LVN Question Cards

A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion started? 1. 5 minutes 2. 15 minutes 3. 30 minutes 4. 45 minutes

2. 15 minutes

A client is taking Humulin NPH insulin daily every morning. The nurse reinforces to the client and should tell the client that which is the most likely time for a hypoglycemic reaction to occur? 1. 2 to 4 hours after administration 2. 6 to 14 hours after administration 3. 16 to 18 hours after administration 4. 18 to 24 hours after administration

2. 6 to 14 hours after administration

Isoniazid is prescribed for a 2-year-old child with a positive tuberculin skin test. The mother of the child asks the nurse how long the child will need to take the medication. Which time frame is the appropriate response to the mother? 1. 4 months 2. 9 months 3. 12 months 4. 18 months

2. 9 months

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. Which should the nurse tell the child? 1. Drink half a cup of orange juice before soccer practice. 2. Eat twice the amount that is normally eaten at lunchtime. 3. Take half the amount of prescribed insulin on practice days. 4. Take the prescribed insulin at noontime rather than in the morning.

1. Drink half a cup of orange juice before soccer practice.

The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions should the nurse use for communicating with the client? Select all that apply. 1. Face the client when talking. 2. Speak slowly and maintain eye contact. 3. Use gestures when talking to enhance words. 4. Avoid the use of body language when talking to the client. 5. Give the client directions using short phrases and simple terms. 6. Phrase what was said differently the second time, if there is a need to repeat it.

1. Face the client when talking. 2. Speak slowly and maintain eye contact. 3. Use gestures when talking to enhance words. 5. Give the client directions using short phrases and simple terms.s

Which are appropriate interventions for caring for the client undergoing alcohol withdrawal? Select all that apply. 1. Monitor vital signs. 2. Maintain an NPO status. 3. Provide a safe environment. 4. Address hallucinations therapeutically. 5. Provide stimulation in the environment. 6. Provide reality orientation as appropriate.

1. Monitor vital signs. 3. Provide a safe environment. 4. Address hallucinations therapeutically. 6. Provide reality orientation as appropriate.

A child is diagnosed with scarlet fever. The nurse collects data regarding the child. Which is characteristic of scarlet fever? 1. Pastia's sign 2. Abdominal pain and flaccid paralysis 3. Dense pseudoformation membrane in the throat 4. Foul-smelling and mucopurulent nasal drainage

1. Pastia's sign

The nurse is preparing to administer 35 mg of a prescribed intramuscular (IM) dose of medication to a client. The medication label reads 50 mg/mL. How many milliliters should the nurse administer to the client? Fill in the blank. _____ mL

0.7 mL

The nurse has provided instructions to the mother of an infant with viral pneumonia. Which statement by the mother would indicate the need for further teaching? 1. "I understand I will need to have my baby on antibiotics for this pneumonia." 2. "I will need to give a cough suppressant before meals if his cough gets too bad." 3. "I will be careful and allow my baby to sleep, so he can conserve energy and fight this infection." 4. "I understand that my baby has viral pneumonia and I need to monitor his temperature because of the risk for febrile seizures."

1. "I understand I will need to have my baby on antibiotics for this pneumonia."

A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style? 1. Autocratic 2. Situational 3. Democratic 4. Laissez-faire

1. Autocratic

Saquinavir is prescribed for the client who is diagnosed with human immunodeficiency virus (HIV) seropositive. The nurse should reinforce medication instructions about which health care measure to the client? 1. Avoid sun exposure. 2. Eat low-calorie foods. 3. Eat foods that are low in fat. 4. Take the medication on an empty stomach.

1. Avoid sun exposure.

After a renal biopsy, the client complains of pain at the biopsy site that radiates to the front of the abdomen. Which would this indicate? 1. Bleeding 2. Infection 3. Renal colic 4. Normal, expected pain

1. Bleeding

The nurse is caring for a client with hyperparathyroidism and notes that the client's calcium level is 13 mg/dL (3.25 mmol/L). Which prescribed medication should the nurse plan to assist in administering to the client? 1. Calcitonin 2. Calcium chloride 3. Calcium gluconate 4. Large doses of vitamin D

1. Calcitonin

The nurse is assisting with caring for a client who has a placenta previa. The nurse understands that cervical examination should not be performed on the client primarily because it could have which consequence? 1. Cause hemorrhage 2. Initiate premature labor 3. Rupture the fetal membranes 4. increase the chance of infection

1. Cause hemorrhage

The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notices fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate? 1. Continue to monitor. 2. Empty the drainage. 3. Encourage the client to deep breathe. 4. Encourage the client to hold his or her breath periodically.

1. Continue to monitor.

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for he presence of an infection. The nurse should tell the mother that which is a sign of infection? 1. A darkened drying stump 2. A moist cord with discharge 3. A purple stump that shows pinkness around the base 4. A purple stump that shows some moistness at the base

2. A moist cord with discharge

When caring for a 3-year-old child, the nurse should provide which toy for the child? 1. A puzzle 2. A wagon 3. A golf set 4. A miniature farm set

2. A wagon

The client is admitted to the emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? 1. Warm the client. 2. Maintain a patent airway. 3. Monitor intravenous fluids. 4. Administer thyroid hormone.

2. Maintain a patent airway.

The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV)-positive. The nurse understands that which should be included in the plan of care? 1. Monitoring the neonate's vital signs routinely 2. Maintaining standard precautions at all times 3. Instructing breastfeeding mothers regarding the treatment of their nipples with an antifungal cream 4. Initiating a referral to evaluate for blindness, deafness, learning or behavioral problems in the neonate

2. Maintaining standard precautions at all times

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 3. Respiratory alkalosis

2. Metabolic alkalosis

Ketoconazole is prescribed for a client with a diagnosis of candidiasis. Which interventions should the nurse include when administering this medication? Select all that apply. 1. Restrict fluid intake. 2. Monitor liver function studies. 3. Instruct the client to avoid alcohol. 4. Administer the medication with an antacid. 5. Instruct the client to avoid exposure to the sun. 6. Administer the medication on an empty stomach.

2. Monitor liver function studies. 3. Instruct the client to avoid alcohol. 5. Instruct the client to avoid exposure to the sun.

The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which? 1. Hypothermia 2. Respiratory distress 3. Hematoma in the left groin 4. Discomfort in the left groin

2. Respiratory distress

The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse? 1. Blood pressure 2. Status of airway 3. Oxygen flow rate 4. Level of consciousness

2. Status of airway

Isotretinoin is prescribed for client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed? 1. Potassium level 2. Triglyceride level 3. Hemoglobin A1C 4. Total cholesterol level

2. Triglyceride level

The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse should tell the client that fecal circulation consists of which components? 1. Two umbilical veins and one umbilical artery 2. Two umbilical arteries and one umbilical vein 3. Arteries that carry oxygenated blood to the fetus 4. Veins that carry deoxygenated blood to the fetus

2. Two umbilical arteries and one umbilical vein

A client with ascites is scheduled for a paracentesis. The nurse is assisting the primary health care provider (PHCP) with performing the procedure. Which position should the nurse assist the client into for this procedure? 1. Flat 2. Upright 3. Left side-lying 4. Right side-lying

2. Upright

A client with delirium becomes agitated and confused at night. The best initial intervention by the nurse is which action? 1. Move the client next to the nurse's station. 2. Use a night light and turn off the television. 3. Keep the television on and a soft light on during the night. 4. Play soft music during the night and maintain a well-lit room.

2. Use a night light and turn off the television.

Silver sulfadiazine is prescribed for a client with a partial thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? 1. "The medication is an antibacterial." 2. "The medication will help heal the burn." 3. "The medication is likely to cause stinging initially." 4. "The medication should be applied directly to the wound."

3. "The medication is likely to cause stinging initially."

A client is admitted to a medical unit with acute blindness. Many tests are performed, and there seems to be no organic reason why this client cannot see. The nurse later learns that the client became blind after witnessing a hit-and-run car crash in which a family of three was killed. The nurse suspects that the client may be experiencing which diagnosis? 1. Psychosis 2. Repression 3. Conversion disorder 4. Dissociative disorder

3. Conversion disorder

The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made? 1. Skin color becomes cyanotic. 2. Secretions are becoming bloody. 3. Coughing occurs with suctioning. 4. Heart rate decreases from 78 beats/minute to 54 beats/minute.

3. Coughing occurs with suctioning.

The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse should expect to note which specific characteristic of this condition? 1. Dyspnea 2. Hacking cough 3. Dependent edema 4. Crackles on lung auscultation

3. Dependent edema

A client is scheduled for intravenous pyelography (IVP). Which priority nursing action should the nurse take? 1. Restrict fluids. 2. Administer a sedative. 3. Determine if there is a history of allergies. 4. Administer an oral preparation of radiopaque dye.

3. Determine if there is a history of allergies.

The nurse is monitoring a client receiving baclofen for side effects related to the medication. Which should indicate that the client is experiencing a side effect? 1. Polyuria 2. Diarrhea 3. Drowsiness 4. Muscular excitability

3. Drowsiness

After birth the nurse prevents hypothermia as a result of evaporation by performing which action? 1. Warming the crib bed 2. Closing the doors of the room 3. Drying the baby with a warm blanket 4. Turning on the overhead radiant warmer

3. Drying the baby with a warm blanket

The nurse is planning to reinforce nutrition instructions to an African American client. When reviewing the plan, the nurse is aware that which food may be a common dietary practice of clients with African American heritage? 1. Raw fish 2. Red meat 3. Fried Foods 4. Rice is the basis for all meals

3. Fried Foods

The nurse reinforces postoperative liver biopsy instructions to a client. Which should the nurse tell the client? 1. Avoid alcohol for 8 hours. 2. Remain NPO for 24 hours. 3. Lie on the right side for 2 hours. 4. Save all stools to be checked for blood.

3. Lie on the right side for 2 hours.

A client is diagnosed with an acute myocardial infarction and is receiving tissue plasminogen activator, alteplase. Which action is a priority nursing intervention? 1. Monitor for kidney failure. 2. Monitor psychosocial status. 3. Monitor for signs of bleeding. 4. Have heparin sodium available.

3. Monitor for signs of bleeding.

The nurse assists with developing a plan of care for the child with meningitis. Which would be the priority client problem for a child with a meningitis diagnosis? 1. Pain 2. Inadequate knowledge 3. Neurological dysfunction 4. Difficult family coping processes

3. Neurological dysfunction

The nurse is performing a neurovascular check on a hospitalized child who had a cast applied to the lower leg. The child complains of tingling in the toes distal to the fracture site. Which action should the nurse take? 1. Elevate the extremity. 2. Document the findings. 3. Notify the registered nurse (RN). 4. Ambulate the child with crutches.

3. Notify the registered nurse (RN).

The nurse is checking the casted extremity of a client. The nurse should check for which sign indicative of infection? 1. Dependent edema 2. Diminished distal pulse 3. Presence of a "hot spot" on the cast 4. Coolness and pallor of the extremity

3. Presence of a "hot spot" on the cast

The nurse assists to prepare a teaching plan regarding the administration of ear drops for the parents of a 2-year-old child with otitis media. Which should be included in the plan? 1. Wear gloves when administering the eardrops. 2. Pull the ear up and back before instilling the eardrops. 3. Pull the earlobe down and back before instilling the eardrops. 4. Hold the child in a sitting position when instilling the eardrops.

3. Pull the earlobe down and back before instilling the eardrops.

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. Which is a life-threatening complication that could be occurring? 1. Pneumonia 2. Pulmonary edema 3. Pulmonary embolism 4. Myocardial infarction

3. Pulmonary embolism

The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse should take which appropriate action? 1. Document the finding 2. Continue to monitor vital signs 3. Report the finding to the registered nurse (RN) 4. Mark the drainage on the dressing and monitor for any increase in bleeding

3. Report the finding to the registered nurse (RN)

The nurse notes that a 6-year-old child does not recognize that objects exist even when the objects are outside of the visual field. Based on this observation, which action should the nurse take? 1. Move the objects in the child's direct field of vision. 2. Teach the child how to visually scan the environment. 3. Report the observation to the primary health care provider. 4. Provide additional lighting for the child during play activities.

3. Report the observation to the primary health care provider.

The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid-base imbalance? 1. Metabolic acidosis 2. Metabolic acidosis 3. Respiratory acidosis 4. Respiratory alkalosis

3. Respiratory acidosis

The nursing student is asked to identify the characteristics of bulimia nervosa. Which characteristic if identified by the student indicates a need for further teaching? 1. Dental erosion 2. Electrolyte imbalances 3. Enlarged parotid glands 4. Body weight well below ideal range

4. Body weight well below ideal range

The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? Select all that apply. 1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus

4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus

The nurse is caring for a client with a diagnosis of chronic gastritis. The nurse anticipates that the client is at risk for which vitamin deficiency? 1. Vitamin A 2. Vitamin B 3. Vitamin E 4. Vitamin B12

4. Vitamin B12

The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further teaching? 1. "Frequent hand washing is important." 2. "I need to provide a well-balanced, high-fat diet to my child." 3. "I need to clean contaminated household surfaces with bleach." 4. "Diapers should not be changed near any surfaces that are used to prepare food."

2. "I need to provide a well-balanced, high-fat diet to my child."

The nurse is reinforcing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates the need for further teaching? 1. "I need to have my child wear a soft fabric under the brace." 2. "I will apply lotion under the brace to prevent skin breakdown." 3. "I need to encourage my child to perform the prescribed exercises." 4. "I need to avoid applying powder under the brace, because it will cake."

2. "I will apply lotion under the brace to prevent skin breakdown."

The nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further teaching? 1. "I will take my child out into the humid night air." 2. "I will place a steam vaporizer in my child's bedroom." 3. "I will place a cool-mist humidifier in my child's bedroom." 4. "I will place my child in a closed room and allow my child to inhale steam from the running water."

2. "I will place a steam vaporizer in my child's bedroom."

The nurse is preparing a 2-year-old child with suspected nephrotic syndrome for a renal biopsy to confirm the diagnosis. The mother asks the nurse, "Will my child ever look thin again?" The nurse should respond by giving which statement? 1. "Do you feel guilty about your child's weight gain?" 2. "In most cases, medication and diet will control fluid retention." 3. "Wearing loose-fitting clothing should help conceal the extra weight." 4. "When children are little, it's expected that they'll look a little chubby."

2. "In most cases, medication and diet will control fluid retention."

The nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the student indicates the need to further research the disease? 1. "The femur is the most common site of this sarcoma." 2. "The child does not experience pain at the primary tumor site." 3. "If a weight-bearing limb is affected, then limping is a clinical manifestation." 4. "The symptoms of the disease during the early stage are almost always attributed to growing pains."

2. "The child does not experience pain at the primary tumor site."

A client asks the nurse about the causes of acne. The nurse should respond by making which statement to the client? 1. "It is caused by oily skin." 2. "The exact cause of acne is not known." 3. "It occurs as a result of exposure to heat and humidity." 4. "Acne is caused by eating chocolate, nuts, and fatty foods."

2. "The exact cause of acne is not known."

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a two-bed hospital room. A newly admitted client will be assigned to this client's room. Which client should be an appropriate choice as this client's roommate? 1. A client with pneumonia 2. A client receiving diagnostic tests 3. A client who thrives on managing others 4. A client who could benefit from the client's assistance at mealtimes

2. A client receiving diagnostic tests

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)? 1. A client who requires wound irrigation 2. A client who requires frequent ambulation 3. A client who is receiving continuous tube feedings 4. A client who requires frequent vital signs after a cardiac catheterization

2. A client who requires frequent ambulation

The client calls the office of the primary health care provider (PHCP) and states to the nurse that they were just stung by a bumblebee while gardening. The client is afraid of a severe reaction because their neighbor experienced such a reaction just 1 week ago. Which should be the appropriate nursing action? 1. Advise the client to soak the site in hydrogen peroxide. 2. Ask the client if they ever sustained a bee sting in the past. 3. Tell the client to call an ambulance for transport to the emergency room. 4. Tell the client not to worry about the sting unless difficulty breathing occurs.

2. Ask the client if they ever sustained a bee sting in the past.

A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item? 1. Apples 2. Cheese 3. Oranges 4. Skim milk

2. Cheese

A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing? 1. Veal, potatoes, gelatin, and orange juice 2. Chicken breast, broccoli, strawberries, and milk 3. Peanut butter and jelly sandwich, cantaloupe and tea 4. Spaghetti with tomato sauce, garlic bread, and ginger ale

2. Chicken breast, broccoli, strawberries, and milk

A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, should offer which items during an episode of nausea? 1. Low-calorie foods 2. Cool, clear liquids 3. Low-protein foods 4. The child's favorite foods

2. Cool, clear liquids

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to the breath sounds expecting to hear which breath sounds bilaterally? 1. Rhonchi 2. Crackles 3. Wheezes 4. Diminished breath sounds

2. Crackles

The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure? 1. Eliminate between-meal snacks. 2. Drink decaffeinated coffee and tea. 3. Lie down for 30 minutes after eating. 4. Substitute salt in cooking for other spices.

2. Drink decaffeinated coffee and tea.

The police arrive at the emergency department with a client who has seriously lacerated both wrists. Which is the initial nursing action? 1. Administer an antianxiety agent. 2. Examine and treat the wound sites. 3. Secure and record a detailed history. 4. Encourage and assist the client with venting their feelings.

2. Examine and treat the wound sites.

The client is diagnosed with stage I of Lyme disease. The nurse should check the client for which characteristic of this stage? 1. Arthralgia 2. Flu-like symptoms 3. Enlarged and inflamed joints 4. Signs of a neurological disorder

2. Flu-like symptoms

The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse should document which as the GTPAL for this client? 1. G = 3, T = 2, P = 0, A = 0, L = 1 2. G = 2, T = 1, P = 0, A = 0, L = 1 3. G = 1, T = 1, P = 1, A = 0, L = 1 4. G = 2, T = 0, P = 0, A = 0, L = 1

2. G = 2, T = 1, P = 0, A = 0, L = 1

The nurse is performing a follow-up teaching session with a client discharged 1 month ago who is taking fluoxetine. Which information should be important for the nurse to gather regarding the adverse effects related to the medication? 1. Cardiovascular symptoms 2. Gastrointestinal symptoms 3. Problems with mouth dryness 4. Problems with excessive sweating

2. Gastrointestinal symptoms

The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3-year-old child who was born at 39 weeks' gestation. The nurse should document which gravida and para status on this client? 1. Gravida I, para I 2. Gravida II, para I 3. Gravida II, para II 4. Gravida III, para II

2. Gravida II, para I

The client has been taking omeprazole for 4 weeks. The nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom? 1. Diarrhea 2. Heartburn 3. Flatulence 4. Constipation

2. Heartburn

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription? 1. Adding a dose of heparin sodium 2. Holding the next dose of warfarin 3. Increasing the next does of warfarin 4. Administering the next dose of warfarin

2. Holding the next dose of warfarin

The nurse is instructing a client with diabetes mellites about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of what complication? 1. Peritonitis 2. Hyperglycemia 3. Hyperphosphatemia 4. Disequilibrium syndrome

2. Hyperglycemia

The nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions does the nurse anticipate to be prescribed? Select all that apply. 1. Administer a Fleet enema. 2. Initiate an intravenous line. 3. Maintain nothing-by-mouth status. 4. Administer intravenous antibiotics. 5. Administer preoperative medications. 6. Place a heating pad on the abdomen to decrease pain.

2. Initiate an intravenous line. 3. Maintain nothing-by-mouth status. 4. Administer intravenous antibiotics. 5. Administer preoperative medications.

The nurse is preparing to administer beractant to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which route? 1. Intradermal 2. Intratracheal 3. Subcutaneous 4. Intramuscular

2. Intratracheal

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was October 20, 2019. Using Nagele's rule, the nurse determines the estimated date of birth is which date? 1. July 12, 2020 2. July 27, 2020 3. August 12, 2020 4. August 27, 2020

2. July 27, 2020

The nurse is reviewing the laboratory studies on a client receiving dantrolene sodium. Which laboratory test(s) would identify an adverse effect associated with the administration of this medication? 1. Creatinine 2. Liver function tests 3. blood urea nitrogen 4. Hematological function tests

2. Liver function tests

The nurse is assigned to care for a client hospitalized with Meniere's disease. The nurse expects that which would most likely be prescribed for the client? 1. Low-fat diet 2. Low-sodium diet 3. Low-cholesterol diet 4. Low-carbohydrate diet

2. Low-sodium diet

Betaxolol hydrochloride eyedrops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication? 1. Monitoring temperature 2. Monitoring blood pressure 3. Checking peripheral pulses 4. Checking the blood glucose level

2. Monitoring blood pressure

The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago, after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. Based on this data, the nurse should make which determination about the client's neurovascular tissue? 1. Moderately impaired, and the surgeon should be called 2. Normal, caused by increased blood flow through the leg 3. Slightly deteriorating, and should be monitored for another hour 4. Adequate from an arterial approach, but venous complications are arising

2. Normal, caused by increased blood flow through the leg

The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? Select all that apply. 1. Use a dry table that is below waist level. 2. Open the distal flap of a sterile package first. 3. Prepare the sterile field just before the planned procedure. 4. Don clean gloves before touching items on the sterile field. 5. Place the sterile field 1 foot behind the working area and out of view of the client. 6. Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.

