Hesi Nurse 1010

The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? A)Blood urea nitrogen 50 mg/dl B)Hemoglobin of 10.3 mg/dl C)venous blood pH 7.30 D)Serum potassium 6 mEq/L

Serum potassium 6 mEq/L

The high pressure alarm goes off on the ventilator. what is the first action the nurse should perform. A)disconnect the client from the ventilator and use a manual resuscitation bag B)perform a quick assessment of the client's condition C)call the respiratory therapist for help D)press the alarm re-set

perform a quick assessment of the client's condition

The nurse has been teaching a client with insulin dependent diabetes mellitus. Which statement by the client indicates a need for further teaching A)"I use a sliding scale to adjust regular insulin to my sugar level." B)Since my eyesight is so bad, I ask the nurse to fill several syringes." C)"I keep my regular insulin bottle in the refrigerator." D)`"I always make sure to shake the NPH bottle hard to mix it well."

"I always make sure to shake the NPH bottle hard to mix it well."

The nurse is preparing a client who will undergo a myelogram . Which of the following statements by the client indicates a contradiction for this test A)"I can't lie in 1 position for more than thirty min" B)"I am allergic to shrimp C)" I suffer from claustrophobia D)"I developed a severe headache after a spinal tap"

"I developed a severe headache after a spinal tap"

The nurse assesses a 72 yr old client who was admitted for right sided congestive heart failure. which of the following would the nurse anticipate finding? A)Decreased urinary output B)jugular vein distention C)Pleural effusion D)Bibasilar

)jugular vein distention

When interviewing the parents of a child with asthma, it is most important to gather what information about the child's environment? A) Household pets B) new furniture C) Lead based paint D) plants such as cactus

Household pets

Therapeutic nurse client interaction occurs when the nurse A) Assists the client to clarify the meaning of what the client has said B) interprets the client's covert communication C) praises the client for appropriate feelings and behavior D) Advises the client on ways to resolve problems

Assists the client to clarify the meaning of what the client has said

After a myocardial infarction, client is placed on a sodium restricted diet . When the nurse is teaching the client about the diet, which meal plan would be most appropriate A) 3 oz broiled fish, I bake potato, cup canned beets, 1 orange and milk B) 3 oz canned salmon, fresh broccoli, 1 biscuits, tea , and 1 apple C) A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice D) 3 oz turkey, 1 fresh sweet potato, 1/2 cup fresh beans, milk and 1 orange

3 oz turkey, 1 fresh sweet potato, 1/2 cup fresh beans, milk and 1 orange

Which of the following times is a depressed client at highest risk for attempting suicide? A) immediately after admission during one to one observation B) 7 to 14 days after initiation of anti depressant medication and psychotherapy C) following an angry outburst with family D) When the client is removed from the security room

7 to 14 days after initiation of antidepressant medication and psychotherapy

Following change of shift report on an orthopedic unit, which client should the nurse see first? A) 16 year old who had an open reduction of a fractured wrist 10 hours ago B) 20 year old in skeletal traction for 2 weeks since a motor cycle accident C) 72 year old recovering from surgery after a hip replacement 2 hours ago D) 75 year old who is in skin traction prior to planned hip pinning surgery

72 year old recovering from surgery after a hip replacement 2 hours ago

A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? A)A 79 yr old malnourished client on bed rest B) an obese client who uses a wheel chair C)a client who had 3 incontinent diarrhea stools D)an 80 yr old ambulatory diabetic client

A 79 yr old malnourished client on bed rest

The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. which of the following findings is cause for the most concern A) Diminished B) Loss of appetite C) A cold, lower leg D) Tachypnea

A cold, pale lower leg

Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? A) An increase in appetite B) A decrease in fluid retention C) A decrease in lethargy D) A reduction in jaundice

A decrease in lethargy

A nurse from the maternity unit is floated to critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A) a dopamine drip IV with signs monitored B) A myocardial infarction that is free from pain and dysrhythmias C) A tracheotomy of 24 hours in some respiratory distress D) a pacemaker inserted this morning with intermittent capture

A myocardial infarction that is free from pain and dysrhythmias

A client enters the emergency department unconscious via ambulance from the client's work place. What document should be given priority to guide the direction of care for this client? A)The statement of client rights and the client self determination act B) Orders written by the health care provider C) A notarized original of advance directives brought in by the partner D) The clinical pathway protocol of the agency and the emergency department

A notarized original of advance directives brought in by the partner

which of these clients who are in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump A) a young with a history of downs syndrome B)a teenager who reads at a 4th grade level c) an elderly client with numerous arthritic nodules on the hands D)A preschooler with intermittent episodes of alertness

A preschooler with intermittent episodes of alertness

Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category? A) An infant with intermittent bulging anterior fontanel between crying episodes B) A toddler with severe deep abrasions over 98% of the body C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture D) A school age child with singed eyebrows and hair on the arms

A toddler with severe deep abrasions over 98% of the body

The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these? A) lymphedema B) Hearing loss and ataxia C) headaches and vomiting D) Abdominal mass and weakness

Abdominal mass and weakness

A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate A) non stress test B) Abdominal ultrasound C) pelvic exam D) xray of abdomen

Abdominal ultrasound

A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values A) Bleeding time B)platelet count C)activated count D)clotting time

Activated PTT

A client who was medicated with meperidine hydrochloride ( Demerol) 100 mg and hydroxyzine hydrochloride ( Vistaril intramuscular) 50 mg IM for pain related to a fractured lower right leg 1 hour ago reports that the pain is getting worse. The nurse should recognize that the client may be developing which complications A) acute compartment syndrome B) thromboemolitic complications. C) fatty embolism D) osteomyelitis

Acute compartment syndrome

The nurse is teaching an elderly client how to use MDI's ( multidose inhalers) The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication? A) Nebulized treatment for home care B) Adding a spacer device to the MDI canister C) Asking a family member to assist the client with the MDI D) Request a visiting nurse to follow the client at home

Adding a spacer device to the MDI canister

A nurse administers the influenza vaccine to a client in a clinic.Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to A) Maintain the airway B) Administer epinephrine 1::1000 as ordered C) Monitor for hypotension with shock D) Administer diphenhydramine as ordered

Administer epinephrine 1::1000 as ordered

A client with a documented pulmonary embolism has the following arterial blood gases: P02 - 70 mm hg, PCO2-32mm hg, pH-7.45, SaO2-87%, HCO3-22. Based on this data, what is the first nursing action? A) Review other lab data B) Notify the health care provider C) Administer Oxygen D) Calm the client

Administer oxygen

Which of these nursing diagnosis of 4 elderly clients would place 1 client at the greatest risk for falls A) sensory perceptual alternative related to decreased vision B) alteration in mobility related to fatigue C) impaired gas exchange related to retained secretions D) altered patterns of urinary elimination related to nocturia

Altered patterns of urinary elimination related to nocturia

A nurse who is reassigned to the emergency department needs to understand that gastric lavage is priority in which situation? A) an infant who has been identified to have botulism B) a toddler who ate a number of ibuprofen tablets C) a preschooler who swallowed powdered plant food D) a school aged child who took a handful of vitamins

An infant who has been identified to have botulism

A client has an order for 1000 ml of D5W over 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action? A) Ask the client if there are any breathing problems B) Have the client void as much as possible problems C) Check the vital signs D) Auscultate the lungs

Auscultate the lungs

The nurse is preparing to administer a tube feeding to a post operative client. To accurately assess for a gastrostomy tube placement, the priority is to A) Auscultate the abdomen while instilling 10 cc of air into the tube B) place the end of the tube in water to check for air bubbles C) retract the tube several inches to check for resistance D) Measure the length of tubing from nose to epigastrium

Auscultate the abdomen while instilling 10 cc of air into the tube

the nurse is planning care for a 14 year old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan? A) antibiotic therapy for 10 days B) Teach client isometric exercises for legs C) Assess movement and sensation of extremities D) Assist to stand up at beside within the first 24 hours

Assess movement and sensation of extremities

An 85 year old client complains of generalized muscle aches and pains. The first action by the nurse should be A) assess the severity and location of the pain B) obtain an order for an analgesic C) reassure him that this is not unusual for him age D) encourage him to increase his activity

Assess the severity and location of the pain

a client continuously calls out to the nursing staff when anyone passes the client's door and asks them to do something in the room. the best response by the charge nurse would be to A) Keep the client's room door cracked to minimize the distractions B) Assign 1 of the nursing staff to visit the client regularly C) Reassure the client that 1 staff person will check frequently if the client needs D) Arrange for each staff member to go into the client's room to check on needs every hour on the hour

Assign 1 of the nursing staff to visit the client regularly

The nurse is assessing a client with a stage 2 skin ulcer. Which of the following treatments is most effective to promote healing? A) covering the wound with a dry dressing B) using hydrogen peroxide soaks C) leaving the area open to dry D) Applying a hydrocolloid or foam dressing

Applying a hydrocolloid or foam dressing

A 65-year-old catholic Hispanic Latino client with prostate cancer adamantly refuses pain medication because the client believes that suffering is part of life. The client states everyone's life is in God's hands. The next action for the nurse to take is to A) report the situation to the health care provider B) Discuss the situation with the client's family C) Ask the client if talking with a priest would be desired D) document the situation on the notes

Ask the client if talking with a priest would be desired

An explosion has occurred at a high school for children with special needs and severe developmental delays. One of the students accompanied with a parent is seen at a community health center a day later. After the initial assessment the nurse concludes that the student appears to be in a crisis state. Which of these interventions based on crisis intervention principles is appropriate to do next? A) help the student to identify a specific problem B) Ask the parent to identify the major problem C) Ask the student to think of different alternatives D) Examine with the parent a variety of options

Ask the parent to identify the major problem

The nurse is planning care for a 3 month old infant immediately postoperative following placement of a venticuloperitoneal shunt for hydrocephalus. The nurse needs to A) Assess for abdominal distention B) Maintain infant in an upright position C) Begin formula feeding when infant is alert D) Pump the shunt to assess for proper function

Assess for abdominal distention

The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important? A)Avoid chocolate and cheese B)take frequent naps C)take the medication with milk D)avoid walking without assistance

Avoid chocolate and cheese

A 2 year old child is brought to the health care provider 's office with a chief complaint of the mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement? A) Place the child on clear liquids and gelatin for 24 hours B) Continue with the regular diet and include oral rehydration fluids C) Give bananas, apples, rice, and toast as tolerated D) Place NPO for 24 hours, then rehydrate with milk and water

B) Continue with the regular diet and include oral rehydration fluids

An 8 year old client is admitted to the hospital for surgery. The child's parent reports the following allergies. Of these allergies which one should all health care personnel be aware of ? A) Shellfish B) Molds C) Balloons D) perfumed soup

