hesi practice quizzes (all courses)

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When caring for a client with anorexia nervosa, how many kg per week is a reasonable goal for weight gain?

1 kg/week

The MAP for a client who has a BP of 180/95 is?

123 mmHg

how many days is the neonatal period?

28 days

Upon assessment of a newborn, the nurse finds that the baby is pink with bluish discoloration of the hands and feet. The heart rate is 120 bpm and respirations are 36 breaths per minute. The baby is flexed and crying loudly. What is the neonate's 1-minute apgar score?

According to Naegele rule, which is the expected date of delivery (EDD) of a client whose last menstrual period began on April 15?

January 22

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? a. Patellar reflex 4+. b. Blood pressure 158/80. c. Four-hour urine output 240 ml. d. Respiration 12/minute.

A dark-skinned client has a gray-colored tongue and lips. Which complication does the nurse suspect? a. cyanosis b. jaundice c. bleeding d. inflammation

An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked and his eyeballs are sunken into his head. What nursing intervention is indicated? a. Help the client to determine ways to increase his fluid intake. b. Obtain an appointment for the client to see an ear, nose, and throat specialist. c. Schedule an appointment with an allergist to determine if the client is allergic to the cat. d. Encourage the client to slightly increase his use of oxygen at night and to always use humidified oxygen.

An older female client arrives for an annual visit by the urologist due to a history of changes in serum values related to renal function. What changes should the registered nurse (RN) expect for an older client due to normal aging? a. Decrease in glomerular filtration rate (GFR). b. Hematuria during urinalysis. c. Chronic bladder infections. d. Urinary incontinence.

For which condition would an infant born with exstrophy of the bladder be at risk for? a. infection b. dehydration c. urine retention d. intestinal obstruction

Information about which vitamin would be included when teaching a client with atrial fibrillation about a new prescription for warfarin? a. K b. D c. B1 d. B12

The nurse formulates the nursing diagnosis of, "Urinary retention related to sensorimotor deficit" for a client with multiple sclerosis. Which nursing intervention should the nurse implement? a. Teach the client techniques of intermittent self-catheterization. b. Decrease fluid intake to prevent over distention of the bladder. c. Use incontinence briefs to maintain hygiene with urinary dribbling. d. Explain that anticholinergic drugs will decrease muscle spasticity.

The nurse identifies bright-red drainage, about 6 cm in diameter, on the dressing of a client who is one day post abdominal surgery. Which action should the nurse take next? a. Mark the drainage on the dressing and take vital signs. b. Notify the healthcare provider of a potential for hemorrhage. c. Remove the dressing and assess the surgical incision site. d. Reassess dressing in one hour for increased drainage.

The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? a. Compress the flank and upper buttocks. b. Measure the client's abdominal girth. c. Gently palpate the lower abdomen. d. Apply light pressure over the shins.

The nurse is educating about managing hypoglycemia unawareness. Which information would the nurse provide? a. refrain from using alternative testing sites b. use any available meter to monitor levels c. initiate continuous glucose monitoring d. calibrate the meter before managing hypoglycemia

The registered nurse (RN) is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the RN after the removal of the chest tube? a. Prepare the client for chest x-ray at the bedside. b. Review arterial blood gases after removal. c. Elevate the head of bed to 45 degrees. d. Assist with disassembling the drainage system.

When monitoring the direct care nurse administering pain medication to a client, the nurse leader tells the client, "I will come back in 30 min to check your pain level." Which right of the client would the leader fulfill upon returning within 30 min? a. fidelity b. veracity c. beneficence d. confidentiality

When preparing to administer medications safely, it is important for the nurse to remember at which age an infant's gastric emptying time reaches adult values? a. 6-8 months b. 10-12 months c. 14-16 months d. 18-24 months

Which action should the nurse implement when preparing to measure the fundal height of a pregnant client? a. Have the client empty her bladder. b. Request the client lie on her left side. c. Perform Leopold's maneuvers first. d. Give the client some cold juice to drink.

Which action would the nurse take for a newly admitted client diagnosed with schizophrenia who refuses to remove dirty clothing? a. allow the client to undress when ready to help maintain identity b. provide two outfits and help the client decide which one to wear c. explain that clean clothes will look more attractive and increase self-esteem d. get assistance to remove the clothing

Which information would the nurse teach parents about their newborn's diagnosis of phenylketonuria (PKU)? a. a low-pheylalanine diet is required b. phenylalanine is not necessary for growth c. phenylalanine can be administered to correct the deficiency d. a substitute for phenylalanine is an increased amount of other amino acids

Which instruction should the nurse include in the discharge teaching for a client who is taking an antipsychotic medication? a. Increase daily intake of raw fruits and vegetables. b. Follow a low carbohydrate diet. c. Take a multivitamin daily. d. Report increased urine output to the healthcare provider immediately.

Which is an example of a sentinel event? a. a splenectomy is perfomed on the wrong client b. vital signs taken every 2 hours instead of every 4 hours per hospital policy c. the confused client falls out of bed because the nurse forgot to put up the prescribed siderails d. the client receives an incorrect antibtiotic in the holding area before a surgical procedure

Which stage of the HIV disease is present in the client with a lab report revealing a CD4 T-cell count of 520? a. stage 1 b. stage 2 c. stage 3 d. stage 4

Which statement describes the function of the dermis? a. provides cells for wound healing b. assists in retention of body heat c. acts as mechanical shock absorber d. inhibits proliferation of microorganisms

Which statement shows that the newly diagnosed asthma patient understands how to use a peak expiratory flow meter (PEFM)? a. "I have to blow out as fast and hard into the machine as I can" b. "I can stand and sit to use it, but I can't lie down" c. "I have to take three readings and record the average on the flow sheet" d. "I'll use the meter whenever I can throughout the day; it doesn't really matter when"

Which structure helps bend light rays and allows them to fall onto the retina? a. lens b. zonule c. cornea d. aqeous humor

Which risk to the fetus is associated with a maternal diagnosis of chorioamnionitis? Select all that apply. a. sepsis b. bacteremia c. pneumonia d. cerebral palsy e. respiratory distress syndrome (RDS)

a, b, c, d, e

Fetal heart rate increases can be associated with a variety of factors. These include: (Select all that apply) a. maternal fever or infection b. maternal hypotension c. fetal anemia d. the mother receiving the drug Brethine (terbutaline) e. the mother receiving the drug Yutopar (ritodrine)

a, c, d, e

Which finding would the nurse expect when assessing a client with peripheral arterial disease (PAD)? Select all that apply. a. Pallor of feet b. Warm extremities c. Ulcers on the toes d. Delayed capillary refill e. Thick, hardened skin f. Hair loss to lower extremities g. Muscle atrophy h. Intermittent claudication

a, c, d, f, g, h

A pregnant adolescent is diagnosed with an ectopic pregnancy. Which risk factors contribute to ectopic pregnancy? Select all that apply. a. smoking b. irregular menses c. use of contraceptive pills d. damage to fallopian tubes e. history of pelvic inflammatory disease

a, d, e

A client is 36 hours after admission with severe burns and the nurse identifies the client's potassium level is 6.0. The nurse would recommend susbstituting current dietary fluids with which drink? a. milk b. tea c. orange juice d. tomato juice

A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced myocardial damage? a. Creatine Kinase (CK-MB). b. Serum troponin. c. Myoglobin. d. Ischemia modified albumin.

A mother tells the nurse that her children are asking questions about divorce, but one male child tells her that he is sorry that he caused the divorce of the parents. Which age group is most likely to experience feelings of punishment or responsibity for the divorce of parents? a. 1 year. b. 4 years. c. 8 years. d. 13 years.

A nurse whose tuberculosis (TB ) skin test result reveals an 8 mm induration obtains a negative chest radiograph, which indicates latent tuberculosis. The employee-health nurse should implement which intervention for this nurse? a. Repeat the skin test and chest radiograph in three weeks. b. Administer isoniazid (INH) daily for 6 to 9 months. c. Give combination therapy of antitubercular drugs for 6 months. d. Recommend the bacille Calmette-Gu rin (BCG) vaccine.

The nurse is providing dietary instructions to a 68-year-old client who is at high risk for development of coronary heart disease (CHD). Which information should the nurse include? a. Limit dietary selection of cholesterol to 300 mg per day. b. Increase intake of soluble fiber to 10 to 25 grams per day. c. Decrease plant stanols and sterols to less than 2 grams/day. d. Ensure saturated fat is less than 30% of total caloric intake.

The nurse working on a telemetry unit finds a client unconscious and in pulseless ventricular tachycardia (VT). The client has an implanted automatic defibrillator. What action should the nurse implement? a. Prepare the client for transcutaneous pacemaker. b. Shock the client with 200 joules per hospital policy. c. Use a magnet to deactivate the implanted pacemaker. d. Observe the monitor until the onset of ventricular fibrillation.

Thick mucous gland secretions, elevated sweat electrolytes, meconium ileus, and difficulty maintaining and gaining weight are associated with which autosomal recessive disorder? a. cerebral palsy b. cystic fibrosis c. muscular dystrophy d. mulitple sclerosis

Which clinical condition is associated with lead poisoning? a. asthma b. anemia c. metabolic acidosis d. systemic infection

Which communication pattern is defined as confabulation? a. the flow of thoughts is interrupted b. imagination is used to fill in memory gaps c. speech flits from one topic to another d. statements are too loose to understand

Which component of the human personality, according to Freud, allows an individual to judge reality accurately? a. Id b. ego c. superego d. oedipus complex

Which condition is commonly seen following infestation with pediculosis capitis? a. eczema b. impetigo c. cellulitis d. folliculitis

Which issue related to antibiotic use is an increased risk for the older adult? a. allergy b. toxicity c. resistance d. superinfection

Which milestone indicates to the nurse successful achievement of young adulthood? a. Demonstrates a conceptualization of death and dying. b. Completes education and becomes self-supporting. c. Creates a new definition of self and roles with others. d. Develops a strong need for parental support and approval.

Which nursing theory focuses on the client's self-care needs? a. roy's theory b. orem's theory c. watson's theory d. leininger's theory

Which of the following is the expected progression of lochial changes during the puerperium? a. serosa, alba, rubra b. rubra, serosa, alba c. serosa, rubra, alba d. alba, serosa, rubra

Which pain-related clinical manifestation would the nurse expect in a client who has a peptic ulcer? a. the pain intensifies after vomiting b. the pain occurs 1 to 2 hours after having a meal c. the pain increases when ingesting an excess of fatty foods d. the pain begins in the epigastrium and radiates to the abdomen

Which term would the nurse use to document a 1 cm elevated solid lesion noted on a client's skin? a. papule b. nodule c. vesicle d. pustule

which hormone is formed from cholesterol? a. insulin b. cortisol c. prolactin d. growth hormone

which is the etiological factor of nephrogenic diabetes insipidus? a. meningitis b. lithium therapy c. graves disease d. sulfonamide therapy

A client reports right ear hearing loss. When performing a Weber test with a tuning fork, the client hears the sound better with the right ear. Which condition would the nurse suspect from these results? a. normal hearing b. mixed hearing loss c. conductive loss d. sensorineural loss

A client who returns to the unit after having a percutaneous transluminal coronary angioplasty (PTCA) complains of acute chest pain. What action should the nurse implement next? a. Inform the healthcare provider. b. Obtain a 12-lead electrocardiogram. c. Give a sublingual nitroglycerin tablet. d. Administer prescribed analgesic.

The nurse is assessing a client who smokes cigarettes and has been diagnosed with emphysema. Which finding would the nurse expect this client to exhibit? a. A decreased total lung capacity. b. Normal arterial blood gases. c. Normal skin coloring. d. An absence of sputum.

To which disaster triage class would the nurse infer a client with a green triage tag belong? a. I b. II c. III d. IV

Arrange in order of occurence the steps involved in the changes during puberty. a. stimulation of production and secretion of FSH and LH b. movement of GnRH through a network of capillaries to the anterior pituitary gland c. triggering of GnRH by the hypothalamus d. stimulation of the gonadal response

c --> b --> a --> d

A nurse is teaching about women's health with a female client who is in a homosexual relationship. Which topic is the most important for the nurse to address? a. Sexually transmitted diseases. b. Annual gynecologic examination. c. Monthly breast self-examination. d. Domestic violence interventions.

A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client? a. Left supine with thighs flexed on her abdomen. b. Right lateral side with both legs flexed. c. Semi-Fowler's with head of bed elevated 30 degrees. d. Supine with the foot of the bed elevated.

The nurse is teaching a child with juvenile idiopathic arthritis (JIA) activities to prevent the loss of joint function. Which activities would the nurse caution the child to avoid? a. bicycle riding b. walking to school c. isometric exercises d. sendentary actvities

When can a primigravida fetal heartbeat be heard for the first time? a. a stethoscope at 4 weeks b. a fetoscope at 10-12 weeks c. doppler ultrasound after 20 weeks d. doppler ultrasound at 10-12 weeks

Which action should the nurse implement first for a client experiencing alcohol withdrawal? a. Apply vest or extremity restraints. b. Give an alpha-adrenergic blocker. c. Provide a diet high in protein and calories. d. Prepare the environment to prevent self-injury.

Which group has the highest rate of meningococcal infection? a. infants b. toddlers c. older adults d. young adults

Which intervention relieves itching, promoting comfort of the client exposed to poison ivy? a. saline rinse b. cold therapy c. heat therapy d. wet compress

Which public health risk became a major focus for hospitals after the 9/11 attacks? a. anthrax exposure b. multicasualty incidents c. mass casualty incidents (MCIs) d. weapons of mass destruction (WMD)

which intervention would the nurse classify as an independent nursing care function? a. administering a medication b. performing an IV infusion c. inserting a Foley catheter d. repositioning a client to prevent a pressure ulcer

The healthcare provider prescribes acetazolamide (Diamox) 600 mg/m2/day divided into 3 doses. The nurse calculates the child's body surface area (BSA) as 0.7 m2 . How many mg should the child receive per dose? (Enter the numeric value, whole number, only.)