2. Open the distal flap of a sterile package first. 3. Prepare the sterile field just before the planned procedure. 6. Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.

A client who has been taking isoniazid for 1 1/2 months complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which adverse effect? 1. Hypercalcemia 2. Peripheral neuritis 3. Small blood vessel spasm 4. Impaired peripheral circulation

2. Peripheral neuritis

The nurse reinforces teaching to a client with diabetes mellitus regarding differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops? 1. Polyuria 2. Shakiness 3. Blurred vision 4. Fruity breath odor

2. Shakiness

The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position? 1. Squatting 2. Side-lying 3. Tailor sitting 4. Semi-Fowler's

2. Side-lying

The nurse is attempting to communicate with a hearing-impaired client. Which strategy by the nurse would be least helpful when talking to this client? 1. Reducing any background noise 2. Smiling continuously during conversation 3. Facing the client so that there is light on the nurse's face 4. Ensuring that showing frustration through facial expression is not done

2. Smiling continuously during conversation

Cycloserine is added to the medication regimen for a client with tuberculosis. Which instruction should the nurse reinforce in the client-teaching plan regarding this medication? 1. To take the medications before meals 2. To return to the clinic weekly for serum drug-level testing 3. It is not necessary to restrict alcohol intake with this medication. 4. It is not necessary to call the primary health care provider (PHCP) if a skin rash occurs.

2. To return to the clinic weekly for serum drug-level testing

The client is receiving meperidine hydrochloride for pain. Which signs/symptoms are side and adverse effects of this medication? Select all that apply. 1. Diarrhea 2. Tremors 3. Drowsiness 4. Hypotension 5. Urinary frequency 6. Increased respiratory rate

2. Tremors 3. Drowsiness 4. Hypotension

Bethanechol chloride is prescribed for a client with urinary retention. Which disorder should be a contraindication to the administration of this medication? 1. Gastric atony 2. Urinary strictures 3. Neurogenic atony 4. Gastroesophageal reflux

2. Urinary strictures

The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placentae is accompanied by which additional finding? 1. Soft abdomen on palpation 2. Uterine tenderness on palpation 3. No complaints of abdominal pain 4. Lack of uterine irritability or tetanic contractions

2. Uterine tenderness on palpation

The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the primary health care provider? 1. Garlic 2. Valerian 3. Lavender 4. Glucosamine

2. Valerian

The low-pressure alarm sounds on the ventilator. The nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. Which initial action should the nurse take? 1. Administer oxygen. 2. Ventilate the client manually. 3. Check the client's vital signs. 4. Start cardiopulmonary resuscitation (CPR).

2. Ventilate the client manually.

The nurse is assigned to are for a client with a diagnosis of a detached retina. Which findings would indicate that bleeding has occurred as a result of retinal detachment? Select all that apply. 1. Total loss of vision 2. Vision may be cloudy 3. A reddened conjunctiva 4. A sudden sharp pain in the eye 5. Complaints of a burst of black spots or floaters 6. Vision is clear straight ahead but not to the right

2. Vision may be cloudy 5. Complaints of a burst of black spots or floaters

The nurse prepares to give a bath and change the bed linens for a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which should the nurse incorporate in the plan during the bathing of this client? 1. Wearing gloves 2. Wearing a gown and gloves 3. Wearing a gown, gloves, and a mask 4. Wearing a gown and gloves to change the bed linens and gloves only for the bath

2. Wearing a gown and gloves

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids? 1. Dilated pupils, tachycardia, and diaphoresis 2. Yawning, irritability, diaphoresis, cramps, and diarrhea 3. Tachycardia, hypertension, sweating, and marked tremors 4. Depressed feelings, high drug craving, fatigue, and agitation

2. Yawning, irritability, diaphoresis, cramps, and diarrhea

The nurse should place the client in which position to administer an edema? 1. Prone position 2. left side-lying (Sims') position 3. Dorsal recumbent position 4. Supine position

2. left side-lying (Sims') position

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit? 1. The client with cirrhosis 2. The client with a ileostomy 3. The client with heart failure 4. The client with decreased kidney function

2. The client with a ileostomy

The nurse is monitoring the laboratory results of a client preparing to receive chemotherapy. The nurse determines that the white blood cell count (WBC) is normal if which result is present? 1. 2000 mm^3 (2 x 10^9/L) 2. 3000 mm^3 (3 x 10^9/L) 3. 5000 mm^3 (5 x 10^9/L) 4. 15,000 mm^3 (15 x 10^9/L)

3. 5000 mm^3 (5 x 10^9/L)

The nurse is assigned to care for a client at risk for alcohol withdrawal. The client's spouse asks the nurse, "When will the first signs of withdrawal appear?" The nurse should give which reply? 1. "In 7 days" 2. "In 14 days" 3. "In 21 days" 4. "Within a few hours"

4. "Within a few hours"

Trimethoprim-sulfamethoxazole is prescribed for a client. The nurse should instruct the client to report which symptom if it developed during the course of this medication therapy? 1. Nausea 2. Diarrhea 3. Headache 4. Sore throat

4. Sore throat

The medication prescribed is heparin 5,000 units subcutaneously, every 12 hours. The medication vial reads heparin 10,000 units/mL. The nurse prepares how many milliliters to administer the dose?

0.5 mL

During data collection, which behavior should the nurse expect a client diagnosed with agoraphobia to describe? 1. A fear of leaving the house 2. A fear of riding in elevators 3. A fear of speaking in public 4. A fear of uncleanliness and the need to bathe every hour

1. A fear of leaving the house

The medication prescription reads phenytoin 0.2 g orally, twice daily. The medication label states 100-mg capsules. The nurse prepares how many capsule(s) to administer one dose?

2 capsules

The nurse is choosing age-appropriate toys for a toddler. Which toy is the best choice for this age? 1. A Puzzle 2. Toy Soldiers 3. Large Stacking Blocks 4. A card game with large pictures

3. Large Stacking Blocks

The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal? 1. Unwrapping the eating utensils for the client 2. Replacing the plastic utensils with metal utensils 3. Carefully transferring the food from paper plates to glass plates 4. Allowing the client to unwrap the utensils and prepare his own meal for eating

4. Allowing the client to unwrap the utensils and prepare his own meal for eating

Skin breakdown occurs on a client's hand at the site of an intravenous catheter that had medication infusing. The nurse determines that which adverse effect occurred? 1. Phlebitis 2. infiltration 3. Thrombosis 4. Extravasation

4. Extravasation

The primary health care provider's (PHCP's) prescription reads acetaminophen 240 mg orally every 6 hours as needed for relief of pain, for a 5-year-old child. The medication label reads "acetaminophen 160 mg per 5 mL." How many mL per dose should the nurse administer to the child?

7.5 mL

The nurse is collecting data from a client, and the client's spouse reports that the client is taking donepezil hydrochloride. Which disorder should the nurse suspect that this client may have based on the use of this medication? 1. Dementia 2. Schizophrenia 2. Seizure disorder 4. Obsessive-compulsive disorder

1. Dementia

A client is admitted to a psychiatric unit for treatment of a psychiatric disorder. The client is at the locked exit door and is shouting, "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which defense mechanism? 1. Denial 2. Projection 3. Regression 4. Rationalization

1. Denial

The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder? 1. Metabolic acidosis 2. Metabolic acidosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic acidosis

A Hispanic American mother brings her child to the clinic for an examination. Which is most important when gathering data about the child? 1. Avoiding eye contact 2. Using body language only 3. Avoiding speaking to the child 4. Touching the child during the examination

4. Touching the child during the examination

A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching, How should the nurse correctly document these findings? 1. Bacteremia 2. Fluid overload 3. Hypovolemic shock 4. Transfusion reaction

4. Transfusion reaction

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action? 1. Call the nursing supervisor to initiate a court order for the surgical procedure. 2. Try calling the client's spouse to obtain telephone consent before the surgical procedure. 3. Ask a friend who accompanied the client to the emergency department to sign the consent form. 4. Transport the client to the operating department immediately without obtaining an informed consent.

4. Transport the client to the operating department immediately without obtaining an informed consent.

A client who is taking hydrochlorothiazide has also been prescribed triamterene. The client asks the nurse why both medications are required. Which response is the most accurate to give to the client? 1. Both are weak potassium-excreting diuretics. 2. The combination of these medications prevents renal toxicity. 3. Hydrochlorothiazide is an expensive medication, so using a combination of diuretics is cost-effective. 4. Triamterene is a potassium-retaining (sparing) diuretic, whereas hydrochlorothiazide is a potassium-excreting diuretic.

4. Triamterene is a potassium-retaining (sparing) diuretic, whereas hydrochlorothiazide is a potassium-excreting diuretic.

A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client knowing that which finding indicates the occurrence of a systemic effect? 1. Hyperventilation 2. Elevated blood pressure 3. Local rash at the burn site 4. Local pain at the burn site

Hyperventilation

The client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which class of medications? 1. Diuretics 2. Antibiotics 3. Antitussives 4. Decongestants

4. Decongestants

The medication prescribed is prochlorperazine 5 mg intramuscularly, every 4 hours as needed. The medication label states prochlorperazine 10 mg /mL. The nurse prepares how much medication to administer the dose?

0.5 mL

The nurse is providing instructions to a new parent regarding the psychosocial development of an infant. Using Erikson's psychosocial development theory, which instruction should the nurse reinforce to the parents? 1. Allow the infant to signal a need. 2. Anticipate all the needs of the infant. 3. Attend to the crying infant immediately. 4. Avoid the infant during the first 10 minutes of crying.

1. Allow the infant to signal a need.

The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation? 1. A urinary output of 20mL/hour 2. A temperature of 37.6° C (99.6° F) 3. A blood pressure of 100/70 mmHg 4. Serous drainage on the surgical dressing

1. A urinary output of 20mL/hour

The client is diagnosed with pleurisy. The nurse should expect to see which signs and symptoms? Select all that apply. 1. Pleural friction rub 2. Sharp, knife-like pain 3. Cyanosis of the lips and nailbeds 4. Pain that occurs on both sides of the chest 5. Pain that occurs most often during inspiration

1. Pleural friction rub 2. Sharp, knife-like pain 5. Pain that occurs most often during inspiration

The nurse observes a mother giving an oral iron supplement to her 6-year-old child with iron deficiency anemia. Which action by the mother indicates the need for further teaching? 1. The mother administered the iron with milk. 2. The mother administered the iron with water. 3. The mother administered the iron with apple juice. 4. The mother administered the iron with orange juice.

1. The mother administered the iron with milk.

Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? 1. The return of distal pulses 2. Decreasing edema formation 3. Brisk bleeding from the injury site 4. The formation of granulation tissue

1. The return of distal pulses

The client has been taking medication for rheumatoid arthritis for 3 weeks. During the administration of etanercept, it is most important for the nurse to collect which data? 1. The white blood cell and platelet counts 2. A metallic taste in the mouth, with a loss of appetite 3. Whether the client is experiencing fatigue and joint pain 4. Whether the client is experiencing itching and edema at the injection site

1. The white blood cell and platelet counts

The nurse should implement which in the care of a child who is having a seizure? Select all that apply. 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Insert an oral airway. 5. Place the child in a supine position. 6. Loosen clothing around the child's neck.

1. Time the seizure. 3. Stay with the child. 6. Loosen clothing around the child's neck.

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? 1. Tinnitus 2. Diarrhea 3. Constipation 4. Decreased respirations

1. Tinnitus

The nurse is assisting with caring for a client with cancer who is receiving cisplatin. Which adverse effects are associated with this medication? Select all that apply. 1. Tinnitus 2. Ototoxicity 3. Hyperkalemia 4. Hypercalcemia 5. Nephrotoxicity 6. Hypomagnesemia

1. Tinnitus 2. Ototoxicity 5. Nephrotoxicity 6. Hypomagnesemia

The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply. 1. To avoid activities that require bending over 2. To contact the surgeon if eye scratchiness occurs 3. To take acetaminophen for minor eye discomfort 4. To place an eye shield on the surgical eye at bedtime 5. That episodes of sudden severe pain in the eye are expected 6. To contact the surgeon if a decrease in visual acuity occurs

1. To avoid activities that require bending over 3. To take acetaminophen for minor eye discomfort 4. To place an eye shield on the surgical eye at bedtime 6. To contact the surgeon if a decrease in visual acuity occurs

A client taking lithium carbonate reports vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, and tremors. The lithium level is checked as a part of the routine follow-up, and the level is 3.0 mEq/L (3.0 mmol/L). The nurse knows that this is which level? 1. Toxic 2. Normal 3. Slightly above normal 4. Excessively below normal

1. Toxic

After a tonsillectomy, the child begins to vomit bright red blood. Which is the initial nursing action? 1. Turn the child to the side. 2. Notify the registered nurse (RN). 3. Administer the prescribed antiemetic. 4. Maintain NPO (nothing by mouth) status.

1. Turn the child to the side.

Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L (2.7 mmol/L)? 1. U waves 2. Flat P waves 3. Elevated T waves 4. Prolonged PR interval

1. U waves

A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing Allen's test before drawing the blood to determine the adequacy of which? 1. Ulnar circulation 2. Carotid circulation 3. Femoral circulation 4. Brachial circulation

1. Ulnar circulation

The nurse reinforces instructions to the client about breast self-examination (BSE). The nurse instructs the client to lie down and examine the left breast. Which is the correct area for placing a pillow when examining the left side? 1. Under the left shoulder 2. Under the right scapula 3. Under the right shoulder 4. Under the small of the back

1. Under the left shoulder

The nurse is planning to feed an older client who is at risk for aspiration of food. During the meal how should the nurse position the client? 1. Upright in a chair 2. On the left side in bed 3. On the right side in bed 4. In a low-Fowler's position, with the legs elevated

1. Upright in a chair

The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions should the nurse use to move this client? Select all that apply. 1. Use a friction-reducing slide sheet. 2. Use a mechanical lift to move the client. 3. Place the client in Trendelenburg position. 4. Keep elbows close and work close to the body. 5. Administer oral pain medication 5 minutes before moving the client. 6. Obtain assistance of a second caregiver to assist with mechanical aids.

1. Use a friction-reducing slide sheet. 2. Use a mechanical lift to move the client. 4. Keep elbows close and work close to the body. 6. Obtain assistance of a second caregiver to assist with mechanical aids.

A primary health care provider (PHCP) prescribed potassium chloride (KCl) elixir, 20 mEq orally daily. The medication label states potassium chloride (KCl), 30 mEq/15 mL. How many milliliters should the nurse prepare to administer the dose? Fill in the blank. _____ mL

10 mL

The nurse is asked to regulate the flow rate of an intravenous (IV) solution being administered to a client. The IV bag contains 50 mL of solution and the solution is to be administered over 30 minutes. The administration set has a drop factor of 10 drops (gtts) /mL. The nurse should regulate the roller clamp on the infusion set to deliver how many drops per minute? Fill in the blank. Round answer to the nearest whole number. _____ gtts/minute

17 gtt/minute

The primary health care provider (PHCP) has prescribed an antibiotic for a child. The average adult dose is 500 mg. The child has a body surface area (BSA) of 0.63 m^2. What is the dose for the child?

182 mg

A prescription reads: acetaminophen liquid, 650 mg orally every 4 hours PRN for pain. The medication label reads: 500mg/15 mL. The nurse prepares how many milliliters to administer one dose?

19.5 mL

The medication prescribed is metoclopramide hydrochloride 10 mg intramuscularly times one dose. The medication label reads metoclopramide hydrochloride 5 mg/mL. The nurse prepares how much medication to administer the dose?

2 mL

The medication prescribed is digoxin 0.25 mg orally, daily. The medication label reads digoxin 0.125 mg/tablet. The nurse should prepare how many tablet(s) to administer the dose?

2 tablets

The medication prescribed is levodopa 1g orally daily. The medication label states levodopa , 500 mg tablets. The nurse prepares to administer how many tablets at the evening dose?

2 tablets

The medication prescribed is zidovudine, 0.2 g orally, three times daily. The medication label states zidovudine, 100-mg tablets. The nurse prepares to administer how many tablets for one dose?

2 tablets

Laboratory work is prescribed for a client who has been experiencing delusions. When the laboratory technician approaches the client to obtain a specimen of the client's blood, the client begins to shout, "You're all vampires. Let me out of here!" The nurse present at the time should respond with which question or statement? 1. "The technician is not going to hurt you but is going to help." 2. "Are you fearful and think that others may want to hurt you?" 3. "What makes you think that the technician wants to hurt you?" 4. "The technician will leave and come back later for your blood."

2. "Are you fearful and think that others may want to hurt you?"

The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement made by the student indicates an accurate understanding of this disorder? 1. "Cushing's disease is characterized by an oversecretion of insulin." 2. "Cushing's disease is characterized by an oversecretion of glucocorticoid hormones." 3. "Cushing's disease is characterized by an undersecretion of corticotropic hormones." 4. "Cushing's disease is characterized by an undersecretion of glucocorticoid hormones."

2. "Cushing's disease is characterized by an oversecretion of glucocorticoid hormones."

A couple comes to the family planning clinic and asks about sterilization procedures. Which questions by the nurse helps determine whether this method of family planning is appropriate? 1. "Have either of you ever had surgery?" 2. "Do you plan to have any other children?" 3. "Do either of you have diabetes mellitus?" 4. "Do either of you have problems with high blood pressure?"

2. "Do you plan to have any other children?"

The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement? 1. "This diet will help lower my blood pressure." 2. "Fresh foods such as fruits and vegetables are high in sodium." 3. "This diet is not a replacement for my antihypertensive medications." 4. "The reason I need to lower my salt intake is to reduce fluid retention."

2. "Fresh foods such as fruits and vegetables are high in sodium."

The nurse is caring for a client who is suspected of being dependent on drugs. Which question should be appropriate for the nurse to ask when collecting data from the client regarding drug abuse? 1. "Why did you get started on these drugs?" 2. "How much do you use and what effect does it have on you?" 3. "How long did you think you could take these drugs without someone finding out?" 4. The nurse does not ask any questions because of fear that the client is in denial and will throw the nurse out of the room.

2. "How much do you use and what effect does it have on you?"

The nurse has reinforced homecare instructions to the parent of a child who is being discharged after cardiac surgery. Which statement by the parent indicates the need for further teaching? 1. "A balance of rest and exercise is important." 2. "I can apply lotion or powder to the incision if it is itchy." 3. "Activities during which the child could fall need to be avoided for 2 to 4 weeks." 4. "Large crowds of people need to be avoided for at least 2 weeks after this surgery."

2. "I can apply lotion or powder to the incision if it is itchy."

The nurse is providing care for a client admitted to the hospital with a diagnosis of anxiety disorder. The nurse is talking with the client, and the client says, "I have a secret that I want to tell you. You won't tell anyone about it, will you?" Which is the appropriate nursing response? 1. "No, I won't tell anyone." 2. "I cannot promise to keep a secret." 3. "If you tell me the secret, I will tell it to your doctor." 4. "If you tell me the secret, I will need to document it in your record."

2. "I cannot promise to keep a secret."

A client with benign prostatic hypertrophy (BPH) undergoes a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigations postoperatively. Which are the sings/symptoms of transurethral resection (TUR) syndrome? 1. Tachycardia and diarrhea 2. Bradycardia and confusion 3. Increased urinary output and anemia 4. Decreased urinary output and bladder spasms

2. Bradycardia and confusion

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium? 1. Milk 2. Butter 3. Spinach 4. Collard greens

2. Butter

The client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication? 1. Glucose level 2. Calcium level 3. Potassium level 4. Prothrombin time

2. Calcium level

A client is wearing a continuous cardiac monitor which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which action first? 1. Call a code blue. 2. Check the client status and lead placement. 3. Call the primary health care provider (PHCP). 4. Press the recorder button on the ECG console.

2. Check the client status and lead placement.

The nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. What action should the nurse take first? 1. Provide pin care. 2. Check the client's alignment in bed. 3. Medicate the client with an analgesic. 4. all the primary health care provider (PHCP).

2. Check the client's alignment in bed.

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. The nurse should take which actions? Select all that apply. 1. Contact the nephrologist. 2. Check the level of the drainage bag. 3. Reposition the client to his or her side. 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system for kinks. 6. Increase the flow rate of the peritoneal dialysis solution.

2. Check the level of the drainage bag. 3. Reposition the client to his or her side. 4. Place the client in good body alignment. 5. Check the peritoneal dialysis system for kinks.

A client with Crohn's disease is scheduled to receive an infusion of infliximab. The nurse assisting with caring for the client should take which action to monitor the effectiveness of treatment? 1. Monitoring the leukocyte count for 2 days after the infusion 2. Checking the frequency and consistency of bowel movements 3. Checking the serum liver enzyme levels before and after the infusion 4. Carrying out a Hematest on gastric fluids after the infusion is completed

2. Checking the frequency and consistency of bowel movements

The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately? 1. Sore throat or ear ache 2. Chills, itching or rash 3. Unusual sleepiness or fatigue 4. Mild discomfort at the catheter site

2. Chills, itching or rash

The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions should be included to accurately administer the medication? Select all that apply. 1. Position the client supine to assist with medication absorption. 2. Clamp the NG tube for 30 minutes after medication administration. 3. Before medication administration, verify correct placement of tube. 4. Flush the NG tube with saline before and after medication administration. 5. Discontinue the suction from the tube during the administration of medication.