Balloons

The nurse is reinforcing teaching to a 24 year old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client? A) complete the entire course of the medication for an effective cure B) Begin treatment with acyclovir at the onset of symptoms of recurrence C) Stop treatment if she thinks she may be pregnant to prevent birth defects D) continue to take prophylactic doses for at least 5 years after diagnosis

Begin treatment with acyclovir at the onset of symptoms of recurrence

The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken? A) Leave the order for the oncoming staff to follow up B) Contact the charge nurse for an interpretation C) Ask the pharmacy for assistance in the interpretation D) Call the provider for clarification

Call the provider for clarification

the unlicensed assistive personnel (UAP) reports a sudden increase in temperature 101 degrees for a post-surgical client. The nurse checks on the client's condition and observes a cup of steaming coffee at the bedside, What instructions are appropriate to give to the UAP? A) encourage oral fluids for temperature elevation B) Check temperature 15 minutes after hot liquids are taken C) Ask the client to drink only cold water and juices D) chart this temperature elevation on the flow sheet

Check temperature 15 minutes after hot liquids are taken

An 86 yr old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next A) add a thickening agent to the fluids B)Check the clients gag reflex C)feed the client only solid foods D)Increase the rate of intravenous fluids

Check the clients gag reflex

Which order can be associated with the prevention of atelectasis and pneumonia in a client with amyotriphic lateral sclerosis? A) Active and passive range of motion exercises twice a day B) every 4 hours incentive spirometer C) chest physiotherapy twice a day D) repositioning every 2 hours around the clock

Chest physiotherapy twice a day

The nurse planning care for a 12-year-old child with sickle cell disease in a vasoocclusive crisis of the elbow should include which one of the following as a priority? A) limit fluids B) Client controlled analgesia C) Cold compresses to elbow D) Passive range of motion exercise

Client controlled analgesia

As the nurse takes a history of a 3 year old with neuroblastoma, what comments by the parents require follow up and are consistent with the diagnosis ? A) The child has been listless and has lost weight B) The urine is dark yellow and small in amounts C) Clothes are becoming tighter across her abdomen D) We notice muscle weakness and some unsteadiness

Clothes are becoming tighter across her abdomen

The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action? A) clamp the chest tube B) Call the surgeon immediately C) Continue to monitor the client to see if the bubbling increases D) Instruct the client to try to avoid coughing

Continue to monitor the client to see if the bubbling increases

the mother of a 2 month old baby calls the nurse 2 days after the first DTap, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to baby's record and expect which immunization to be most associated to the findings in the infants? A) DTaP B) Hepatitis B C) Polio D) H. Influenza

DTaP

The nurse is assigned to care for a client whomhad a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time? A) Daily needs and concerns B) the overview cardiac rehabilitation C) Medication and diet guideline D) Activity and rest guidelines

Daily needs and concerns

The nurse is caring for a 7 year old with acute glomerulonephrhritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate? A) decreased carbohydrates and fats B) decreased sodium and potassium C) increased potassium and protein D) increased sodium and fluids

Decreased sodium and potassium

When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote A)Relaxation and sleep B) Deep breathing and coughing C)Incisional healing D)Range of motion exercises

Deep breathing and coughing

A client frequently admitted to the locked psychiatrist unit repeatedly compliments and invites one of the nurse's to go out on date. The nurse's response should be to A) Ask to not be assigned to this client or to work on another unit B) tell the client that such behavior is inappropriate C)Inform the client that hospital policy prohibits staff to date clients D) Discuss the boundaries of the therapeutic relationship with the client

Discuss the boundaries of the therapeutic relationship with the client

A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance with the client. The next action by the nurse should be to A) Discuss the feeling of reluctance with an objective peer or supervisor B) Limit contacts with the client to avoid reinforcement of the manipulative behavior C) Confront the client about the negative effects of behaviors on other clients and staff D) Develop a behavior modification plan that will promote more functional behavior

Discuss the feeling of reluctance with an objective peer or supervisor

During the change of shift report the assigned nurse notes a catholic client is scheduled to be admitted for the delivery of a ninth child. Which comment stated angrily to a colleague by this nurse indicates an attitude of prejudice? A) I wonder who is paying for this trip to the hospital B) I think she needs to go to the city hospital C) all these people indulge in large families D) Doesn't she know there's such a thing as birth control

Doesn't she know there's such a thing as birth control

The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized? A) call the poison Control Center once the situation is identified B) Empty the child's mouth in any case of possible poisoning C) have the child move minimally if a toxic substance was inhaled D) do not induce vomiting if the poison is a hydrocarbon

Empty the child's mouth in any case of possible poisoning

The nurse is assessing 55 year old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post operative period? A) Estrogen replacement therapy B) 10% less than ideal body weight C)Hypersensitivity to heparin D history of hepatitis

Estrogen replacement therapy

The nurse has performed the initial assessment of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the health care provider immediately? A) Prolonged inspiration with each breath B) Expiratory wheezes that are suddenly absent in 1 lobe C) Expectoration of large amounts of purulent mucous D) Appearance of the use of abdominal muscles for breathing

Expiratory wheezes that are suddenly absent in 1 lobe

A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor A)FHT 168 beat/min B) Temperature 100 degrees Fahrenheit C)cervical dilation of 4 D) BP 138/88

FHT 168 beat/min

The client with infective endocarditis must be assessed frequently by the home health nurse. which finding suggests that antibiotic therapy is not effective and must be reported to the nurse immediately A) Nausea and vomiting B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius) C) Diffuse macular rash D) Muscle tenderness

Fever of 103 degrees Fahrenheit (39.5° c)

A middle aged woman talks to the nurse in the health care providers office about uterine fibroids also called leiomyomas or myomas. what statement by the woman indicates more education is needed A)I am one out of every 4 women that get fibroids, and of women my age - between the 30s or 40s, fibroids occurs more frequently. B)My fibroids are noncancerous tumors that grow slowly. C)My associated problems i have had are pelvic pressure and pain urinary incontinence frequent urination and urine retention and constipation. D)Fibroids that cause no problems still needs to be taken out

Fibroids that cause no problems still needs to be taken out

A client has been admitted with fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority? A) Maintaining proper body alignment B) Frequent neurovascular assessments of the affected leg C) Inspection of pin sites for evidence of drainage or inflammation D) applying an over-bed trapeze to assist the client with movement

Frequent neurovascular assessments of the affected leg

Upon completing the admission documents, the nurse learns that the 87 year old client does not have an advance directive. What action should the nurse take? A) Record the information on the chart B) Give information about advance directives C) Assume that this client wishes a full code D) Refer this issue to the unit secretary

Give information about advance directives

When teaching suicide prevention to the parents of a 15 year old who recently attempted suicide, the nurse describes the following behavioral cue A) Angry outbursts at significant others B) fear of being left alone C) Giving away valued personal items D) experiencing the loss of a boyfriend

Giving away valued personal items

A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client 's condition? A) Comatose, breathing unlabeled B) Glascow Coma Scale 8, respiration regular C) Appears to be sleeping, vital signs stable D) Glascow Coma Scale 13, no ventilator required

Glascow Coma Scale 8, respiration regular

The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which dinner menu would be best? A) fish sticks, french fries, banana, cookies, milk B) Ground beef patty, lima beans, wheat roll, raisins, milk C) Chicken nuggests, macaroni, peas, cantaloupe, milk D) peanut butter and jelly sandwich, apple slices, milk

Ground beef patty, lima beans, wheat roll, raisins, milk

Which serum blood findings with diabetic ketoacidosis alerts the nurse that immediate action is required? A) pH below 73 B) potassium of 5.0 C) HCT of 60 D) Pa 02 of 79%

HCT of 60

Which statements by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year old surgical client to ambulate for the first time? A) Have the client sit on the side of the bed for at least 2 minutes before helping him stand B) if the client is dizzy on stand ask him to take some deep breaths C) assist the client to the bathroom at least twice on this shift D) after you assist him to the chair, let me know how he feels

Have the client sit on the side of the bed for at least 2 minutes before helping him stand

A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the clients blood pressure is increasing. Which action should the nurse take first. A) Check the protein level in urine B) Have the client turn to the left side C)take the temperature D) Monitor the urine output

Have the client turn to the left side

A depressed client in an assisted living facility tells the nurse that life isn't worth living anymore What is best response to this statement ? A) come on it is not that bad B) have you thought about hurting yourself C) Did you tell that to your family D) think of the many positive things in life

Have you thought about hurting yourself

After working with a very demanding client, unlicensed assistive personnel (UAP) tells the nurse, I have had it with that client. I just can't do anything that pleases him. I'm not going in there again. The nurse should respond by saying A) He has a lot of problems/ You need to have patience with him B) I will talk with him and try to figure out what to do C) He is scared and taking it out on you. Let's talk to figure out what to do D) Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day

He is scared and taking it out on you. Let's talk to figure out what to do

The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate is 10. Which action should the nurse take? A)Hold the tube feeding and notify the provider B)administer the tube feeding as scheduled C)Irrigate the tube with diet cola soda D)apply intermittent suction to the feeding tube

Hold the tube feeding and notify the provider

Which statement made by a client indicates to the nurse that he may have a thought disorder? A) I'm so angry about this. Wait until my partner hears about this B) I'm a little confused. What time is it? C) I can't find my 'mesmer' shoes. Have you seen them D) I'm fine. It's my daughter who has the problem

I can't find my 'mesmer' shoes. Have you seen them

A client tells the nurse, I have something very important to tell you if you promise not to tell, the best response by the nurse is A) I must document and report any information B) I can't make such a promise C) that depends on what you tell me D) I must report everything to the treatment team

I can't make such a promise

A client with diagnosed with hepatitis C discussed his health history with the admitting nurse. The nurse should recognize which statement by the client as the most important? A) I got back from Central America a few weeks ago B) I had the best raw oysters last week C) I have many different sex parents D) I had a blood transfusion 15 years ago

I had a blood transfusion

A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago During the nurses initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication A) " I have a sharp pain in my chest when i take a breath B) " I have been coughing up foul tasting, brown, thick sputum C) " I have been sweating all day D)" I feel hot off and on

I have been coughing up foul tasting, brown, thick sputum

A 42 year old male client refuses to take propranolol hydrochloride (inderal) as prescribed. Which client statements from the assessment data is likely to explain his noncompliance? A) I have problems with diarrhea B) I have difficulty falling asleep C) I have diminished sexual function D) I often feel jittery

I have diminished sexual function

Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode? A) I think all children should have their heads shaved B) I have been restricted in thought and harmed C) I have powers to get you whatever you wish, no matter the cost D) I think all of my contacts last week have attempted to poison me

I have powers to get you whatever you wish, no matter the cost

The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month old infant and her 4 her old child? A) " I strap the infant car seat on the front seat to face backwards." B) " I place my infant in the middle of the living room floor on a blanket to play with my 4 year old while I make supper in the kitchen." C) " My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year old naps on the sofa" D) I have the 4 year old hold and help feed the four month old a bottle in the kitchen while I make supper

