar level is 62mg/dl (3.44 mmol/l). c. An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350 ml in the last hour. d. A client taking corticosteroids who has become disoriented in the last two hours.

d. A client taking corticosteroids who has become disoriented in the last two hours.