2. Clamp the NG tube for 30 minutes after medication administration. 3. Before medication administration, verify correct placement of tube. 4. Flush the NG tube with saline before and after medication administration. 5. Discontinue the suction from the tube during the administration of medication.

The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which action first? 1. Administer oxygen by facemask. 2. Clear and maintain an open airway. 3. Check the blood pressure and the fetal heart tones. 4. Prepare for the administration of intravenous magnesium sulfate.

2. Clear and maintain an open airway.

The nurse in the newborn nursery receives a telephone call to prepare for the admission of a neonate born at 43 weeks' gestation with Apgar scores of 1 and 4. When planning for the admission of this infant, which is the nurse's highest priority? 1. Turning on the apnea and cardiorespiratory monitor 2. Connecting the resuscitation bag to the oxygen outlet 3. Setting up the intravenous line with 5% dextrose in water 4. Setting the radiant warmer control temperature at 36.5° C (97.6° F)

2. Connecting the resuscitation bag to the oxygen outlet

A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented? Select all that apply. 1. Enteric 2. Contact 3. Airborne 4. Protective 5. Neutropenic

2. Contact 3. Airborne

The nurse is assigned to assist the primary health care provider (PHCP) with the removal of a chest tube. Which interventions should the nurse anticipate performing during this process? Select all that apply. 1. Reinforce instructions to breathe deeply while the tube is removed. 2. Cover the site with an occlusive dressing after the tube is removed. 3. Clamp the chest tube near the insertion site just before the removal. 4. Raise the drainage system to the level of the chest tube insertion site. 5. Have the client perform the Valsalva maneuver as the chest tube is pulled out.

2. Cover the site with an occlusive dressing after the tube is removed. 5. Have the client perform the Valsalva maneuver as the chest tube is pulled out.

The nurse is evaluating the client's use of a cane for left-sided weakness. The nurse should intervene and correct the client if the nurse observed that the client performed which action? 1. Holds the cane on the right side 2. Moves the cane when the right leg is moved 3. Leans on the cane when the right leg swings through 4. Keeps the cane 6 inches out to the side of the right foot

2. Moves the cane when the right leg is moved

A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings which is the priority nursing action? 1. Monitor the maternal vital signs. 2. Notify the registered nurse (RN) immediately. 3. Continue monitoring labor and the fetal heart rate. 4. Encourage relaxation and breathing techniques between contractions.

2. Notify the registered nurse (RN) immediately.

The nurse is monitoring for bleeding in a child after surgery to remove a brain tumor. The nurse checks the head dressing for the presence of blood and notices a colorless drainage on the back of the dressing. Which nursing action is appropriate? 1. Reinforce the dressing. 2. Notify the registered nurse (RN). 3. Document the findings and continue to monitor. 4. Circle the area of drainage and continue to monitor.

2. Notify the registered nurse (RN).

The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client. Which instructions should be included in the list? Select all that apply. 1. Restrict fluid intake. 2. Obtain a MedicAlert bracelet. 3. Keep the humidity in the home low. 4. Prevent debris from entering the stoma. 5. Avoid exposure to people with infections. 6. Avoid swimming and use care when showering.

2. Obtain a MedicAlert bracelet. 4. Prevent debris from entering the stoma. 5. Avoid exposure to people with infections. 6. Avoid swimming and use care when showering.

A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel and a hyphema has been diagnosed. Which position should the nurse prepare to position the client? 1. Flat on bed rest 2. On bed rest in a semi-Fowler's position 3. In lateral position on the unaffected side 4. In the lateral position on the affected side

2. On bed rest in a semi-Fowler's position

Which data would indicate a potential complication associated with age-related changes in the musculoskeletal system? 1. Decrease in height 2. Overall sclerotic lesions 3. Diminished lean body mass 4. Change in structural bone tissue

2. Overall sclerotic lesions

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which problem? 1. Hypercalcemia 2. Peripheral neuritis 3. Small blood vessel spasm 4. Impaired peripheral circulation

2. Peripheral neuritis

A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which intervention? 1. Massage the skin at the rim of the cast 2. Petaling the cast edges with adhesive tape 3. Using a rough file to smooth the cast edges 4. Applying lotion to the skin at the rim of the cast

2. Petaling the cast edges with adhesive tape

The nurse is caring for an infant who had come to the nursing unit for observation and treatment of tetralogy of Fallot. The child suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. The nurse should perform which action first? 1. Assist to administer morphine sulfate. 2. Place the child in a knee-chest position. 3. Administer 100% oxygen by face mask. 4. Prepare to administer intravenous fluids.

2. Place the child in a knee-chest position.

In preparation for cataract surgery, the nurse is to administer cyclopentolate eyedrops. The nurse administers the eyedrops knowing that which is the purpose of this medication? 1. To produce miosis of the operative eye 2. To dilate the pupil of the operative eye 3. To provide lubrication to the operative eye 4. To constrict the pupil of the operative eye

2. To dilate the pupil of the operative eye

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse understands that a potassium value at this level would be noted with which condition? 1. Diarrhea 2. Traumatic burn 3. Cushing's syndrome 4. Overuse of laxatives

2. Traumatic burn

The client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value should the nurse specifically monitor during treatment with this medication? 1. Clotting time 2. Uric acid level 3. Potassium level 4. Blood glucose level

2. Uric acid level

The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of fluid resuscitation? 1. Vital signs 2. Urine output 3. Mental status 4. Peripheral pulses

2. Urine output

The nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. The client has a short burst of ventricular tachycardia (VT), followed by ventricular fibrillation (VF). The client suddenly loses consciousness. Which intervention should the nurse do first? 1. Go to the nurse's station quickly and call a code. 2. Run to get a defibrillator from an adjacent nursing unit. 3. Call for help and initiate cardiopulmonary resuscitation (CPR). 4. Start oxygen by cannula at 10L/minute and lower the head of the bed.

3. Call for help and initiate cardiopulmonary resuscitation (CPR).

Following kidney transplantation, cyclosporine is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication? 1. Hemoglobin level of 14.0 g/dL (140 g/L) 2. Creatinine level of 0.6 mg/dL (53 mcmol/L) 3. Blood urea nitrogen level of 25 mg/dL (8.8 mmol/L) 4. Fasting blood glucose level of 99 mg/dL (5.5 mmol/L)

3. Blood urea nitrogen level of 25 mg/dL (8.8 mmol/L)

Oxybutynin chloride is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication? 1. Pallor 2. Drowsiness 3. Bradycardia 4. Restlessness

3. Bradycardia

The nurse who is administering bethanechol chloride is monitoring for toxicity associated with the medication. The nurse should check the client for which sign of toxicity? 1. Dry skin 2. Dry mouth 3. Bradycardia 4. Signs of dehydration

3. Bradycardia

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding should be reported immediately to the primary health care provider (PHCP)? 1. Dry cough 2. Hematuria 3. Bronchospasm 4. Blood-tinged sputum

3. Bronchospasm

The nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose intolerance. The nurse should tell the mother that which supplement will be required as a result of the need to avoid lactose in the diet? 1. Fats and vitamin A 2. Zinc and vitamin C 3. Calcium and vitamin D 4. Thiamine and vitamin B

3. Calcium and vitamin D

The nurse checks the food on a tray delivered for an Orthodox Jewish client and notes that the client has received a cheeseburger and potato fries with whole milk as a beverage. Which action should the nurse take? 1. Deliver the food tray to the client. 2. Replace the whole milk with lactose-free milk. 3. Call the dietary department and ask for a different meal. 4. Ask the dietary department to replace the beef with pork.

3. Call the dietary department and ask for a different meal.

A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first? 1. Induce vomiting. 2. Call an ambulance. 3. Call the poison control center. 4. Bring the child to the emergency department.

3. Call the poison control center.

A child has fluid volume deficit. The nurse collects data and determines that the child is improving and the deficit is resolving if which finding is noted? 1. The child has no tears. 2. Urine specific gravity is 1.030. 3. Capillary refill is less than 2 seconds. 4. Urine output is less than 1 mL/kg/hour.

3. Capillary refill is less than 2 seconds.

A client has been started on long-term therapy with rifampin. Which information about this medication should the nurse provide to the client? 1. Should always be taken with food or antacids 2. Should be double-dosed if one dose is forgotten 3. Causes red-orange discoloration of sweat, tears, urine and feces 4. May be discontinued independently if symptoms are gone in 3 months

3. Causes red-orange discoloration of sweat, tears, urine and feces

The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which outcome? 1. Common 2. Suggestive of anemia 3. Characteristic of a thrush infection 4. Indicative of a need to improve oral hygiene

3. Characteristic of a thrush infection

A hospitalized client with coronary artery disease complains of substernal chest pain. After checking the client's heart rate and blood pressure, the nurse administers nitroglycerin, 0.4 mg, sublingually. After 5 minutes, the client states, "My chest still hurts." Which appropriate actions should the nurse take? Select all that apply. 1. Call a code blue. 2. Contact the client's family. 3. Check the client's pain level. 4. Check the client's blood pressure. 5. Administer a second nitroglycerin, 0.4 mg, sublingually.

3. Check the client's pain level. 4. Check the client's blood pressure. 5. Administer a second nitroglycerin, 0.4 mg, sublingually.

The nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely manifestation of this condition in the medical record? 1. Incessant crying 2. Coughing at nighttime 3. Choking with feedings 4. Severe projectile vomiting

3. Choking with feedings

A client is brought to the emergency department by the ambulance team after a collapse at home. Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that their eyes are to be donated. Which action should the nurse take next? 1. Place dry, sterile dressings over the eyes of the deceased. 2. Call the national Donor Association to confirm that the client is a donor. 3. Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes. 4. Ask the wife to obtain the legal documents regarding organ donation from the lawyer.

3. Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes.

Which laboratory result would verify the diagnosis of bacterial meningitis? 1. Clear cerebrospinal fluid with high protein and low glucose levels 2. Cloudy cerebrospinal fluid with low protein and low glucose levels 3. Cloudy cerebrospinal fluid with high protein and low glucose levels 4. Decreased pressure and cloudy cerebrospinal fluid with a high protein level

3. Cloudy cerebrospinal fluid with high protein and low glucose levels

An older client has recently been taking cimetidine. The nurse should monitor the client for which most frequent central nervous system side effect from this medication? 1. Tremors 2. Dizziness 3. Confusion 4. Hallucinations

3. Confusion

The nurse is monitoring an older client suspected of having a urinary tract infection (UTI) for signs of infection. Which sign/symptom is likely to present first? 1. Fever 2. Urgency 3. Confusion 4. Frequency

3. Confusion

The nurse assists with admitting a child with a diagnosis of acute stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted? 1. Cracked lips 2. A normal appearance 3. Conjunctival hyperemia 4. Desquamation of the skin

3. Conjunctival hyperemia

A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states which about the ductus venosus? 1. Connects the pulmonary artery to the aorta 2. Is an opening between the right and left atria 3. Connects the umbilical vein to the inferior vena cava 4. Connects the umbilical artery to the inferior vena cava

3. Connects the umbilical vein to the inferior vena cava

The nurse is reviewing the results of serum laboratory studies drawn on a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving didanosine. The nurse determines that the client may have the medication discontinued by the primary health care provider (PHCP) if which significantly elevated result is noted? 1. Serum protein 2. Blood glucose 3. Serum amylase 4. Serum creatinine

3. Serum amylase

The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of automatic dysreflexia and suspects this complication if which sign/symptom is noted? 1. Sudden tachycardia 2. Pallor of the face and neck 3. Severe, throbbing headache 4. Severe and sudden hypotension

3. Severe, throbbing headache

The nurse is caring for a client diagnosed with catatonic stupor. The client is laying on the bed, with the body pulled into a fetal position. Which is the most appropriate nursing intervention? 1. Ask direct questions to encourage talking. 2. Leave the client alone and intermittently check on them. 3. Sit beside the client in silence and verbalize occasional open-ended questions. 4. Take the client into the dayroom with other clients so they can help watch him.

3. Sit beside the client in silence and verbalize occasional open-ended questions.

A client has been placed in Buck's extension traction. Which technique provided by the nurse will provide countertraction? 1. Using a footboard 2. Providing an overhead trapeze 3. Slightly elevating the foot of the bed 4. Slightly elevating the head of the bed

3. Slightly elevating the foot of the bed

The client is receiving external radiation to the neck for cancer of the larynx. The nurse monitors the client knowing that which are side/adverse effects of the external radiation? Select all that apply. 1. Dyspnea 2. Diarrhea 3. Sore throat 4. Constipation 5. Red and dry skin over neck

3. Sore throat 5. Red and dry skin over neck

The nurse is caring for a client who is hearing-impaired and should take which approach to facilitate communication? 1. Speak loudly. 2. Speak frequently. 3. Speak in a normal tone. 4. Speak directly into the impaired ear.

3. Speak in a normal tone.

The nurse is gathering data on a client with a diagnosis of tuberculosis. The nurse should review the results of which diagnostic test to confirm this diagnosis? 1. Chest x-ray 2. Bronchoscopy 3. Sputum culture 4. Tuberculin skin test

3. Sputum culture

A client is admitted to the hospital with possible rheumatic endocarditis. The nurse should check for a history of which type of infection? 1. Viral infection 2. Yeast infection 3. Streptococcal infection 4. Staphylococcal infection

3. Streptococcal infection

A postoperative client has received a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. After administration of the medication, the nurse should check the client for which sign/symptom? 1. Pupillary changes 2. Scattered lung wheezes 3. Sudden increase in pain 4. Sudden episodes of diarrhea

3. Sudden increase in pain

A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is reinforcing instructions to the client regarding the program. Which instruction should the nurse include? 1. Try to exercise before mealtime. 2. Administer insulin after exercising. 3. Take a blood glucose test before exercising. 4. Exercise should be performed during peak times of insulin.

3. Take a blood glucose test before exercising.

The nurse is reviewing the postoperative primary health care provider's (PHCP's) prescriptions for a 3-week-old infant with Hirschsprung's disease admitted to the hospital for surgery. Which prescriptions documented in the child's record should the nurse question? Select all that apply. 1. Measure abdominal girth daily. 2. Monitor strict intake and output. 3. Take temperature measurements rectally. 4. Start clear liquid diet after 8 hours postoperatively. 5. Maintain IV fluids until the child tolerates oral intake. 6. Monitor the surgical site for redness, swelling, and drainage

3. Take temperature measurements rectally. 4. Start clear liquid diet after 8 hours postoperatively.

The nurse is reinforcing discharge instructions to a client with cancer of the prostate after a suprapubic prostatectomy. The nurse should reinforce which discharge instruction? Select all that apply. 1. Avoid driving a car for 1 week. 2. Restrict fluid intake to prevent incontinence. 3. Take the prescribed stool softener every day. 4. Avoid lifting objects heavier than 20 pounds for 6 weeks. 5. Inspect the incision on the scrotum every day for redness. 6. notify the primary health care provider (PHCP) if small blood clots are noticed during urination.

3. Take the prescribed stool softener every day. 4. Avoid lifting objects heavier than 20 pounds for 6 weeks.

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury?

36%

Sulfisoxazole 1 g orally four times daily, is prescribed for an adolescent with a urinary tract infection. The medication label reads, "250-mg tablets." The nurse has determined that the prescribed dose is safe. how many tablets per dose should the nurse administer to the adolescent?

4 tablets

The parents of an 8-year-old child tell the nurse that they are concerned about their child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response? 1. "You need to be concerned." 2. "You need to monitor the child's behavior closely." 3. "You need to praise the child more often to stop this behavior." 4. "At this stage, the child is developing his or her own personality."

4. "At this stage, the child is developing his or her own personality."

The nurse is monitoring the leg pain of a client who has just undergone right femoral-popliteal artery bypass grafting. Which question would be most useful in determining whether the client is experiencing graft occlusion? 1. "Can you describe what the pain feels like?" 2. "Can you rate the pain on a scale of 1 to 10?" 3. "Did you get any relief from the last dose of pain medication?" 4. "Can you compare this pain to the pain you felt before surgery?"

4. "Can you compare this pain to the pain you felt before surgery?"

The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF? 1. "Has the child complained of back pain?" 2. "Has the child complained of headaches?" 3. "Has the child had any nausea or vomiting?" 4. "Has the child had a sore throat or a fever within the last 2 months?"

4. "Has the child had a sore throat or a fever within the last 2 months?"

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to assist the registered nurse with which action? 1. Administering an antidote 2. Drawing a sample for type and crossmatch and transfuse the client. 3. Drawing a sample for an activated partial thromboplastin time (aPTT) level. 4. Drawing a sample for a prothrombin time (PT) and international normalized ratio (INR).

4. Drawing a sample for a prothrombin time (PT) and international normalized ratio (INR).

A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder? 1. Hematuria and pyuria 2. Dysuria and proteinuria 3. Hematuria and urgency 4. Dysuria and penile discharge

4. Dysuria and penile discharge

The nurse visits a client at home who has been discharged from the hospital after implantation of a permanent pacemaker. The nurse should check the client's home for the presence of which priority item? 1. Hair dryer 2. Electric blanket 3. Electric toothbrush with holder 4. Electrical items with strong magnetic fields

4. Electrical items with strong magnetic fields

The nurse is admitting a client with Guillain-Barre syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which items into the client's room? 1. Nebulizer and pulse oximeter 2. Blood pressure cuff and flashlight 3. Flashlight and incentive spirometer 4. Electrocardiographic monitoring electrodes and intubation tray

4. Electrocardiographic monitoring electrodes and intubation tray

The nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should perform which intervention? 1. Keep the leg in a level position. 2. Elevate the leg for 3 hours, and put it flat for 1 hour. 3. Keep the leg elevated for 3 hours, and elevate it for 1 hour. 4. Elevate the leg on pillows continuously for 24 to 48 hours.

4. Elevate the leg on pillows continuously for 24 to 48 hours.

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of burn? 1. A dependent position 2. Elevation of the knees 3. Flat, without elevation 4. Elevation above the level of the heart

4. Elevation above the level of the heart

The nurse is assisting with preparing a plan of care for a 4-year-old hospitalized with nephrotic syndrome. Which intervention is most appropriate for this child? 1. Provide a high-salt diet. 2. Provide a high-protein diet. 3. Discourage visitors at mealtimes. 4. Encourage the child to eat in the playroom.

4. Encourage the child to eat in the playroom.

A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22mEq/L (22mmol/L), and a PCO2 of 30 mm Hg. Which action should the nurse plan to take? 1. Perform Allen's test. 2. Prepare the client for dialysis. 3. Administer insulin as prescribed. 4. Encourage the client to slow down breathing.

4. Encourage the client to slow down breathing.

A female client with anorexia nervosa is a member of a support group. The client has verbalized that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes for the client to replace her old clothes. The client believes that the new clothes were much too tight, so she has reduced her calorie intake to 800 calories daily. The nurse identifies this behavior as which finding? 1. Normal 2. Regressive 3. Indicative of the client's ambivalence 4. Evidence of the client's altered and distorted body image

4. Evidence of the client's altered and distorted body image

The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning

4. Exhaling during repositioning

A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure? 1. Checking visual acuity 2. Covering the eye with a pressure patch 3. Swabbing the eye with antibiotic ointment 4. Irrigating the eye with sterile normal saline

4. Irrigating the eye with sterile normal saline

The nurse is assigned to care for a lien diagnosed with systemic lupus erythematosus (SLE). The nurse should plan care considering which factor regarding this diagnosis? 1. A local rash occurs as a result of allergy. 2. It is a disease caused by overexposure to sunlight. 3. A continuous release of histamine in the body causes this disease. 4. It is an inflammatory disease of collagen contained in connective tissue.

4. It is an inflammatory disease of collagen contained in connective tissue.

The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action? 1. Maintain strict bed rest 2. Monitor the vital signs every 2 hours 3. Perform firm fundal massage every 2 hours 4. Keep the client and her family members informed of her progress.

4. Keep the client and her family members informed of her progress.

The nurse observes that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, rapid respirations. How should the nurse correctly document this observation in the medical record? 1. Apnea 2. Bradypnea 3. Cheyne stokes 4. Kussmaul's respirations

4. Kussmaul's respirations

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin (aPPT) time is 65 seconds. The licensed practical nurse reviews the laboratory results with the registered nurse, anticipating that which action is needed? 1. Discontinuing the heparin infusion 2. Increasing the rate of heparin infusion 3. Decreasing the rate of heparin infusion 4. Leaving the rate of heparin infusion as is

4. Leaving the rate of heparin infusion as is

The nurse reinforces client instructions about ethambutol. The nurse determines that the client understands the instructions if the client indicates to report which occurrence? 1. Impaired sense of hearing 2. Distressing gastrointestinal side effects 3. Orange-red discoloration of body secretions 4. Difficulty discriminating the color red from green

4. Difficulty discriminating the color red from green

Alendronate is prescribed for a client with osteoporosis and the nurse is providing instructions for the administration of the medication. Which instruction should the nurse reinforce? 1. Take the medication at bedtime. 2. Take the medication in the morning with breakfast. 3. Lie down for 30 minutes after taking the medication. 4. Take the medication with a full glass of water after rising in the morning.