140

A client who has a sinus infection is receiving a prescription for amoxicillin/clavulanate potassium (Augmentin) 500 mg PO q8 hours. The available form is 250 mg amoxicillin/125mg clavulanate tablets. How many tablets should the nurse administer for each dose? (Enter numeric value only.)

During an 8 hours shift, a client drinks two 6-oz (180- mL) cups of tea and vomits 125 mL of fluid. IV fluids absorbed equaled the urinary output. What is the client's fluid balance?

235 mL

A client with heart failure weighed 175 lb yesterday, and today's weight is 181 lb. How many mL of fluid has the client retained?

2700 1 L of fl = 1 kg 82.1 kg - 79.4 kg = 2.7 kg = 2700 mL

A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.) Select all that apply a. Snack of potato chips, and diet soda. b. Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. c. Breakfast of eggs, bacon, toast, and coffee. d. Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea. e. Bedtime snack of crackers and milk.

A, B, C, E

A child with meningitis suddenly assumes a opisthotonic posture. In which position would the nurse position the child? a. side-lying b. knee-chest c. high-fowlers d. trendelenburg

The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands? a. A pregnant woman. b. A teenager beginning puberty. c. A 3-month-old infant. d. A school-aged child.

The registered nurse (RN) is assessing common complications related to a client's recent diagnosis, systemic lupus erythematosus (SLE). Which symptom should the RN instruct the client to report immediately? a. Fever related to infection. b. Weight loss and anorexia. c. Depressed mood. d. Break in tissue integrity.

The severity of diabetic retinopathy is directly related to which condition? a. Poor blood glucose control. b. Neurological effects of diabetes. c. Susceptibility to infection. d. Uncontrolled hypertension.

Which food would the nurse recommend for a child who is at risk for developing rickets? a. yogurt b. carrots c. fruit juice d. dried fruit

Which information would the nurse consider when planning care for a client with scabies? a. scabies is highly contagious b. it is caused by a fungus c. chronic with exacerbations are classic symptoms d. there is a correlation with other allergies

For which client illness would airborne precautions be implemented? a. influenza b. chickenpox c. pneumonia d. respiratory syncytial virus

Lasix 20 mg PO is prescribed for a client at 0600. The medication is available in a scored tablet of 40 mg. Before breaking the tablet, what action should the nurse take? a. Apply non-sterile gloves. b. Perform hand hygiene. c. Consult with the pharmacist. d. Chart "half tablet administered."

Morning sickness generally disappears by the end of which month? a. fifth month b. third month c. fourth month d. second month

Which intervention would the nurse recommend for post-cesarean gas pain? a. lying on the right side b. walking around the room c. using a straw when drinking water d. supporting the incision when moving

For which age group would the nurse recommend that parents teach their children to safely cross roads and walk in parking lots? a. toddlers b. adolescents c. preschoolers d. school-age children

Which manifestation indicates tertiary syphilis? a. chancre b. alopecia c. gummas d. condylomata lata

A client is being admitted with a diagnosis of pulmonary tuberculosis. Which type of room would the nurse assign this client? a. private room b. semiprivate room c. room with windows that can be opened d. negative-airflow room

A newborn with Erb palsy has an asymmetric Moro reflex. Which cause would the nurse suspect? a. acquired in utero b. a tumor arising from muscle tissue c. an x-linked inheritance pattern d. an injury to the shoulder during birth

In response to the occurrence of a late deceleration, which of the following actions should be carried out FIRST? a. Increase LRs IV rate b. notify the physician c. administer oxygen d. turn the patient on her left side

Which STI causes condylomata acuminate? a. chlamydia b. gonorrhea c. herpes simplex d. HPV

which secondary skin lesion may include athlete's foot as an example? a. scar b. scale c. ulcer d. fissure

which virus is responsible for causing infectious mononucleosis in clients? a. parvovirus b. coronavirus c. rotavirus d. epstein-barr virus

A 2-year-old child with Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated with Down syndrome? a. Congenital heart disease. b. Fragile X chromosome. c. Trisomy 13. d. Pyloric stenosis.

A 51-year-old truck driver who smokes two packs of cigarettes a day and is 30 pounds overweight is diagnosed with having a gastric ulcer. What content is most important for the nurse to include in the discharge teaching for this client? a. Information about smoking cessation. b. Diet instructions for a low-residue diet. c. Instructions on a weight-loss program. d. The importance of increasing milk in the diet.

A child who has a history of a 5-lb weight gain in 1 week and periorbital edema is admitted with a diagnosis of acute glomerulonepritis. How can the nurse obtain the most accurate information on the status of the child's edema? a. weighing daily b. observing body changes c. measuring intake and output d. monitoring electrolyte values

A client develps a vitamin K deficiency due to intestinal malabsorption. What intervention should the registered nurse (RN) implement in the plan of care? a. Monitor for signs of hematuria, melena, ecchymosis. b. Increase intake of leafy green vegetables. c. Drink orange juice with a prescribed daily iron supplement. d. Monitor for cardiac irregularities.

A client is told that her infant will be stillborn. What is the most important action for the nurse to implement after the birth? a. Ask the family if they would like to see and hold the infant after birth. b. Inquire if the parents want a picture taken after the infant is born. c. Discuss with the parents which funeral home should be notified. d. Find out if the client has a special outfit for the infant after the birth.

A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? a. Continue gabapentin. b. Discontinue ibuprofen. c. Add aspirin to the protocol. d. Add oral methadone to the protocol.

A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make? a. How long has the client been taking the medication? b. Does the client use any tobacco products? c. Has the client experienced constipation recently? d. Did the client miss any doses of the medication?

A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to monitor? a. Liver. b. Kidney. c. Sensory. d. Cardiorespiratory.

A client's susceptibility to ulcerative colitis is most likely due to which aspect in the client's history? a. Jewish European ancestry. b. H. pylori bowel infection. c. Family history of irritable bowel syndrome. d. Age between 25 and 55 years.

A female client receiving IV vasopressin (Pitressin) for esophageal varice rupture reports to the nurse that she feels substernal tightness and pressure across her chest. Which PRN protocol should the nurse initiate? a. Start an IV nitroglycerin infusion. b. Nasogastric lavage with cool saline. c. Increase the vasopressin infusion. d. Prepare for endotracheal intubation.

A low potassium diet is prescribed for a client. What foods should the nurse teach this client to avoid? a. Dried prunes. b. Cottage cheese. c. Mashed potatoes. d. Mustard greens.

A male client who has never smoked but has had COPD for the past 5 years is now being assessed for cancer of the lung. The nurse knows that he is most likely to develop which type of lung cancer? a. Adenocarcinoma. b. Oat-cell carcinoma. c. Malignant melanoma. d. Squamous-cell carcinoma.

A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage? a. Generativity. b. Ego integrity. c. Identification. d. Valuing wisdom.

A newborn who is breastfeeding is diagnosed with galactosemia. What action should the nurse implement? a. Stop the infant breastfeeding. b. Add amino acids to breast milk. c. Give galactokinase with breast milk. d. Substitute a lactose-containing formula.

A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide this client? a. "Complete bedrest decreases oxygen needs and demands on the heart muscle tissue." b. "We want your baby to be healthy, and this is the only way we can make sure that will happen." "c. I know you're upset. Would you like to talk about some things you could do while in bed?" d. "Labor is difficult and you need to use this time to rest before you have to assume all child-caring duties."

At which interval are humidified oxygen systems replaced to prevent infection? a. 1 day b. 3 days c. 5 days d. 7 days

During the physical assessment, which finding should the nurse recognize as a normal finding? a. Regular pulsation at the epigastric area when the client is supine. b. Apical pulse noted over an area 4 to 5 centimeters with a duration of 2 seconds. c. Jugular venous pressure palpable with the client in an upright position. d. Point of maximal impulse at the third intercostal space in the right midclavicular line.

In which stage of Piaget's theory does an infant develop an action pattern to deal with the environment? a. sensorimotor b. preoperational c. formal operations d. concrete operations

The home health registered nurse (RN) is changing an older client's wet to dry dressing. Which observation should the RN evaluate as a therapeutic response with the removal of the dry dressing? a. Debridment and removal of slough and eschar. b. Drainage of purulent exudate from the wound. c. Moist skin edges around the wound field. d. Presence of capillary growth in the wound.

The home health registered nurse (RN) is reinforcing instructions to the family about how to prevent pressure ulcers for their older family member who is bedridden. Which measure should the RN discuss? a. LIft the client when turning instead of sliding. b. Massage directly over reddened sites. c. Change client's position every 4 hours. d. Place pillows under both the knees.

The nurse is assessing a postmenopausal woman who is complaining of urinary urgency and frequency and stress incontinence. She also reports difficulty in emptying her bladder. These complaints are most likely due to which condition? a. Cystocele. b. Bladder infection. c. Pyelonephritis. d. Irritable bladder.

The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone (SIADH). This condition is most often related to which predisposing condition? a. Small cell lung cancer. b. Active tuberculosis infection. c. Hodgkin's lymphoma. d. Tricyclic antidepressant therapy.

The nurse is caring for a premature infant who needs an IV access restarted. What action should the nurse take when using adhesive tape? a. Remove adhesives with water, mineral oil, or petrolatum. b. Avoid using tape and adhesives until skin is more mature. c. Use scissors carefully to remove tape instead of pulling tape off. d. Employ solvents to remove adhesives instead of pulling on skin.

The nurse is preparing a child who has undergone a myringotomy for discharge. Which would the parent be taught about care at home? a. insert earplugs for baths b. keep cotton in the ears until drainage subsides c. keep the child out of school until ears are healed d. clean the child's ears with cottin-tipped swabs after each bath

The nurse is preparing to administer an IM injection to a newborn. The nurse would be cognizant of which cause of slow absorption in newborns? a. blood flow b. binding ability c. renal excretion d. hepatic metabolism

The nurse is providing instruction to a parent of a child with influenza. Which statement by the parent indicates the need for further instruction? a. "I'll manage the fever with baby aspirin." b. "We'll make sure to get a flu shot next season." c. "Providing fluids will help relieve the symptoms." d. "Staying home from school will prevent transmission."

The nurse is screening children at a local community health clinic for infectious diseases. Which child is at highest risk for hepatitis B virus (HBV)? a. A newborn. b. A 3-year-old. c. A 7-year-old. d. An 11-year-old.

The parents of a child with acute poststreptococcal glomerulonephritis ask the nurse why their child is being weighed every morning. Which response by the nurse is best? a. "It's the best way to measure your child's fluid balance." b. "it provides a measure of how much protein is being lost." c. "this disease process is usually obver when weight loss stios" d. "plans for the daily caloric intake are made according to the daily weight change."

The registered nurse (RN) assesses a client's results for arterial blood gases who has emphysema. Which finding is consistent with respiratory acidosis? a. pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L. b. pH 7.45 , pCO2 37 mmHg, HCO3 24 mEq/L. c. pH 7.34, pCO2 36 mmHg, HCO3 21 mEq/L. d. pH 7.46, pCO2 35 mmHg, HCO3 28 mEq/L.

The registered nurse (RN) is caring for a client with a newly placed nasogastric tube (NGT). Once the placement of the NG tube is verified by x-ray, which technique should the RN use as a reliable method to ensure the NGT is not displaced? a. Check pH of aspirated stomach contents obtained from the NGT. b. Auscultate over the epigastrium while injecting air into the NGT. c. Disconnect and place the end of NGT in water to see if bubbles appear. d. Listen for hyperactive bowel sounds in all four quadrants of abdomen.

Upon assessing a client who underwent abdominal surgery 10 days ago, the client reports abdominal pain. Which type of pain would the client experience? a. visceral b. somatic c. referred d. intractable

When a client expresses anxiety about being given anesthesia, which team member should sit with the person and provide comfort during the induction? a. circulating nurse b. surgical assistant c. registered nurse first assistant d. certified registered nurse anesthetist

When teaching diaphragmatic breathing to a client with chronic obstructive pulmonary disease (COPD), which information should the nurse provide? a. Place a small book or magazine on the abdomen and make it rise while inhaling deeply. b. Purse the lips while inhaling as deeply as possible and then exhale through the nose. c. Wrap a towel around the abdomen and push against the towel while forcefully exhaling. d. Place one hand on the chest, one hand the abdomen and make both hands move outward.

Which action should the nurse implement on the scheduled day of surgery for a client with type 1 diabetes mellitus (DM)? a. Obtain a prescription for an adjusted dose of insulin. b. Administer an oral anti-diabetic agent. c. Give an insulin dose using parameters of a sliding scale. d. Withhold insulin while the client is NPO.

Which age-related effects on the immune system occur in the older client? a. Increased autoantibodies. b. Increased expression of IL-2 receptors. c. Increased delayed hypersensitivity reaction. d. Increased primary and secondary antibody responses

Which assessment if a component of the primary survey? a. Disability b. Abdomen and flanks c. head, neck, and face d. history of the illness or injury

Which client assessment data is most important for the nurse to consider before ambulating a postoperative client? a. Respiratory rate. b. Wound location. c. Pedal pulses. d. Pain rating.