I have the 4 year old hold and help feed the four month old a bottle in the kitchen while I make supper

Which statements by the client would indicate to the nurse an understanding of the issues with end stage renal disease? A) I have to go at intervals for epoetin (Procrit) injections at the health department B) I know I have a high risk of clot formation since my blood is thick from too many red cells C) I expect to have periods of little water with voiding and then sometimes to have a lot of of water D) My bones will be stronger with this disease since I will have higher calcium than normal

I have to go at intervals for epoetin (Procrit) injections at the health department

Which statement by the client during the initial assessment in the emergency department is most indicative for suspected domestic violence? A) I am determined to leave my house in a week B) No one else in the family has been treated like this C) I have only been married for 2 months D) I have tried leaving, but have always gone back

I have tried leaving, but have always gone back

A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements? A) I am sorry, Referral information can only be provided by the client's health care providers B) I can never give any information out by telephone. How do I know who you are? C) Since this is a referral, i can give you this information D) I need to get the client's written consent before I release any information to you

I need to get the client's written consent before I release any information to you

A client expresses anger when the call light is not answered within 5 minutes. The client demanded a blanket. The best response for the nurse to make is A) I apologize for the delay. I was involved in an emergency B) Let's talk, why are you upset about this C) I am surprised that you are upset. The request could have waited a few more minutes D) I see this is frustrating for you. I have a few minutes so let's talk

I see this is frustrating for you. I have a few minutes so let's talk

A school aged child has had a long leg ( hip to ankle ) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate? A) i will keep the cast for the next day uncovered to prevent burning of the skin B) I can apply an ice pack over the area to relieve itching inside the cast C) the cast should be propped on at least 2 pillows when my child is lying down D) I think I remember that standing cannot be done until after 72 hours

I think I remember that standing cannot be done until after 72 hours

Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider A)I started my period and now my urine has turned bright red. B)I am an diabetic and today i have been going to the bathroom every hour C)I was started on medicine yesterday for a urine infection. Now my lower belly hurts when i go to the bathroom D)I went to the bathroom and my urine looked very red and it didnt hurt when i went

I went to the bathroom and my urine looked very red and it didnt hurt when i went

A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be the most indicative of the etiology of this crisis A)"I knew this would happen. I've been eating too much red meat lately" B)"I really enjoyed my fishing trip yesterday. I caught 2 fish." C)" I have really been working hard practicing with the debate team at school" D)" I went to the heal care provider last week for a cold and i have gotten worse."

I went to the heal care provider last week for a cold and i have gotten worse."

A 15 year old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching? A) I will only have to wear this 6 months B) I should inspect my skin daily C) the brace will be worn day and night D) I can take it off when I shower

I will only have to wear this for 6 months

The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit . However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self scheduling knowing that this method will A) improve the quality of care B) Decrease staff turnover C) The brace will be worn day and night D) I can take it off when I shower

I will only have to wear this for 6 months

A client, recovering from alcoholism asks the nurse, What can I do when I start recognizing relapse triggers within myself? How might the nurse best respond? A) when you have the impulse to stop in a bar , contact B) Go to an AA meeting when you feel the urge to drink C) it is important to exercise daily and get involved in activities that will cause you not to think about drug use D) identify your relapse triggers as part of getting better

Identify your relapse triggers as part of getting better

The nurse admits a 7 year old to the emergency room after a leg injury. The xrays show a femur fracture near the epiphysis. The parent ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements? A) The injury is expected to heal quickly because of thin periosteum B) In some instances the result is retarded bone growth C) Bone growth is stimulated in the affected leg D) This type of injury shows more rapid union than that of younger children

In some instances the result is retarded bone growth

A nurse is providing care to a 17 year old client in the post operative care unit (PACU) after an emergency appendectomy. Which finding isan early indication that the client is experiencing poor oxygenation? A) abnormal breath sounds B) cyanosis of lips C) increasing pulse rate D) pulse oxidizer reading of 82%

Increase pulse rate

The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority? A) risk for dehydration B) Ineffective airway clearance C) Altered nutrition D) risk for injury

Ineffective airway clearance

The nurse is caring for a client undergoing the placement of central venous catheter line. Which of the following would require the nurses immediate attention A)Pallor B)Increased temperature C)Dyspnea D)Involuntary muscle spasms

Involuntary muscle spasms

The nurse is assessing an 8-month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit? A) lethargy B) Irritability C) Negative Moro D) depressed fontanel

Irritability

Which these findings would the nurse more closely associate with anemia in a 10 month old infant A)Hemoglobin level of 12 g/dl B)Pale mucosa of the eyelids and lips C)hypoactivity D)A heart rate between 140 to 160

Pale mucosa of the eyelids and lips

A client has been diagnosed with zollinger-ellison syndrome. Which information is most important for the nurse to reinforce with the client A) It is a condition in which one or more tumors called gastrinomas for in the pancreas or in the upper part of the small intestine B) It is critical to report promptly to your health care provider any findings of peptic ulcers C) Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors D) With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine

It is critical to report promptly to your health care provider any findings of peptic ulcers

The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect. A) It is also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes B) In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint abdominal pain C) Kawasaki disease occurs most often in boys, children younger than age 5 and children of hispanic descent D) Initially findings area a sudden high fever, usually above 104 degrees Fahrenheit, Which lasts 1 to2weeks

Kawasaki disease occurs most often in boys, children younger than age 5 and children of hispanic descent

The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to A) Maintain previous calorie intake B) Keep a candy bar available at all times C) Reduce carbohydrates intake to 25% of total calories D) Keep a regular schedule of meals and snacks

Keep a regular schedule of meals and snacks

A nurse is providing care to 63 year old client with pneumonia. Which intervention promotes the client's comfort? A) increase oral fluid intake B) encourage visits from family and friends C) keep conversations short D) monitor vital signs frequently

Keep conversations short

The mother of a 2 year old hospitalized child asks the nurse's advice the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse? A) I think you or your partner needs to stay with the child while in the hospital B) Oh, that behavior will stop in a few days C) Keep in mind that for the age this is normal response to being in the hospital D) You might want to sneak out of the room once the child falls asleep

Keep in mind that for the age this is normal response to being in hospital

A nurse is providing a parent class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning? A) Use ready to feed commercial infant formula B) Boil the tap water run for 10 minutes prior to preparing the formula C) Let tap water run for 2 minutes before adding to concentrate D) Buy bottled water labeled " lead free" to mix the formula

Let tap water run for 2 minutes before adding to concentrate

A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care? A)Esophagitis B)Leukopenia C)Fatigue D)Skin irritation

Leukopenia

The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion? A) Storing the packed red cells in the medicine refrigerator while starting IV B) Slow the rate of infusion if the client develops fever or chillis C) Limit the infusion time of each of the unit to a maximum of 4 hours D) Assess vital signs every 15 minutes throughout the entire infusion

Limit the infusion time of each of the unit to a maximum of 4 hours

The nurse is caring for a 17 month old with acetaminophen poisoning. Which of the following lab reports should the nurse review first? A) Protime (PT) and partial thromboplastin time (PTT) B) Red blood cell and white blood cell counts C) Blood urea nitrogen and creatinine clearance D) Liver Enzymes (AST and ALT)

Liver Enzymes (AST and ALT)

A client who is thought to be homeless is brought to the emergency department by police. The client is unkempt, has difficulty concentrating is unable to sit still and speaks in a loud tone of voice A) allow the client in an activity that requires focus and individual effort B) engage the client in an activity that requires focus and individual effort C) isolate the client in a secure room until control is regained by the client D) Locate a room that has minimal stimulation outside of it for admission process

Locate a room that has minimal stimulation outside of it for admission process

the nurse's primary intervention for a client who is experiencing a panic attack is to A) Develop a trusting relationship B) Assist the client to describe his experience in detail C) Maintain safety for the client D) teach the client to control his or her own behavior

Maintain safety for the client

What findings signifies that children have attained the stage of concrete operations (Piaget)? A) Explores the environment with the use of sight and movement B) Thinks in mental images or word pictures C) Makes the moral judgement that stealing is wrong D) Reasons that homework is time consuming yet necessary

Makes the moral judgement that stealing is wrong

What findings signifies that children have attained the stage of concrete operations (Piaget)? A.) Explores the environment with use of sight and movement B) Thinks in mental images or word pictures C) Makes the moral judgement that stealing is wrong D) Reasons that homework is time consuming yet necessary

Makes the moral judgement the stealing is wrong

Which information is a priority for the RN to reinforce to an older client after intravenous pylegraphy A) Eat a light diet for the rest of the day B) Rest for the next 24 hours since the preparation and the test is tiring. C) During waking hours drink at least 1 8-ounce glass of liquid every hour for the next two days D) Measure the urine output for the next day and immediately notify the health care provider if it should decrease

Measure the urine output for the next day immediately notify the health care provider if it should decrease.

a PN is assigned to care for qa newborn with a neural tube defect. Which dressing if applied by the PN would need no further intervention by the charge nurse? A) Telfa dressing with antibiotic ointment B) Moist sterile non adherent dressing C) Dry sterile dressing that is occlusive D) Sterile occlusive pressure dressing

Moist sterile non adherent dressing

a client has returned to the unit following a renal biopsy. Which of the following nursing interventions is appropriate? A) Ambulate the client 4 hours after procedure B) Maintain client on NPO status for 24 hours C) Monitor vital signs D) change dressing every 8 hours

Monitor vital signs

The nurse is teaching a client about precautions with coumadin therapy. The client should be instructed to avoid which over-the-counter medication? A)Non-steroidal anti-inflammatory drugs B)cough medicines with guaifenesin C)Histamine blockers D)laxatives containing magnesium salts

Non-steroidal anti-inflammatory drugs

When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to A) Change whichever item is incorrect information B) Use the bracelet and admission form until a replacement is supplied C) Notify the admission office and wait to apply the bracelet D) Make a corrected identification bracelet for the client

Notify the admission office and wait to apply the bracelet

A 4 yr old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first A)Notify the health care provider B)readjust the traction C)administer the ordered prn medication D)reassess the foot in fifteen min

Notify the health care provider

Although non steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects? A) Urinary incontinence B) Constipation C) Nystagmus D) Occult bleeding

Occult bleeding

The nurse is providing instructions for a child with asthma. Which of the following should the client monitor on a daily basis? A) respiratory B) Peak air flow volumes C) Pulse oximetry D) skin color

Peak air flow volumes

A 3 year old child is brought to the clinic by his grandmother to be seen for" scratching his bottom and wetting the bed at night" Based on these complaints, the nurse would initially assess for which problems? A) allergies B) Scabies C) Regression D) Pinworms