4. Take the medication with a full glass of water after rising in the morning.

The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. The nurse should plan to maintain bed rest for this client in which position? 1. High Fowler's position 2. Supine with no head elevation 3. Left lateral (side-lying) position 4. Supine with head elevation no greater than 30 degrees

4. Supine with head elevation no greater than 30 degrees

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should plan to place the client in which position? 1. Prone 2. Reverse Trendelenburg's 3. Supine, with the residual limb flat on the bed 4. Supine, with the residual limb supported with pillows

4. Supine, with the residual limb supported with pillows

The nurse is preparing to assist the health care provider to test the extraocular movements in a client and muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done? 1. Testing the Ishihara chart 2. Testing the Snellen eye chart 3. Testing the corneal light reflexes 4. Testing the six cardinal positions of gaze

4. Testing the six cardinal positions of gaze

The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100° F (37.7° C) orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place? 1. The transfusion will begin as prescribed. 2. The transfusion will begin after the administration of an antihistamine. 3. The transfusion will begin after the administration of 650 mg of acetaminophen. 4. The blood will be held, and the primary health care provider (PHCP) will be notified.

4. The blood will be held, and the primary health care provider (PHCP) will be notified.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing which client is at risk for a potassium deficit? 1. The client with Addison's disease 2. The client with metabolic acidosis 3. The client with intestinal obstruction 4. The client receiving nasogastric suction

4. The client receiving nasogastric suction

The clinical nurse instructs an adolescent with iron deficiency edema about the administration of oral iron preparations. The nurse should tell the adolescent that it is best to take the iron with which item? 1. Cola 2. Soda 3. Water 4. Tomato Juice

4. Tomato Juice

The medication prescribed is morphine sulfate 6 mg subcutaneously. The medication label states morphine sulfate 10 mg/1 mL. The nurse plans to prepare how much medication to administer the dose?

0.6 mL

The medication prescribed is hydromorphone hydrochloride 3 mg intramuscularly, every 4 hours as needed. The medication label reads hydromorphone hydrochloride 4 mg/1mL. The nurse should prepare to administer how many mL to the client?

0.75 mL

The medication prescribed is haloperidol, 4 mg intramuscularly, immediately. The medication label states 5 mg/1 mL. The nurse prepares how much medication to administer the dose?

0.8 mL

The parents of a 16-year-old child tell the nurse that they are concerned because the child sleeps until noon every weekend. Which is the most appropriate nursing response? 1. "Adolescents love to sleep late in the morning." 2. "The child shouldn't be staying up so late at night." 3. "If the child eats properly, that shouldn't be happening." 4. "The child should have a blood test to check for anemia."

1. "Adolescents love to sleep late in the morning."

Glimepiride is prescribed for a client with diabetes mellitus. The nurse reinforces instructions for the client and tells the client to avoid which while taking this medication? 1. Alcohol 2. Organ meats 3. Whole-grain cereals 4. Carbonated beverages

1. Alcohol

A client is scheduled for angioplasty. The client says to the nurse, "I'm so afraid that it will hurt and make me worse off than I am." Which response by the nurse is therapeutic? 1. "Can you tell me what you understand about the procedure?" 2. "Your fears are a sign that you really should have this procedure." 3. "Try not to worry. This is a well-known and easy procedure for your doctor." 4. "Those are very normal fears, but please be assured that everything will be okay."

1. "Can you tell me what you understand about the procedure?"

The nurse is monitoring a client who has been newly diagnosed with diabetes mellitus for signs of complications. Which statement by the client would indicate hyperglycemia and thus warrant primary health care provider (PHCP) notification? 1. "I am urinating a lot." 2. "My pulse is really slow." 3. "I am sweating for no reason." 4. "My blood pressure is really high."

1. "I am urinating a lot."

The nurse is reinforcing discharge teaching to a client who has Cushing's syndrome. Which statement by the client indicates that the instructions related to dietary management were understood? 1. "I can eat foods that contain potassium." 2. "I will need to limit the amount of protein in my diet." 3. "I am fortunate that I can eat all the salty foods I enjoy." 4. "I am fortunate that I do not need to follow any special diet."

1. "I can eat foods that contain potassium."

The home care nurse visits a client at home who has been prescribed prednisone 5 mg orally. The nurse reinforces teaching for the client about the medication. Which statement made by the client indicates a need for further teaching? 1. "I can take aspirin or my antihistamine if I need it." 2. "I need to take my medication everyday at the same time." 3. "I need to avoid coffee, tea, cola, and chocolate in my diet." 4. "If I gain more than 5 pounds a week, I will call my doctor."

1. "I can take aspirin or my antihistamine if I need it."

The psychiatric nurse is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the appropriate nursing response? 1. "I cannot discuss any client situation with you." 2. :I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she is doing great!" 3. "You may want to know about Carol, so you need to ask her yourself so you can get the story firsthand." 4. "I'm not supposed to discuss this, but because you are my neighbor, I can tell you that she really has some problems!"

1. "I cannot discuss any client situation with you."

A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement? 1. "I don't need birth control because I will be breast feeding." 2. "I need to increase my caloric intake by 500 calories a day." 3. "I shouldn't use soap to wash my breasts because I will be breastfeeding." 4. "I need to be sure that I increase my fluid intake and take my prenatal vitamins while breastfeeding."

1. "I don't need birth control because I will be breast feeding."

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, though reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response? 1. "I have a legal obligation to report this type of abuse." 2. "I promise I won't tell anyone, but let's see what we can do about this." 3. "Let's talk about ways that will prevent your daughter from hitting you." 4. "This should not be happening. If it happens again, you must call the emergency department."

1. "I have a legal obligation to report this type of abuse."

The nurse provides homecare instructions to the parent of a child with attention deficit hyperactivity disorder regarding behavioral therapy interventions. Which statement made by the parent indicates a need for further teaching? 1. "I hear that the side effects of the medication that my child will be on can cause overeating." 2. "I know that consistent medication and regular follow-up visits are a part of the plan for my child." 3. "I know I need to maintain a consistent home environment because my child is easily distracted." 4. "I understand that I will need to learn some behavioral modification techniques to help my child's impulsivity."

1. "I hear that the side effects of the medication that my child will be on can cause overeating."

The nurse is providing instructions to a parent of a child with patent ductus arteriosus (PDA). Which statement by the parent would indicate a need for further teaching? 1. "I know that my child will outgrow this problem, just give him time." 2. "I know that I need to be alert for signs of heart failure with this defect until it is repaired." 3. "The doctors tell me that my child has a heart murmur caused by the ductus not closing after birth." 4. "As I understand it, my child may have to have this defect closed, either during a catheterization or by surgery."

1. "I know that my child will outgrow this problem, just give him time."

A client is being discharged after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement? 1. "I need to avoid getting the cast wet." 2. "I will use my fingertips to lift and move the leg." 3. "I need to cover the casted leg with warm blankets." 4. "I can use a padded coat hanger end to scratch under the cast."

1. "I need to avoid getting the cast wet."

The nurse determines that the wife of an alcoholic client is benefiting from attending an Al-Anon group when the nurse hears the wife make which statement? 1. "I no longer feel that I deserve the beatings my husband inflicts on me." 2. "My attendance at the meetings has helped me to see that I provoke my husband's violence." 3. "I enjoy attending the meetings because they get me out of the house and away from my husband." 4. "I can tolerate my husband's destructive behaviors now that I know they are common for alcoholics."

1. "I no longer feel that I deserve the beatings my husband inflicts on me."

The client has just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of postprocedure care? 1. "I should drink extra fluids for the remainder of the day." 2. "I should not take any medication for at least 4 hours." 3. "I should eat lightly for the remainder of the day." 4. "I should rest quietly for the remainder of the day."

1. "I should drink extra fluids for the remainder of the day."

The nurse is reinforcing home-care instructions to the parents of a 3-year-old child with scabies. Which statement by a parent indicates the need for further teaching? 1. "I understand that I need to leave the scabicide on for 4 hours before washing it off." 2. "I will need to seal up all of my child's nonwashable toys in a plastic bag for at least 4 days." 3. "I realize that everyone who has come in contact with my child will need to be treated for scabies." 4. "I know I need to wash all the clothing and bedding in hot water with detergent and dry in a hot dryer."

1. "I understand that I need to leave the scabicide on for 4 hours before washing it off."

The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed? 1. "I will flush the eyes after instilling the ointment." 2. "I will clean the newborn's eyes before instilling ointment." 3. "I need to administer the eye ointment within 1 hour after delivery." 4. "I will instill the eye ointment into each of the newborn's conjunctival sacs."

1. "I will flush the eyes after instilling the ointment."

The nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which statement made by the mother would indicate the need for further teaching? 1. "I will give my child cough syrup if a cough develops." 2. "During an attack, I will take my child to a cool location." 3. "I can give acetaminophen if my child develops a fever." 4. "I will be sure that my child drinks at least three to four glasses of fluids every day."

1. "I will give my child cough syrup if a cough develops."

Phenytoin, 100 mg orally three times daily, has been prescribed for a client for seizure control. The nurse reinforces instructions regarding the medication to the client. Which statement made by the client indicates an understanding of the instructions? 1. "I will use a soft toothbrush to brush my teeth." 2. "It's all right to break the capsules to make it easier for me to swallow them." 3. "If I forget to take my medication, I can wait until the next dose and eliminate that dose." 4. "If my throat becomes sore, it's a normal effect of the medication and there's nothing to be concerned about."

1. "I will use a soft toothbrush to brush my teeth."

The nurse is reinforcing discharge instructions to a client with diabetes mellitus. The client's hemoglobin, glycosylated (HbA1C) level is 10%. Based on this level, which statement should the nurse make to the client? 1. "Increase the amount of vegetables and water intake in your diet regimen." 2. "Change the time of day you exercise because it may cause hypoglycemia." 3. "Continue with the same diet and exercise regimen you are currently using." 4. "Utilize a high-intensity exercise regimen and decrease carbohydrate consumption."

1. "Increase the amount of vegetables and water intake in your diet regimen."

Which statement made by a nursing student about Kohlberg's theory of moral development indicates the need for further teaching about the theory? 1. "Individuals move through all six stages in a sequential fashion." 2. "Moral development progresses in relation to cognitive development." 3. "A person's ability to make moral judgements develops over a period of time." 4. "It provides a framework for understanding how individuals determine a moral code to guide his or her behavior."

1. "Individuals move through all six stages in a sequential fashion."

The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term? 1. "It is the fetal movement that is felt by the mother." 2. "It is the compressibility of the lower uterine segment." 3. "It is the irregular, painless contractions that occur throughout pregnancy." 4. "It is the soft blowing sound that can be heard when the uterus is auscultated."

1. "It is the fetal movement that is felt by the mother."

The nurse is instructing a mother of a 1-year-old child with strabismus about the treatment options. Which statement by the mother would indicate the need for further teaching? 1. "My child will outgrow this by the time he is 2 years old and be able to see just fine." 2. "I will have my child wear an eye patch over the good eye to help strengthen the weak eye." 3. "If this eye patch does not work I know that we will have to do surgery to correct my child's crossed eyes." 4. "There are a few causes of this condition and they tell me my child has crossed eyes because of a muscle imbalance."

1. "My child will outgrow this by the time he is 2 years old and be able to see just fine."

The nurse is assisting with collecting data on a child with seizures. The nurse is interviewing the child's parents to establish their adjustment to caring for the child with a chronic illness. Which statement by the parents indicates a need for further teaching? 1. "Our child sleeps in our bedroom at night." 2. "We worry about injuries when our child has a seizure." 3. "Our child is involved in a swim program with neighbors and friends." 4. "Our babysitter just completed first-aid and child resuscitation training."

1. "Our child sleeps in our bedroom at night."

The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response by the student indicates an understanding of this physiological process? 1. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high." 2. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are low." 3. "The low levels of estrogen and progesterone increase the release of follicle-stimulating hormone and luteinizing hormone." 4. "The high levels of estrogen and progesterone promote the release of follicle-stimulating hormone and luteinizing hormone."

1. "Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high."

The nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response indicates an understanding of the anatomy of this structure? 1. "The uterus weighs about 2 ounces." 2. "The uterus weighs about 2.2 pounds." 3. "The uterus has a capacity of about 50 milliliters." 4. "The uterus is round in shape and weighs approximately 1000 grams."

1. "The uterus weighs about 2 ounces."

The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement? 1. "We will be sure not to leave hot liquids unattended." 2. "I guess my child needs to understand what the word 'hot' means." 3. "We will be sure that our child stays in his room when we work in the kitchen." 4. "We will instill a safety gate as soon as we get home so our child can't get in the kitchen."

1. "We will be sure not to leave hot liquids unattended."

The mother of a child with Marfan syndrome asks the nurse what can be done to help her child. Which are the vest responses by the nurse? Select all that apply. 1. "You may need to consider surgery in the future." 2. "You will need to make regular pediatric appointments for your child." 3. "You will need to keep your child indoors and avoid sports." 4. "You will need to have your child take cardiac medication(s) to decrease stress on the aorta." 5. "You will need to let the dentist know that antibiotics should be given before any procedure."

1. "You may need to consider surgery in the future." 2. "You will need to make regular pediatric appointments for your child." 4. "You will need to have your child take cardiac medication(s) to decrease stress on the aorta." 5. "You will need to let the dentist know that antibiotics should be given before any procedure."

The nurse is talking to a pregnant client with human immunodeficiency virus (HIV) infection regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. "You will need to bottle-feed your newborn." 2. "You will need to feed your own newborn by nasogastric tube feeding." 3. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." 4. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."

1. "You will need to bottle-feed your newborn."

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would suggest to the registered nurse the need for implementing neutropenic precautions if the client's white blood cell count was which value? 1. 2,000 mm^3 (2.0 x 10^9/L) 2. 5,800 mm^3 (5.8 x 10^9/L) 3. 8,400 mm^3 (8.4 x 10^9/L) 4. 11,500 mm^3 (11.5 x 10^9/L)

1. 2,000 mm^3 (2.0 x 10^9/L)

A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? 1. 3.2 mEq/L (3.2 mmol/L) 2. 3.8 mEq/L (3.8 mmol/L) 3. 4.2 mEq/L (4.2 mmol/L) 4. 4.8 mEq/L (4.8 mmol/L)

1. 3.2 mEq/L (3.2 mmol/L)

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated? 1. A change in the uterine contour 2. A sudden and sharp abdominal pain 3. A shortening of the umbilical cord 4. A decrease in blood loss from the introitus

1. A change in the uterine contour

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)? 1. A client who requires a 24-hour urine collection 2. A client who requires twice-daily dressing changes 3. A client with diabetes mellitus who requires daily insulin and the reinforcement of dietary measures 4. A client who has been placed on a bowel management program and requires rectal suppositories and a daily enema

1. A client who requires a 24-hour urine collection

Which of these clients is/are the most likely to develop fluid (circulatory) overload? Select all that apply. 1. A premature infant 2. A 101-year-old man 3. A client with heart failure 4. A client with diabetes mellitus 5. A client receiving renal dialysis 6. A 29-year-old client with pneumonia

1. A premature infant 2. A 101-year-old man 3. A client with heart failure 5. A client receiving renal dialysis

The nurse is reviewing the record of a client who has been prescribed baclofen. Which disorder should alert the nurse to contact the primary health care provider? 1. A seizure disorder 2. Hyperthyroidism 3, Diabetes mellitus 4. Coronary artery disease

1. A seizure disorder

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the health care provider has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which change that occurs with pregnancy? 1. A softening of the cervix 2. The presence of fetal movement 3. The presence of human chorionic gonadotropin in the urine 4. A soft blowing sound that corresponds with the maternal pulse that is heard while auscultating the uterus

1. A softening of the cervix

The nurse is preparing a list of homecare instructions for the client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse reinforce? Select all that apply. 1. Activities should be resumed gradually. 2. Avoid contact with other individuals except family members for at least 6 months. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members have already been exposed. 5. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags. 6. When one sputum culture is negative, the client is no longer considered infectious and can usually return to his or her former employment.

1. Activities should be resumed gradually. 3. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. 4. Respiratory isolation is not necessary because family members have already been exposed. 5. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags.

The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to be prescribed? Select all that apply. 1. Administer antacids, as prescribed. 2. Encourage coughing and deep breathing. 3. Administer anticholinergics, as prescribed. 4. Maintain the client in a supine and flat position. 5. Encourage small, frequent, high-calorie feedings.

1. Administer antacids, as prescribed. 2. Encourage coughing and deep breathing. 3. Administer anticholinergics, as prescribed.

The client is receiving an eyedrop and eye ointment to the right eye. Which action should the nurse take? 1. Administer the eyedrop first, followed by the eye ointment. 2. Administer the eye ointment first, followed by the eyedrop. 3. Administer the eyedrop, wait 10 minutes, and administer the eye ointment. 4. Administer the eye ointment, wait 10 minutes, and administer the eyedrop.

1. Administer the eyedrop first, followed by the eye ointment.

The medication prescription states to administer acetaminophen 650 mg orally for a temperature of more than 38° C. The medication bottle states acetaminophen 325 mg tablets. The nurse takes the client's temperature and notes that it is 101° F. The nurse plans to take which action? 1. Administer two tablets. 2. Administer three tablets. 3. Do not administer at this time. 4. Check the client's temperature in 30 minutes.

1. Administer two tablets.

The nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse (RN) and expects which interventions to be prescribed? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously 5. Transporting the client to the coronary care unit 6. Placing the client in a low-Fowler's side-lying position

1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide 4. Administering morphine sulfate intravenously

A client is unwilling to get out of the house for fear of "doing something crazy in public." Because of this fear, the client remains homebound except when accompanied outside by the spouse. The spouse asks the nurse, "what is the name of my wife's disorder?" Which answer should the nurse give to the spouse? 1. Agoraphobia 2. Hematophobia 3. Claustrophobia 4. Hypochondriasis

1. Agoraphobia

The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to distinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse should perform? 1. Aim at the base of the fire. 2. Squeeze the handle on the extinguisher. 3. Sweep the fire from side to side with the extinguisher. 4. Sweep the fire from top to bottom with the extinguisher.

1. Aim at the base of the fire.

The nurse is assisting with conducting a health-promotion program to community members regarding testicular cancer. The nurse determines that further teaching is needed if a community member states that which is a sign/symptom of testicular cancer? Select all that apply. 1. Alopecia 2. Back pain 3. Painless testicular swelling 4. A heavy sensation in the scrotum 5. Elevation in prostate specific antigen (PSA) levels

1. Alopecia 5. Elevation in prostate specific antigen (PSA) levels

The nurse is assigned to care for a client after a cesarean section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action? 1. Ambulate frequently. 2. Wear support stockings. 3. Apply warm, moist packs to the legs. 4. Remain on bed rest, with the legs elevated.

1. Ambulate frequently.

The nurse monitors a client receiving digoxin for which early manifestation of digoxin toxicity? 1. Anorexia 2. Facial pain 3. Photophobia 4. Yellow color perception

1. Anorexia

The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? Select all that apply. 1. Apply disposable gloves. 2. Place the client in the right Sims' position. 3. Lubricate the enema tube and insert it approximately 4 inches. 4. Clamp the tubing if the client expresses discomfort during the procedure. 5. Hang the enema solution container 24 inches above the client's anus. 6. Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C).

1. Apply disposable gloves. 3. Lubricate the enema tube and insert it approximately 4 inches. 4. Clamp the tubing if the client expresses discomfort during the procedure. 6. Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C).

A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action? 1. Apply ice to the affected eye. 2. Irrigate the eye with cool water. 3. Notify the primary health care provider (PHCP). 4. Accompany the client to the emergency department.

1. Apply ice to the affected eye.

The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should the nurse perform for this procedure? Select all that apply. 1. Apply suction for up to 10 seconds. 2. Hyperoxygenate the client before suctioning. 3. Set the wall suction unit pressure at 160 mm HG. 4. Apply suction while gently inserting the catheter. 5. Apply intermittent suction while rotating and withdrawing the catheter. 6. Advance the catheter until resistance is met and then pull the catheter back 1 cm.

1. Apply suction for up to 10 seconds. 2. Hyperoxygenate the client before suctioning. 5. Apply intermittent suction while rotating and withdrawing the catheter. 6. Advance the catheter until resistance is met and then pull the catheter back 1 cm.

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included? 1. As-needed medications given that shift 2. Normal vital signs that have been normal since admission 3. All of the tests and treatments the client has had since admission 4. Total number of scheduled medications that the client received on that shift

1. As-needed medications given that shift

A child is admitted to the hospital with a probably diagnosis of nephrotic syndrome. Which findings should the nurse expect to observe? Select all that apply. 1. Ascites 2. Anorexia 3. Weight loss 4. Proteinuria 5. Decreased serum lipids 6. Periorbital and facial edema

1. Ascites 2. Anorexia 4. Proteinuria 6. Periorbital and facial edema

A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery? 1. Assess patency of the airway. 2. Check tubes or drains for patency. 3. Check dressing for bleeding or drainage. 4. Obtain vital signs to compare with those recorded preoperatively.

1. Assess patency of the airway.

The nurse is assisting to develop a diabetic teaching program. To meet the clients' needs, the nurse should plan to take which action first? 1. Assess the clients' functional abilities. 2. Ensure that insurance will pay for participation in the program. 3. Discuss the focus of the program with the interprofessional team. 4. Include everyone who comes into the clinic in the teaching sessions.

1. Assess the clients' functional abilities.

A client is to undergo a gastroscopy and the nurse reinforces preprocedure instructions. The nurse should instruct the client to take which action in the preprocedure period? 1. Avoid eating or drinking after midnight before the test. 2. Limit self to only two cigarettes on the morning of the test. 3. Have a clear liquid breakfast only on the morning of the test. 4. Take all routine medications with a glass of water on the morning of the test.