Which condition would the nurse document when a newborn infant is notes to have small, flat pink spots on the nape of the neck? a. nevi b. desquamation c. mongolian spots d. erythema toxicum

Which dietary instruction would be benficial to a client who has undergone a hypophysectomy and has difficulty passing stools? a. "drink plenty of water" b. "eat foods rich in potassium" c. "drink a glass of milk daily" d. "eat foods rich in carbs"

Which emergency response team helps set up shelters for victims who lost their homes due to a disaster? a. american red cross b. disaster medical assistance team (DMAT) c. internation medical-surgical response teams (IMSRTs) d. disaster mortuary operational response teams (DMORTs)

Which functional level of trauma is involved in providing a full continuum of trauma services? a. level 1 b. level 2 c. level 3 d. level 4

Which high-risk nutritional practice must be assessed for when a pregnant client is found to be anemic? a. pica b. caffeine intake c. alcohol abuse d. artificial sweetener use

Which point would the nurse include in a teaching plan to help manage pain during dressing changes if a client has burns over 18% of body surface? a. deep breathing exercises b. progressive muscle relaxation c. active ROM d. important elements of wound care

Which reaction is an example of a type 1 hypersenstivity reaction? a. anaphylaxis b. serum sickness c. contact dermatitis d. blood transfusion reaction

Which response would the telehealth nurse provide to a mother who calls and states, "My daughter is cutting her wrists and I'm worried about infection. They are just superficial cuts like the others in the past."? a. "You should call 911 now and let them know that your daughter has made a suicide attempt and needs help." b. "You should let your daughter's provider know about this occurence in the morning and see whether the provider wants you take make an appointment." c. "It sounds like you're very experienced with this situation. You can probably talk to her at home and see whether she'll tell you why she decided to cut herself." d. "Call her provider in the morning and let them know what has happened. Don't have any further conversations about suicide, because you don't want to give her any more ideas about hurting herself"

Which statement regarding Roy's theory of nursing needs correction? a. the roy adaptation model views the environment as an adaptive system b. the need for nursing care occurs when the client cannot adapt to internal and external environmental demands c. the goal of nursing is to help the client adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness d. all individuals must adapt to the following demands: meeting basic physiological needs, developing a postive self-concept, performing social roles, and achieving a balance between dependence and independence.

While assessing the apical pulse of a 13-year-old, the nurse determines that the rate is 88 beats/minute, and the rhythm is irregular. The heart rate is phasic with respirations, increasing during inspiration and decreasing with expiration. What action should the nurse take? a. Continue the cardiac examination. b. Inquire about daily caffeine intake. c. Re-assess the apical pulse in 15 minutes. d. Schedule a consultation with a cardiologist.

While caring for a client who has esophageal varices, which nursing intervention is most important for the registered nurse (RN) to implement? a. Monitor infusing IV fluids and any replacement blood products. b. Prepare for esophagogastroduodenoscopy (EGD). c. Maintain the client on strict bedrest. d. Insert a nasogastric tube (NGT) for intermittent suction.

While the nurse is administering a bolus feeding to a client via nasogastric tube, the client begins to vomit. What action should the nurse implement first? a. Discontinue the administration of the bolus feeding. b. Auscultate the client's breath sounds bilaterally. c. Elevate the head of the bed to a high Fowler's position. d. Administer a PRN dose of a prescribed antiemetic.

during an annual physical, a client reports not being able to smell coffee and most foods. Which cranial nerve function would the nurse assess? a. I b. II c. X d. VII

which catecholamine receptor is responsible for increased heart rate? a. beta-1 b. beta-2 c. alpha-1 d. alpha-2

which clinical manifestation is associated with cellulitis? a. lymohadenopathy b. occasional papules c. vesicles that evolve into pustules d. isolated erythematous pustules

which component of skin maintains optima barrier function? a. keratin b. melanin c. collagen d. adipose tissue

which developmental conflict affects a 4-year-old according to Erikson's stages of development? a. initiative v guilt b. industry v inferiority c. trust v mistrust d. autonomy v shame

which feature is associated with the "maturation phase" of normal wound healing? a. the scar is firm and inelastic on palpation b. fibrin strands form a scaffold or framework c. WBCs migrate into the wound d. epithelial cells are grown over the granulation tissue bed

which hormone has both inhibiting and releasing action? a. prolactin b. somatostatin c. somatotropin d. gonadotropin

which hormone is released from the posterior pituitary gland? a. oxytocin b. prolactin c. growth hormone d. luteinizing hormome

which information would the nurse focus on when teaching a high school student about scoliosis? a. effect on body image b. least invasive treatment c. continuation with schooling d. maintenance of contact with peers

which phrase describes the function of the limbic system? a. influence emotional behavior b. regulate autonomic functions c. facilitate automatic movements d. relay sensory and motor inputs for cerebrum

which treatment would the nurse anticipate for an infant admitted with bronchiolitis caused by RSV? a. humidified cool air and adequate hydration b. postural drainage and oxygen by hood c. bronchodilators and cough suppressants d. corticosteroids and broad-spectrum antibiotics

which type of hepatitis spreads through contaminated food and water? a. hepatitis A b. hepatitis B c. hepatitis C d. hepatitis D

Arrange the stages of the menstrual cycle in sequential order. a. follicular phase b. follicular involution c. feedback mechanism d. ovulation

a --> d --> b --> c

The nurse is preparing to administer methylphenidate to an older adult with apathy and depression. Which assessment would be inlcuded to monitor for complications? a. vision b. weight c. heart rate d. skin turgor e. bowel sounds

a, b, c

Which alternative treatments would a nurse recommend to help ease a young child's pain at home? Select all that apply. a. yoga b. biofeedback c. guided imagery d. spinal manipulation e. herbal supplements

a, b, c

Which clinical manifestation of withdrawal will the nurse expect to identify in a newborn of a known opioid user? Select all that apply. a. Sneezing b. Hyperactivity c. High-pitched cry d. Exaggerated Moro reflex e. Reduced deep tendon reflexes f. Constipation g. Somnolence h.Increased feeding

a, b, c, d

Which information about deacreasing the risk for complications would the nurse provide to a pregnant adolescent who remains sexually active with other partners? Select all that apply. a. calcium consumption b. exercise c. folic acid d. condom use e. prenatal care

a, b, c, d, e

Which instruction would the nurse include when teaching the client how to perform peritoneal dialysis and the importance of preventing peritonitis? Select all that apply. a. wear a mask during the procedure b. clean the catheter exit site daily c. maintain meticulous aseptic technique d. wash your hands before the exchange e. store supplies in a clean and dry location

a, b, c, d, e

Which intervention would the nurse include in the plan of care for a client admitted with herpes zoster? a. acyclovir b. silvadene c. gabapentin d. wet compresses e. contact isolation

a, b, c, d, e

Which action would the nurse include in the plan of care for a client who is being treated for a STI and reports fever and irregular bleeding? Select all that apply. a. use of analgesics b. abdominal palpation c. CBC d. culture of cervical canal e. administration of antibiotics as prescribed f. teaching about negative effects of douching

a, b, c, d, e, f

Which symptom indicates pelvic inflammatory disease? Select all that apply. a. fever b. elevated ESR c. chronic pelvic pain d. irregulae vaginal bleeding e. abnormal vaginal discharge f. bilateral adnexal tenderness

a, b, c, d, e, f

Which recommendation would the nurse make for a pregnant client experiencing nausea and vomiting? Select all that apply. a. Avoid an empty or excessively full stomach b. Drink real ginger ale or tea, or use real ginger in another recipe c. Try sucking on sour candies or smelling a citrus-scented food or product d. Eat crackers or vanilla wafers or drink a small amount of liquid before getting out of bed e. Try eating three good-sized meals throughout the day f. Eat carbohydrate-rich, low-fat meals throughout the day, such as toast, oatmeal, or noodle soup g. Locate the pressure points to reduce nausea in the middle of the wrist and press firmly for 3 minutes h. Maintain a good posture.

a, b, c, d, f, g, h

What information should the nurse include in a teaching plan about the onset of menopause? Select all that apply a. Smoking. b. Oophorectomy with hysterectomy. c. Early menarche. d. Cardiac disease. e. Genetic influence. f. Chemotherapy exposure.

a, b, c, e, f

Which consideration would be included in caring for an infant who is failing to thrive (FTT)? a. dietary history b. signs of malnutrition c. familial stress factors d. 75th percentile for weight e. parent and infant interaction f. sustained growth under 5th percentile

a, b, c, e, f

Which clinical manifestations will the nurse expect when caring for a client with a diagnosis of pulmonary edema? Select all that apply. a. Crackles b. Coughing c. Orthopnea d. Yellow sputum e. Anxiety f. Dependent edema g. Restlessness h. Lethargy

a, b, c, e, g, h

The newborn is prone to hypothermia because: (Select all that apply) a. blood vessels are close to skin surface b. there is minimal subcutaneous fat c. newborns tend to shiver a lot d. newborns have large body surface to body weight ratio

a, b, d

When assessing a client with varicose veins, which clinical manifestation would the nurse expect to find? a. Presence of ankle edema b. Increased leg fatigue c. Diminished peripheral pulses d. Report of leg fullness and pruritus e. Leg pain with activity that resolves with rest f. No hair on lower extremities g. Thickened toenails h. Pallor to bilateral lower extremities

a, b, d

Which clinical manifestation will the nurse expect to assess in a client experiencing marijuana withdrawal? Select all that apply. a. Depression b. Chills c. Red eyes d. Abdominal pain e. Increased appetite f. Reduced short-term memory g. Impaired coordination h. Dry mouth

a, b, d

Which foods are considered the most allergenic? Select all that apply. a. milk b. eggs c. apples d. peanuts e. bananas

a, b, d

Which educational statements regarding the use of long-acting naltrexone would the nurse use for this client? Select all that apply. a. "You may have nausea, vomiting, and diarrhea while taking this medication." b. "Taking too much naltrexone will damage your liver." "c. If you miss a dose, take 2 doses to catch up." d. "Notify your doctor if you have right-sided upper stomach pain." e. "There is a once-per month injectable version." f. "Using opioids while on naltrexone will not give you the sedative effect you are used to." g. "It's important to take this medicine at the same time every day." h. "Be careful driving because dizziness and sleepiness are side effects."

a, b, d, e, f, h

The nurse is inspecting the abdomen of an 18-month-old child. Which method would the nurse adopt to inspect for inguinal hernia? Select all that apply. a. Visualize the inguinal sacral area for obvious bulging. b. Have the child blow a bubble. c. Palpate the umbilicus for abdominal contents. d. Get the child to laugh to raise the intra-abdominal pressure. e. Palpate the hernia sac for ovaries in a female client. f. Place the index finger of the right hand on the child's right femoral pulse. g. Slide the little finger into the external inguinal ring while having the child cough. h. Examine the client in both standing and supine positions.

a, b, d, e, h

When a client with heart failure is seen in the clinic with new onset ankle edema, the nurse would question the client about which lifestyle factor that may have contributed to the ankle swelling? Select all that apply. a. Intake of salty foods b. Increased fluid consumption c. Dietary fat intake d. Medication compliance e. Family stresses f. Recent travel g. Alcohol intake h. Increased physical activity

a, b, d, f, g

Which medication would the nurse question if prescribed for a pregnant client? Select all that apply. a. Warfarin b. Phenytoin c. Citalopram d. Isotretinoin e. Fluoxetine f. Clavulanate g. Methotrexate h. Sertraline

a, b, d, f, g

Which gerontological assessment finding of the auditory system is related to the inner ear? Select all that apply. a. hair cell degeneration b. reduced blood supply to the cochlea c. atrophic changes of the tympanic membrane d. decline in the ability to filter out unwanted sounds e. less effective vestibular apparatus in the semicircular canals

a, b, e

The nurse is preparing a client for orthopedic surgery on the left leg and completing a safety checklist before transport to the operating room. Which items should the nurse remove from the client? (Select all that apply.) a. Nail polish. b. Hearing aid. c. Wedding band. d. Left leg brace. e. Contact lenses. f. Partial dentures.

a, b, e, f

Which clinical manifestation of withdrawal will the nurse expect to assess in a client recently hospitalized with an opioid use disorder? Select all that apply. a. Lacrimation b. Yawning c. Drowsiness d. Constipation e. Muscle aches f. Nausea and vomiting g. Cold flushes h. Anxiety

a, b, e, f, g, h

Select the 5 assessment findings that are consistent with acute rheumatic fever. a. Murmur b. Opening snap c. Split S2 d. Epigastric discomfort e. Joint pain f. Painless nodules over elbows g. Constipation h. Alcohol consumption i. Previous sore throat and upper respiratory infection

a, b, e, f, i

Which STI is caused by bacteria? Select all that apply. a. syphilis b. hepatitis c. gonorrhea d. herpes simplex e. trichomoniasis

a, c

Which behavior pattern may be exhibited by teenagers in late adolescence? Select all that apply. a. concealed temper b. introspective nature c. consistent emotions d. feeling of inadequacy e. intense daydreaming

a, c

Which diseases would the nurse include when teaching a parent about viruses? Select all that apply. a. mumps b. tetanus c. measles d. hepatitis B e. diptheria

a, c, d

Which preventative wellness recommendation will the nurse make to a male client who tests positive for the BRCA mutation after his mother and two sisters are found to carry the gene? Select all that apply. a. get a baseline mammogram at 40 years b. get a prostate screening starting at 50 years c. get breast self-examination training (BSE) at 35 years d. get a clinical breast examination (CBE) every 6 months starting at 35 years e. get a CBE every 6 months beginning at 40 years

a, c, d

The nurse plans to teach the patient about nausea and vomiting of pregnancy. Select the 5 priority teaching points for a patient with nausea and vomiting of pregnancy. a. Eat a small number of crackers or toast before getting out of bed in the morning. b. Be sure to consume enough calories by eating three meals every day. c. Eat a snack with protein, such as peanut butter, before bedtime. d. Signs of dehydration include excessive thirst, tachycardia, fever, and concentrated urine. e. Take your prenatal vitamin first thing in the morning. f. Onions, cabbage, and curry tend to help to prevent nausea. g. Some women find it helpful to experiment with food combinations such as sweet and salty or sweet and sour to prevent nausea. h. Ask your healthcare provider before you take herbal remedies or medication for your nausea and vomiting. i. Avoid sucking on hard candy.