Pinworms

A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? A) institute seizure precautions B) monitor neurologic status every hour C) Place in respiratory/ secretion precautions D) cefotaxime IV 50 mg/kg/day divided q6h

Place in respiratory/secretion precautions

A 10-year-old child has a history of epilepsy with tonic clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure would be to A) move any chairs or desks at least 3 feet away from the child B) Note the sequence of movements with the time lapse of the event C) provide privacy as much as possible to mini,ize fighting the other children D) Place the hands or a folded blanket under the head of the child

Place the hands or a folded blanket under the head of the child

when caring for a client receiving warfarin sodium (coumadin), which lab test would the nurse monitor to determine therapeutic response to the drug? A) bleeding time B) Coagulation time C) Prothrombin time D) Partial thromboplastin time

Prothrombin time

Which intervention best demonstrates the nurses sensitivity to a 16 year old's appropriate need for autonomy A) alertness for feelings regarding body image B) allows young siblings to visit C) provides opportunity to discuss concerns without presence of parents D) explores his feeling of resentment to identify causes

Provides opportunity to discuss concerns without presence of parents

The nurse is performing a physical assessment on a client who just had an endotracheal tune inserted. Which finding would call for immediate action by the nurse A)Breathe sounds can be heard bilaterally B)Mist is visible in the T-piece C)Pulse oximetry of 88 D)Client is unable to speak

Pulse oximetry of 88

Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose? A) drowsiness, lethargy, and inactivity B) Dry mouth, nasal congestion, and blurred vision C) Rash, blood dyscrasias, severe depression D) Hyperglycemia, weight gain, and edema

Rash, blood dyscrasias, severe depression

Which of these findings would indicate that the nurse client relationship has passed from the orientation phase to the working phase? The client A) has revitalized a relationship with her family to help cope with the death of a daughter B) had recognized regressive behavior as a defense mechanism C) expresses a desire to be cared for and pampered D) Recognizes feeling with appropriate expression of feeling

Recognizes feeling with appropriate expression of feelings

The nurse is observing a client with an obsessive complusive disorder in an inpatient setting. Which behavior is consistent with this diagnosis? A) Repeatedly checking that the door is locked B) Verbalized suspicions about thefts C) preference for consistent care givers D) repetitive involuntary movement

Repeatedly checking that the door is locked

the nurse manager hears a health care provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the health care provider's complaints. The nurse manager 's next action should be to A) walk up to the health care provider and quietly state Stop this unacceptable behavior B) allow the staff nurse to handle this situation without interference C) Notify the of the other administrative persons of a breech of professional conduct D) Request an immediate private meeting with the health care provider and staff nurse

Request an immediate private meeting with the health care provider and staff nurse

The nurse is performing an assessment on a client in congestive heart failure . auscultation of the the heart is most likely to reveal A) S3 ventricular gallop B) Apical click C) Systolic murmur D) Split S2

S3 ventricular gallop

Which statement best describes time management strategies applied to role of a nurse manager? A) schedule staff efficiently to cover the needs on the managed unit B) Assume a fair share of direct client care as a model C) Set daily goals with a prioritization of the work D) Delegate tasks to reduce work load associated with direct care and meetings

Set daily goals with a prioritization of work

The nurse is preparing a handout on infant feeding to be distributed to families visiting included the clinic. Which notation should be included in teaching materials A) Solid foods are introduced 1 at a time beginning with cereal B) Finely ground meat should be started early to provide iron C) Egg white is added early to increase protein intake D) Solid foods should be mixed with formula in a bottle

Solid foods are introduced 1 at a time beginning with cereal

Handshaking is the preferred form of touch or contact used with clients in a psychiatric setting. The rationale behind this limited touch practice is that A) Some clients misconstrue hugs as an invitation to sexual advances B) Handshaking keeps the gesture on a professional level C) Refusal to touch a client denotes lack of concern D) inappropriate touch often results in charges of assault and battery

Some clients misconstrue hugs as an invitation to sexual advances

What assessment data should the nurse obtain next? A) status of eyes and the tongue (skin turgor) B) Description of play activity C) history of fluid intake D) dietary patterns

Status of eyes and the tongue (skin turgor)

The nurse has admitted a 4 year old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? A) Our child had chickenpox 6 months ago B) Strep throat went through all the children at the day care last month C.) Both ears were infected over 3 months age D) Last week both feet had a fungal skin infection

Step throat went through all the children at the day care last month

The nurse instructs the client taking dexamethasone ( Decadron) to take it with food or milk. What is the physiological basis for this instruction? A) retards pepsin production B) stimulates hydrochloric acid production C) Slows stomach emptying time D) Decreases production of hydrochloric acid

Stimulates hydrochloric acid production

During the initial home visit a nurse is discussing the care of a newly diagnosed client with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time? A) leave a book about relaxation techniques B) write out a daily exercise routine for them to assist the client to do C) List actions to improve the client's daily nutritional intake D) Suggest communication strategies

Suggest communication strategies

A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes the assessment finding as what? A) Dystonia B) Akathesia C) Brady dyskenia D) Tardive dyskenia

Tardive dyskenia

A client is recovering from a thyroidectomy. While monitoring the client 's initial post operative condition, which of the following should the nurse report immediately? A) tetany and paresthesia B) Mild stridor and hoarseness C) irritability and insomnia D) headache and nausea

Tetany and parasthesia

A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this . What is the appropriate comment for the nurse to make A.) Why don't we now have the client turn back to the left side B) That was done correctly.Did you have problems with the insertions C) Let's check to see if the suppository is in far enough D) Did you feel any stool in the intestinal tract

That was done correctly. Did you have problems with the insertions

an 18 month old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When the nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The nurse understands that which of the following is true in regard to giving immunization to this child? A) Live vaccines are withheld in children with renal chronic illness B) The MMR vaccines should be given now, prior to the transplant C) An inactivated form of the vaccine can be given at any time D) the risk of vaccine side effects precludes giving the vaccine

The MMR vaccines should be given now, prior to the transplant

A nurse is preparing the teaching plan for a group of parents about risk to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate ? A) The parents' name and telephone number B) The currency of the immunization and allergy history of the child C) The estimated time of the accidental poisoning and a confirmation that the parents will bring the containers of the ingested substance D) The affected child's age and weight

The affected child's age and weight

A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse? A) report of 10 pounds weight loss in the last month B) a comment by the client " I just can't sit still" C) The appearance of eyeballs that appear to "pop" out of the client's eye sockets D) A report of the sudden onset of irritability in the past 2 weeks

The appearance of eyeballs that appear to "pop" out of the client's eye sockets

Which of these observations made by the nurse during an excretory urogram indicate a complication? A)The client complains of a salty taste in the mouth when the dye is injected B) The client entire body turns a bright red color C)The client states "i have a feeling of getting warm". D)The client gags and complains "I am getting sick."

The client entire body turns a bright red color

a client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states I don't think i need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects. The nurse should understand that A) a referral is needed to the psychiatrist who is to provide the client with answers B) The client has a right to know about the prescribed medications C) such education is an independent decision of the individual nurse whether or not to D) clients with schizophrenia are a higher risk of psychological complications when they know about their medication side effects

The client has a right to know about the prescribed medications

A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse. A) Until the health care provider has determined that your ejaculate doesnt contain sperm, continue to use another form of contraception B) This procedure doesnt impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate. C)after your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesnt involve hard physical labor, you can return to your job as soon as you feel up to it. The stiches generally dissolve in seven to ten days. D) The health care provider at this clinic recommends res, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort.

Until the health care provider has determined that your ejaculate doesnt contain sperm, continue to use another form of contraception

The nurse is performing a physical assessment on a toddler. Which of the following should be the first action? A) perform traumatic procedures B) Use minimal physical contact C) proceed from head to toe D) explain the exam in detail

Use minimal physical contact

A 20 year old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: A) visitors must wear a mask and gown B) there are no special requirements for visitors of clients on contact precautions C) visitors should wash their hands before and after touching the client D) visitors

Visitors should wash their hands before and after touching the client

As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspiring. What should the nurse do? A) Ask the student: " What did you forget to do? B) Stop. Tell me why aspiration is needed C) Loudly state: " You forgot to aspirate" D) Walk up and whisper in the student 's ear " Stop. Aspirate. Then inject."

Walk up and whisper in the student 's ear " Stop. Aspirate. Then inject."

During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches? A) Wash hands thoroughly before and after client contact B) wear gloves when in contact with body secretions C) double glove when in contact with feces or vomitus D) wear gloves when disposing of contaminated linens

Wash hands thoroughly before and after client contact

When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the nurse would suggest for the parents to give sips of which substance? A) Tea B) Walter C) Milk D) soda

Water

The nurse is caring for a client with uncontrollable hypertension. Which findings require priority nursing action? A) lower extremity pitty edema B) rales C) Jugular vein distension D) weakness in left arm

Weakness in left arm

A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is A) difference in the intake and output B) changes in the mucous membranes C) skin turgor D) weekly weight

Weekly weight

A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for nurse to ask about at this time? A) what are you taking for pain and does it provide total relief? B) What does the skin on the testicle look and feel like C) Do you have any questions about your care D) Did you know a consequence of epididymitis is infertility

What does the skin on the testicles look and feel like

The nurse is to administer a new medication to a client. Which actions are in the best interest of the client? verify the order for the medication. prior to giving the medication the nurse should say A) please state your name, upon entering the room the nurse should ask B) What is your name? What allergies do you have? then check the client's name band and allergy band as the client enters the room room C) What is your name ? then check the client's name band verify the client allergies on the admission sheet and order D) verify the client's name on the name plate outside the room then as the nurse enters the room ask the client, What is your first, middle, and last name?

What is your name? What allergies do you have? then check the client's name band and allergy band as the client enters room

The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied A)When it is 1/3 to 1/2 full B) Prior to meals C) After each fecal elimination D) at the same time each day

When it is 1/3 to 1/2 full

Which of the following manifestation observed by the school nurse confirms the presence of pediculosis capital in students? A) Scratching the head more than usual B) Flakes evident on a student's shoulders C) Oval pattern occipital hair loss D) Whitish oval specks sticking to the hair

Whitish oval specks sticking to the hair

The mother of a 3 month old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? A) Solid foods should be introduced at 3-4 months B) Whole milk is difficult for a young infant to digest C) Fluoridated tap water should be used to dilute milk D) Supplemental apple juice can be used between feedings

Whole milk is difficult for a young infant to digest

a client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts you think you're so perfect and pure and good. An appropriate response for the nurse is A) Is that why you've been starring at me B) you seem to be in a really bad mood C) perfect, I don't quite understand D) You are angry right now

You are angry right now

A client is scheduled for an IVP (intravenosa pyelogram Which of the following data from the client 's history indicates a potential hazard for this test? A) Reflex incontinence B) allergies to shellfish C) claustrophobia D) hypotension

allergic to shellfish

Which of these statements by the nurse reflects the best use of therapeutic interaction techniques? A) You look upset. Would you like to talk about it? B) I'd like to know more about your family. Tell me about them C) I understand that you lost your partner. I don't think I could go on if that happened to me. D) you look very sad. How long have you been this way?