1. Avoid eating or drinking after midnight before the test.

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply the medication to which body area? Select all that apply. 1. Back 2. Axilla 3. Eyelids 4. Soles of the feet 5. Palms of the hands

1. Back 4. Soles of the feet 5. Palms of the hands

A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet? 1. Baked turkey 2. Tomato soup 3. Boiled shrimp 4. Chicken gumbo

1. Baked turkey

A histamine (H2)-receptor antagonist will be prescribed for a client. The nurse understands that which medications are H2-recceptor antagonists? 1. Nizatidine 2. Ranitidine 3. Famotidine 4. Cimetidine 5. Esomeprazole 6. Lansoprazole

1. Nizatidine 2. Ranitidine 3. Famotidine 4. Cimetidine

The nurse is checking a client's record for probable signs of pregnancy. Which are probable signs of pregnancy that the nurse should note? Select all that apply. 1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions 5. Outline of fetus via radiography or ultrasound 6. Fetal heart rate detected by a nonelectronic device

1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first? 1. Baseline fetal heart rate 2. Intensity of contractions 3. Maternal blood pressure 4. Frequency of contractions

1. Baseline fetal heart rate

The nurse is caring for the client with epididymitis. Which treatment modalities should be implemented? Select all that apply. 1. Bed rest 2. Sitz bath 3. Antibiotics 4. Heating pad 5. Scrotal elevation

1. Bed rest 2. Sitz bath 3. Antibiotics 4. Heating pad 5. Scrotal elevation

The nurse is reinforcing measures regarding the care of the newborn with a mother, To bathe the newborn, the mother should be taught which intervention? 1. Begin with the eyes and face. 2. Start with the dirtiest area first. 3. Begin with the feet and work upward. 4. Only wash the diaper area, because this is the only part of the baby that gets soiled.

1. Begin with the eyes and face.

A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now. I have to go. I don't want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. Which is the appropriate nursing action? 1. Call the nursing supervisor. 2. Call security to block all exit areas. 3. Tell the client that she cannot return to this hospital again if she leaves now. 4. Restrain the client until the primary health care provider (PHCP) can be reached.

1. Call the nursing supervisor.

A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma? 1. Cardiovascular disease 2. A history of migraine headaches 3. Frequent urinary tract infections 4. Frequent upper respiratory infections

1. Cardiovascular disease

The nurse is preparing an intravenous (IV) solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should take which plan of action? 1. Change the IV tubing 2. Wipe the tubing with Betadine 3. Scrub the tubing with an alcohol swab. 4. Scrub the tubing before attaching it to the IV bag.

1. Change the IV tubing

The nurse is caring for a postoperative client who has a Jackson-Pratt drain inserted into the surgical wound. Which actions should the nurse take in the care of the drain? Select all that apply. 1. Check the drain for patency. 2. Check that the drain is decompressed. 3. Observe for bright red, bloody drainage. 4. Maintain aseptic technique when emptying. 5. Empty the drain when it is half full and every 8-12 hours. 6. Secure the drain by curling or folding it and taping it firmly to the body.

1. Check the drain for patency. 2. Check that the drain is decompressed. 3. Observe for bright red, bloody drainage. 4. Maintain aseptic technique when emptying. 5. Empty the drain when it is half full and every 8-12 hours.

The nurse notes that the 4-hour postpartum client has cool, clammy skin and she is restless and excessively thirsty. The nurse immediately notifies the registered nurse then performs which action? 1. Checks the vital signs 2. Begins fundal massage 3. Encourages ambulation 4. Encourages the client to drink fluids

1. Checks the vital signs

The client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed? Select all that apply. 1. Chest x-ray 2. Echocardiography 3. Electrocardiography 4. Cervical radiography 5. Pulmonary function studies

1. Chest x-ray 5. Pulmonary function studies

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. Based on this finding, the nurse should institute which intervention? 1. Collect data to determine factors for fall risk. 2. Close the blinds and turn off the overhead light. 3. Instruct the client to ask for assistance when getting up to walk. 4. Teach the client to lift legs high while walking, as if walking over planks. 5. Ensure the client is upright when eating and swallows twice after each bite.

1. Collect data to determine factors for fall risk. 3. Instruct the client to ask for assistance when getting up to walk.

Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1. Communicate expected behaviors to the client. 2. Follow through about the consequences of behavior in a nonpunitive manner. 3. Ensure that the client knows that he or she is not in charge of the nursing unit. 4. Assist the client with developing a means of setting limits on personal behavior. 5. Enforce rules and inform the client that he or she will not be allowed to attend therapy groups. 6. Be clear with the client regarding consequences of exceeding limits set regarding behavior.

1. Communicate expected behaviors to the client. 2. Follow through about the consequences of behavior in a nonpunitive manner. 4. Assist the client with developing a means of setting limits on personal behavior. 6. Be clear with the client regarding consequences of exceeding limits set regarding behavior.

A client taking buspirone for 1 month returns to the clinic for a follow-up visit. Which should indicate medication effectiveness? 1. No rapid heartbeats or anxiety 2. No paranoid thought processes 3. No thought broadcasting or delusions 4. No reports of alcohol withdrawal symptoms

1. No rapid heartbeats or anxiety

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action? 1. Decline to sign the will. 2. Sign the will as a witness to the signature only. 3. Call the hospital lawyer before signing the will. 4. Sign the will, clearly identifying credentials and employment agency.

1. Decline to sign the will.

Desmopressin acetate is prescribed for the treatment of diabetes insipidus. The nurse monitors the client after medication administration for which therapeutic response? 1. Decreased urinary output 2. Decreased blood pressure 3. Decreased peripheral edema 4. Decreased blood glucose level

1. Decreased urinary output

A primigravida's membranes rupture spontaneously. Which action should the nurse take first? 1. Determine the fetal heart rate. 2. Prepare for immediate delivery. 3. Monitor the contraction pattern. 4. Note the amount, color, and odor of the amniotic fluid.

1. Determine the fetal heart rate.

The nurse is reviewing the record of a client with Crohn's disease. Which stool characteristic should the nurse expect to see documented in the record? 1. Diarrhea 2. Constipation 3. Bloody stools 4. Stool constantly oozing from the rectum

1. Diarrhea

The home care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client, prescribed repaglinide and metformin, asks the nurse to explain these medications. The nurse should reinforce which instructions to the client? Select all that apply. 1. Diarrhea can occur secondary to metformin. 2. The repaglinide is not taken if a meal is skipped. 3. The repaglinide is taken 30 minutes before eating. 4. Candy or other simple sugar is carried and used to treat mild hypoglycemia episodes. 5. Muscle pain is an expected side effect of metformin and may be treated with acetaminophen. 6. Metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide.

1. Diarrhea can occur secondary to metformin. 2. The repaglinide is not taken if a meal is skipped. 3. The repaglinide is taken 30 minutes before eating. 4. Candy or other simple sugar is carried and used to treat mild hypoglycemia episodes.

The nurse has reinforced instructions to a client with tuberculosis about proper handling and disposal of respiratory secretions. The nurse determines that the client understands the instructions if the client verbalizes to take which measure? 1. Discard used tissues in a plastic bag. 2. Wash hands at least four times a day. 3. Brush teeth and rinse the mouth once a day. 4. Turn the head to the side if coughing or sneezing.

1. Discard used tissues in a plastic bag.

The nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The nurse notices a small amount of reddish drainage from the child's left ear after the surgery. On the basis of this finding, which action should the nurse take? 1. Document the findings. 2. Notify the registered nurse immediately. 3. Change the ear tubes so that they do not become blocked. 4. Check the eat drainage for the presence of cerebrospinal fluid.

1. Document the findings.

The nurse prepares to administer a prescribed dose of scopolamine. The nurse should monitor for which side effect of this medication? 1. Dry mouth 2. Diaphoresis 3. Excessive urination 4. Pupillary constriction

1. Dry mouth

The nurse educator is asking the nursing student to recall the signs/symptoms of hypothyroidism. The nurse educator determines that the student understands this disorder if which are included in the student's response? Select all that apply. 1. Dry skin 2. Irritability 3. Palpitations 4. Weight loss 5. Constipation 6. Cold intolerance

1. Dry skin 5. Constipation 6. Cold intolerance

A hospitalized client is a lacto-vegetarian. Which food item should the nurse remove from the meal tray? 1. Eggs 2. Milk 3. Cheese 4. Broccoli

1. Eggs

A 4-year-old child sustains a fall at home injuring the right arm and is brought to the emergency department by the mother. The nurse should perform which emergency actions in the care of the child? Select all that apply. 1. Elevate the right arm. 2. Apply warm packs to the right arm. 3. Check the neurovascular status of the right extremity. 4. Check the range of motion of the right arm and shoulder. 5. Determine the level of pain using a pediatric pain assessment tool.

1. Elevate the right arm. 3. Check the neurovascular status of the right extremity. 5. Determine the level of pain using a pediatric pain assessment tool.

The nurse is reviewing the client's record and notes that the primary health care provider (PHCP) has documented that the client has a renal disorder. Which laboratory results would indicate a decrease in renal function? Select all that apply. 1. Elevated serum creatinine level 2. Elevated thrombocyte count 3. Decreased red blood cell (RBC) count 4. Decreased white blood cell (WB) count 5. Elevated blood urea nitrogen (BUN) level

1. Elevated serum creatinine level 3. Decreased red blood cell (RBC) count 5. Elevated blood urea nitrogen (BUN) level

The nurse is caring for a client with a fresh application of a plaster leg cast. The nurse should plan to prevent the development of compartment syndrome by which action? 1. Elevating the limb and applying ice to the affected leg 2. Elevating the limb and covering it with bath blankets 3. Keeping the leg horizontal and applying ice to the affected leg 4. Placing the leg in a slightly dependent position and applying ice

1. Elevating the limb and applying ice to the affected leg

The nurse is preparing to administer atenolol to a client. The nurse should check which priority item before administering the medication? 1. Temperature 2. Blood pressure 3. Potassium level 4. Blood glucose level

2. Blood pressure

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care knowing that which facts are true with the use of a fenestrated tracheostomy tube? Select all that apply. 1. Enables the client to speak. 2. Is necessary for mechanical ventilation. 3. Must have the cuff deflated when capped 4. Eliminates the need for tracheostomy care 5. Prevents air from being inhaled through the tracheostomy opening

1. Enables the client to speak. 3. Must have the cuff deflated when capped

The nurse is assisting with developing a plan of care for the client with multiple myeloma. Which nursing intervention should be included to prevent renal failure for this client? Select all that apply. 1. Encouraging fluids 2. Providing frequent oral care 3. Coughing and deep breathing 4. Monitoring the red blood cell count 5. Monitoring serum calcium and uric acid levels

1. Encouraging fluids 5. Monitoring serum calcium and uric acid levels

A manic client announces to everyone in the dayroom that a stripper is coming to perform that evening. When the psychiatric nurse's aid firmly states that the client's behavior is not appropriate, the manic client becomes verbally abusive and threatens physical violence to the nurse's aid. Based on the analysis of this situation, the nurse determines that the appropriate action should be which intervention? 1. Escort the manic client to his or her room. 2. Orient the client to time, person and place. 3. Tell the client that the behavior is not appropriate. 4. Tell the client that smoking privileges are revoked for 24 hours.

1. Escort the manic client to his or her room.

The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently? 1. Every hour 2. Every 2 hours 3. Every 3 hours 4. Every 4 hours

1. Every hour

The nurse is planning to begin a continuous tube feeding on a client with a nasogastric (NG) tube. Which interventions should the nurse perform before initiating the feeding? Select all that apply. 1. Explain the procedure to the client. 2. Irrigate the NG tube with saline. 3. Aspirate all stomach contents and discard. 4. Elevate the head of the bed to 45 degrees. 5. Have a pair of scissors for emergency use at the bedside. 6. Ensure that the end of the NG tube is in the esophagus.

1. Explain the procedure to the client. 2. Irrigate the NG tube with saline. 4. Elevate the head of the bed to 45 degrees.

The client is admitted to the hospital with a diagnosis of suspected Hodgkin's disease. Which signs and symptoms of the client are associated with Hodgkin's disease? Select all that apply. 1. Fatigue 2. Weakness 3. Joint pain 4. Weight gain 5. Night sweats 6. Enlarged lymph nodes

1. Fatigue 2. Weakness 5. Night sweats 6. Enlarged lymph nodes

A client experiencing a severe major depressive episode is unable to address activities of daily living. Which is the appropriate nursing intervention? 1. Feed, bathe, and dress the client as needed until the client can perform these activities independently. 2. Offer the client choices and consequences to the failure to comply with the expectation of maintaining activities of daily living. 3. Structure the client's day so the adequate time can be devoted to the client's assuming responsibility for the actions of daily living. 4. Have the client's peers confront the client about how their noncompliance with addressing activities of daily living affects the milieu.

1. Feed, bathe, and dress the client as needed until the client can perform these activities independently.

A mother of a child with a diagnosis of intussusception calls the nurse into the hospital room because the child is screaming in pain. Which manifestations of perforation should the nurse report immediately? 1. Fever 2. Ribbon-like stools 3. Increased heart rate 4. Hypoactive bowel sounds 5. Profuse projectile vomiting 6. Change in level of consciousness

1. Fever 3. Increased heart rate 6. Change in level of consciousness

A hospitalized client is prescribed phenelzine sulfate for the treatment of depression. The nurse reinforces instructions to the client and tells the client to avoid consuming which foods while taking this mediation? Select all that apply. 1. Figs 2. Yogurt 3. Crackers 4. Aged cheese 5. Tossed salad 6. Oatmeal cookies

1. Figs 2. Yogurt 4. Aged cheese

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes

1. Flushing 4. Depressed respirations 5. Extreme muscle weakness

Which home care instructions should the nurse plan to reinforce to the mother of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1. Frequent hand washing is important. 2. The child should avoid exposure to other illnesses. 3. The child's immunization schedule will need revision. 4. Kissing the child on the mouth will never transmit the virus. 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). 6. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention.

1. Frequent hand washing is important. 2. The child should avoid exposure to other illnesses. 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach).

The client who is diagnosed with human immunodeficiency virus (HIV) seropositive has been taking stavudine. The nurse should monitor which parameter closely while the client is taking this medication? 1. Gait 2. Appetite 3. Level of consciousness 4. Hemoglobin and hematocrit blood levels

1. Gait

Cyclobenzaprine is prescribed for a client to treat muscle spasms, and the nurse is reviewing the client's record. Which disorder would indicate a need to contact the primary health care provider (PHCP) regarding the administration of this medication? 1. Glaucoma 2. Emphysema 3. Hyperthyroidism 4. Diabetes mellitus

1. Glaucoma

The nurse is planning to administer amlodipine to a client. The nurse should check which before giving the medication? 1. Respiratory rate 2. Blood pressure and heart rate 3. Heart rate and respiratory rate 4. Level of consciousness and blood pressure

2. Blood pressure and heart rate

The nurse is developing a care plan for a client who is scheduled for surgery. The nurse should include which activities in the nursing care plan for the client on the day of the surgery? 1. Have the client void before surgery. 2. Avoid oral hygiene and rinsing with mouthwash. 3. Verify that the client has not eaten for the last 24 hours. 4. Determine that the client has signed the informed consent for the surgical procedure. 5. Report immediately any slight increase in blood pressure or pulse from the client's baseline vital signs.

1. Have the client void before surgery. 4. Determine that the client has signed the informed consent for the surgical procedure.

The nurse should implement which activity to promote reminiscence among older adults? 1. Having storytelling hours 2. Setting up pet therapy sessions 3. Displaying calendars and clocks 4. Encouraging client participation in a pottery class

1. Having storytelling hours

The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which findings are associated with the diagnosis of glomerulonephritis? Select all that apply. 1. Headache 2. Hypotension 3. Red-brown urine 4. Periorbital edema 5. Increased urine output 6. A low blood urea nitrogen (BUN) level

1. Headache 3. Red-brown urine 4. Periorbital edema

The nurse is preparing to administer digoxin, 0.125 mg orally, to a client with heart failure. Which vital sign is most important for the nurse to check before administering the medication? 1. Heart rate 2. Temperature 3. Respirations 4. Blood pressure

1. Heart rate

A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication? 1. Hematocrit of 33% (0.33) 2. Platelet count of 400,000 mm^3 (400 x 10^9/L) 3. White blood cell count of 6000 mm^3 (6 x 10^9/L) 4. Blood urea nitrogen level of 15 mg/dL (5.25 mmol/L)

1. Hematocrit of 33% (0.33)

It has been determined that a client with hepatitis has contracted the infection from a contaminated food. Which type of hepatitis is this client most likely experiencing? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D

1. Hepatitis A

To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse should include which in the plan of care? 1. Initiating seizure precautions 2. Using a wheelchair for out-of-bed activities 3. Assisting the child with ambulation at all times 4. Avoiding contact with other children on the nursing unit

1. Initiating seizure precautions

The nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply. 1. Insomnia 2. Weight loss 3. Bradycardia 4. Constipation 5. Mild heat intolerance

1. Insomnia 2. Weight loss 5. Mild heat intolerance

The nurse assists to create a nursing care plan for the child with an arm cast and should include which interventions in the plan? Select all that apply. 1. Instruct parents to keep the cast clean and dry. 2. Monitor the extremity for circulatory impairment. 3. Instruct the child not to stick objects down the cast. 4. Ensure that rough cast materials are cut off to keep smooth. 5. Notify the registered nurse (RN) immediately if circulatory impairment occurs.

1. Instruct parents to keep the cast clean and dry. 2. Monitor the extremity for circulatory impairment. 3. Instruct the child not to stick objects down the cast. 5. Notify the registered nurse (RN) immediately if circulatory impairment occurs.

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and should be reported to the primary health care provider before the surgery? Select all that apply. 1. Is allergic to penicillin 2. Quit smoking 3 months earlier 3. History of tonsillectomy at the age of 7 years 4. Wonders if the surgery could cause incontinence 5. Takes daily multivitamin and calcium supplement. 6. History of deep vein thrombosis in right leg 10 years earlier

1. Is allergic to penicillin 2. Quit smoking 3 months earlier 4. Wonders if the surgery could cause incontinence 6. History of deep vein thrombosis in right leg 10 years earlier

A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 0 mg/dL (0 mcmol/L). The nurse reviews this result and makes which interpretation? 1. It is negative. 2. It is a concern. 3. It is inconclusive. 4. It requires rescreening at 6 weeks.

1. It is negative.

The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid. The nurse determines that which client complaint may be associated with the use of this medication? 1. Itching 2. Euphoria 3. Drowsiness 4. Frequent urination

1. Itching

The nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply. 1. Keep the cast and extremity elevated. 2. The cast needs to be kept clean and dry. 3. Allow the wet cast 24 to 72 hours to dry. 4. Expect tingling and numbness in the extremity. 5. Use a hair dryer set on a warm to hot setting to dry the cast. 6. Use a soft-padded object that will fit under the cast to scratch the skin under the cast.

1. Keep the cast and extremity elevated. 2. The cast needs to be kept clean and dry. 3. Allow the wet cast 24 to 72 hours to dry.

The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client? 1. Lateral position 2. Low Fowler's position 3. Semi-Fowler's position 4. Head of the bed elevation at 40 degrees

1. Lateral position

The nurse is reinforcing teaching to a client about an upcoming colonoscopy procedure. The nurse should include in the instructions that the client will be placed in which position for the procedure? 1. Left Sims' position 2. Lithotomy position 3. Knee-chest position 4. Right Sims' position

1. Left Sims' position

Which findings indicate to the nurse that placental separation has occurred? Select all that apply. 1. Lengthening of the umbilical cord 2. Sudden trickle or spurt of blood 3. Fundus is boggy following separation 4. Change from globular to discoid shape 5. Fetal membranes are seen at the introitus

1. Lengthening of the umbilical cord 2. Sudden trickle or spurt of blood 5. Fetal membranes are seen at the introitus

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be documented in the client's record? Select all that apply. 1. Lesion has a waxy border 2. An irregularly shaped lesion 3. Papule, with a red, central crater 4. A small papule with a dry, rough scale 5. A firm nodular lesion topped with a crust

1. Lesion has a waxy border 2. An irregularly shaped lesion

The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric (NG) tube. The nurse checks the residual and obtains an amount of 200 mL. Which actions should the nurse take? Select all that apply. 1. Listen to the client's bowel sounds. 2. Document and discard the residual. 3. Offer the client sips of water to drink. 4. Question the client regarding nausea. 5. Determine whether the client has abdominal distention. 6. Hold the feeding after flushing the tubing with 30 mL saline.

1. Listen to the client's bowel sounds. 4. Question the client regarding nausea. 5. Determine whether the client has abdominal distention. 6. Hold the feeding after flushing the tubing with 30 mL saline.

The nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection? Select all that apply. 1. Listening to lung sounds 2. Obtaining the client's temperature 3. Checking the strength of peripheral pulses 4. Obtaining information about the client's respirations 5. Performing a musculoskeletal and neurological examination 6. Asking the client about a family history of any disease or illness

1. Listening to lung sounds 2. Obtaining the client's temperature 4. Obtaining information about the client's respirations

Which data indicate to the nurse that a client is experiencing effective coping following the loss of a spouse? Select all that apply. 1. Looks at old snapshots of family 2. Constantly neglects personal grooming 3. Visits the spouse's grave once a month 4. Visits the senior citizens' center once a month 5. Prefers to spend time alone and avoids contact with others

1. Looks at old snapshots of family 3. Visits the spouse's grave once a month 4. Visits the senior citizens' center once a month

A client with hiatal hernia chronically experiences heartburn after meals. Which should the nurse teach the client to avoid? 1. Lying recumbent after meals 2. Eating small, frequent, bland meals 3. Raising the head of the bed on 6 inch blocks 4. Taking histamine receptor antagonist medication, as prescribed

1. Lying recumbent after meals

The camp nurse prepares to instruct a group of children about Lyme disease. Which information should the nurse include in the instructions? 1. Lyme disease is caused by a tick carried by deer. 2. Lyme disease is caused by contamination from cat feces. 3. Lyme disease can be contagious by skin contact with an infected individual. 4. Lyme disease can be caused by the inhalation of spores from bird droppings.

1. Lyme disease is caused by a tick carried by deer.

A child is diagnosed with chicken pox. The nurse collects data regarding the child. Which finding is characteristic of chicken pox? 1. Macular rash on the trunk and scalp 2. Pseudomembrane formation on the throat 3. Maculopapular or petechial rash on the extremities 4. Small, red spots with bluish-white center and red base

1. Macular rash on the trunk and scalp

The nurse is reinforcing discharge instructions to a client receiving sulfisoxazole. Which should be included in the plan of care for instructions? 1. Maintain a high fluid intake. 2. Discontinue the medication when feeling better. 3. If the urine turns dark brown, call the primary health care provider (PHCP) immediately. 4. Decrease the dosage when symptoms are improving to prevent an allergic response.

1. Maintain a high fluid intake.

A nursing student is asked to identify the practices and beliefs of the Amish society. Which should the student identify? Select all that apply. 1. Many choose not to have health insurance. 2. They believe that health is a gift from God. 3. The authority of women is equal to that of men. 4. They remain secluded and avoid helping others. 5. They use both traditional and alternative health care, such as healers, herbs, and massage. 6. Funerals are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple, without adornment.

1. Many choose not to have health insurance. 2. They believe that health is a gift from God. 5. They use both traditional and alternative health care, such as healers, herbs, and massage. 6. Funerals are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple, without adornment.

The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse should tell the client to select which food item that is high in riboflavin? 1. Milk 2. Tomatoes 3. Citrus fruits 4. Green, leafy vegetables

1. Milk

The nurse is reviewing the laboratory results of a client who is receiving chemotherapy and notes that the platelet count is 10,000 mm^3 (10 x 10^9/L). On the basis of this laboratory value, the nurse should perform which intervention? Select all that apply. 1. Monitor stools for occult blood. 2. Keep away from persons who have colds or feel ill. 3. Instruct the client not to bend over at the waist or lift. 4. Floss teeth and rinse mouth with mouthwash after every meal. 5. Instruct the client to blow nose very gently without blocking either nostril.

1. Monitor stools for occult blood. 3. Instruct the client not to bend over at the waist or lift. 5. Instruct the client to blow nose very gently without blocking either nostril.

A client enters the emergency department confused, twitching, and having seizures. Upon assessment, flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor is noted. The serum sodium level is 172 mEq/L (172 mmol/L). Which interventions should the primary health care provider (PHCP) likely prescribe? Select all that apply. 1. Monitor vital signs. 2. Monitor intake and output. 3. Increase water intake orally. 4. Monitor electrolyte levels. 5. Provide a sodium-reduced diet. 6. Administer sodium replacements.

1. Monitor vital signs. 2. Monitor intake and output. 3. Increase water intake orally. 4. Monitor electrolyte levels. 5. Provide a sodium-reduced diet.

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory depression occurs? 1. Naloxone 2. Morphine sulfate 3. Betamethasone 4. Meperidine hydrochloride

1. Naloxone

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which actions should the nurse take? Select all that apply. 1. Notify the RN. 2. Notify the Rapid Response Team. 3. Finish the suctioning as quickly as possible. 4. Discontinue the suctioning until the client is stabilized. 5. Contact the respiratory department to suction the client.

1. Notify the RN. 4. Discontinue the suctioning until the client is stabilized.

The nurse is caring for a client who is receiving an intravenous (IV) infusion of an antineoplastic medication. During the transfusion, the client complains of pain at the insertion site. During an inspection of the site, the nurse notes redness and swelling. The nurse should take which appropriate action? 1. Notify the registered nurse immediately. 2. Administer pain medication to reduce the discomfort. 3. Apply ice and maintain the infusion rate, as prescribed. 4. Elevate the extremity of the IV site, and slow the infusion.

1. Notify the registered nurse immediately.

The nurse is assisting with planning the care of a client being admitted to the nursing unit who has attempted suicide. Which priority nursing intervention should the nurse include in the plan of care? 1. One-on-one suicide precautions 2. Suicide precautions, with 30-minute checks 3. Checking the whereabouts of the client every 15 minutes 4. Asking that the client to report suicidal thoughts immediately

1. One-on-one suicide precautions

The nurse is assigned to care for a client experiencing disturbed thought processes. The nurse is told that the client believes that their food is being poisoned. Which communication technique should the nurse plan to use to encourage the client to eat? 1. Open-ended questions and silence 2. Focusing on self-disclosure regarding food preferences 3. Stating the reasons that the client may not want to eat 4. Offering opinions about the necessity of adequate nutrition

1. Open-ended questions and silence

A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply. 1. Pad the bed's side rails. 2. Place an airway at the bedside. 3. Place oxygen equipment at the bedside. 4. Place suction equipment at the bedside. 5. Tape a padded tongue blade to the wall at the head of the bed.

1. Pad the bed's side rails. 2. Place an airway at the bedside. 3. Place oxygen equipment at the bedside. 4. Place suction equipment at the bedside.

A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible incarcerated hernia. The nurse tells the parents that which manifestation requires primary health care provider (PHCP) notification by the parents? 1. Pain 2. Diarrhea 3. Constipation 4. Increased flatus

1. Pain

A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and should question which intervention that is written in the plan? 1. Palpate the abdomen for a mass. 2. Check the urine for the presence of hematuria. 3. Monitor the blood pressure for the presence of hypertension. 4. Monitor the temperature for the presence of a kidney infection.

1. Palpate the abdomen for a mass.

The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase, an antineoplastic agent. The nurse consults with the registered nurse regarding the administration of the medication if which is documented in the client's history? 1. Pancreatitis 2. Diabetes mellitus 3. Myocardial infarction 4. Chronic obstructive pulmonary disease

1. Pancreatitis

The nurse is reinforcing instructions for a client in how to perform a testicular self-examination (TSE). Which instructions should the nurse include? Select all that apply. 1. Perform TSE after a shower or bath. 2. Perform TSE after emptying the bladder. 3. Perform TSE on the same day each month. 4. Observe for urethral discharge after performing TSE. 5. Perform TSE by rolling each testicle between the thumb and fingers.

1. Perform TSE after a shower or bath. 3. Perform TSE on the same day each month. 5. Perform TSE by rolling each testicle between the thumb and fingers.

The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which? 1. Phlebitis of the vein 2. Infiltration of the IV line 3. Hypersensitivity to the IV solution 4. An allergic reaction to the IV catheter material

1. Phlebitis of the vein

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Which interventions should be included in the plan of care? Select all that apply. 1. Place the infant in a private room. 2. Place the infant in a room near the nurses' station. 3. Ensure that the infant's head is in a flexed position. 4. Wear a mask at all times when in contact with the infant. 5. Place the child in a tent that delivers warm, humidified air. 6. Position the infant side-lying, with the head lower than the chest.

1. Place the infant in a private room. 2. Place the infant in a room near the nurses' station.

The nurse has inserted a nasogastric (NG) tube in a client and is checking for the correct placement of a NG tube. Which is the most reliable data to ensure that the end of the tube is in the stomach? 1. Placement is verified on x-ray. 2. The pH of the aspirated fluid is 5. 3. The aspirated fluid is bile green in color. 4. Air injection is auscultated in the left upper quadrant.

1. Placement is verified on x-ray.

The nurse notes that a client with type 1 diabetes mellitus has lipodystrophy on both upper thighs. Which further information should the nurse obtain from the client during data collection? 1. Plan for injection rotation 2. Consistency of aspiration 3. Preparation of the injection site 4. Angle at which the medication is administered

1. Plan for injection rotation

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply. 1. Platelets 35,000 mm^3 (35 x 10^9/L) 2. Sodium 150 mEq/L (150 mmol/L) 3. Potassium 5.0 mEq/L (5.0 mmol/L) 4. Segmented neutrophils 40% (0.40) 5. Serum creatinine, 1mg/dL (88.3 mcmol/L) 6. White blood cells, 3,000 mm^3 (3.0 x 10^9/L)

1. Platelets 35,000 mm^3 (35 x 10^9/L) 2. Sodium 150 mEq/L (150 mmol/L) 4. Segmented neutrophils 40% (0.40) 6. White blood cells, 3,000 mm^3 (3.0 x 10^9/L)

The nurse is caring for a client with an internal radiation implant. The nurse should observe which principle Select all that apply. 1. Pregnant women are not allowed into the client's room. 2. Limit the time with the client to 1 hour per 8-hour shift. 3. Wear a lead apron while delivering bedside care to the client. 4. Remove the dosimeter badge when entering the client's room. 5. Individuals less than 16 years old are allowed in the room if they stand 6 feet away from the client.

1. Pregnant women are not allowed into the client's room. 3. Wear a lead apron while delivering bedside care to the client.

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL (2.0 mmol/L). The nurse understands that which condition would cause this serum calcium level? 1. Prolonged bed rest 2. Adrenal insufficiency 3. Hyperparathyroidism 4. Excessive ingestion of vitamin D

1. Prolonged bed rest

The nurse is assisting with planning the care of a client with a diagnosis of immunodeficiency. The nurse should incorporate which intervention as a priority in the plan of care? 1. Protecting the client from infection 2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes 4. Identifying factors that decreased the immune function

1. Protecting the client from infection

The nurse is monitoring a pregnant client with gestational hypertension (GH) who is at risk for preeclampsia. The nurse should check the client for which signs of preeclampsia? Select all that apply. 1. Proteinuria 2. Hypertension 3. Low-grade fever 4. Increased pulse rate 5. Increased respiratory rate

1. Proteinuria 2. Hypertension

The nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to include which interventions in the care of the child? Select all that apply. 1. Provide adequate nutrition. 2. Restriction of fluids, as prescribed. 3. Institute measures to prevent infection. 4. Monitoring the arteriovenous fistula 5. Administer blood products to treat severe anemia 6. Anticipate the child will have central nervous system involvement.

1. Provide adequate nutrition. 2. Restriction of fluids, as prescribed. 3. Institute measures to prevent infection. 5. Administer blood products to treat severe anemia 6. Anticipate the child will have central nervous system involvement.

The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's effect is belligerent. Based on these observations, which is the nurse's immediate priority of care? 1. Provide safety for the client and other clients on the unit. 2. Provide the clients on the unit with a sense of comfort and safety. 3. Assist the staff with caring for the client in a controlled environment. 4. Offer the client a less-stimulating area to calm down and gain control.

1. Provide safety for the client and other clients on the unit.

Which interventions are appropriate for the care of an infant? Select all that apply. 1. Provide swaddling. 2. Talk in a loud voice. 3. Provide the infant with a bottle of juice at naptime. 4. Hang mobiles with black-and-white contrast designs. 5. Caress the infant while bathing or during diaper changes. 6. Allow the infant to cry for at least 10 minutes before responding.

1. Provide swaddling. 4. Hang mobiles with black-and-white contrast designs. 5. Caress the infant while bathing or during diaper changes.

The nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by which technique? 1. Pulling the pinna up and back 2. Pulling the earlobe down and back 3. Tilting the client's head forward and down 4. Instructing the client to stand and lean to one side

1. Pulling the pinna up and back

The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions should the nurse use to perform this procedure? 1. Put on a mask. 2. Don gown and gloves. 3. Apply shoe protectors. 4. Wear a pair of protective goggles. 5. Have the client wear a mask and goggles.

1. Put on a mask. 2. Don gown and gloves. 4. Wear a pair of protective goggles.

The client with spinal cord injury suddenly experiences an episode of automatic dysreflexia. After checking the vital signs, which immediate action should the nurse take? 1. Raise the head of the bed and remove the noxious stimulus 2. Lower the head of the bed and remove the noxious stimulus 3. Lower the head of the bed and administer an antihypertensive agent 4. Remove the noxious stimulus and administer an antihypertensive agent

1. Raise the head of the bed and remove the noxious stimulus

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is taking nevirapine. The nurse should monitor for which side/adverse effects of this medication? Select all that apply. 1. Rash 2. Hepatotoxicity 3. Hyperglycemia 4. Peripheral neuropathy 5. Reduced bone mineral density

1. Rash 2. Hepatotoxicity

The nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided? 1. Rectal 2. Axillary 3. Electronic 4. Tympanic

1. Rectal

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note? 1. Red 2. Pink 3. White 4. Serosanguineous

1. Red

The nurse notes blanching, coolness and edema at the peripheral intravenous (IV) site. On the basis of these findings, the nurse should implement which action? 1. Remove the IV. 2. Apply a warm compress. 3. Check for a blood return. 4. Measure the area of infiltration.

1. Remove the IV.

The nurse notes that a hospitalized client has experienced a positive reaction to the tuberculin skin test. Which action by the nurse is priority? 1. Report the findings. 2. Document the findings in the client's record. 3. Call the employee health service department. 4. Call the radiology department for a chest x-ray.

1. Report the findings.

The nurse is assisting with gathering admission assessment data on a 2-year-old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that which is a common characteristic associated with nephrotic syndrome? 1. Hypotension 2. Generalized edema 3. Increased urinary output 4. Frank, bright red blood in the urine

2. Generalized edema

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Rest during the acute phase. 2. Wear a supportive, nonunderwire bra. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breastfeed if the breasts are not too sore. 5. Take prescribed antibiotics until soreness subsides. 6. Avoid decompression of the breasts by breastfeeding or breast pumping.

1. Rest during the acute phase. 2. Wear a supportive, nonunderwire bra. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breastfeed if the breasts are not too sore.

The nurse in the mental health unit reviews the therapeutic and nontherapeutic communication techniques with a nursing student. Which are therapeutic communication techniques? Select all that apply. 1. Restating 2. Listening 3. Asking the client, "Why?" 4. Maintaining neutral responses 5. Giving advice, approval or disapproval 6. Providing acknowledgement and feedback

1. Restating 2. Listening 4. Maintaining neutral responses 6. Providing acknowledgement and feedback

The nurse consults with a dietitian regarding the dietary preferences of an Asian American client. Which food should the nurse suggest to include in the diet plan? 1. Rice 2. Fruits 3. Red meat 4. Fried foods

1. Rice

The nurse reinforces home-care instructions to the parents of a child with celiac disease. Which food item should the nurse advise the parents to include in the child's diet? 1. Rice 2. Oatmeal 3. Rye toast 4. Wheat bread

1. Rice

The licensed practical nurse (LPN) is assisting the registered nurse (RN) to create a teaching plan for the client receiving an antineoplastic medication. The LPN expects which information to be included? Select all that apply. 1. Rinse mouth after meals and use a soft toothbrush. 2. Notify the PHCP if the temperature is above 101° F (37.7° C). 3. Maintain oral hygiene and inspect the mouth for sores daily. 4. A sore throat is expected so the client should suck on soothing throat lozenges. 5. Consult the primary health care provider (PHCP) before receiving immunizations.

1. Rinse mouth after meals and use a soft toothbrush. 3. Maintain oral hygiene and inspect the mouth for sores daily. 5. Consult the primary health care provider (PHCP) before receiving immunizations.

The nurse working in a prenatal clinic reviews a client's chart and notes that the primary health care provider documents that the client has a gynecoid pelvis. The nurse plans care understanding that which findings are characteristic of this type of pelvis? Select all that apply. 1. Round shape 2. Shallow depth 3. Narrow pubic arch 4. Diagonal conjugate measures 12.5 cm to 13 cm 5. Blunt, somewhat widely separated ischial spines

1. Round shape 4. Diagonal conjugate measures 12.5 cm to 13 cm 5. Blunt, somewhat widely separated ischial spines

The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item? 1. Scallops 2. Chocolate 3. Cornbread 4. Macaroni products

1. Scallops

The nurse is caring for a client following a craniotomy in which a large tumor was removed from the left side. In which position can the nurse safely place the client? 1. Semi-Fowler's position 2. Trendelenburg's position 3. Reverse Trendelenburg's position 4. Supine position

1. Semi-Fowler's position

The parent of a 3-year-old tells the nurse that the child is constantly rebelling and having temper tantrums. Which instruction should the nurse reinforce to the parent? 1. Set limits on the child's behavior. 2. Ignore the child when this behavior occurs. 3. Allow the behavior, because this is normal at this age period. 4. Punish the child every time the child says "no" to change the behavior.

1. Set limits on the child's behavior.

The school nurse prepares a list of home care products for the parents of school children who have been diagnosed with pediculosis capitis (head lice). Which should be included in this list? Select all that apply. 1. Siblings may also need treatment. 2. Use antilice sprays on all bedding and furniture. 3. Use a pediculicide shampoo and repeat the treatment in 14 days. 4. Grooming items such as combs and brushes should not be shared. 5. Launder all the bedding and clothing in hot water and dry on high heat. 6. Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits.

1. Siblings may also need treatment. 4. Grooming items such as combs and brushes should not be shared. 5. Launder all the bedding and clothing in hot water and dry on high heat. 6. Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits.

Rifabutin is prescribed for a client with active Mycobacterium avium complex (MAC) disease and tuberculosis. The nurse should monitor for which side/adverse effects of the medication? Select all that apply. 1. Signs of hepatitis 2. Flu-like syndrome 3. Low neutrophil count 4. Vitamin B6 deficiency 5. Ocular pain or blurred vision 6. Tingling and numbness of the fingers

1. Signs of hepatitis 2. Flu-like syndrome 3. Low neutrophil count 5. Ocular pain or blurred vision

A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. Next, the nurse should check the client's medical history for which item? 1. Smoking history 2. Recent exposure to allergens 3. History of recent insect bites 4. Familial tendency toward peripheral vascular disease

1. Smoking history

The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented initially? 1. Stand in front of the client. 2. Exaggerate lip movements. 3. Obtain a sign-language interpreter. 4. Pantomime and write the client notes.

1. Stand in front of the client.

The nurse is performing range-of-motion (ROM) exercises on a client when the client unexpectedly develops spastic muscle contractions. The nurses should implement which interventions? Select all that apply. 1. Stop movement of the affected part. 2. Massage the affected part vigorously. 3. Force movement of the joint supporting the muscle. 4. Notify the primary health care provider immediately. 5. Ask the client to stand and walk rapidly around the room. 6. Place continuous gently pressure on the muscle group until it relaxes.

1. Stop movement of the affected part. 6. Place continuous gently pressure on the muscle group until it relaxes.

The nurse observes the unlicensed assistive personnel (UAP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse? 1. Head midline 2. Head turned to the side 3. Neck in neutral position 4. Head of bed elevated 30 to 45 degrees

2. Head turned to the side

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened? 1. Support the mother in her reaction to the newborn. 2. Encourage the mother to breastfeed soon after birth. 3. Tell the mother that it is important to hold the newborn. 4. Document a complete account of the mother's reaction in the birth record.

1. Support the mother in her reaction to the newborn.

The nurse is reinforcing instructions for a postpartum woman on how to bathe her newborn. The nurse should emphasize which instructions provided to the mother? Select all that apply. 1. Support the newborn's body during the bath. 2. Clean any eye discharge using a wet cotton ball. 3. Fill the bathtub with no more than 10 inches of water. 4. Clean the eyes, moving from the outer canthus to the inner canthus. 5. Cover the newborn's body except for the part being washed or rinsed. 6. Begin the bath with the face, and clean the newborn's diaper area next.

1. Support the newborn's body during the bath. 2. Clean any eye discharge using a wet cotton ball. 5. Cover the newborn's body except for the part being washed or rinsed.

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence? 1. Sweating and pallor 2. Dry skin and stomach pain 3. Bradycardia and indigestion 4. Double vision and chest pain

1. Sweating and pallor

During the monitoring of a client's response to disease-modifying antirheumatic drugs (DMARDs), which findings should the nurse intercept as acceptable responses? Select all that apply. 1. Symptom control during periods of emotional stress 2. Normal white blood cell, platelet, and neutrophil counts 3. Radiological findings that show nonprogression of joint degeneration 4. An increased range of motion in the affected joints 3 months into therapy 5. Inflammation and irritation at the injection site 3 days after the injection is given 6. A low-grade temperature when rising in the morning that remains throughout the day

1. Symptom control during periods of emotional stress 2. Normal white blood cell, platelet, and neutrophil counts 3. Radiological findings that show nonprogression of joint degeneration 4. An increased range of motion in the affected joints 3 months into therapy

The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn? 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. The presence of a barrel chest with acrocyanosis

1. Tachypnea and retractions

Ibuprofen is prescribed for a client. Which instruction should the nurse give the client about taking this medication? 1. Take with 8 oz of milk. 2. Take in the morning after rising. 3. Take 60 minutes before breakfast. 4. Take at bedtime on an empty stomach.