a, c, d, g, h

Which presumptive sign of pregnancy will the nurse expect to find when assessing a client at 10 weeks' gestation? Select all that apply. a. Amenorrhea b. Hegar sign c. Breast changes d. Urinary frequency e. Chadwick sign f. Abdominal enlargement g. Headaches h. Nausea

a, c, d, h

When a client develops internal bleeding after abdominal surgery, which clinical manifestation would the nurse expect the client to exhibit? a. Pallor b. Polyuria c. Decreased mean arterial pressure (MAP) d. Bradypnea e. Tachycardia f. Hypertension g, Increased pulse pressure h. Warm skin temperature

a, c, e

Which birth factor places the neonate at risk for SIDS? Select all that apply. a. birth order b. postmaturity c. multiple births d. method of delivery e. low apgar scores

a, c, e

Click to highlight the 3 assessments that the nurse would perform to assess readiness for introduction of solid foods. a. Head control b. Pincer grasp c. Extrusion reflex d. Tonic neck reflex e. Drinks from a straw f. Swallow coordination

a, c, f

The father of a newborn asks, "Why does he need to have a shot already?" Your explanation to him is based on the knowledge that: (Select all that apply) a. newborns are unable to synthesize vitamin K due to absence of intestinal flora at birth b. vitamin K is necessary to prevent the occurrence of physiologic jaundice in newborns c. vitamin K provides protection from infection during the first week after birth d. vitamin K is needed to prevent bleeding problems in the early neonatal period

a, d

which hormones are secreted by the posterior pituitary gland? Select all that apply. a. oxytocin b. prolactin c. corticotropin d. ADH e. melanocyte-stimulating hormone

a, d

Which physiological changes that occurs with aging causes stress incontinence? Select all that apply. a. estrogen deficiency b. prostatic enlargement c. decrease bladder capacity d. decreased sensory receptors e. unstable bladder contractions f. weakening of the urinary sphincter

a, f

A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which nurse should be assigned to care for this client? a. The nurse who is caring for another client receiving intracavitary radiation. b. A nurse with Marfan's syndrome who is postmenopausal. c. A nurse with oncology experience who may be pregnant. d. The nurse who is caring for another client who has Clostridium difficile.

A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer? a. Osteoporosis is a progressive genetic disease with no effective treatment. b. Calcium loss from bones can be slowed by increasing calcium intake and exercise. c. Estrogen replacement therapy should be started to prevent the progression osteoporosis. d. Low-dose corticosteroid treatment effectively halts the course of osteoporosis.

A 6-year-old squirms and giggles when the nurse begins to palpate the abdomen. What action should the nurse implement? a. Postpone the abdominal palpation until the next examination. b. Place the child's hand under the examiner's hand while palpating. c. Touch the abdomen firmly as the child takes short, quick breaths. d. Press the abdomen with the child bearing down and holding the breath.

A client at 29-weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client? a. Amniocentesis. b. Ultrasonography. c. Chorionic villus sampling. d. Maternal serum alpha-fetoprotein.

A client comes in to the clinic for her six week postpartum check up and complains that her left breast is eythematous and painful. The client asks, "Can I still breastfeed my baby?" What is the best response for the nurse to provide? a. Advise to stop breastfeeding until the infection clears. b. Inform the client to continue breastfeeding. c. Begin all feedings with the infected breast. d. Tell the client to pump then discard the milk from the affected breast.

A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission? a. Administer thiamine (B1) to prevent Korsakoff's syndrome. b. Monitor for increased blood pressure and pulse. c. Administer a PRN benzodiazepine as needed for anxiety. d. Encourage fluid intake of non-caffeinated beverages.

A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the nurse take? a. Notify the healthcare provider immediately and prepare for administration of an antidote. b. Notify the healthcare provider of the symptoms prior to the next administration of the drug. c. Record the symptoms as normal side effects and continue administration of the prescribed dosage. d. Hold the medication and refuse to administer additional amounts of the drug.

A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination week at college. Which outcome is most important for the nurse to include in the plan of care? a. Sleeping six to eight hours. b. Achieve a sense of control. c. Utilize problem solving skills. d. Increased focus of attention.

A client with hepatic cirrhosis begins to exhibit slurred speech, confusion, drowsiness, and a flapping tremmor. Based upon this assessment, which prescribed diet would the nurse anticipate? a. no protein b. moderate protein c. high protein d. strict protein restriction

A client's family asks why their mother with heart failure needs a pulmonary artery (PA) catheter now that she is in the intensive care unit (ICU). What information should the nurse include in the explanation to the family? a. A central monitoring system reduces the risk of complications undetected by observation. b. A pulmonary artery catheter measures central pressures for monitoring fluid replacement. c. Pulmonary artery catheters allow for early detection of lung problems. d. The healthcare provider should explain the many reasons for its use.

A frail, elderly client is admitted to the unit with a diagnosis of pneumonia. Which finding is most important for the registered nurse (RN) to report to the healthcare provider? a. Fever and chills. b. Confusion and dehydration. c. Crackles in lung fields. d. Nausea and vomiting.

A full-term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? a. The length of labor and method of delivery. b. The infant's condition at birth and treatment received. c. The feeding method chosen by the parents. d. The history of drugs given to the mother during labor. Submit

A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response? a. Bradycardia. b. Increase in pulse rate. c. Peripheral vasodilation. d. Increase in cardiac output.

A man who was recently diagnosed with Huntington's disease asks the nurse if his adolescent son should be tested for the disease. What response is best for the nurse to provide? a. Autosomal dominant disorders, such as Huntington's, cannot be inherited from the parent. b. Genetic counseling should be obtained prior to undertaking any genetic testing procedure. c. Testing is needed in adolescents because of the risk of passing the gene to each offspring. d. Positive genetic testing may contribute to insurance discrimination that denies coverage.

A mother whose son has acute glomerulonephritis (AGN) is fearful that her other children may contract the disorder. Which response would the nurse tell the mother about the origin of AGN? a. "The disorder is difficult to prevent beacause the cause is unknown." b. "it is a result of an autoimmune response after a streptococcal infection." c. "it is transmitted through a sex-linked chromosome that occurs only in males." d. "the disorder is caused by clot formation in the kidney tubules as a response to an infection."

A primigravida who is at 40 weeks' gestation arrives with abdominal cramping and a bloody show. Her membranes ruptured 30 minutes before arrival. A vagonal examination reveals 1 cm of dilation and the presenting part at -1 station. Which action would the nurse take after obtaining the fetal HR and maternal vitals? a. teach the client how to push with each contraction b. provide the client with comfort measures for relaxation c. prepare to have the client's blood typed and cross-matched d. encourage the client to perform patterned, paced breathing

A young adult male client, diagnosed with paranoid schizophrenia, believes that world is trying to poison him. What intervention should the nurse include in this client's plan of care? a. Remind the client that his suspicions are not true. b. Ask one nurse to spend time with the client daily. c. Encourage the client to participate in group activities. d. Assign the client to a room closest to the activity room.

An adolescent client with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a PCA pump. The current pain rating is 5 out of 10 at the right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. Which action would the nurse implement? a. turning on the TV for diversion b. placing the prescribed as-needed warm, wet compress on the elbow c. calling the provider for another analgesic prescription d. informing the client gently that they must wait until the pump reactivates to get more medicine

An older client who recently moved into an assisted living community refuses to eat or join any activities. When evaluating the client further, what should the registered nurse (RN) focus on during the next examination? a. Anxiety. b. Depression. c. Exhaustion. d. Confusion.

An older male client is admitted for emergency treatment of acute closed-angle glaucoma. The registered nurse (RN) begins administering the prescribed miotic medications and glycerin (Glycol)therapy. Which intervention is most important for the RN to maintain during the client's therapy? a. Maintain lighting control in the room during therapy. b. Monitor intake and output q2 hours for 24 hours. c. Place an eye patch over the affected eye during sleep. d. Administer the eye drops at the scheduled intervals.

During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not moving. What action should the nurse take first? a. Use a laryngoscope to check for a foreign body lodged in the esophagus. b. Reposition the head to validate that the head is in the proper position to open the airway. c. Turn the client to the side and administer three back blows. d. Perform a finger sweep of the mouth to remove any vomitus.

In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement? a. Elevate the head of the bed and attempt to palpate the site again. b. Document the presence and volume of the pulse palpated. c. Use a thigh cuff to measure the blood pressure in the leg. d. Record the presence of pitting edema in the inguinal area.

Prior to a cardiac catheterization, which activity should the nurse have the client practice? a. Flexing hips and knees bilaterally. b. Valsalva's maneuver and coughing. c. Talking while walking on a treadmill. d. Remain motionless for 5 minutes.

The charge nurse working the 3 to 11 shift of a 24-bed medical unit in a large acute care hospital is making assignments. Currently, there are 20 clients on the unit and 4 admissions are scheduled to arrive during the shift. Besides the charge nurse, the staff consists of two experienced practical nurses (PN) and one UAP who has worked on the unit for 10 years. Taking into consideration the acuity of each client, which distribution of clients is the best assignment for the nurse to make? a. 10 clients and 2 admissions to each of the PNs. Have the UAP take all vital signs and collect all I&Os. b. 10 clients to each of the PNs. Have the UAP take vital signs. The charge nurse takes the 4 new admissions. b. 8 clients to each of the PNs, 4 clients to the charge nurse, and the 4 admissions to the UAP. c. 8 clients to each of the PNs, 4 admissions to the charge nurse, and 4 low-acuity clients to the UAP.

The daughter of an older woman who became depressed following the death of her husband asks, "My mother was always well-adjusted until my father died. Will she tend to be sick from now on?" Which response is best for the nurse to provide? a. "She is almost sure to be less able to adapt than before." b. "It's highly likely that she will recover and return to her pre-illness state." c. "If you can interest her in something besides religion, it will help her stay well." d. "Cultural strains contribute to each woman's tendencies for recurrences of depression."

The healthcare provider prescribes a new medication, atrovastatin (Lipitor), for an older client who arrives at the clinic for an annual physical examination. What common side effect should the registered nurse (RN) advise the client to observe for with this medication? a. Constipation. b. Headaches. c. Muscle weakness. d. Nausea and vomiting.

The nurse cares for a client with an abnormal cortisol level. The nurse recalls which information about cortisol? a. cortisol metabolizes free fatty acids b. cortisol stimulates gluconeogenesis c. cortisol stimulates protein synthesis d. cortisol levels decline in stressful situations

The nurse explains to the parents of a child with a pinworm infestation how pinwprms are transmitted, Which statement indicates that the teaching has been understood? a. "we need to keep the cat off the bed" b. "she needs to wash her hands before eating anything" c. "she needs to cover her mouth whenever she coughs" d. "we need to tell the school so that the cafeteria can be cleaned"

The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? a. Check for a blood return. b. Reposition the client's arm. c. Remove the IV site dressing. d. Flush the lock with saline.

The nurse is caring for a 9-year-old male child who frequently speaks about sex and uses correct sexual vocabulary. What action should the nurse implement with this child? a. Ask the child whether he was sexually abused. b. Ascertain what the child understands about sex. c. Inquire where the child got this important information. d. Involve the child in teaching sex information to peers.

The nurse is planning care for a client who has a right hemispheric stroke. Which nursing diagnosis should the nurse include in the plan of care? a. Impaired physical mobility related to right-sided hemiplegia. b. Risk for injury related to denial of deficits and impulsiveness. c. Impaired verbal communication related to speech-language deficits. d. Ineffective coping related to depression and distress about disability.

The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the healthcare provider? a. Expresses fear about the surgical procedure. b. Recalls drinking a glass of juice after midnight. c. Reports a history of hives after eating shellfish. d. States has a history of post-operative nausea.

The nurse is preparing to administer atropine, an anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain the reason for the prescribed medication. What response is best for the nurse to provide? a. Provide a more rapid induction of anesthesia. b. Decrease the risk of bradycardia during surgery. c. Induce relaxation before induction of anesthesia. d. Minimize the amount of analgesia needed postoperatively.

The nurse is preparing to give a client dehydration IV fluids delivered at a continuous rate of 175 ml/hour. Which infusion device should the nurse use? a. Portable syringe pump. b. Cassette infusion pump. c. Volumetric controller. d. Nonvolumetric controller.

The nurse is providing care to an immobile client who was admitted for exacerabtion of COPD. Which nursing intervention is priority when the client becomes short of breath during care? a. obtain a pulse oximeter b. put the client in high Fowler's position c. darken the lights and provide a rest period of at least 15 minutes d. continue the hygiene activities while reassurign the client

The nurse leader teaches the student nurse about the quality assurance (QA) process. Which statement made by the student nurse indicates ineffective learning? a. "The goal is to improve quality." b. "the major task is staff development." c. "the focus is on discovery and correction of errors. d. "the outcomes are set by the QA team with input from staff."

The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of "heart trouble," but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action is best for the nurse to implement? a. Ask the client what he means by "heart trouble." b. Call for an ECG to be performed immediately. c. Notify surgery that the ECG is over two years old. d. Notify the client's surgeon immediately.

The nursing manger wants to transfer a nurse to the intensive care unit (ICU) and describes the roles and responsibilities of the position in detail to the nurse. After disclosing all details, the nurse manager inquires about the nurse's decision. Which type of principle is the nurse manger following? a. Justice b. Veracity c. Nonmaleficence d. Respect for others

The parents of an infant who is to undergo insertion of a right ventriculoperitoneal shunt for hydrocephalus are taught about postop positioning that helps prevent pressure on the vavle site. Which statement indicates that they understand the teaching? a. "We'll place her in the position that seems comfortable." b. "the flat left side-lying position is the safest position." c. "we should place her on her back with a small support under the neck." d. "the right side-lying position with the head supported is the best position."