You look upset. Would you like to talk about it?

The nurse admitting a 5 month old who vomited 9 times in the past should observe for signs of which overall imbalance? A) metabolic acidosis B) metabolic alkalosis C) Some increase in the serum hemoglobin D) a little decrease in the serum potassium

a little decrease in the serum potassium

a nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP), which newly admitted clients would be most appropriate to assign to the UAP? A) a 76-year-old client with severe depression B) a middle-aged client with an obsessive compulsive disorder C) A adolescent with dehydration and anorexia D) a young adult who is a heroin addict in withdrawal with hallucinations

a middle-aged client with an obsessive compulsive disorder

an elderly client who lives in a retirement community is admitted with these behaviors as reported by the daughter: absence in the daily senior group activity, missing the weekly card games, a change in calling the daughter from daily to once a week, and the client's tomato garden is overgrown with weeds. The nurse should assign this client to a room with which one of these clients A) an adolescent who was admitted the day before with acute situational expression B) a middle-aged person who has been on the unit for 72 hours with a dysthymia C) An elderly person who was admitted 3 hours ago with cycothymia D) A young adult who was admitted 24 hours ago for detoxification

a middle-aged person who has been on the unit for 72 hours with a dysthymia

several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition? A) autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV) B) a positive purified protein derivative with an abnormal chest xray C) a tentative diagnosis of viral pneumonia with productive brown sputum D) advanced carcinoma of the lung with hemoptasis

a positive purified protein derivative with an abnormal chest xray

which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency? A) an adolescent diagnosed with sepsis 7 days ago with vital signs maintained within low normal B) a middle aged woman documented to have had an uncomplicated myocardial infarction 4 days ago C) an elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis D) a young adult in the second day of treatment for an overdose of acetaminophen

a young adult in the second day of treatment for an overdose of acetaminophen

after a client has an enteral feeding tube inserted, the most accurate method for verification of placement is A)abdominal x ray B)auscultation C)flushing tube with saline D)aspiration for gastric contents

abdominal x ray

A client in a long term care facility complains of pain. The nurse collects data about the client 's pain. The first step in pain assessment is for the nurse to A) have the client identify coping methods B) get the description of the location and intensity of the pain C) accept the client's report of pain D) determine the client's status of pain

accept the client's report of pain

While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius) The appropriate nursing intervention is to A)call the health care provider immediately B)administer acetaminophen as ordered as this is normal at this time C)send blood, urine and sputum for culture D) increase the clients fluid intake

administer acetaminophen as ordered as this is normal at this time

a client with moderate persistent asthma is admitted for a minor surgical procedure. On the admission the peak flow meter is measured at 480 liters/ minute. Post-operatively the client is complaining of chest tightness. The peak flow dropped to 200 liters/ minute. What should the nurse do first? A) notify the healthcare provider B) administer the PRN dose of Albuterol C) Apply oxygen at 2 liters per nasal cannula D) repeat the peak flow reading in 30 minutes

administer the PRN dose of Albuterol

An antibiotic IM injection for a 2 yr old child is ordered. The total volume of the injection equals 2.0ml the correct action is to A)administer the medication in 2 separate injections B)give the medication in the dorsal gluteal site C)call to get a smaller volume ordered D)check with the pharmacy for a liquid form of the medication skip.

administer the medication in 2 separate injections

a client who has a belief based in Hinduism is nearing death. The nurse should plan for which action? A) after death a Hindu priest will pour water into the mouth of the client and tie a thread around the client's wrist B) The elderly may be with the client during the process of the client dying and no last rites are given C) The family must be with the client during the process of dying and be the only ones to wash the body after death D) the body is ritually cleansed, and burial is to be as soon as possible after the death occurs

after death a Hindu priest will pour water into the mouth of the client and tie a thread around the client's wrist

The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN, nursing student. Which assignment should be questioned by the nurse manager? A) an admission at the change of shifts with atrial fibrillation and heart failure -PN B) Client who had a major stroke 6 days ago-PN student C) a child with burns who has packed cells and albumin IV running- charge nurse D) an Elderly client who had a myocardial infarction a week ago- UAP

an admission at the change of shifts with atrial fibrillation and heart failure -PN

Which of these clients with associat ed lab reports is a priority for the nurse to report to the public health department within the next 24 hours? A) an infant with a positive culture of stool for Shigelia B) an elderly factory worker with a lab report that is positive for acid fast bacillus smear C) a young adult commercial pilot with a positive histopathological examination from an induced sputum for pneumocystis carinii D) a middle aged nurse with a history of varicella zoster virus and with crops of vesicles on an erythematous base that appear on the skin

an elderly factory worker with a lab report that is positive for acid fast bacillus smear

The charge nurse is planning assignments on a medical unit. Which client should be assigned to the unlicensed assistive personnel (UAP)? A client with A) difficult swallowing after a mild stroke B) an order of enemas until clear prior to colonoscopy C) an order for a post-op abdominal dressing change D) transfer orders to a long-term facility

an order of enemas until clear prior to colonoscopy

A parent asks the school nurse how to eliminate lice from their child. what is the most appropriate response by the nurse? A)cut the Childs hair short to remove the nits B)Apply warm soaks to the head twice daily C)wash the Childs linen and clothing in a bleach solution D)application of pediculicides

application of pediculicides

A client is receiving Total Parental Nutrition (TPN) via Hickman catheter. The catheter accidentally becomes dislodged from the site. Which action by the nurse should take priority? A) Check that the catheter tip is intact B) Apply a pressure dressing to the site C) monitor respiratory status D) Assess for mental status changes

apply a pressure dressing to the site

Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)? A) be with a client who self-administers insulin B) cleanse and dress a small decubitus ulcer C) monitor a client 's response to passive range of motion exercises D) apply and care for a client's rectal pouch

apply and care for a client's rectal pouch

To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must A) apply suction for no more than 10 seconds B) maintain sterile technique C) lubricate 3 to 4 inches of the catheter tip D) withdraw catheter in a circular motion

apply suction for no more than 10 seconds

A female client is admitted for breast biopsy. She says, tearfully to the nurse, If this turns out to be cancer and i have to have my breast removed, my partner will never come near me. The nurse's best response would be which of these statements? A) I hear you saying that you have a fear for the loss of love B) you sound concerned that your partner will reject you C) are you wondering about the effects on your sexuality D) Are you worried that the surgery will change you

are you worried that the surgery will change you

a mother calls the hospital hot line and is connected to the triage nurse, The mother proclaims: I found my child with odd stuff coming from the mouth and an unmarked bottle nearby. Which of these comments would be the for nurse to ask the mother to determine if the child has swallowed a corrosive substance? A) ask the child if the mouth is burning or throat pain is present B) Take the child; pulse at the wrist and see if the child is has trouble breathing lying flat C) what color is the child's lips and nails and has the child voided today D) has the child had vomiting or diarrhea or stomach cramps yet

ask the child if the mouth is burning or throat pain is present

While interviewing a client, the nurse notices that the client is shifting positions, wringing her hands and avoiding eye contact. It is important for the nurse to A) ask the client what she is feeling B) assess the client for auditory hallucinations C) recognize the behavior as a side effect of medication D)refocus the discussion on a less anxiety provoking topic

ask the client what she is feeling

A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be A)cover the areas with dry sterile dressings B)assess for dyspnea or stridor C)initiate intravenous therapy D)administer pain mediation

assess for dyspnea or stridor

The nurse is caring for a child immediately after surgery correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? A) Blanch nail beds for color and refill B)assess for post operative arrhythmias C)auscultate for pulmonary congestion D)monitor equality of peripheral pulses

assess for post operative arrhythmias

A client has had heart failure. Which intervention is most important for the nurse to implement prior to the initial administration of digoxin to the client? A) assess the apical pulse, counting., for full 60 seconds B) take a radial pulse, counting for a full 60 seconds C) Use the pulse reading from the electronic blood pressure device D) check for a pulse deficit

assess the apical pulse, counting., for full 60 seconds

a child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is A) Call for emergency transport to the hospital B) immobilize the limb and joints above and below the injury C) assess the child and the extent of the injury D) apply cold compresses to the injured area

assess the child and the extent of the injury

a 72 year old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse? A) investigating the client's insurance coverage for home IV antibiotic therapy B)Determining if there are adequate hand washing facilities in the home c) assessing the client's ability to participate in self care and/ or the reliability of a caregiver D) Selecting the appropriate venous access device

assessing the client's ability to participate in self care and/ or the reliability of a caregiver

The most effective nursing intervention to prevent atelectasis from developing in a post operative client is to A)Maintain adequate hydration B)assist client to turn, deep breathe, and cough C)Ambulate client within 12 hours D)splint incision

assist client to turn, deep breathe, and cough

A 60 yr old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago, He received 1000ml of IV fluid . Which action would be most likely to help him void A)Have him drink several glasses of water B)cred' the bladder from the bottom to the top C)assist him to stand by the side of the bed to void D)wait 2 hours and have him try to void again

assist him to stand by the side of the bed to void

A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? A)Ask client to cough sputum into container B)have the client take several deep breaths C)provide a appropriate specimen container D)assist with oral hygiene

assist with oral hygiene

the charge nurse on the night shift at an urgent care center history deal with admitting clients of a higher acuity than usual because of a large fire in the area. Which style of leadership and decision making would be best in this circumstance? A) assume a decision making role B) seek input from staff C) use a non directive approach D) shared decision making with others

assume a decision making role

The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of A) anonymity B) beneficence C) justice D) autonomy

autonomy

The nurse is teaching the client to select foods rich in potassium to help digitalis toxicity. Which choice indicates the client understands dietary needs? A) Three apricots B) medium banana C) naval orange D) baked potato

baked potato

which bed position is preferred for use with a client in an extended care facility on fall risk prevention protocol A)all 4 side rails up, wheels locked, bed closest to door B)lower side rails up, bed facing doorway C)knees bent, head slightly elevated, bed in lowest position D)bed in lowest position, wheels locked, place bed against wall

bed in lowest position, wheels locked, place bed against wall

The nurse is caring for a 4 year old admitted after receiving burns to more than 50% of his body. Which laboratory data should be reviewed by the nurse as a priority in the first 24 hours? A) blood urea nitrogen B) Hematocrit C) Blood glucose D) white blood count

blood urea nitrogen

A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe are A) brittle hair, lanugo, amenorrhea B) diarrhea, nausea, vomiting, dental erosion C) hyperthermia, tachycardia, increased metabolism rate D) Excessive anxiety about symptoms

brittle hair , lanugo, amenorrhea

A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A)can predispose to dysrhythmias B)may lead to oliguria C)may cause irritability and anxiety D)sometimes alters consciousness