1. Take with 8 oz of milk.

A client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client? 1. The bladder must be full during the examination. 2. The bladder must be empty during the examination. 3. She should not eat or drink anything 4 to 6 hours before the examination. 4. She will be given Rh0(D) immune globulin because she is Rh positive.

1. The bladder must be full during the examination.

Which behaviors observed by the nurse might lead to the suspicion that a depressed adolescent client could be suicidal? 1. The client gives away a DVD and a cherished autographed picture of the performer. 2. The client runs out of the therapy group swearing at the group leader and then runs to their room. 3. The client gets angry with her roommate when the roommate borrows their clothes without asking. 4. The client becomes angry while speaking on their cell phone and slams the phone down on her bed.

1. The client gives away a DVD and a cherished autographed picture of the performer.

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior? 1. The client is at increased risk for suicide. 2. The client is dealing with pertinent issues. 3. The client may need some time off the unit. 4. The client is responding normally to hospitalization.

1. The client is at increased risk for suicide.

A client is being prepared for a thoracentesis. The nurse reinforces instructions with the client given by the registered nurse. Which points should be included in the instructions? Select all that apply. 1. The client leans over a bedside table. 2. The client should sit on the edge of the bed. 3. The procedure involves obtaining a biopsy. 4. A time-out is performed during a bronchoscopy. 5. The procedure is performed during a bronchoscopy. 6. A local anesthetic is administered before the procedure.

1. The client leans over a bedside table. 2. The client should sit on the edge of the bed. 4. A time-out is performed during a bronchoscopy. 6. A local anesthetic is administered before the procedure.

A client is admitted to the psychiatric nursing unit. When collecting data from the client, the nurse notes that the client was admitted on an involuntary status. Based on this type of admission, which should the nurse expect to note? 1. The client presents a harm to self. 2. The client requested the admission. 3. The client consented to the admission. 4. The client provided written application to the facility for admission.

1. The client presents a harm to self.

The primary health care provider (PHCP) is going to perform carotid massage on a client with rapid rate atrial fibrillation. Which interventions should the nurse anticipate? Select all that apply. 1. The client should be placed on a cardiac monitor. 2. The PHCP massages the carotid artery for a full minute. 3. The head should be turned toward the side being massaged. 4. Rhythm strips should be obtained before, during and after the procedure. 5. Monitor the vital signs, cardiac rhythm, and level of consciousness after the procedure.

1. The client should be placed on a cardiac monitor. 4. Rhythm strips should be obtained before, during and after the procedure. 5. Monitor the vital signs, cardiac rhythm, and level of consciousness after the procedure.

Which identifies accurate nursing documentation notations? Select all that apply. 1. The client slept thought the night. 2. Abdominal wound dressing is dry and intact without drainage. 3. The client seemed angry when awakened for vital sign measurement. 4. The client appears to become anxious when it is time for respiratory treatments. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

1. The client slept thought the night. 2. Abdominal wound dressing is dry and intact without drainage. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

Which interventions should be implemented in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. 1. Use nonlatex gloves. 2. Use medications from glass ampules. 3. Place the client in a private room only. 4. Do not puncture rubber stoppers with needles. 5. Keep a latex-safe supply cart available in the client's area. 6. Use a blood pressure cuff from an electronic device only to measure the blood pressure.

1. Use nonlatex gloves. 2. Use medications from glass ampules. 4. Do not puncture rubber stoppers with needles. 5. Keep a latex-safe supply cart available in the client's area.

The nurse should implement which measures to prevent infection in a hospitalized immunocompromised client? Select all that apply. 1. Use strict aseptic technique for all invasive procedures. 2. Insert a Foley catheter to eliminate the need to use a bedpan. 3. Use good hand-washing technique before touching the client. 4. Keep fresh flowers and potted plants out of the client's room. 5. Place the client in a semiprivate room with another client who is immunocompromised. 6. Keep frequently used equipment such as a blood pressure cuff in the client's room for use by the client.

1. Use strict aseptic technique for all invasive procedures. 3. Use good hand-washing technique before touching the client. 4. Keep fresh flowers and potted plants out of the client's room. 6. Keep frequently used equipment such as a blood pressure cuff in the client's room for use by the client.

A client is receiving digoxin daily. The nurse suspects digoxin toxicity after noting which signs and symptoms? Select all that apply. 1. Visual disturbances 2. Nausea and vomiting 3. Apical pulse rate of 63 beats per minute 4. Serum digoxin level of 2.3 ng/mL (2.93 nmol) 5. Serum potassium level of 3.9 mEq/L (3.9 mmol/L)

1. Visual disturbances 2. Nausea and vomiting 4. Serum digoxin level of 2.3 ng/mL (2.93 nmol)

The nurse is assisting with caring for a client who will receive a unit of blood. Just before infusion, it is the most important for the nurse to check which item? 1. Vital signs 2. Skin color 3. Oxygen saturation 4. Latest hematocrit level

1. Vital signs

The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should initially check which item? 1. Vital signs 2. Fundal height 3. Presence of calf pain 4. Level of consciousness (LOC)

1. Vital signs

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to consult with the registered nurse if the client is also taking which medications? Select all that apply. 1. Warfarin 2. Glimepiride 3. Amlodipine 4. Simvastatin 5. Hydrochlorothiazide

1. Warfarin 2. Glimepiride 3. Amlodipine

The nurse assists with preparing the client for ear irrigation as prescribed by the primary health care provider (PHCP). Which action should the nurse plan to take? 1. Warm the irrigating solution to 98° F (36.6° C). 2. Position the client with the affected side up after irrigation. 3. Direct a slow, steady stream of irrigation solution toward the eardrum. 4. Assist the client with turning his or her head so that the ear to be irrigated is facing upward.

1. Warm the irrigating solution to 98° F (36.6° C).

The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? Select all that apply. 1. Wash hands. 2. Put on gloves. 3. Place the drop in the conjunctival sac. 4. Pull the lower lid down against the cheekbone. 5. Instruct the client to squeeze the eyes shut after instilling the eyedrop. 6. Instruct the client to tilt the head forward, open the eyes, and look down.

1. Wash hands. 2. Put on gloves. 3. Place the drop in the conjunctival sac. 4. Pull the lower lid down against the cheekbone.

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply. 1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a firm (dosimeter) badge when in the client's room 4. Wearing a lead apron when providing direct care to a client 5. Placing the client in a semiprivate room at the end of the hallway

1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a firm (dosimeter) badge when in the client's room 4. Wearing a lead apron when providing direct care to a client

A client has reported that crying spells have been a major problem over the past several weeks and that the doctor said depression is probably the reason. The nurse observes that the client is sitting slumped in the chair, and the clothes that the client is wearing do not fit well. The nurse interprets that further data collection should focus on which assessment? 1. Weight loss 2. Sleep pattern 3. Medication compliance 4. Onset of the crying spells

1. Weight loss

The nurse is reinforcing teaching for a client regarding how to mix regular insulin with NPH insulin in the same syringe. Which action performed by the client indicates the need for further teaching? 1. Withdraws the NPH insulin first 2. Withdraws the regular insulin first 3. Injects air into the NPH insulin vial first 4. Injects an amount of air equal to the desired dose of insulin into the vial

1. Withdraws the NPH insulin first

The medication is an intramuscular dose of 400,000 units of penicillin G benzathine. The medication label reads penicillin G benzathine 300,000 units/mL. The nurse prepares how much medication to administer the correct dose?

1.3 mL

The medication prescribed is methylprednisolone acetate 60 mg intramuscularly. The medication label states methylprednisolone acetate 40 mg/1 mL. How many milliliters will the nurse prepare to administer to the client?

1.5 mL

The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching? 1. "I need to wear sunscreen when participating in outdoor activities." 2. "I need to avoid sun exposure before 10:00 AM and after 4:00 PM." 3. "I need to wear a hat, opaque clothing, and sunglasses when in the sun." 4. "I need to examine my body monthly for any lesions that may be suspicious."

2. "I need to avoid sun exposure before 10:00 AM and after 4:00 PM."

A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further instructions are needed about skin care if the client makes which statement? 1. "I will soak the skin and then wash it gently." 2. "I need to scrub the skin vigorously with soap and water." 3. "I need to apply an emollient lotion to enhance softening." 4. "I need to use a sunscreen on the skin if it will be directly exposed to the sun."

2. "I need to scrub the skin vigorously with soap and water."

The nurse reinforces instructions to the parents of a child with leukemia regarding measures relating to monitoring for infection. Which statement by a parent indicates the need for further teaching? 1. "I need to use proper hand-washing techniques." 2. "I need to take my child's rectal temperature daily." 3. "I need to inspect my child's skin daily for redness." 4. "I need to inspect my child's mouth daily for lesions."

2. "I need to take my child's rectal temperature daily."

The nurse reviews the home care instructions with a parent of a 3-year-old with pertussis. Which statement by the parent indicates a need for further teaching? 1. "I know that my child will make a loud whooping sound." 2. "I understand this whooping cough is viral and I have to let it run its course." 3. "I understand that I need to watch for respiratory distress signs with pertussis." 4. "I can reduce the environmental factors that can trigger coughing, like dust and smoke."

2. "I understand this whooping cough is viral and I have to let it run its course."

A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed? 1. "I will be sure to wash my hands before feeding my newborn." 2. "I will breastfeed, especially for the first 6 weeks postpartum." 3. "I will be sure to wash my hands before and after bathroom use." 4. "I will administer the prescribed antiviral medication to the newborn for the first 6 weeks after delivery."

2. "I will breastfeed, especially for the first 6 weeks postpartum."

The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made? 1. "I will use a straw for drinking." 2. "I will drive only during the daytime." 3. "I will use caution because the device alters balance." 4. "I will wash the skin daily under the lamb's-wool liner of the vest.

2. "I will drive only during the daytime."

The nurse is reinforcing home-care instructions to a client and family regarding care after left cataract surgery with lens implant. Which statements made by the client indicate an understanding of the instructions? Select all that apply. 1. "I will bend over to tie my shoes." 2. "I will not sleep lying on my left side." 3. "I will sit at the table to eat breakfast." 4. "I will sit in my recliner with my feet elevated." 5. "I will not lift anything heavier than 10 pounds." 6. "I will resume my exercise routine including pushups."

2. "I will not sleep lying on my left side." 3. "I will sit at the table to eat breakfast." 4. "I will sit in my recliner with my feet elevated." 5. "I will not lift anything heavier than 10 pounds."

A client has a prescription to take guaifenesin every 4 hours, as needed. The nurse determines that the client understands the most effective use of this medication if the client makes which statement? 1. "I will watch for irritability as a side effect." 2. "I will take the tablet with a full glass of water." 3. "I will take an extra dose if the cough is accompanied by a fever." 4. "I will crush the sustained-release tablet if immediate relief is needed."

2. "I will take the tablet with a full glass of water."

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply. 1. "An event is termed a mass casualty when it overwhelms local medical capabilities. 2. "Mass casualty events do not require an increase in the number of staff that are needed." 3. "A mass casualty event occurs only within the health care facility and could endanger staff." 4. "Mass casualty events may require the collaboration of many local agencies to handle the situation." 5. "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

2. "Mass casualty events do not require an increase in the number of staff that are needed." 3. "A mass casualty event occurs only within the health care facility and could endanger staff." 5. "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client makes which statement? 1. "Smoking cessation is very important." 2. "Moving to a warmer climate should help." 3. "Sources of caffeine should be eliminated from the diet." 4. "Taking nifedipine as prescribed will decrease vessel spasm."

2. "Moving to a warmer climate should help."

The nursing instructor asks a nursing student about phenylketonuria (PKU). Which statement made by the student indicates a need for further teaching? 1. "PKU is an autosomal-recessive disorder." 2. "PKU primarily affects the gastrointestinal system." 3. "Treatment of PKU includes the dietary restriction of phenylalanine." 4. "All 50 states require routine screening of all newborns for PKU."

2. "PKU primarily affects the gastrointestinal system."

The nurse is reinforcing instructions to the parents of an infant with clubfoot about the care of a plaster cast. Which statement should the nurse include in the instructions? Select all that apply. 1. "The cast can be cleansed with a wet cloth on the outside." 2. "The foot should be kept elevated for the first 24 to 48 hours." 3. "The cast will dry in 30 minutes so it can be handled after that time." 4. "Reposition the infant every 2 to 4 hours until the cast is thoroughly dried." 5. "The edges of the cast can be 'petaled' with small pieces of moleskin or adhesive tape."

2. "The foot should be kept elevated for the first 24 to 48 hours." 4. "Reposition the infant every 2 to 4 hours until the cast is thoroughly dried." 5. "The edges of the cast can be 'petaled' with small pieces of moleskin or adhesive tape."

The nursing instructor asks a nursing student about sudden infant death syndrome (SIDS). Which statement made by the student indicates further teaching is needed? 1. "Some of the interventions that are used to prevent SIDS include having infants sleep in the supine position." 2. "The incidence of SIDS has been found to be higher in breastfed infants and infants that use a pacifier." 3. "Infants exposed to cigarette smoking during pregnancy and after birth are considered at risk for SIDS." 4. "SIDS refers to sudden infant death syndrome that can occur in healthy infants under 1 year of age, and no exact cause is known."

2. "The incidence of SIDS has been found to be higher in breastfed infants and infants that use a pacifier."

The nurse is teaching a session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which statement indicates successful learning? 1. "Iron supplements will give me diarrhea." 2. "The iron is needed for the red blood cells." 3. "Meat does not provide iron and should be avoided." 4. "My body has all the iron it needs and I don't need to take supplements."

2. "The iron is needed for the red blood cells."

A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test? 1. "Uterine contractions are stimulated by Leopold's maneuvers." 2. "The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation." 3. "An internal fetal monitor is attached, and you will walk on a treadmill until contractions begin." 4. "Small amounts of oxytocin are administered during internal fetal monitoring to stimulate uterine contractions."

2. "The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation."

The client is taking phenytoin for seizure control, and a blood sample for a serum drug level is drawn. Which laboratory finding indicates a therapeutic serum drug result? 1. 5 mcg/mL (19.84 mcmol/L) 2. 15 mcg/mL (59.52 mcmol/L) 3. 25 mcg/mL (99.2 mcmol/L) 4. 30 mcg/mL (119.0 mcmol/L)

2. 15 mcg/mL (59.52 mcmol/L)

A client has been admitted to the hospital for a urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to which value? 1. 3 mg/dL (1.05 mmol/L) 2. 15 mg/dL (5.25 mmol/L) 3. 29 mg/dL (10.15 mmol/L) 4. 35 mg/dL (12.25 mmol/L)

2. 15 mg/dL (5.25 mmol/L)

The nurse is caring for a client with emphysema receiving oxygen. The nurse should consult with the registered nurse if the oxygen flow rate exceeded how many L/min of oxygen? 1. 1 L/min 2. 2 L/min 3. 6 L/min 4. 10 L/min

2. 2 L/min

The nurse is collecting data from a pregnant client who is currently at 28 weeks' gestation. At her prior prenatal visit, her fundal height measured 22 cm. The nurse measures the fundal height at this visit in centimeters and should expect which finding? 1. 22 cm 2. 26 cm 3. 32 cm 4. 40 cm

2. 26 cm

The nurse is planning to reinforce instructions to the client about how to stand on crutches. In the instructions, the nurse should plan to tell the client to place the crutches in which position? 1. 3 inches to the front and side of the client's toes 2. 8 inches to the front and side of the client's toes 3. 15 inches to the front and side of the client's toes 4. 20 inches to the front and side of the client's toes

2. 8 inches to the front and side of the client's toes

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first? 1. A client in skeletal traction 2. A client who is dependent on a ventilator 3. A postoperative client preparing for discharge 4. A client admitted during the previous shift with a diagnosis of gastroenteritis

2. A client who is dependent on a ventilator

A sulfonamide is prescribed for a client with a urinary tract infection. During review of the client's record, the nurse notes that the client is taking warfarin sodium daily. Which prescription should the nurse anticipate for this client? 1. Discontinuation of warfarin sodium 2. A decrease in the warfarin sodium dosage 3. An increase in the warfarin sodium dosage 4. A decrease in the usual dose of the sulfonamide

2. A decrease in the warfarin sodium dosage

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply. 1. Scarring is less severe in a child than in an adult. 2. A delay in growth may occur after a burn injury. 3. An immature immune system presents as an increased risk of infection for infants and young children. 4. Fluid resuscitation is unnecessary unless the burned area is more than 25$ of the total body surface area. 5. The lower proportion of body fluid to body mass in a child increases the risk of cardiovascular problems. 6. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

2. A delay in growth may occur after a burn injury. 3. An immature immune system presents as an increased risk of infection for infants and young children. 6. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

The perinatal client is admitted to the obstetrical unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse should consult with the dietitian to ensure which dietary measure? 1. A low-calorie diet to ensure the absence of weight gain 2. A diet that is high in fluids and fiber to decrease constipation 3. A diet that is low in fluids and fiber to decrease blood volume 4. Unlimited sodium intake to increase the circulating blood volume

2. A diet that is high in fluids and fiber to decrease constipation

The nurse is assigned to care for a child with a compound (open) fracture of the arm that occurred as a result of a fall. The nurse plans care knowing that this type of fracture involves which specific characteristic? 1. The entire bone fractured straight across 2. A greater risk of infection than a simple fracture 3. The bone being fractured but not producing a break in the skin 4. One side of the bone being broken and the other side being bent

2. A greater risk of infection than a simple fracture

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated? 1. Leopold's maneuvers 2. A manual pelvic examination 3. Hemoglobin and hematocrit evaluation 4. External electronic fetal heart rate monitoring

2. A manual pelvic examination

The nurse fins the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the primary health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose? 1. Providing clients with necessary stabilizing treatments 2. A method of promoting quality care and risk management 3. Determining the effectiveness of interventions in relation to outcomes 4. The appropriate method of reporting to local, state, and federal agencies

2. A method of promoting quality care and risk management

The nurse is caring for an older client who is reminiscing about past life experiences in a positive manner. The nurse plans care with the understanding that this behavior indicates which? 1. A mental status alteration 2. A normal psychosocial response 3. A need for psychiatric consultation 4. A sensory deficit requiring social activities

2. A normal psychosocial response

The nurse is caring for a client with respiratory insufficiency. The arterial blood gas (ABG) results indicate a pH of 7.50 and a PCO2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note? 1. A sodium level of 145 mEq/L (145 mmol/L) 2. A potassium level of 3.0 mEq/L (3.0 mmol/L) 3. A magnesium level of 1.3 mEq/L (0.65 mmol/L) 4. A phosphorus level od 3.0 mg/dL (0.97 mmol/L)

2. A potassium level of 3.0 mEq/L (3.0 mmol/L)

The nurse is caring for an 18-month-old child who has been vomiting. Which is the appropriate position to place the child during naps and sleep time? 1. A supine position 2. A side-lying position 3. Prone, with the head elevated 4. Prone, with the head turned to the side

2. A side-lying position

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS? 1. A length of 19 inches 2. Abnormal palmer creases 3. A birth weight of 6 pounds and 14 ounces 4. A head circumference that is appropriate for gestational age

2. Abnormal palmer creases

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which should be the initial nursing action? 1. Prepare the triage rooms. 2. Activate the agency emergency response plan. 3. Obtain additional supplies from the central supply department. 4. Obtain additional nursing staff to assist with treating the casualties.

2. Activate the agency emergency response plan.

Dantrolene sodium is prescribed for a client experiencing flexor spasms, and the client asks the nurse about the action of the medication. The nurse responds knowing that which is the therapeutic action of this medication? 1. Depresses spinal reflexes 2. Acts directly on the skeletal muscle to relieve spasticity 3. Acts within the spinal cord to suppress hyperactive reflexes 4. Acts on the central nervous system (CNS) to suppress spasms

2. Acts directly on the skeletal muscle to relieve spasticity

A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL (16.2 mmol/L) and a serum creatinine level of 2.2 mg/dL (193.6 mcmol/L) has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for which condition? 1. Hypovolemia 2. Acute kidney injury 3. Glomerulonephritis 4. Urinary tract infection

2. Acute kidney injury

The nurse notes documentation that a client has conductive hearing loss. The nurse plans care knowing that this kind of hearing loss can be caused by which circumstances? Select all that apply. 1. A defect in the cochlea 2. Acute otitis media with effusion 3. A defect in the 8th cranial nerve 4. A defect in the sensory fibers that lead to the cerebral cortex 5. A physical obstruction to the transmission of sound waves

2. Acute otitis media with effusion 5. A physical obstruction to the transmission of sound waves

The client diagnosed with pemphigus is being seen in the clinic regularly. The nurse should plan care based on which description of this condition? 1. The presence of tiny red vesicles 2. An autoimmune disease that causes blistering in the epidermis 3. The presence of skin vesicles found along the nerve caused by a virus 4. The presence of red, raised papules and large plaques covered by silvery scales

2. An autoimmune disease that causes blistering in the epidermis

When reinforcing dietary instructions to a client with irritable bowel syndrome whose primary symptom is alternating constipation and diarrhea, the nurse would tell the client that which foods are the best to include in the diet for this disorder? Select all that apply. 1. Beans 2. Apples 3. Cabbage 4. Brussel sprouts 5. Whole-grain bread

2. Apples 5. Whole-grain bread

The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which actions should the nurse take to deal with this event? Select all that apply. 1. Turn the client to the side with the knees bent. 2. Apply a sterile dressing soaked with normal saline to the wound. 3. Notify the registered nurse (RN) and the primary health care provider (PHCP) at once. 4. Explain to the client that obesity is a risk factor and weight loss should be a future goal. 5. Gently explore the wound with a cotton-tipped applicator to determine whether evisceration has occurred.