The registered nurse (RN) is caring for an older female client with a 20 year history of rheumatoid arthritis (RA), who is admitted for carpel tunnel release. Which finding associated with RA should the RN document? a. Asymmetrical joint deformity. b. Small joint involvement in fingers. c. Crepitation or grating sensation in joints. d. Weight bearing joint involvement

What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? a. Maintain in a lateral position using protective wrist and vest devices. b. Position prone with a small pillow below the diaphragm. c. Raise the head and knee gatch when lying in a supine position. d. Transfer into a wheelchair close to the nurse's station for observation.

What action should the nurse implement when adding sterile liquids to a sterile field? a. Use an outdated sterile liquid if the bottle is sealed and has not been opened. b. Consider the sterile field contaminated if it becomes wet during the procedure. c. Remove the container cap and lay it with the inside facing down on the sterile field. d. Hold the container high and pour the solution into a receptacle at the back of the sterile field.

What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta? a. Maternal bradycardia. b. Hard, board-like abdomen. c. Decrease in fundal height. d. Decrease in abdominal pain.

When a client with cancer reaches an incurable last stage, which priority need of the client does the nurse address by explaining the situation to the client and calling the client's family members to provide support? a. safety b. belonging c. self-esteem d. self-actualization

When caring for an immobile client, what nursing diagnosis has the highest priority? a. Risk for fluid volume deficit. b. Impaired gas exchange. c. Risk for impaired skin integrity. d. Altered tissue perfusion.

Which B vitamin deficiency will result in Wernicke encephalopathy? a. B3 (niacin) b. B1 (thiamine) c. B2 (riboflavin) d. B6 (pyridoxine)

Which action would promote psychological adjustment and early function after a teenager with a dignosis of osteosarcoma has the affected leg amputated? a. allow the client to change the first dressing b. help the client adjust to the temporary prosthesis c. assign the client to a room with another adolescent d. have the client meet with a member of a cancer survivor organization

Which age group has the highest incidence of lead poisoning? a. adult b. toddler c. adolescent d. school-aged children

Which autoimmune disease can result in damage to the heart? a. uveitis b. rheumatic fever c. myasthenia gravis d. graves disease

Which behavior would the nurse consider suitable for an executive position according to Gardner's tasks of leading/managing? a. to inspire clients/families to achieve their vision b. to assist corporate leaders with planning and priority setting c. to inspire the staff to achieve the mission of the organization d. to ensure the organization systems work on the client's behalf

Which client should the nurse recognize as most likely to experience sleep apnea? a. Middle-aged female who takes a diuretic nightly. b. Obese older male client with a short, thick neck. c. Adolescent female with a history of tonsillectomy. d. School-aged male with a history of hyperactivity disorder.

Which explanation will the nurse give when a client asks about what causes varicose veins? a. "abnormla configuration of the veins" b. "incompetent valves of superifical veins" c. "decreased pressure within the deep veins" d. "atherosclerotic plaque formation in the veins"

Which food item would the nurse instruct a client whose pathology report states a urinary calculus is composed of uric acid to avoid? a. milk b. liver c. cheese d. vegetables

Which hormone would the nurse identify as inhibiting insulin and glucagon secretion? a. amylin b. somatostatin c. triiodothyronine (T3) d. pancreatic polypeptide

Which infection would the nurse identify as requiring a client to be placed on droplet precautions? a. HIV b. influenca c. TB d. MRSA

Which intervention should the nurse plan to implement when caring for a client who has just undergone a right above-the-knee amputation? a. Maintain the residual limb on three pillows at all times. b. Place a large tourniquet at the client's bedside. c. Apply constant, direct pressure to the residual limb. d. Do not allow the client to lie in the prone position.

Which intervention would the nurse recommend if a tennegar with a cast experiences pruritis around the cast edges? a. "scratch the itchy area gently" b. "put an ice pack on the affected area" c. "sprinkle a layer of powder around the itchy spots" d. "ask your doctor for a prescription for an antihistamine"

Which intervention would the nurse suggest to promote comfort for a UTI? a. sitz baths b. drinking water c. leaning forward while sitting up d. pouring cool water over the perineum

Which is prevented by providing warm, humidified oxygen to a preterm infant? a. apnea b. cold stress c. respiratory distress d. bronchopulmonary dysplasia

Which is the goal of critical incident stress debriefing (CISD) after a disaster? a. evaluate the outcomes of the care provided b. prevent PTSD c. ensure all documentation has been completed d. determine if role assignments need to be adjusted

Which is the recommended size of the urinary catheter that can be used in a 3-year-old child? a. 5 to 6 Fr b. 8 to 10 Fr c. 14 to 16 Fr d. 16 to 18 Fr

Which nonpharmalogical nursing intervention is effective in helping relieve postop pain? a. ambulation b. repositioning c. purse-lipped breathing d. deep breathing and coughing

Which nursing actions would be included in the plan of care for a child with acute poststreptococcal glomerulonephritis? a. encouraging fluids b. monitoring for seizures c. measuring abdominal growth d. checking for pupillary reactions

Which nursing intervention is an example of a competent performance criterion for an occupational and environmental health nurse? a. Serves as a consultant to businesses and management. b. Implements health programs for construction workers. c. Designs quality improvement methods that measure health outcomes. d. Conducts research studies that enhance health safety.

Which parent teaching would the nurse provide the parents of an infant being discharged after surgery for pyloric stenosis? a. "offer the baby creamy cereal at each feeding and follow it with regular formula." b. "hold the baby while continuing to feed a regular formula slowly and burp frequently." c. "allow the baby to drink about 1 oz (30 mL) of a regular formula per hour for a week, and progress slowly to larger amounts." d. "place the baby on the right side in the crib during feedings with regular formula and minimize handling for 2 hours after feeding."

Which parental statement indicates the need for further education related to the potential for poor growth in an infant newly diagnosed with cystic fibrosis (CF)? a. "My child's diagnosis is associated with delayed bone growth." b. "my child will have a poor appetite, which will lead to poor growth." c. "my child will have increased oxygen demands, which will lead to poor growth." d. "my child will have a decreased ability to absorb nutrients, which will cause poor growth."

Which principles of body mechanics would the nurse use when providing care for an immbolized client? a. bending at the wait to provide the power for lifting b. placing the feet apart to increase the stability of the body c. keeping the body straight when lifting to reduce pressure on the abdomen d. relaxing the abdominal muscles while using the extremities to prevent strain

Which research finding provides evidence-based practice for an infant's risk for sudden infant death syndrome (SIDS)? a. Breastfeeding reduces the risk for and the incidence of SIDS. b. Infants should be positioned supine or supported laterally to sleep. c. The prone position should be used when an infant sleeps after feeding. d. The peak incidence occurs between the ages of 1 and 2 months.

Which stage of HIV would a client with a CD4+ T-cell count of 325 cells/mm3 be classified? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

Which statement describes the role of the plasma cell in the antigen-antibody response? a. makes an antigen harmless without destroying it b. produces antibodies against the sensitizing agent c. produces antibodies after an exposure to a known agent d. clumps antibody-antigens linkages together to form immune complexs

Which symptoms should the nurse expect a client to exhibit who is diagnosed with a pheochromocytoma? a. Numbness, tingling, and cramps in the extremities. b. Headache, diaphoresis, and palpitations. c. Cyanosis, fever, and classic signs of shock. d. Nausea, vomiting, and muscular weakness.

Which technique is the most important therapeutic tool a nurse should use to provide quality care to a psychiatric client? a. Context. b. Self-analysis. c. Counter transference. d. Therapeutic self-disclosure.

Which technique would the nurse employ for an OB client with a foreign body airway obstruction? a. back blows b. chest thrusts c. suprapublic thrusts d. abdominal thrusts

Which technique would the nurse suggest to a laboring woman's partner that involves gently stroking the woman's abdomen in rhythm with her breathing during a contraction? a. massage b. effleurage c. acupressure d. counterpressure

Which type of needs would the nurse identify as an intermediate priority? a. developmental needs b. potential needs c. needs related to survival d. needs that affect safety

Which urine characteristic is consistent with a UTI? a. smoky b. cloudy c. orange-amber d. yellow-brown

Which volume of solution would be prepared for a cleansing enema for a 3-year-old child? a. 150 to 250 mL b. 250 to 350 mL c. 300 to 500 mL d. 500 to 750 mL

Which would be included in the plan of care for an OB client who has been taking carbamazepine throughout the first trimester? a. evaluation for fetal hydramnios b. evaluation for neural tube defects c. evaluation for cardiac malformation d. chromosomal assessment for down syndrome

While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document? a. Molding. b. Cephalohematoma. c. Caput succedaneum. d. Bulging fontanel.

Why is a multiple-gestation pregnancy considered a high risk? a. Postpartum hemorrhage is an expected complication. b. Perinatal mortality is two to three times more likely in multiple than in single births. c. Optimal psychological adjustment after a multiple birth requires 6 months to 1 year. d. Maternal mortality is higher during the prenatal period in the setting of multiple gestation.

which cation regulates intracellular osmolarity? a. sodium b. potassium c. calcium d. calcitonin

which food item will a client with TB and taking isoniazid be advised to avoid to prevent a reaction? a. hot dogs b. red wine c. sour cream d. grapefruit

which fungal infection does the client refer to as "jock itch"? a. tinea pedis b. tinea cruris c. tinea corporis d. tinea unguium

which lobe of the brain would the nurse conclude is affected in a client unable to differentiate between heat or cold and sharp or dull sensory stimulation? a. frontal b. parietal c. occipital d. temporal

which mechanism of action would a nurse recall when using wet-to-damp saline moistened gauze for wound debridement? a. promoting the dilution of viscous exudate b. removing the necrotic tissue mechanically c. causing a breakdown of the denature protein of the eschar d. promoting the spontaneous separation of necrotic tissue

which nursing intervention would the nurse direct toward a child admitted for acute glomerulonephritis? a. enforcing bed rest b. promoting diuresis c. encouraging fluids d. removing dietary salt

which organ has beta-1 receptors? a. liver b. heart c. bladder d. pancreas

which skin infection would cause facial paralysis? a. candidiasis b. herpes zoster c. herpes simplex d. dermatophytosis

according to freud's theory in what order do the stages of child development occur? a. anal b. oral c. latency d. genital e. oedipal

b --> a --> e --> c --> d

Which are signs/behaviors that characterize the transition stage of labor? (Select all that apply)? a. lethargy b. physical shaking c. reluctance to be touched d. amnesia between contractions e. diaphoresis

b, c, d, e

Which statements regarding acne are correct? Select all that apply. a. acne is a hormonal disease b. acne may be caused by stress c. family history could be a reason for acne d. Propionibacterium acnes causes acne e. acne is commonly found on the face, chest, upper back, and neck

b, c, d, e

A client with long-term cocaine use presents with paranoia. Which additional clinical manifestation will the nurse monitor for? Select all that apply. a. Extreme hunger b. Chest pains c. Panic attacks d. Nasal damage e. Severe dental problems f. Dysphagia g. Loss of smell h. Puncture marks

b, c, d, f, g, h

Which actions by staff of a mental health unit can lead to client violence? Select all that apply. a. displaying hyperactivity b. inconsistent limit setting c. controlling staff members d. avoiding direct eye contact e. randomly taking away privileges

b, c, e

While assessing a pediatric client, a nurse notices that the child is unable to focus on an object with both eyes simultaneously. Which other finding in the client will suggest strabismus? Select all that apply. a. Impaired near vision b. Crossed appearance of eyes c. Red eye reflection in one eye d. Elevated intraocular pressure e. Impaired extraocular muscles f. Degeneration of central retina g. Tilting of head to look at something h. Squinting one eye to focus

b, c, e, g, h

Which are the leading causes of accidental death in infants under 1 year? Select all that apply. a. falls b. drowning c. aspiration d. suffocation e. motor vehicle-related injuries

b, d, e

The nurse is assessing a pregnant 16-year-old client. Which factor associated with adolescent pregnancy would the nurse consider when developing a plan of care for this client? Select all that apply. a. Increased risk of gestational diabetes b. Higher rate of postpartum depression c. Elevated mortality rate d. Inappropriate dietary choices e. Higher rate of anemia f. More prevalent chromosomal abnormalities g. Incomplete bone mass h. Undeveloped secondary sex characteristics

b, d, e, g

A client with a large fetus is to have a pudendal block during the second stage of labor. Which education will the nurse plan to provide regarding the effectiveness of the block? Select all that apply. a. Contractions will decrease. b. Perineal pain will not be felt. c. Bladder sensation may be lost. d. An episiotomy may not be needed. e. The bearing-down reflex will be diminished. f. Fetal heart rate can be reduced. g. Contraction-related pain continues. h. Can affect maternal hemodynamics.

b, e, g

A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. Which assessment finding would provide the nurse the earliest indication that the client is experiencing primary side effects of terbutaline sulfate? a. Drowsiness and bradycardia. b. Depressed reflexes and increased respirations. c. Tachycardia and a feeling of nervousness. d. A flushed, warm feeling and a dry mouth.

A 5-year-old child who is one day postoperative has bilateral eye patches in place and should be out of bed. What nursing intervention should be implemented first before leaving the bedside? a. Speak to the child when entering the room. b. Allow the child to assist in feeding himself. c. Orient the child to the immediate surroundings. d. Allow the parents to stay in the room with the child.

A 67-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor probably led to the fracture in the proximal end of her femur? a. Failing eyesight resulting in an unsafe environment. b. Renal osteodystrophy resulting from chronic renal failure. c. Osteoporosis resulting from hormonal changes. d. Cardiovascular changes resulting in small strokes which impair mental acuity.

A client has been taking oral corticosteroids for the past five days because of seasonal allergies. Which assessment finding is of most concern to the nurse? a. White blood count of 10,000 mm3. b. Serum glucose of 115 mg/dl. c. Purulent sputum. d. Excessive hunger.