can predispose to dysrhythmias

The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel ( UAP). which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process? A) assist a client post cerebral vascular accident to ambulate B) Feed a 2-year-old in balanced skeletal traction C) care for a client with discharge orders D) Collect a sputum specimen for acid fast bacillus

care for a client with discharge orders

Which activity can the RN ask an unlicensed assistive personnal UAP to perform? A.) take a history on a newly admitted client B) Adjust the rate of a gastric tube feeding C) check the blood pressure of a 2 hours post operative client D) check on a client receiving chemotherapy

check the blood pressure of a 2 hours post operative client

An 8 year old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice? A) Bologna sandwich, pudding, milk B) Frankfurter, baked potato, milk C) chicken strips, corn on the cob, milk Grilled cheese sandwich, apple ,milk

chicken strips, corn on the cob, milk

The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? A) the treatment requires reapplication in 8 to 10 days B) Bedding and clothing can be boiled or steamed C) children are not to share hats, scarves and combs D) Nit combs are necessary to comb out nits

children are not to share hats, scarves and combs

The nurse is reviewing with a client how to collect a clean catch urine specimen Which sequence is appropriate teaching? A) Void a little, clean the meatus, then collect specimen B) clean the meatus, begin voiding, then catch urine stream C) Clean the meatus, then urinate into container D) Void continuously and catch some of the urine

clean the meatus, begin voiding, then catch urine stream

a client is diagnosed with methicillin resistant staphylococcus aureus pneumonia What type of isolation is most appropriate for this client? A) reverse B) Airborne C) standard precautions D) contact

contact

A client with a diagnosis of Methicillin resistant staphylococcus aureus ( MRSA) died. Which type of precautions is the appropriate type to use when performing postmortem care? A) airborne precautions B) droplet precautions C) contact precautions D) compromised host precautions

contact precautions

A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. what is the most appropriate nursing action A)Clamp the chest tube B)call the surgeon immediately C)prepare for blood transfusion D)continue to monitor the rate of drainage

continue to monitor the rate of drainage

when administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula A)every four to six hours B)continuously C)in a bolus D)every hours

continuously

The nurse is assessing a 17 year old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? A) increased serum glucose B) decreased albumin C) decreased potassium D) increased potassium

decreased potassium

A client was admitted to the eating disorder unit with bulimia nervosa. The nurse assessing for a history of complications of this disorder expects A) respiratory distress, dyspnea B) bacterial gastrointestinal infections, over hydration C) metabolic acidosis, constricted colon D) dental erosion, parotid gland enlargement

dental erosion, parotid gland enlargement

When teaching a client about the side effects of fluoxetine (Prozac) which of the following will be included? A) tachycardiac blurred vision, hypotension anorexia B) Orthostatic hypotension, vertigo reactions to tyramine rich foods C) Diarrhea, dry mouth, weight loss, reduced libido D) photosensitivity, seizures edema, hyperglycemia

diarrhea, dry mouth, weight loss, reduced libido

a client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing B) Loose, productive cough C) No relief from inhalant D) fever and chills

diffuse expiratory wheezing

a client who is a former actress enters the day room wearing a sheer nightgown, high heels, numerous bracelets, bright red lipstick and highly rouged cheeks. Which nursing action is the best in response to the client's attire? A) gently remind her that she is longer on stage B) directly assist client to her room for appropriate apparel C) Quietly point out to her the dress of other clients on the unit D) tactfully explain appropriate clothing for the hospital

directly assist client to her room for appropriate apparel

A 2-day old child with spina bifida and meningomyocele is in the intensive care unit after the initial surgery. As the nurse accompanies the grandparents for a first visit, which response should the nurse anticipate of the grandparents? A) depression B) anger C) frustration D) disbelief

disbelief

The nurse is teaching a client newly diagnosed with asthma how to use the metered dose inhaler (MDI) The client asks when they will know the canister is empty. The best response is A) drop the canister in water to observe floating B) Estimate how many doses are usually in the canister C) Count the number of doses as the inhaler is used D) Shake the canister to detect any fluid movement

drop the canister in water to observe floating

a 14 month old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child? A) Hypothermia B) Edema C) Dyspnea D) epistaxis

epistaxis

the nurse is instructing a 65 yr old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to A)exercise doing weight bearing activities B) exercise to reduce weight C)avoid exercise activities that increase the risk of fracture D)exercise to strengthen muscles and thereby protect bones

exercise doing weight bearing activities

A client taking isoniazide (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these? A) double vision and visual halos B) extremity tingling and numbness C) Confusion and lightheadedness D) Sensitivity of sunlight

extremity tingling and numbness

a 6 year old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and small teeth with faulty enamel. the mother states: " My child seems to have problems in that the child is most likely showing the effects of which problems? A) congenital abnormalities B) Chronic toxoplasmosis C) fetal alcohol syndrome D) lead poisoning

fetal alcohol syndrome

A client says, it's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland. The nurse would document this behavior as A) perseveration B) circumstantiality C) neologisms D) flight of ideas

flight of ideas

In a client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate? A)Pulverize all medications to a powdery condition B)squeeze the tube before using it to break up stagnant liquids C)cleanse the skin around the tube daily with hydrogen peroxide D)flush adequately with water before and after using the tube skip

flush adequately with water before and after using the tube skip

the mother of a child with a neural tube defect asks the nurse what she can do to decrese the chances of having another baby with a neural tube defect. What is the best response by the nurse? A) folic acid should be taken before and after conception B) multivitamin supplements are recommended during pregnancy C) a well balnced diet promotes normal fetal development D) increase dietary iron improves the health of the mother and fetus

folic acid should be taken before and after conception

The nurse is teaching parents about diet for 4 month old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include A) formula or breast milk B) broth and tea C) Rice cereal and apple juice D) gelatin and ginger ale

formula or breast milk

The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is a firm A) A firm touch to the trapezius muscle or arm B) pinching any body part C) sternal rub D) gentle pressure on eye orbit

gentle pressure on eye orbit

a client diagnosed with anorexia nervosa states after lunch, I shouldn't have eaten all of that sandwich, i don't why ate it, i wasn't hungry. The client's comments indicate that the client is likely experiencing A) guilt B) bloating C) anxiety D) fear

guilt

As the nurse is speaking with a group of teens, which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss

hair loss

Which approach is the best way to prevent infections when providing care to clients in the home setting? A) handwashing before and after examination of clients B) wearing non powdered latex free gloves to examine the clients C) using a barrier between the client's furniture and the nurse's bag D) wearing a mask with a shield during any eye/ mouth/nose examination

handwashing before and after examination of clients

A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these? A) apply appropriate signs outside and inside the room B) apply a mask with a shield if there is a risk of fluid splash C) wear a gown to change soiled linens from incontinence D) have gloves on while handling bed pans with feces

have gloves on while handling bedpans feces

An unlicensed assistive personnel (UAP) who usually works on a surgical unit is assigned to float to a pediatric unit. Which questions by the charge nurse would be most appropriate when making delegation decisions? A) how long have you been a UAP who usually works on a surgical unit is assigned to floated to float to pediatric unit. Which questions by the charge nurse would be most appropriate when making delegation decisions? B) What type of care do you give on the surgical unit and what unit you have worked on C) What is your comfort level in caring for children and at what ages D) have you reviewed the list of expected skills you might need on this unit

have you reviewed the list of expected skills you might need on this unit

The nurse admits a 2-year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure? A) He has been taking long naps for a week B) He has had an ear infection for the past 2 days C) He has been eating more red meat lately D) he seems to be going to the bathroom more frequently

he has had an ear infection for the past 2 days

A client is admitted with invective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition? A. Dyspnea B. Heart murmur C. Macular rash D. Hemorrhage

heart murmur

A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor must closely? A)Bleeding time B)hemoglobin and hematocrit C)white blood cells D)platelets

hemoglobin and hematocrit

the nurse is caring for a client who was successfully resuscitate from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care A) hourly urine output B) white blood count C) blood glucose every 4 hours D) temperature every 2 hours

hourly urine output

A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? A) look up the policy on needle sticks B) Contact employee health services C) immediately wash the hands with vigor D) Notify the supervisor and risk management

immediately wash the hands with vigor

Which statement best describes the effects of immobility in children? A)immobility prevents the progression of language and fine motor development B)immobility in children has similar physical effects to those found in adults C)children are more susceptible to the effects of immobility than are adults D)children are likely to have prolonged immobility with subsequent complications

immobility in children has similar physical effects to those found in adults

The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self scheduling knowing that thus method will A) improve the quality of care B) decrease staff turnover C) minimize the amount of overtime payouts D) improved team morale

improve team morale

a client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to A) promote the client's comfort B) reduce the drying time C) decrease irritation to the skin D) improve venous return

improve venous return

A client with heart failure has lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug A)diaphoresis with decreased urinary output B)increased heart rate with increase respirations C)improved respiratory status and increased urinary out put D)decreased chest pain and decreased blood pressure

improved respiratory status and increased urinary output

which statement made by a nurse about the goal of total quality management or continuous quality improvement in a health care setting? A) It is to observe reactive service and product problem solving B) improvement of the processes in a proactive, preventive mode is paramount C) a chart audits to finds common errors in practice and outcomes associated with goals D) A flow chart to organize daily tasks is critical to the initial stages

improvement of the processes in a proactive, preventive mode is paramount

a client is scheduled to receive an oral solution of radioactive iodine (1311). In order to reduce hazards, the priority information for the nurse to include during the instructions to the client is which of these statements? A) in the initial 48 hours avoid contact with children and pregnant women and after urination or defecation flush the commode twice B) Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose do so in the toilet and flush it twice C) Your family can use the same bathroom that you use without any special precautions D) Drink plenty of water and empty your bladder often during the initial 3 days of therapy

in the initial 48 hours avoid contact with children and pregnant women and after urination or defecation flush the commode twice