A client is admitted to the Emergency Department with a tension pneumothorax. Which assessment should the nurse expect to identify? a. An absence of lung sounds on the affected side. b. An inability to auscultate tracheal breath sounds. c. A deviation of the trachea toward the side opposite the pneumothorax. d. A shift of the point of maximal impulse to the left, with bounding pulses.

A client is admitted with a medical diagnosis of Addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations? a. Thin, fragile skin, ecchymoses, and complaints of weakness. b. Headache, diaphoresis, and palpitations. c. Hypotension, rapid weak pulse, and rapid respiratory rate. d. Abrupt onset of hyperpyrexia, extreme tachycardia, and delirium.

A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? a. Hydrogel. b. Exudate absorber. c. Wet to moist dressing. d. Transparent adhesive film.

A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse implement next? a. Notify the healthcare provider. b. Measure the blood pressure. c. Administer the medication. d. Reassess the apical pulse.

A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pad are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next? a. Cleanse the perineum. b. Obtain a blood pressure. c. Palpate the firmness of the fundus. d. Inspect the perineum for lacerations.

A client who had a miscarriage at 10-weeks gestation tells the nurse that she already purchased some baby things and picked out a name. After the surgical dilation and curettage (D&C), the client wants to go home as soon as possible. Based on the client's statements, which action should the nurse implement? a. Ready the client for discharge. b. Notify pastoral care to offer the client a blessing. c. Ask the client what name she had picked out for the infant. d. Inquire if the client would like to see what was obtained from her D&C.

A deficiency of intrinsic factor should alert the nurse to assess a client's history for which condition? a. Emphysema. b. Hemophilia. c. Pernicious anemia. d. Oxalic acid toxicity.

A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? a. Most herbs are toxic or carcinogenic and should be used only when proven effective. b. There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health. c. Herbs should be obtained from manufacturers with a history of quality control of their supplements. d. Herbal therapies may mask the symptoms of serious disease, so frequent medical evaluation is required during use.

A nurse is answering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to explain the use of tamoxifen (Nolvadex). Which response should the nurse provide? a. Low doses of tamoxifen prevent menopausal hot flashes. b. An option used to reduce the risk of breast cancer for all women. c. This anti-estrogen drug inhibits malignancy growth. d. Part of a combination of chemotherapeutic agents used to treat tumors.

A nurse who is working in the Poison Control Center receives a telephone call from a parent of a 16-month old child who drank 2 ounces of acetaminophen (Children's Tylenol) elixir. What action should the nurse recommend to the parent? a. Administer oral syrup of ipecac. b. Give the child a glass of whole milk. c. Transport to emergency center for gastric decontamination. d. Obtain oral activated charcoal tablets from the pharmacy.

A primigravida at 12-weeks gestation tells the nurse that she does not like diary products. Which food should the nurse recommend to increase the client's calcium intake? a. Canned clams. b. Fresh apricots. c. Canned sardines. d. Spaghetti with meat sauce.

After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the client. Which nursing intervention is most important for the RN to implement? a. Position client on left side with pillow placed under the costal margin. b. Assist the client with voiding immediately after the procedure. c. Evaluate vital signs q10 to 20 minutes for 2 hours after procedure. d. Ambulate client 3 times in first hour with pillow held at abdomen.

After eye drops are instilled, which instruction should the nurse provide to the client? a. "Tilt your head back." b. "Look to each side." c. "Close your eyelids." d. "Blink quickly 3 times."

After the nurse provides education about ATV safety for a parent of an 11-year-old child, which statement made by the parent indicates an understanding of the information? a. "I will have my child ride with an adult" b. "I will make sure my child wears a helmet" c. "I will make sure my child does not get on an ATV" d. "I will make sure my child has had safety training before he or she rides"

An 80-year-old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client? a. Insulin. b. Antacids. c. Tricyclic antidepressants. d. Nonsteroidal antiinflammatory agents.

Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide? a. Initiate the lactation process. b. Prevent neonatal hypoglycemia. c. Stimulate contraction of the uterus. d. Facilitate maternal-infant bonding.

For a client who is learning to walk again after a stroke, which livel of care does the nurse provide to discharge the client to a rehab center? a. primary b. secondary c. tertiary d. secondary acute

How much sleep should a preschooler get each day? a. 8 hours b. 10 hours c. 12 hours d. 14 hours

The hospice nurse is completing a focused assessment of an older female client with end stage Alzheimer's disease, who recently fractured her hip. What technique should the registered nurse (RN) use to determine the client's pain? a. Use the FACES pain scale. b. Ask client to rate pain on a scale of 1 to 10. c. Observe for facial grimacing. d. Review documentation of recent eating habits.

The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, "Imbalanced nutrition: more than body requirements?" a. Morbidly obese. b. Markedly obese. c. Inadequate lifestyle changes in diet and exercise. d. Increased morbidity and mortality risks.

The nurse identifies which weight category as reflective of a client's BMI of 25.5? a. obese b. normal c. overweight d. underweight

The nurse is assessing a 12-hour-old infant with a maternal history of frequent alcohol consumption during pregnancy. Which finding should the nurse report that is most suggestive of fetal alcohol syndrome (FAS)? a. An extra digit on the left hand. b. Corneal clouding. c. Flat nasal bridge. d. Asymmetrical bulging fontanels.

The nurse is assessing a child for neurological "soft" signs. Which finding is most likely demonstrated in the child's behavior? a. Presence of vertigo. b. Loss of visual acuity. c. Poor coordination and sense of position. d. Inability to move tongue in all directions.

The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical picture? a. Blood urea nitrogen 40 m and creatinine 1.0. b. Cloudy, amber urine with sediment, specific gravity of 1.040. c. Serum potassium of 5.5 mEq and total calcium of 6 mg/dl. d. Hemoglobin of 10 g and hypophosphatemia.

The nurse is assisting with the end-of-life care of a client. Which activity is performed when the nurse views family as coontext? a. assess the resources available to the family b. meet the client's family's comfort and nutritional needs c. meet the client's comfort, hygiene, and nutritional needs d. determine the family's need for rest and their stage of coping

The nurse is caring for a client receiving tamoxifen (Nolvadex) for the treatment of breast cancer. Which action should the nurse include in the client's plan of care? a. Increase fluid intake. b. Monitor sodium chloride intake. c. Assist the client in coping with hot flashes. d. Encourage milk products to increase calcium intake.

The nurse is caring for a client who has an implanted port. How often would the nurse change the noncoring needle? a. every 3 days b. every 5 days c. every 7 days d. every 9 days

The nurse is caring for a client who has developed dysphagia and is unable to swallow. The client is receiving around-the-clock opioid pain meds for cancer pain, and hospice has recently begun to care for the client. Which is the best nursing intervention in preparing for the client's discharge? a. contact the provider to ask to substitue a liquid form of meds for the pill form b. teach the client and family members to crush the pills and administer them with applesauce c. contact the provider to discuss use of transdermal meds for pain control d. teach the client and family about addiction that may occur as a result of regular opioid use

The nurse is completing an admission interview and assessment on a client with a history of Parkinson's disease. Which question provides information relevant to the client's plan of care? a. "Have you ever experienced any paralysis of your arms or legs?" b. "Have you ever sustained a severe head injury?" c. "Have you ever been 'frozen' in one spot, unable to move?" d. "Do you have headaches, especially ones with throbbing pain?"

The nurse is giving discharge instructions for a client following a suction curettage for hydatidiform mole. The client asks why oral contraceptives are being recommended for the next 12 months. What information should the nurse provide? a. Oral contraceptives prevent a reoccurrence of a molar pregnancy. b. Pregnancy within 1 year decreases the chances of a future successful pregnancy. c. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy. d. Molar reoccurrences are higher if conception occurs within 1 year after an initial mutation.

The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which statement by a parent indicates understanding of the phototherapy? a. "I need to change the baby's position every four hours." b. "I should leave the baby under the light all of the time." c. "I will keep the baby's eyes covered when the baby is under the light." d. "I should dress the baby in light clothing when the baby is under the light."

The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation? a. A Hispanic client may have inward-turned eyelashes. b. An Asian client may have a horizontal palpebrale fissure. c. An African-American client may have slightly yellow sclerae. d. A Caucasian client may have a slightly protruding eyeball.

The nurse is planning a community-based project to reduce obesity in a school-aged population. Which outcome statement best supports the goal for this population? a. Increase in exercise will decrease obesity in children with a sedentary life style. b. Students with a body mass index above the 95 percentile will decrease. c. Within 2 years, students with a body mass index greater than 95% will be reduced by 50%. d. In the target population, 30% of students will be below the 95 percentile in weight.

The nurse is planning for the care of a 30-year-old primigravida with pre-gestational diabetes. What is the most important factor affecting this client's pregnancy outcome? a. Mother's age. b. Amount of insulin required prenatally. c. Degree of glycemic control during pregnancy. d. Number of years since diabetes was diagnosed.

The nurse is planning to teach the four-point alternate crutch gait to a child with cerebral palsy. How would the nurse explain this choice to the parent? a. the child has minimal step ability in the lower extremities b. it provides for two points of support on the floor at all times c. it provides for equal but partial weight bearing on each limb d. the child has more power in the upper extremities than in the lower

The nurse is preparing a teaching plan for a client with newly diagnosed glaucoma and a history of allergic rhinitis. Which information is most important for the nurse to provide the client about using over-the-counter (OTC) medications for allergies? a. Notify your healthcare provider if there is an increase in heart rate. b. Increase fluid intake while taking an antihistamine or decongestant. c. Avoid allergy medications that contain pseudoephedrine or phenylephrine. d. Ophthalmic lubricating drops may be used for eye dryness due to allergy medications.

The nurse is preparomg to administer a transdernal medication to an infant. To administer the medication safely, the nurse would recognize which as the reason absorption is more rapid via the transdermal route in infants than in older children? a. thinner dermis b. larger skin pores c. increased blood flow d. minimal subcutaneous fat

The nurse is teaching a client with maple syrup urine disease (MSUD), an autosomal recessive disorder, about the inheritance pattern. Which information should the nurse provide? a. This recessive disorder is carried only on the X chromosome. b. Occurrences mainly affect males and heterozygous females. c. Both genes of a pair must be abnormal for the disorder to occur. d. One copy of the abnormal gene is required for this disorder.

The parents of a child with Asperger's disorder asks the nurse to explain the differences between Asperger's and autism. Which information should the nurse share with the parents about Asperger's disorder that is not characteristic in autism? a. Obsession with moving objects. b. Repetitive patterns of behavior. c. Age-appropriate language development. d. Stereotypic movements and speech patterns.

The registered nurse (RN) is assigned the care of an older client who returns to the unit after surgery for closed angle glaucoma. Which intervention in the plan of care should the RN bring to the attention of the healthcare team? a. Assist with ambulating to commode. b. Monitor intake and output q8 hours. c. Administer morphine 4 mg IM q2 hour PRN pain. d. Place an eye patch on operative eye during sleep.

What information best supports the nurse's explanation for promoting the use of alternative or complementary therapies? a. Focuses on the pathogenesis of the disease of an individual. b. Replaces the conventional Western modality treatments. c. Recognizes the value of a client's input into their own health care. d. Continues to be used by a limited number of Americans.

When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement? a. Confirm the finding by further assessing the client for jugular vein distention. b. Offer the client high protein snacks between regularly scheduled mealtimes. c. Continue the planned nursing interventions to restore the client's fluid volume. d. Change the plan of care to include a nursing diagnosis of impaired skin integrity.

When discussing with a graduate nurse the delegation of client tasks such as assitance with ADLs, which statement about accountability would the nurse leader include? a. "Accountability is the ability to perform duties in a specific role." b. "The term accountability refers to the obligation and dependability to accomplish work." c. "Remaining answerable for one's choice to oneself and others characterizes accountability." d. "Accountability is the ability to delegate responsibility for a task to a competent individual."

When documenting assessment data, which statement should the nurse record in the narrative nursing notes? a. Hair is within normal limits. b. Most all permanent teeth are present. c. S1 murmur auscultated in supine position. d. Slight tenderness in the left upper quadrant.

Which aciton would the nurse take for an older client with Alzheimer disease who sleeps very little and becomes more disoriented from sleep deprivation? a. shut the client's door at night b. apply a vest restraint when the client is in bed c. leave a dim light on in the client's room at night d. administer the client's prescrobed as-needed sedative medication

Which action would a nurse take to prevent a parallax error and to ensure accuracy when assessing a client's blood pressure? a. elevate HOB b. use appropriate-sized cuff c. read the manometer at eye level d. place the cuff at the level of the heart

Which action would the nurse take to decrease the risk of transmission of vancomycin-resistant enterococci (VRE)? a. insert a urinary catheter b. initiate droplet precautions c. move the client to a private room d. use a high-efficiency particulate air (HEPA) respirator during care

Which cardiac disease has the lowest risk for maternal mortality? a. endocarditis b. aortic stenosis c. patent ductus arteriosus d. pulmonary hypertension

Which change would the nurse expect when a child transitions from toddlerhood to the stage of preschool? a. begins sleeping soundly at night b. naps frequently during the day c. develops later bedtime e. sleeps less, about 9 hours each night

Which characterisitic does the nurse associate with a punch biopsy? a. it is usually indicated for superficial or raised lesions b. it is more uncomfortable than other biopsies when healing c. it is performed using a circular cutting instrument 2 to 6 mm in diameter d. it removes only the portion of the skin that rises above the surrounding tissue

Which client has the highest risk for developing community-acquired pneumonia? a. a 40-year old first-grade teacher who works with underprivileged children b. a 75-year old retired secretary with exercise-induced wheezing c. a 60-year old homeless person who is an alcoholic and smokes d. a 35-year old aerobics instructor who skips meals and eats only vegetables

Which client statement should the nurse identify as most typical of a client with mania? a. I can't do anything anymore. b. I can't understand where all our money goes. c. I manage our finances great because I buy in big quantities. d. I wonder why my wife is so upset that I spend money easily.

Which factor is related to safety when discussing standards for involuntary admission to a mental health facility? a. mental illness b. severe disability c. currently cutting d. needs treatment

Which factor is the likely cause of a low pH on a client who is being resuscitated after cardiac arrest? a. ketoacidosis b. irregular heatbeat c. lactic acid production d. sodium bicarbonate administration

Which information about mammograms is most important to provide a post-menopausal female client? a.Breast self-examinations are not needed if annual mammograms are obtained. b. Radiation exposure is minimized by shielding the abdomen with a lead-lined apron. c. Yearly mammograms should be done regardless of previous normal x-rays. d. Women at high risk should have annual routine and ultrasound mammograms.

Which intervention would the nurs encourage the parent of a child with plumbism (lead poisoing) to do? a. discourage the child's pica by providing nutritious snacks b. move the family away from areas that are next to gas stations c. assess the family's home environment for lead sources and have them removed d. have the child take repeat x-rays of the wrist and forearm for signs of a lead line

Which intervention would the nurse offer the client to help relieve the symptoms of sinusitis? a. repositioning b. humidified air c. saline irrigation d. frequent suctioning

Which is the priority intervention after discovering an infant is apneic? a. call for help b. begin CPR c. stimulate the trunk d. place the infant prone

Which item would the client with palpitations from premature heartbeats be taugh to avoid? a. bananas b. tomatoes c. energy drinks d. green leafy vegetables

Which leukocyte releases vasoactive amines during a client's allergic reaction? a. neutrophil b. monocyte c. eosinophil d. macrophage

Which method of delivering care works well in disaster situations? a. team nursing b. primary nursing c. functional nursing d. total client care nursing

Which nursing-sensitive indicator would the nurse manager use to evaluate the process of nursing care? a. client falls b. pressure ulcers c. nurse job satisfaction d. supply of nursing staff

Which percentage do health behaviors such as physical activity and diet contribute to health outcomes according to the Robert Wood Johnson Foundation County Health Rankings (CHR) model? a. 10% b, 20% c. 30% d. 40%

Which period of Piaget's theory covers the prevalence of egocentrism in adolescents? a. sensorimotor b. preoperational c. formal operational d. concrete operational

Which position increases cardiac output in the obstetrical client with cardiac disease? a. trendelenburg b. low semi-fowler c. lateral positioning d. supine with legs elevated

Which preexisting diagnosis places a client at greatest risk of developing superior vena cava syndrome? a. Carotid stenosis. b. Steatosis hepatitis. c. Metastatic cancer. d. Clavicular fracture

Which professional strategy is most effective for nurse leaders and managers to implement in improving safety and quality of client-centered care? a. autonomy b. guidance c. delegation d. accountability

Which reliable site would the nurse utilize to assess a client for jaundice? a. skin b. palm c. sclera d. conjunctiva

Which sport would the nurse suggest as therapeutic for an adolescent with idiopathic scoliosis while considering that exeercise and avoidance of fatigue are essential components of care? a. golf b. bowling c. swimming d. badminton

Which substance would the nurse use to perform hand hygiene when caring for an immunocompromised client? a. soap b. betadine c. chlorhexidine d. alcohol-based hand sanitizer

Which triage level would indicate the ED nurse training to be a member of a direct response team to respond to community emergencies needs more education? a. urgent b. emergent c. expectant d. nonurgent

Which type of hypersensitivity reaction is associated with systemic lupus erythematous? a. type I b. type II c. type III d. type IV

Which unique adverse effect of pharmacotherapy is the pediatric population most at risk for? a. organ damage b. cognitive disability c. growth suppression d. developmental delay

Which verablization by the parents of a child with cystic fibrosis (CF) provides evidence that they understand the child's dietary needs? a. restrict fluids during mealtimes b. discontinue the use of salt when cooking c. provide high-calorie foods between meals d. add whole-milk products from the diet

While the nurse obtains a male client's history, review of systems, and physical examination, the client tells the nurse that his breast drains fluid secretions from the nipple. The nurse should seek further evaluation of which endocrine gland function? a. Posterior pituitary and testes. b. Adrenal medulla and adrenal cortex. c. Hypothalamus and anterior pituitary. d. Parathyroid and islets of Langerhans.

Why should the use of baby powder on an infant be avoided? a. skin irritation b. skin infection c. lung irritation d. respiratory infection

a prenatal client's vaginal mucosa is noted to have a purplish discoloration. which sign would be documented in the client's clinical record? a. hegar b. goodell c. chadwick d. braxton-hicks

which definition describes the defense mechanism of sublimation? a. returning to an earlier, less mature stage of development b. acting out of a concious behavior that is opposite of an unconcious feeling c. channeling unacceptable impulses into socially appropriate behavior d. excluding from conciousness thoughts that are psychologically disturbing

which immunoglobulin crosses the placenta? a. IgE b. IgA c. IgG d. IgM

which process does the igd immunoglobulin support? a. manifestation of allergic reactions b. protection of the body's mucous surfaces c. differentiation of B-lymphocytes d. provision of the primary immune response

which statement would the nurse leader associate with the satisficing decision model a. The model involves shared decision-making b. a decision is made by analyzing pros and cons associated with each option c. the model allowss for a quick decision, which is important when lack of time is an issue d. satisficing is more appropriate when conflict is likely to occur or when the problem is unstructured

which type of bone tumor occurs most commonly i elderly adults? a. endochroma b. osteosarcoma c. chrondrosarcoma e. osteochondroma

Blood loss from a fractured femur can be significant. Probable blood loss from a fractured femur can be: a. 150 mL b. 250 mL c. 2000 mL d. 4000 mL

c blood loss of 500 to 3000

The registered nurse (RN) is making early morning rounds on a group of clients when a client begins exhibiting symptoms of an acute asthma attack. The RN administers a PRN prescription for a Beta 2 receptor agonist agent. Which client response should the RN expect? Select all that apply a. Tachycardia. b. Increased blood pressure. c. Rapid resolution of wheezing. d. Improved pulse oximetry values. e. Reduce fever airway inflammation.

c, d

What are the similarities between a preschooler and a toddler? Select all that apply. a. both take daytime naps b. both have bedtime fears c. both have similar dietary requirements d. both are eager to independently perform self-care e. both have an acceptable heart rate of between 80 and 110 bpm

c, d

The nurse is caring for a client with a bowel obstruction. Which assessment findings indicate the possible onset of peritonitis? Select all that apply. a. diarrhea b. bradycardia c. rebound tenderness d. diminished bowel sounds e. rigid, boardlike abdomen

c, d, e

A client who is on the third day of detoxification therapy becomes agitated and restless. Which additional clinical manifestation will the nurse monitor for? Select all that apply. a. Polydipsia b. Drowsiness c. Diaphoresis d. Tachycardia e. Hypertension f. Constipation g. Headaches h. Paranoia

c, d, e, g

Which disease may occur due to rickettsial infections? Select all that apply. a. leprosy b. lyme disease c. epidemic typhus d. west nile fever e. rocky mountain spotted fever

c, e

Which intervention would the nurse perform while caring for an actively dying client? Select all that apply. a. admit the client in hospice care b. perform aggressive laboratory tests c. provide client and family reassurance d. keep the client undisturbed for long periods of time e. offer symptom management

c, e

A 4-year-old boy is brought to the emergency department by his parent, who reports that the child has been pointing at his stomach and saying, "It hurts so bad." Which pain-assessment tool should the nurse use? a. Descriptor Scale. b. Brief Pain Inventory. c. A numeric rating scale. d. Wong-Baker FACES Scale.

A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "Will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide? a. "It may hurt a little because of the incision made in your throat." b. "It won't hurt because you're such a big boy." c. "It won't hurt because we put you to sleep." d. "It may hurt but we'll give you medicine to help you feel better."

A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority nursing intervention? a. Review the client's most recent laboratory reports. b. Refer the client and family members for hospice care. c. Notify the hospital ethics committee of the client situation. d. Determine who is legally empowered to make decisions.

A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan? a. Apply warm compresses to reduce swelling. b. Wear sunglasses to protect eyes from sunlight. c. Take acetaminophen (Tylenol) for any eye discomfort. d. Avoid sharing towels and washcloths with siblings. Submit

A client delivers her first infant and asks the nurse if her skin changes from pregancy are permanent. Which change should the nurse tell the client will remain after pregnancy? a. Pruritus. b. Chloasma. c. Vascular spiders. d. Striae gravidarum.

A client has a staging procedure for cancer of the breast and ask the nurse which type of breast cancer has the poorest prognosis. Which information should the nurse offer the client? a. Stage II. b. Invasive infiltrating ductal carcinoma. c. T1N0M0. d. Inflammatory with peau d'orange.

A client is admitted for complaints of chest pain and aching for the past 4 days. The results for serum creatine kinase-MB (CK-MB) and troponin levels are obtained. What rationale should the nurse use to evaluate the laboratory findings? a. Serum myoglobin levels are needed to confirm myocardial damage. b. The most reliable indicator of myocardial necrosis is serum CK-MB. c. Serum cardiac markers are inconclusive in determining myocardial injury after waiting several days. d. Myocardial damage that occurred several days earlier is best validated by serum troponin levels.

A client is admitted to the emergency department after being lost for four days while hiking in a national forest. Upon review of the laboratory results, the nurse determines the client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which additional assessment should the nurse make? a. Body mass index. b. Skin elasticity and turgor. c. Thought processes and speech. d. Exposure to cold environmental temperatures.

A client is receiving an oxytocin infusion for induction of labor. When the client begins active labor, the fetal heart rate (FHR) slows at the onset of several contractions with subsequent return to baseline before each contraction ends. What action should the nurse implement? a. Insert an internal monitor device. b. Change the woman's position. c. Discontinue the oxytocin infusion. d. Document the finding in the client record.

A client who had severe weight loss is told the importance of eating more proteinto provide the essential amino acids. The client asks the nurse why these substances in protein foods are essentail. How should the nurse respond? a. "They will give you the added energy you need." b. "They contain the necessary nitrogen you need for healing." c. "They are essential for rebuilding your body tissue protein." d. "They must come from your food because your body cannot make them."

A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? a. Encourage the client to take several slow, deep breaths while ambulating. b. Help the client to remain standing by the bedside until the dizziness is relieved. c. Instruct the client to remain on bedrest until the healthcare provider is contacted. d. Advise the client to sit on the side of the bed for a few minutes before standing again.

A client with a high cholesterol level says to the nurse, "Why can't the doctor just give me a medication to eliminate all the cholesterol in my body so it isn't a problem?" Which factor related to why cholesterol is important in the human body should the nurse include in a response to the client's question? a. blood clotting b. bone formation c. muscle contraction d. cellular membrane structure

A client with chronic osteomyelitis is scheduled for surgery to treat the infection which has not responded to three months of intravenous antibiotic therapy. The client asks the nurse why surgery is necessary. Which is the best response for the nurse to provide? a. The dead bone needs to be removed to provide a blood supply for new bone growth. b. The infection is caused by a mutated bacteria that is resistant to most antibiotics. c. If the infected dead bone is not removed, it will make a path to the skin and drain pus. d. The infection has walled off into an area of infected bone creating a barrier to antibiotics.

A client with cirrhosis of the liver asks the registered nurse (RN) to explain how varicose veins can occur in the esophagus. Which statement should the RN provide to teach the client about the physiological etiology? a. The enlarged liver presses on the lower half of the esophagus which weakens blood vessel walls. b. Abnormal vessels form as a result of liver damage that causes chronic low serum protein levels. c. Esophageal swelling and tissue damage causes blood to circulate blood back through the stomach. d. Increased portal pressure causes blood flow through liver to be shunted to the esophageal vessels.

A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to take his chart with him and states the chart is "his" and he doesn't want any more contact with the hospital. How should the nurse respond? a. "Because you are leaving against medical advice, you may not have your chart." b. "The information in your chart is confidential and cannot leave this facility legally." c. "This hospital does not need to keep it if you are leaving and not returning here." d. "The chart is the property of the hospital but I will see that a copy is made for you."

A male client with a history of chronic back pain that was managed with opiate analgesics calls the nurse after having back surgery. The client reports that the back pain is finally gone, but after stopping the pain medication, the client has been having severe diarrhea and painful muscle cramps. Which assessment information should the nurse obtain next? a. Did the client receive a prescription for methadone or clonidine? b. Is the client using a fentanyl patch after stopping the opiate analgesic? c. Has the client taken any over-the-counter agents for these symptoms? d. When did the symptoms begin after the last dose of opiate analgesic?

A male client with chronic atrial fibrillation and a slow ventricular response is scheduled for surgical placement of a permanent pacemaker. The client asks the nurse how this device will help him. How should the nurse explain the action of a synchronous pacemaker? a. Ventricular irritability is prevented by the constant rate setting of pacemaker. b. Ectopic stimulus in the atria is suppressed by the device usurping depolarization. c. An impulse is fired every second to maintain a heart rate of 60 beats per minute. d. An electrical stimulus is discharged when no ventricular response is sensed.

A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student states, "Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical." What response should the nurse provide first? a. Ask the nursing supervisor to meet with the students. b. Notify the student's clinical instructor of the situation. c. Ask the student if permission was obtained from the client. d. Explain that the records are hospital property and may not be removed.

A young adult female arrives at the emergency department with a black right eye and is bleeding from the left side of her head. She reports that her boyfriend has been abusing her physically. The nurse performs a history and physical examination. How should the nurse document these findings? a. Client alleges that her boyfriend beat her up. Client is bleeding from the left side of the face. b. Client reports her boyfriend hit her in the eye and on the head. Bruises and lacerations present on face. c. Client presents with a right black eye and a cut on the left side of her head that is bleeding. Reports abusive boyfriend responsible for injuries. Needs referral to a safe place to stay. d. Young adult female presents with periorbital ecchymosis on right side, 3 cm laceration on left parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is abusive.