The nurse is caring for a 4 year old 2 hours after tonsillectomy and adenoidectomy, which of the following assessments must be reported immediately? A) vomiting of dark emesis B) Complaints of throat pain C) Apical heart rate of 110 D) increased restlessness

increased restlessness

The nurse caring for a 9 year old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hours ago. Which nursing diagnosis is a priority at this time? A) risk for fluid volume deficit related to morphine overdose B) Decreased gastrointestinal mobility related to mucosal irritation C) ineffective breathing patterns related to central nervous system depression D) Altered nutrition related to inability to control nausea and vomiting

ineffective breathing patterns related to central nervous system depression

A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments would the nurse expect to be consistent with this problem? A) chest pain B) pallor C) inspiratory crackles D) heart murmur

inspiratory crackles

a nurse in the emergency department suspects domestic violence as the cause of a client's injuries, what action should the nurse take first? A) ask client if there are any old injuries also present B) interview the client without the persons who came with the client C) Gain client's trust by not being hurried during the intake process D) photograph the specific injuries in question

interview the client without the persons who came with the client

The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN? A) Test a stool specimen for occult blood B) Assist with ambulation of a client with a chest tube C) irrigate and redress a leg wound D) Admit a client from the emergency room

irrigate and redress a leg wound

The nurse is teaching an 87 yr old client methods for maintaining regular bowel movements. the nurse would caution the client to AVOID A)glycerine suppositories B)fiber supplements C)laxatives D)stool softeners

laxatives

A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states I demand to be released now! The appropriate action is for the nurse to A) you cannot be released because you are still suicidal B) you can be released only if you sign a no suicide contract C) let's discuss your decision to leave and then we can prepare you for discharge D) you have a right to sign out as soon as we get an order from the health care provider's discharge order

let's discuss your decision to leave and then we can prepare you for discharge

a young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the most therapeutic approach by the nurse A) listen quietly without comment B) Ask for further information on the spies C) Confront the client on a delusion D) contact the government agency

listen quietly without comment

A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure. A) Increased blood pressure B)increased heart rate C)loss of pulse in the extremity D)decreased urine output

loss of pulse in the extremity

A client has a history of chronic obstructive pulmonary disease (COPD). as the nurse enters the clients room, his oxygen is running at 6 liters per min, his color is flushed and his respirations are 8 per min. What should the nurse do first A)Obtain a 12-lead EKG B)Place client in high fowlers position C)lower the oxygen rate D)take baseline vital signs

lower the oxygen rate

A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to A) stabilize thermoregulation B) Maintain alveolar surface tension C) begin normal pulmonary blood flow D) regulate intra cardiac pressure

maintain alveolar surface tension

a nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to A) stabilize thermoregulation B) Maintain alveolar surface tension C) begin normal pulmonary blood flow D) Regular intra cardiac pressure

maintain alveolar surface tension

While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them about which of the following actions? A) maintain good oral hygiene and dental care B) Omit medication if the child is seizure free C) Administer acetaminophen to promote sleep D) Serve a diet that is high in iron

maintain good oral hygiene and dental care

A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action A) May result in charges of unlawful seclusion and restraint B) Leaves the nurse vulnerable for charges of assault and battery C) was appropriate in view of the client's history of violence D) was necessary to maintain the therapeutic milieu of the unit

may result in charges of unlawful seclusion and restraint

The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter/ The nurse explains that this sound be used to A) Determine oxygen saturation B) measure forced expiratory volume C) monitor atmosphere for presence of allergens D) Provide metered doses for inhaled bronchodilator

measure forced expiratory volume

A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. which findings at this time should be reported to the health care provider A)Light, pink urine B)occasional suprapubic cramping C) minimal drainage into the urinary collection bag D) complaints of the feeling of pulling on the urinary catheter

minimal drainage into the urinary collection bag

The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says. I will receive tissue from.... A) a tissue bank B) a pig C.) my thigh D) synthetic skin

my thigh

A client is recovering from a hip replacement and is taking tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic? A) bruising at the operative site B) elevated heart rate c) decreased platelet count d) no bowel movement for 3 days

no bowel movement for 3 days

The nurse is preparing a client with a deep vein thrombosis (DVT) for a venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test? A) Client should be NPO after midnight B) Client should receive a sedative medication prior to the test C) Discontinue anti coagulation therapy prior to the test D) no special preparation is necessary

no special preparation is necessary

When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because A) normal patterns of behavior may be labeled as deviant, immoral or insane B) The meaning of the client's behavior can be derived from conventional wisdom C) personal values will guide the interaction between persons from 2 cultures D) the nurse should rely on her knowledge of different developmental mental stages

normal patterns of behavior may be labeled as deviant, immoral or insane

a client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus assessment by using which approach? A) the results of a standardized tool that measures depression B) observation of affect and behavior C) inquiry about use of alcohol D) family history of emotional problems or mental illness

observation of affect and behavior

constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurses priority A)obtain a complete blood count B)obtain a health and dietary history C)refer to a provider for a physical examination D)measure height and weight

obtain a health and dietary history

A client asks the nurse to call the police and states , I need to report that I am being abused by a nurse. The nurse should first A) focus on reality orientation to place and person B) assist with the report of the client's complaint to the police C) obtain more details of the client's claim of abuse D) document the statement on the client's chart with a report to the manager

obtain more details of the client's claim of abuse

Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills? A) offer the client frequent opportunities to interact with 1 person B) provide the client with frequent opportunities to interact with other clients C) assist the client to analyze the meaning of the withdrawn behavior D) Discuss with the client the focus that other clients have similar problems

offer the client frequent opportunities to interact with 1 person

What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? A) presence of blood in stools B) oozing liquid stool C) continuous rumbling flatulence D) absence of bowel movement

oozing liquid stool

An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to : A) check the carotid pulse B) deliver 5 abdominal thrusts C) give 2 rescue breaths D) open the client's airway

open the client's airway

a client with diarrhea should avoid which of the following? A) orange juice B)tuna C)eggs D)macaroni

orange juice

Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? A)orthostatic hypotension is common side effect B)most antipsychotic drugs cause elevated blood pressure C)this provides information on the amount of sodium allowed in the diet D)It will indicate the need to institute anti parkinsonian drugs

orthostatic hypotension is common side effect

The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). which of following statements suggests that the teaching was effective? A)"We will call the health care provider if the child develops acne " B)"our child should brush and floss carefully after every meal" C)"we will skip the next dose if vomiting or fever occur" D)"when our child is seizure-free for 6 months, we can stop the medication"

our child should brush and floss carefully after every meal

A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? A) pain related to ischemia B) risk for altered elimination: constipation C) risk for complication: dysrhythmias D) anxiety related to pain

pain related to ischemia

The nurse is about to assess a 6 month old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A)Irritable and "colicky" with no attempts to pull to standing B)Alert laughing and playing with a rattle sitting with support C)skin color dusky with poor skin turgor over abdomen D)pale, thin arms and legs uninterested in surroundings

pale, thin arms and legs uninterested in surroundings

Which of these clients would the nurse recommend to keep in the hospital during an internal diaster at the agency? A) get temperatures B) take blood pressure C) palpate pulses D) check alertness

palpate pulses

after an explosion at a factory one of the workers approaches the nurse and says i am an unlicensed assistive personnel (UAP) at the local hospital. Which of these tasks should the nurse assign to this worker who wqnts to help during the care of the wounded workers? A) get temperature B) take blood pressure c) palpate pulses D) check alertness

palpate pulses

A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the clients pulse and respirations what should be the function of the second nurse A)Relieve the nurse performing CPR B)go get the code cart C)participate with the compressions or breathing D)validate the client's advanced directive

participate with the compressions or breathing

A client is admitted with a right upper lobe infiltrate and to rule out tuberculosis. The most appropriate action by the nurse to protect the self would be which of these? A) negative room ventilation B) Face mask with shield C) Particulate respiratory mask D) airborne precautions

particulate respiratory mask

a client was just taken off the ventilator after surgery and has a nasogastric tube... colored liquids. which nursing measure will provide the most comfort to the client A)allow the client to melt ice chips in the mouth B)provide mints to freshen the breathe C)perform frequent oral care with a tooth sponge D)swab the mouth with glycerin swabs

perform frequent oral care with a tooth sponge

A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)? A) to observe the type and amount of nasogastric tube drainage B) monitor the client for nausea or other complications C) irrigate the nasogastric tube with the ordered irrigate D) perform nostril and mouth care

perform nostril and mouth care

The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement? A) have the client cough into a tissue and dispose in a separate bag B) Instruct the client to cover the mouth with a tissue when coughing C) reinforce for all to wash their hands before and after entering the room D) place client in a negative pressure private room and have all who enter the room use masks with shields

place client in a negative pressure private room and have all who enter the room use masks with shields

The nurse is planning discharge for a 90 year old client with musculoskeletal weakness. Which intervention should be included in the plan and would be most effective for the prevention of falls? A) place nightlight in the bedroom B) Wear eyeglasses at all times C) install grab bars in the bathroom D) Teach muscle strengthening exercise

place nightlight in the bedroom

A 10-year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9g /dL and a hematocrit of 28 percent. The best approach for the nurse to use is to A) limit milk and milk products B) Encourage bed activities C) plan nursing care around lengthy rest periods D) promote a diet rich in iron

plan nursing care around lengthy rest periods

A client is admitted to the rehabilitation unit following a CVA and mild dysphagia The most appropriate intervention for this client is A) position client in upright position while eating B) place client on a clear liquid diet C) tilt head back to facilitate swallowing reflex D) Offer finger foods such as crackers or pretzels

position client in upright position while eating

A client is diagnosed with cirrhosis of the liver and ascites is receiving spironolactone (aldactone). The nurse understands that this medication spares elimination of which element? A)sodium B)potassium C)phosphate D)albumin

potassium

an 80 year old client on digitalis (Lanoxin) reports neausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze first A) potassium levels B) blood pH C) magnesium levels D) Blood urea nitrogen

potassium levels

3 year old child diagnosed as having celiac disease attends a day are center. Which of the following would be an appropriate snack? A) cheese crackers B) peanut butter sandwich C) potato chips D) Vanilla cookies

potato chips

A mother with a roman catholic belief has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do? A) the refusal of any treatment for self and the neonate until she talks to a reader B) the placement of a rosary necklace around the neonate until she talks to a reader C) arrange for a church elder to be at the emergency department when the ambulance arrives so a laying on hands can be done D) pour fluid over the forehead backwards towards the back of the head and say, I baptize you in the name of the father, the son and the holy spirit. Amen

pour fluid over the forehead backwards towards the back of the head and say, I baptize you in the name of the father, the son and the holy spirit. Amen