After one month of short-term corticosteroid therapy, a client with an acute exacerbation of rheumatoid arthritis returns to the clinic for a follow-up visit. Which laboratory finding should the nurse review for a therapeutic response? a. Fasting serum glucose. b. Serum liver function test. c. Serum electrolyte levels. d. Erythrocyte sedimentation rate.

An abcess develops in an obese adult after abdominal surgery. The would is healing by secondary intention. Which diet would the nurse expect the provider to prescribe to meet this client's immediate nutritional needs? a. low in fat and vitamin D b. high in calories and fiber c. low in residue and bland d. high in protein and vitamin C

An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom? a. Leukocytosis and febrile. b. Polycythemia and crackles. c. Pharyngitis and sputum production. d. Confusion and tachycardia.

An infant is found to have developmental dysplasia of the hip (DDH) 6 weeks after birth. The parents ask a nurse at the clinic why their infant must be restrained in a harness at such an early age. How should the nurse respond? a. infants are easier to manage in a harness b. mobility will be delayed if correction is postponed until later c. adduction devices cannot be used as effectively after the toddler age d. infants' hip joints are catilaginous, allowing molding of the acetabulum

An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day.What is the best action for the nurse to implement when assisting the client from the bed to the chair? a. Use a mechanical lift to transfer from the bed to a chair. b. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. c. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. d. Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed. Submit

During a health fair, a 72-year-old male client tells the nurse that he is experiencing shortness of breath. Auscultation reveals crackles and wheezing in both lungs. Suspecting that the client might have chronic bronchitis, which classic symptom would the nurse expect this client to have? a. Racing pulse with exertion. b. Clubbing of the fingers. c. An increased chest diameter. d. Productive cough with grayish-white sputum.

In which parts of the kidney are glucose and amino acids reabsorbed? a. distal tubule b. loop of henle c. collecting duct d. proximal tubule

Prior to transferring a client to a chair using a mechanical lift, what is the most important client characteristic the nurse should assess? a. Ability to grasp objects. b. Ability to bear weight. c. Upper body muscle strength. d. Tolerance of exertion.

Several hours after surgical repair of an abdominal aortic aneurysm (AAA), the client develops left flank pain. The nurse determines the client's urinary output is 20 ml/hr for the past 2 hours. The nurse should conclude that these findings support which complication? a. Infection. b. Hypovolemia. c. Intestinal ischemia. d. Renal artery embolization.

The model of primacy of caring is the base for development of which theory? a. roy's theory b. watson's theory c. neuman's theory d. benner and wrubel's theory

The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8 F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement? a. Administer a PRN antihypertensive prescription. b. Provide the client with an additional blanket. c. Encourage additional fluid intake. d. Turn the client q2h.

The nurse is assessung a preschool child that has frequent episodes of diarrhea as well as poor oral hygiene and dental caries. Which is the most likely cause for the child's health issues? a. the family often consumes fast foods b. the parents neglect the child's dietary needs c. the family does not follow hygienic practices d. the child consumes excessive amounts of fruit juice

The nurse is assisting with the triage of clients at a large community disaster and finds a man lying on the ground, who states that the blast blew him out of a second story window. Which action should the nurse implement first? a. Logroll the client to his side and assess for back injuries. b. Perform a complete neurological assessment. c. Open the client's airway immediately. d. Place the nurse's hands around client's neck to stabilize.

The nurse is caring for a client admitted with peritonitis. Which finding is most likely the cause? a. gastritis b. hiatal hernia c. diverticulosis d. bowel obstruction

The nurse is caring for an adult male client with catatonic schizophrenia who is mute and motionless. What is the priority nursing problem? a. Impaired mobility. b. Ineffective individual coping. c. Impaired verbal communication. d. High risk for fluid and electrolyte imbalance.

The nurse is collecting a blood sample from a newborn for a screening test for phenylketonuria (PKU). When should the nurse obtain the blood sample? a. At birth from cord blood. b. Fourteen days after birth. c. Before oral feedings are initiated. d. After ingestion of a source of protein.

The nurse is planning preoperative teaching for a client who will undergo a radical neck dissection and total laryngectomy. Which information has the greatest priority for this client? a. Prognosis after treatment is excellent. b. Techniques for esophageal speech are relatively easy to learn with practice. c. The stoma should never be covered after this type of surgery. d. There is a radical change in appearance as a result of this surgery.

The nurse notes a client has dependent edema around the feet and ankles. To characterize the severity, the nurse presses on the area, noting an 8-mm depression after release. In which way would the nurse document the edema? a. 1+ b. 2+ c. 3+ d. 4+

The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take? a. Assess respiratory rate for one minute next. b. Give the medication dosage as scheduled. c. Wait 30 minutes and give half of the dosage of medication. d. Withhold the medication and contact the healthcare provider.

The nurse provides education to students about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise? a. decreases chest pain b. conserves energy c. increases oxygen saturation d. promotes elimination of co2

The parents of an adolescent male with Ewing sarcoma ask the nurse what is the most significant factor contributing to their son's prognosis. Which factor should the nurse include when answering the parent's concern? a. Age of onset. b. Gender of child. c. Appearance on X-ray. d. Degree of metastasis.

The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The healthcare provider recently changed the medication to enalaprilto manage the client's blood pressure. Which instruction should the RN provide the client regarding the new medication? a.Take the medication at bedtime. b.Report presence of increased bruising. c. Check pulse before taking medication. d. Rise slowly when getting out of bed or chair.

The registered nurse (RN) is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the RN to report the healthcare provider? a. Lower back pain.\b. Headache of 7 on scale 1 to 10. c. Blood pressure of 140/98. d. Dyspnea.

To benefit client care delivery, the nurse leader assists multidisciplinary leaders to achieve optimal functioning. Which Gardner's task of leadership did the nurse apply? a. managing b. developing trust c. serving as a symbol d. achieving workable unity

What histologic finding in an affected area of the body would suggest the presence of chronic inflammation? a. Predominance of neutrophils. b. Absence of fibroblasts and proteases. c. Decrease in degradation products. d. Increase in monocytes and macrophages.

What is the best action for the nurse to take when initiating contact with a toddler for the first time? a. Ask the toddler to point to where it hurts. b. Tell the child your name and that you are the nurse. c. Call the child by name while picking up the toddler. d. Kneel in front of the toddler and speak softly to the child.

What nursing action should be included in the plan of care for a newborn experiencing symptoms of drug withdrawal? a. Play soft music and talk to soothe the infant. b. Administer chloral hydrate for sedation. c. Feed every 4 to 6 hours to allow extra rest. d. Swaddle the infant snugly and hold tightly.

Which action would the nurse take for a client with an obsessive- compulsive disorder who continually walks up and down the hall, touching every other chair and becomes upset if interrupted? a. distract the client, which will help the client forget about touching the chairs b. encourage the client to continue touching the chairs as long as the client wants until fatigue sets in c. remove chairs from the hall, thereby relieving the client of the necessity of touching eveery other one d. Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed

Which action would the nurse take when caring for an older adult with a history of recent memory loss? a. instruct the client to move slowly when changing positions b. remind the client to look where he or she places their feet while walking c. adjust the daily schedule to accomodate sleep pattern d. employ electronic devices that provide alerts

Which antibody forms first, after exposure to an antigen? a. IgA b. IgE c. IgG d. IgM

Which area of the cerbral lobe is linked to Wernicke's area of speech? a. limbic b. frontal c. parietal d. temporal

Which assessment would the nurse complete to promote safety before administering pain medication to an older adult? a. blood pressure b. pain level c. bowel sounds and function d. other prescribed meds

Which client care activity requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? a. Removing the empty food tray from a client with a urinary catheter. b. Washing and combing the hair of a client with a fractured leg in traction. c. Administering oral medications to a cooperative client with a wound infection. d. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

Which condition is correlated with a positive Babinski sign in a newborn infant? a. hypoxia during labor b. neurological injury during birth c. hyperreflexia of the muscular system d. immaturity of the CNS

Which dietary need would the nurse and the nutritionist consider when planning meals for a client who practices the Russian Orthodox faith? a. no pork or shellfish b. no blood-containing foods c. vegetarian diet d. no meat on wednesdays and fridays

Which factor is the strongest predictor of illness in a childcare setting? a. unsanitary conditions b. a caregiver who smokes c. age of the children being care for d. number of unrelated children in a room

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? a. Apply a condom catheter. b. Apply a skin protectant. c. Encourage increased fluid intake. d. Assess for bladder distention.

Which intervention would provide comfort to the client experiencing alcohol toxicity? a. dim the lights b. use distraction c. offer activities d. stay with the client

Which intervention would the nurse use to promote the safety of a client experiencing alcohol withdrawal? a. infuse IV fluids b. monitor the level of anxiety c. obtain frequent vitals d. administer chlordiazepoxide

Which is a complication that may develop in the child with hypospadias with chordee? a. Renal failure b. Testicular cancer c. Testicular torsion d. Sexual difficulties

Which is a sensory simulation strategy a laboring client can use as a nonpharmalogical strategy for pain management? a. gentle massage of the abdomen b. biofeedback-assisted relaxation techniques c. application of a heat pack to the lower back d. selecting a focal point and beginning breathing techniques

Which is the priority intervention for the infant with development dysplasia of the hip? a. flexion of the hip d. extension of the hip c. adduction of the hip d. abduction of the hip

Which medication acts as an antidote to benzodiazepine? a. zolpidem b. temazepam c. suvorexant d. flumazenil

Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter? a. Ensure that the client's perineal area is cleansed twice a day. b. Maintain accurate documentation of the fluid intake and output. c. Encourage frequent ambulation if allowed or regular turning if on bedrest. d. Obtain a prescription for removal of the catheter as soon as possible.

Which pain scale would the nurse use when assessing a 4-year-old child? a. CRIES b. FLACC c. numerical d. wong-baker

Which percentage of total body surface aread (TBSA) would the nurse calculate for a burn victim who has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms? a. 20 b. 25 c. 30 d. 36

Which physiological factor increases the risk of falls for a toddler? a. poor muscle coordination b. underdeveloped propioception c. underdeveloped skeletal muscles d. poorly developed depth perception

Which precaution would the nurse identify as a prevention for transmission of HIV and other bloodborne illnesses? a. barrier b. droplet c. contact d. standard

Which principle underlying the function of a portable drainage system will the nurse consider when caring for a client returning from surgery with a drain attached to a portable wound drainage system exiting from the surgical site? a. gravity b. osmosis c. active transport d. negative pressure

Which procedure would the nurse use to elevate the head of an infant in a spica cast? a. use of a donut head pad b. inserting pillows under the shoulders c. padding the edge of the cast with folded diapers d. raising the entire mattress at the head of the crib

Which sign in the newborn infant would reflect an Apgar score of 1 in the category of respiration? a. good cry b. grimace c. absent respiration d. slow, weak cry

Which statement indictaes the function of natural killer cells? a. secrete immunoglobulins in reponse to a specific antigen b. exhibit heightened selectivity and destroy nonself cells, including virally infected cells c. enhance immune activity through secretion of cytokines and lymphokines d. attack nonselectively on nonself cells, especially mutated and malignant cells

Which statement would the nurse correlate with Watson's theory of transpersonal caring? a. views the client as an adaptive system b. based on stress and the client's reaction to the stressor c. focuses on providing the client with culturally specific nursing care d. defines the outcomes of nursing activity in relation to the humanistic aspects of life

Which toxic effect would the nurse find in a client who has overdosed on isocarboxazid? a. mydriasis b. bradycardia c. hypothermia d. circulatory collapse

Which volume of solution would be prepared for a cleansing enema for an adolescent client? a. 150 to 250 mL b. 250 to 350 mL c. 300 to 500 mL d. 500 to 750 mL

Whiicg effect has resulted in the avoidance of tetracylcine use in children under 8? a. birth defects b. allergic reactions c. severe nausea and vomiting d. permanent tooth discoloration

a full-term infant who is large for gestational age (LGA) should be monitored for which risk? a. hypotension b. hypothermia c. hypocalcemia d. hypoglycemia

according to erikson's stages of development, which is the stage of development when a child begins walking, feeding, and toileting? a. trust v mistrust b. initiative v guilt c. identity v role confusion d. autonomy v sense of shame and doubt

in which stage of psychosocial development would toilet training be achieved? a. trust v mistrust b. initiative v guilt c. industry v inferiority d. autonomy v shame

which documentation would the nurse utilize to report that a client's degree of edema has a depth of 8 mm? a. 1+ b. 2+ c. 3+ d. 4+

which hormone would the nurse explain as stimulating the release of estrogen and progesterone after fertilization? a. inhibin b. testosterone c. FSH d. human chorionic gonadotropin (hCG)

which statement would the nurse manager utilize when explaing diffusion of innovational (DOI) theory with the example of how intramuscular injection techniques changed? a. evidence supports the use of the dorsogluteal site as the recommended injection site b. the IM injection is used to effectively deliver short-acting antibiotics to adult clients c. the technique of IM injection will be taught in the final nursing orientation class d. use of IM injections for pain management decreased with the use of IV and epidural routes

The nurse is teaching a female client who uses a contraceptive diaphragm about reducing the risk for toxic shock syndrome (TSS). Which information should the nurse include? (Select all that apply.) a. Remove the diaphragm immediately after intercourse. b. Wash the diaphragm with an alcohol solution. c. Use the diaphragm to prevent conception during the menstrual cycle. d. Do not leave the diaphragm in place longer than 8 hours after intercourse. e. Replace the old diaphragm every 3 months.

d, e

Which physical changes are characteristic of a preschool-aged child? Select all that apply. a. flexed thoracic spine b. increased foot eversion c. growth spurt d. balanced and coordinated body e. decreased abdominal pressure

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