An American Indian chief visit his newborn son and performs a traditional ceremony that involves feathers and chanting. The attending nurse tells a colleague, I wonder if he has any idea how ridiculous he looks he's a grown man, The nurse's response is an example of A) discrimination B) stereotyping C) ethnocentrism D) prejudice

prejudice

The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to A)enhance absorption of the medication B)ensure that the entire dose of medication is given C)provide more even distribution of the drug D)prevent the drug from tissue irritation skip

prevent the drug from tissue irritation skip

A 16 year old enters the emergency department. The triage nurse identities that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? A) ask the teenager to wait until a parent or legal guardian can be contacted B) withhold treatment until telephone consent can be obtained from the partner C) refer the teenager to a community pediatric hospital emergency department D) Proceed with the triage process in the same manner as any adult client

proceed with the triage process in the same manner as any adult client

A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin A) protamine B) amicar C) imferon D)diltiazem

protamine -protamine binds to heparin making it ineffective

an important goal in the development of a therapeutic inpatient milieu is to A) provide a businesslike atmosphere where clients can work on individual goals B) provide a group forum in which clients decide on unit rules, regulations and policies C) provide a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions D) Discourage expressions of anger because they can be disruptive to other clients

provide a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions

The provisions of the law for the american with disabilities act require nurse managers to A) maintain an environment free from associated hazards B) provide reasonable accommodations for disabled individuals C) Make all necessary accommodation for disabled individuals D) Consider both mental and physical disabilities

provide reasonable accommodation for disabled individuals

The nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. 36 hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees Fahrenheit. The first assessment the nurse should perform is A) orientation to time, place and person B) pulse oximetry C) circulation to casted extremity D) Blood pressure

pulse oximetry

The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is A) Heart rate B)pedal pulses C)lung sounds D)pupil responses

pupil responses

A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern A)Flaccid fixed and dilated B)pupils fixed and dilated C)diminished spinal reflexes D) reduced sensory responses

pupils fixed and dilated

The nurse notes that a 2 year old child recovering from tonsillectomy has an temperature of 98.2 degrees Fahrenheit at 8:00 am to 10 am the child's mother reports that the child feels very warm to touch. The first action by the nurse should be to A) reassure the mother that this is normal B) offer the child cold oral fluids C) reassess the child's temperature D) administer the prescribed acetaminophen

reassess the child's temperature

The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse first action should be to A)wrap the leg with elastic bandages B)apply pressure at the bleeding site C)reinforce the dressing and elevate the leg D)remove the dressings and re-dress the incision

reinforce the dressing and elevate the leg

A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)? A) Converse with the client to determine if the mucous membranes are impared B) Report hourly outputs of less than 30 ml/hr C) Monitor client 's ability for movement in the bed D) check skin turgor every 4 hours

report output of less than 30 ml / hr

The nurse is planning care for a client with a CVA. which of the following measures planned by the nurse would be most effective in preventing skin breakdown? A)place client in the wheelchair for four hours each day B) pad the bony prominence C)reposition every two hours D)massage reddened bony prominence

reposition every two hours

An 18 year old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's priority assessment should be A) response to stimuli B) bladder control C) respiratory function D) muscle weakness

respiratory function

A nurse checks a client who is on a volume-cycled ventilator. Which findings indicates that the client may need suctioning A)drowsiness B)complaint of nausea C)pulse rate of 92 D)restlessness

restlessness

A mother brings her 3 month old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? A) increased temperature and lethargy B) Restlessness and increased mucus production C) Increased sleeping and listlessness D) Diarrhea and poor skin turgor

restlessness and increased mucus production

a nurse is reinforce teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes? A) grilled chicken sandwich and skim milk B) roast beef, mashed potatoes, and green beans C) peanut sandwich, banana, and green beans D) barbecue beef, baked beans and cole slaw

roast beef, mashed potatoes, and green beans

A client has viral pneumonia affecting 2/3 of the right lung. what would be the best position to teach the client to lie in every other during first 12 hours after admission? A) side-lying on the left side with the head elevated 10 degrees B) side-lying on the left side with the head elevated 35 degrees C) side-lying on the right side with the head elevated 10 degrees D) side-lying on the right side with the head elevated 35 degrees

side-lying on the left side with the head elevated 10 degrees

The nurse has been teaching a client with congestive heart failure about proper nurtition. the selection of which lunch indicates the client has learned about sodium restriction. A) cheese sandwich with a glass of 2% milk B)sliced turkey and sandwich and canned pineapple C)cheeseburger and baked potato D)mushroom pizza and ice cream

sliced turkey and sandwich and canned pineapple

An 80 year old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the health care provider? A) Slurred speech B) Incontinence C) muscle weakness D) rapid pulse

slurred speech

A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? A)Change in libido, breast enlargement B)sore throat, fever C)abdominal pain, nausea, diarrhea D)Dyspnea

sore throat, fever

An elderly client admitted after a fall begins to seize and loses and consciousness. what action by the nurse is appropriate to do next A)stay with client and observe for airway obstruction B)collect pillows and pad the side rails of the bed C)place an oral airway in the mouth and suction D)announce a cardiac arrest, and assist with intubation

stay with client and observe for airway obstruction

A nurse states, I dislike caring for African American clients because they all are so hostile, the nurse's statement is an example A) prejudice B) discrimination C) stereotyping D) racism

stereotyping

The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? A)Stop the infusion B)Slow the rate of infusion C)take vital signs and observe for further deterioration D)administer benadryl and continue the infusion

stop the infusion

discharge instructions for client taking alprazolam (Xanax) should include which of the following A)Sedative hypnotics are effective analgesics B)sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares C)caffeine beverages can increase the effect of sedative hypnotics D)Avoidance of excessive exercise and high temperature is recommended

sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares

The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client? A) assign an RN to provide total care of the client B) assign a nursing assistant to help the client with self-care activities C) delegate complete care to unlicensed assistive personnel D) supervise a nursing assistant for skin care

supervise a nursing assistant for skin care

a client is admitted to a psychiatric unit with delusions. What findings can the nurse expect? A) flight of ideas and hyperactivity B) suspiciousness and resistance to therapy C) anorexia and hopelessness D) Panic and multiple physical complaints

suspiciousness and resistance to therapy

The nurse is teaching about non steroidal anti-inflammatory drugs to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions? A) reporting joint stiffness in the morning B) taking the medication 1 hour before or 2 hours after meals C) Using alcohol in moderation unless driving D) Continuing to take aspirin for short term relief

taking the medication 1 hour before or 2 hours after meals

The nurse is performing a pre-kindergarten physical on 5 year old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse? A) Vastus intermedius B) Gluteus rain linus C) vastus lateralis D) Dorsogluteal

vastus lateralis

During the check up of a 2 month old infant at a well baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse? A) Mongolian spots are a normal finding in dark skinned children B) Port wine stains are often associated with other malformations C) telangiectatic nevi are normal and will disappear as the baby grows D) The child is too young for consideration of surgical removal of these at this time

telangiectatic nevi are normal and will disappear as the baby grows

A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of assorted pills in the client's drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be A) these pills aren't antacids since they are all different B) Some teenagers use pills to lose weight C) tell me about your week prior to being admitted D) Are you taking pills to change your weight

tell me about your week prior to being admitted

The nurse is caring for a 69-year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel? A) test blood sugar 2 hours by accu check B) review with family and client signs of hyperglycemia C) monitor for mental status changes D) check skin condition of lower extremities

test blood sugar every 2 hours by accucheck

The mother of a toddler who is being treated for pesticide poisoning asks , Why is activated charcoal used? What does it do? What is the nurse's best response? A) Activated charcoal decreases the systemic absorption of the poison from the stomach B) the charcoal absorbs the poison and forms a compound that doesn't hurt your child C) this substance helps to get the poison out of the body by the gastrointestinal system D) The action may bind or inactive the toxins or irritants that are ingested by children or adults

the charcoal absorbs the poison and forms a compound that doesn't hurt your child

a client had 20 mg of Lasix ( furosemide) PO at 10 am. Which would be essential for the nurse to include at the change of shift report? A) The client lost 2 pounds in 24 hours B) The client's potassium level is 4 mEq/liter. C) The client's urine output was 1500 cc in 5 hours D) The client is to receive another dose of Lasix at 10 PM

the client's urine output was 1500 cc in five hours

A client who is to have antineoplastic chemotherapy tells the nurse of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture A) some needles go as deep as 3 inches, depending on where they're placed in the body and what treatment is for. The needles usually are left in for 15 to 30 minutes. B)In traditional Chinese medicine, imbalances in the basic energetic flow of life - known as qi or chi - are thought to cause illness. C) the flow of life is believed to flow through major pathways or nerve cluster in your body D) By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over

the flow of life is believed to flow through major pathways or nerve cluster in your body

As the nurse provides discharge teaching to the parents of a 15-month-old child with Kawasaki disease. The child has received immunoglobin therapy. Which instruction would be appropriate? A) high doses of aspirin will be continued for some time B) Complete recovery is expected within several days C) Active range of motion exercise should be done frequently D) the measles, mumps, and rubella vaccine should be delayed

the measles, mumps, and rubella vaccine should be delayed

While providing home care to a client with congestive heart failure, the nurse is asked long diuretics must be taken. what is the nurses best response A)"as you urinate more, you will need less medication B)"you will have to take this medication for about a year C)"the medication must be continued so the fluid problem is controlled D)"please talk to your health care provider about medications and treatments

the medication must be continued so the fluid problem is controlled

A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. what is the best explanation for the nurse to provide this client A)The tube will drain fluid your chest B)the tube will remove excess air from your chest C)the tube controls the amount of air that enters your chest D)the tube will seal the hole in your lung

the tube will remove excess air from your chest

The parents of a 4 year old hospitalized child tell the nurse, we are leaving now and will be back at 6 PM a few hours later the child asks the nurse when the parents will come again. What is the best response by the nurse? A) they will be back after supper B) In about 2 hours, you will see them C) After you play awhile, they will be here D) when the clock hands are on 6 and 12

they will be back after supper

A couple experienced the loss of a 7 month old fetus. In planning for discharge, what should the nurse emphasize? A) to discuss feelings with each other and use support persons B) to focus on the other healthy children and move through the loss C) to seek causes for the fetal death and come to some safe conclusion D) to plan for another pregnancy within 2 years and maintain physical health

to discuss feelings with each other and use support persons

The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? A) donating blood B) Using public bathrooms C) unprotected sex D) Touching a person with AIDS

unprotected sex

The nurse receives a report on an older adult client with middle stage dementia What information suggests the nurse should do immediately follow up rather than delegate care to the nursing assistant? The client A) has had a change in respiratory rate by an increase of 2 breaths B) has had a change in heart rate by an increase in of 10 beats C) was minimally response to voice or touch D) has had a blood pressure change by a drop in 8 mmHg systolic

was minimally response to voice or touch

The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily? A) spaghetti B) watermelon C) chicken D) tomatoes

watermelon

The nurse is assessing an 8 month old child with atonic cerebral palsy. Which statement from the mother supports the presence of this problem? A) when I put my finger in the left hand the baby doesn't respond with a grasp. B) my baby doesn't seem to follow when I shake toys in front of the face C) when it thundered loudly last night the baby didn't even jump D) when I put the baby in a back lying position that's how I find the baby

when I put the baby in a back lying position that's how I find the baby

The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would emphasize that pancreatic enzymes should be taken A) once each day B) 3 times daily after meals C) with each meal or snack D) Each time carbohydrates are eaten

with each meal or snack

A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman six in a chair. The mother states. this is not my baby and I do not want it A) this is a common occurrence after birth, but you will come to accept the baby B) many women have postpartum blues and need some time to love the baby C) what a beautif ul baby Her eyes are just like yours D) you seem upset , tell me what the pregnancy and birth were like for you

you seem upset , tell me what the pregnancy and birth were like for you