2. Apply a sterile dressing soaked with normal saline to the wound. 3. Notify the registered nurse (RN) and the primary health care provider (PHCP) at once.

The nurse is caring for a client with a diagnosis of pemphigus. The nurse should include which interventions in the plan of care for the client? Select all that apply. 1. Administering prescribed acyclovir 2. Applying prescribed topical antibiotic 3. Applying prescribed corticosteroid 4. Administering prescribed oral amphotericin B 5. Applying Domeboro solution to the affected skin

2. Applying prescribed topical antibiotic 3. Applying prescribed corticosteroid 5. Applying Domeboro solution to the affected skin

To use an external cardiac defibrillator on a client, which action should be performed to check the cardiac rhythm? 1. Holding the defibrillator paddles firmly against the chest 2. Applying the adhesive patch electrodes to the skin and moving away from the client 3. Applying standard electrocardiographic monitoring leads to the client and observing the rhythm 4. Connecting standard electrocardiographic electrodes to a transtelephonic monitoring device

2. Applying the adhesive patch electrodes to the skin and moving away from the client

The nurse is caring for a client after a mastectomy. which finding would indicate that the client is experiencing a complication that may become a chronic problem related to the surgery? 1. Pain at the incision site 2. Arm edema on the operative side 3. Sanguineous drainage in the Jackson Pratt drain 4. Complaints of decreased sensation near the operative side

2. Arm edema on the operative side

The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which actions should the nurse take? Select all that apply. 1. Ask if the client is thirsty and assist with drinking a glass of water. 2. Ask how the client feels and inquire about any feelings of dizziness. 3. Review the client record to determine time and type of analgesia last received. 4. Review the client record to determine whether the client has voided postoperatively. 5. Assist the client to perform leg exercises and then recheck the blood pressure and pulse rate. 6. Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU).

2. Ask how the client feels and inquire about any feelings of dizziness. 3. Review the client record to determine time and type of analgesia last received. 6. Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU).

After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note? 1. To the right of the abdomen 2. At the level of the umbilicus 3. About 4 cm above the level of the umbilicus 4. One fingerbreadth above the symphysis pubis

2. At the level of the umbilicus

Pilocarpine hydrochloride is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity? 1. Metipranolol 2. Atropine sulfate 3. Timolol maleate 4. Carteolol hydrochloride

2. Atropine sulfate

A licensed practical nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 36.2° C (97.2° F) orally, pulse 52 beats per minute, blood pressure 101/58 mmHg, respiratory rate 11 breaths per minute, and SPO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take first? 1. Document the findings. 2. Attempt to arouse the client. 3. Contact the registered nurse immediately. 4. Check the medication administration history on the PCA pump.

2. Attempt to arouse the client.

The nurse is reinforcing discharge instructions to a client receiving baclofen. Which should the nurse include in the instructions? 1. Restrict fluid intake. 2. Avoid the use of alcohol. 3. Stop the medication if diarrhea occurs. 4. Notify the primary health care provider (PHCP) if fatigue occurs.

2. Avoid the use of alcohol.

An 18-month-old child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measure should the nurse stress to the parents as they prepare to take this child home? 1. Leave diapers off to allow the site to heal. 2. Avoid tub baths until the stent has been removed. 3. Encourage toilet training to ensure that the flow of urine is normal. 4. Restrict the fluid intake to reduce urinary output for the first few days.

2. Bacteriuria

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely expect to note which finding? 1. Hematuria 2. Bacteriuria 3. Glucosuria 4. Proteinuria

2. Bacteriuria

The nurse is assisting in planning care for a client with a chest tube. The nurse should suggest to include which interventions in the plan? Select all that apply. 1. Pin the tubing to the bed linens. 2. Be sure all connections remain airtight. 3. Be sure all connections are taped and secure. 4. Monitor closely for tubing that is kinked or obstructed. 5. Empty the drainage from the drainage collection chamber daily.

2. Be sure all connections remain airtight. 3. Be sure all connections are taped and secure. 4. Monitor closely for tubing that is kinked or obstructed.

The nursing student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately relates to this stage? 1. Gratification of self 2. Beginning of toilet training 3. Tapering off of conscious biological and sexual urges 4. Association with pleasurable and conflicting feelings about the genital organs

2. Beginning of toilet training

A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and her contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? 1. Nalbuphine 2. Betamethasone 3. RH0 (D) immune globulin 4. Dinoprostone vaginal insert

2. Betamethasone

The nurse is assisting in caring for a post-term neonate immediately after admission to the nursery. The priority nursing action should be to monitor which clinical parameter? 1. Urinary output 2. Blood glucose level 3. Total bilirubin level 4. Hemoglobin and hematocrit levels

2. Blood glucose level

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority nursing assessment? 1. Uterine tone 2. Blood pressure 3. Amount of lochia 4. Deep tendon reflexes

2. Blood pressure

The nurse is receiving the health care record of a client admitted to the psychiatric unit. The nurse has documented that the client is experiencing anxiety as a result a situational crisis. The nurse should determine that this type of crisis could be caused by which event? 1. Witnessing a murder 2. Death of a loved one 3. A fire that destroyed the client's home 4, A recent rape episode experienced by the client

2. Death of a loved one

When the nurse is collecting data from the older adult, which findings should be considered normal physiological changes? Select all that apply. 1. Increased heart rate 2. Decline in visual acuity 3. Decreased respiratory rate 4. Decline in long-term memory 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset

2. Decline in visual acuity 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset

The nurse is reviewing the medical record of a client with a diagnosis of pyelonephritis. Which disorder noted on the client's record should the nurse identify as a risk factor for this diagnosis? 1. Hypoglycemia 2. Diabetes mellitus 3. Coronary artery disease 4. Orthostatic hypotension

2. Diabetes mellitus

The nurse is assigned to care for a client with a peripheral intravenous (IV) infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown? 1. Using a hospital gown with snaps at the sleeves 2. Disconnecting the IV tubing from the catheter in the vein 3. Checking the IV flow rate immediately after changing the hospital gown 4. Putting the bag and tubing through the sleeve, followed by the client's arm

2. Disconnecting the IV tubing from the catheter in the vein

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do? Select all that apply. 1. Hold the feeding. 2. Document the amount of residual. 3. Place it into a container for laboratory analysis. 4. Reinstill the residual and administer the feeding. 5. Deduct the amount of the residual from the new feeding before administering.

2. Document the amount of residual. 4. Reinstill the residual and administer the feeding.

Upon palpation of the fontanel of a 3-month-old newborn, the nurse notes that the anterior fontanel is not closed and is soft and flat. Which action should the nurse take? 1. Increase oral fluids. 2. Document the findings. 3. Notify the registered nurse. 4. Elevate the head of the bed to 90 degrees.

2. Document the findings.

The nurse is caring for a client with severe depression. Which activity is appropriate for this client? 1. A puzzle 2. Drawing 3. Checkers 4. Paint by number

2. Drawing

A client with renal insufficient has a magnesium level of 3.5 mEq/L (1.75 mmol/L). On the basis of this laboratory result, the nurse interprets which sign as significant? 1. Hyperpnea 2. Drowsiness 3. Hypertension 4. Physical hyperactivity

2. Drowsiness

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client? Select all that apply. 1. Hypocapnia 2. Dyspnea during exertion 3. Presence of a productive cough 4. Difficulty breathing while talking 5. Increased oxygen saturation with exercise 6. A shortened expiratory phase of respiration

2. Dyspnea during exertion 3. Presence of a productive cough 4. Difficulty breathing while talking

In planning activities for the depressed client, especially during the early stages of hospitalization, which action is best? 1. Plan nothing until the client asks to participate in the milieu. 2. Encourage the client to participate in a structured daily program of activities. 3. Give the client a menu of daily activities and insist that the client participate in all activities offered. 4. Provide an activity that is quiet and solitary in nature to avoid increased fatigue, such as drawing or reading a book.

2. Encourage the client to participate in a structured daily program of activities.

The emergency department nurse is caring for a child suspected of acute epiglottis. Which interventions apply in the care of the child? Select all that apply. 1. Obtain a throat culture. 2. Ensure a patent airway. 3. Prepare the child for a chest x-ray. 4. Maintain the child in a supine position. 5. Obtain a pediatric-size tracheostomy tray. 6. Place the child on an oxygen saturation monitor.

2. Ensure a patent airway. 3. Prepare the child for a chest x-ray. 5. Obtain a pediatric-size tracheostomy tray. 6. Place the child on an oxygen saturation monitor.

A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. Which interventions should be included in the procedure? Select all that apply. 1. Remove the air from the balloon. 2. Explain the procedure to the client. 3. Ask the client to take a deep breath and hold. 4. Pull the tube out in one continuously steady motion. 5. Remove the device or tape securing the tube from the nose.

2. Explain the procedure to the client. 3. Ask the client to take a deep breath and hold. 4. Pull the tube out in one continuously steady motion. 5. Remove the device or tape securing the tube from the nose.

The nurse reviews the history and physical examination documented in the medical record of a client requesting a prescription for oral contraceptives. The nurse determines that oral contraceptives are contraindicated because of which documented item? 1. History and Physical: Has renal calculi 2. History and Physical: Has thrombophlebitis 3. Medications: Daily multivitamin taken orally 4. Diagnostic Results: Electrocardiogram normal

2. History and Physical: Has thrombophlebitis

The nurse is planning to administer hydrochlorothiazide to a client. Which are concerns related to the administration of this medication? 1. Hypouricemia, hyperkalemia 2. Hypokalemia, hyperglycemia, sulfa allergy 3. Hypokalemia, increased risk of osteoporosis 4. Hyperkalemia, hypoglycemia, penicillin allergy

2. Hypokalemia, hyperglycemia, sulfa allergy

The nurse is assisting with identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? 1. Children in daycare centers 2. Individuals with spina bifida 3. Individuals with cardiac disease 4. Individuals living in group homes

2. Individuals with spina bifida

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed and the serum calcium level is 12.0 mg/dL (3.0 mmol/L). Based on this laboratory value, the nurse should take which action? 1. Document the value in the patient's record. 2. Inform the registered nurse of the laboratory value. 3. Place the laboratory result form in the client's record. 4. Reassure the client that the laboratory result is normal.

2. Inform the registered nurse of the laboratory value.

A client who experienced a myocardial infarction is being monitored via cardiac telemetry. The nurse notices the sudden onset of coarse ventricular fibrillation (VF) and should plan to take which immediate action? 1. Take the client's blood pressure. 2. Initiate cardiopulmonary resuscitation (CPR). 3. Place a nitroglycerin tablet under the client's tongue. 4. Continue to monitor the client and then contact the primary health care provider (PHCP).

2. Initiate cardiopulmonary resuscitation (CPR).

The nurse is preparing to perform an abdominal examination. Which step should be taken first? 1. Palpation 2. Inspection 3. Percussion 4. Auscultation

2. Inspection

The nurse is caring for a female client who has recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate? 1. Interrupt the client and weigh her immediately. 2. Interrupt the client and offer to take her for a walk. 3. Allow the client to complete her exercise program. 4. Tell the client that she is not allowed to exercise vigorously.

2. Interrupt the client and offer to take her for a walk.

The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF? Select all that apply. 1. cough 2. Irritability 3. Scalp diaphoresis 4. Tachypnea, tachycardia 5. Slow and shallow breathing

2. Irritability 3. Scalp diaphoresis 4. Tachypnea, tachycardia

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. Which is the priority nursing action? 1. Prepare for an oxytocin infusion. 2. Keep the client in a side-lying position. 3. Prepare the client for epidural anesthesia. 4. Encourage the client to start pushing with the contractions.

2. Keep the client in a side-lying position.

The nurse is reviewing the postoperative prescriptions for an infant with hydrocephalus, who came back from surgery with a ventriculoperitoneal shunt. Which of the primary health care provider's prescriptions does the nurse question? 1. Position the infant on the inoperative side 2. Keep the head of the bed elevated 45 degrees 3. Monitor for signs of infection and check dressings for drainage 4. Observe for irritability, a high shrill cry, lethargy, and poor feeding

2. Keep the head of the bed elevated 45 degrees

The nurse is caring for a postoperative parathyroidectomy client. Which would require the nurse's immediate attention? 1. Incisional pain 2. Laryngeal stridor 3. Difficulty voiding 4. Abdominal cramps

2. Laryngeal stridor

A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which area as a high-risk area for pressure and breakdown? 1. Scapulae 2. Left heel 3. Right heel 4. Back of the head

2. Left heel

The nurse is assisting with caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention? 1. Limiting movement and abduction of the left arm 2. Limiting movement and abduction of the right arm 3. Assisting the client to get out of bed and ambulate with a walker 4. Having the physical therapist do active range of motion to the right arm

2. Limiting movement and abduction of the right arm

The nurse is reinforcing discharge instructions to a client receiving sulfadiazine. Which should be included in the list of instructions? 1. Restrict fluid intake. 2. Maintain a high fluid intake. 3. Decrease the dosage when symptoms are improving to prevent an allergic response. 4. If the urine turns dark brown, call the primary health care provider (PHCP) immediately.

2. Maintain a high fluid intake.

The client brought to the emergency department is experiencing an anaphylactic reaction from eating shellfish. The nurse should implement which immediate action? 1. Administering epinephrine 2. Maintaining a patent airway 3. Administering a corticosteroid 4. Instructing the client on the importance of obtaining a MedicAlert bracelet

2. Maintaining a patent airway

The client was seen and treated in the emergency department (ED) for a concussion. Before discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom? 1. Vomiting 2. Minor headache 3. Difficulty speaking 4. Difficulty awakening

2. Minor headache

A client with active tuberculosis (TB) is to be admitted to a medical-surgical unit. Which action should the nurse take when assisting in planning a bed assignment? 1. Tell the admitting office to send the client to the intensive cate unit. 2. Place the client in a private, airborne infection isolation room (AIIR). 3. Assign the client to a room with another client because intravenous antibiotics will be administered. 4. Assign the client to a room with another client and place a "strict hand washing" sign outside the door.

2. Place the client in a private, airborne infection isolation room (AIIR).

The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse should dispose of the used needle by which method? 1. Asking the client to recap the needle 2. Placing the needle and syringe in a puncture-resistant container 3. Recapping the needle before placing it in a puncture-resistant container 4. Laying the needle and syringe on the bedside table and carefully recapping the needle

2. Placing the needle and syringe in a puncture-resistant container

The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? 1. Positive patch test 2. Positive culture tests 3. Abnormal biopsy results 4. Wood's light examination indicative of infection

2. Positive culture tests

The nurse is caring for a client who is taking digoxin and is monitoring routine laboratory values. Which laboratory value requires the need for follow-up by the nurse? 1. Sodium 138 mEq/L (138 mmol/L) 2. Potassium 3.3 mEq/L (3.3 mmol/L) 3. Phosphorus 3.1 mg/dl (1.0 mmol/L) 4. Magnesium 1.8 mg/dl (0.9 mmol/L)

2. Potassium 3.3 mEq/L (3.3 mmol/L)

A client with diabetes mellitus visits a healthcare clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 mg/dL to 200 mg/dL (10.2 mmol/L to 11.4 mmol/L). Which medication, added to the client's regimen, may have contributed to the hyperglycemia? 1. Atenolol 2. Prednisone 3. Phenelzine 4. Allopurinol

2. Prednisone

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states to report which occurrence immediately? 1. Impaired sense of hearing 2. Problems with visual acuity 3. Gastrointestinal (GI) side effects 4. Red-orange discoloration of body secretions

2. Problems with visual acuity

The nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data should the nurse expect to note as having been documented in the child's record? 1. Watery diarrhea 2. Projectile vomiting 3. Increased urine output 4. Vomiting large amounts of bile

2. Projectile vomiting

The nurse is assisting with collecting data from an African American client admitted to the ambulatory care unit who is scheduled for a hernia repair, Which information about the client is of lowest priority during the data collection? 1. Respiratory 2. Psychosocial 3. Neurological 4. Cardiovascular

2. Psychosocial

The homecare nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should provide which information? 1. Freeze the insulin. 2. Refrigerate the insulin. 3. Store the insulin in a dark, dry place. 4. Keep the insulin at room temperature.

2. Refrigerate the insulin.

The client who frequently uses nonsteroidal antiinflammatory drugs (NSAIDs) has been taking misoprostol. The nurse determines that this medication is having the intended therapeutic effect if which is noted? 1. Resolved diarrhea 2. Relief of epigastric pain 3. Decreased platelet count 4. Decreased white blood cell count

2. Relief of epigastric pain

A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. The nurse should implement which action to prepare the client for this test? 1. Shave the groin for insertion of a femoral catheter. 2. Remove all metal-containing objects from the client. 3. Keep the client NPO (nil per os; nothing by mouth) for 6 hours before the test. 4. Instruct the client in inhalation techniques for the administration of the radioisotope.

2. Remove all metal-containing objects from the client.

A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to provide which information to the client? 1. Drink alcohol in small amounts only. 2. Report yellow eyes and skin immediately. 3. Increase intake of Swiss or aged cheeses. 4. Avoid vitamin supplements during therapy.

2. Report yellow eyes and skin immediately.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted during the assessment? Select all that apply. 1. Proteinuria of 3 + 2. Respirations of 10 beats per minute 3. Presence of deep tendon reflexes 4. Urine output of 20 mL in an hour 5. Serum magnesium level of 6 mEq/L (3 mmol/L)

2. Respirations of 10 beats per minute 4. Urine output of 20 mL in an hour

A client who has been newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. Which teaching information should the nurse reinforce upon discharge? 1. Keep insulin vials refrigerated at all times. 2. Rotate the insulin injection sites systematically. 3. Increase the amount of insulin before unusual exercise. 4. Monitor the urine acetone level to determine the insulin dosage.

2. Rotate the insulin injection sites systematically.

The nurse is caring for a client who has been prescribed furosemide and is monitoring for adverse effects associated with this medication. Which should the nurse recognize as potential adverse effects? Select all that apply. 1. Nausea 2. Tinnitus 3. Hypotension 4. Hypokalemia 5. Photosensitivity 6. Increased urinary frequency

2. Tinnitus 3. Hypotension 4. Hypokalemia

The nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? 1. Inflammation 2. Serous drainage 3. Pain at the pin site 4. Purulent drainage

2. Serous drainage

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present? 1. Oily skin 2. Silvery-white scaly lesions 3. Patchy hair loss and round, red macules with scales 4. The presence of wheal patches scattered about the trunk

2. Silvery-white scaly lesions

A postoperative client requests medication for flatulence (gas pains). Which medication from the PRN list should the nurse administer to this client? 1. Ondansetron 2. Simethicone 3. Acetaminophen 4. Magnesium hydroxide

2. Simethicone

A licensed practical nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicated the need for further teaching? 1. Taking a rectal temperature for a client who has undergone nasal surgery 2. Taking an oral temperature for a client with a cough and nasal congestion 3. Taking an axillary temperature on a client who has just consumed hot coffee 4. Taking a temporal temperature on the neck behind the ear on a client who is diaphoretic

2. Taking an oral temperature for a client with a cough and nasal congestion

The nurse notes the physical assessment findings for a client with a diagnosis of possible meningitis. Which findings should the nurse expect to observe because of meningeal irritation? Select all that apply. 1. Pupils are unequal and react slowly to light. 2. The client reports stiffness and soreness in the neck area. 3. The client reports pain in the vertebral column and passively flexes the hip and knee in response to hip flexion. 4. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 5. The client's upper arms are flexed and held tightly to the sides of the body, and the legs are extended and internally rotated.

2. The client reports stiffness and soreness in the neck area. 3. The client reports pain in the vertebral column and passively flexes the hip and knee in response to hip flexion. 4. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended.

The nurse in a psychiatric unit is assigned to care for a client admitted to the unit 2 days ago. During review of the client's record, the nurse notes that the admission was a voluntary one. Based on this type of admission, which would the nurse expect to note? 1. The client will be angry and will refuse care. 2. The client will participate in the treatment plan. 3. The client will be very resistant to treatment measures. 4. The client's family will be very resistant to treatment measures.

2. The client will participate in the treatment plan.

The nurse is monitoring a client who is taking propranolol. Which data collection finding would indicate a potential serious complication associated with propranolol? 1. The development of complaints of insomnia 2. The development of audible expiratory wheezes 3. A baseline resting heart rate of 88 beats/min followed by a resting heart rate of 72 beats/min after two doses of the medication 4. A baseline blood pressure of 150/88 mmHg followed by a blood pressure of 138/72 mmHg after two doses of the medication

2. The development of audible expiratory wheezes

The primary health care provider (PHCP) prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. The nurse knows that which is the most appropriate intervention? 1. The medication is administered within 60 minutes before the morning and evening meal. 2. The medication is withheld and the PHCP is called to question the prescription for the client. 3. The client is monitored for gastrointestinal (GI) side effects after administration of the medication. 4. The insulin is withdrawn from the Penlet into an insulin syringe to prepare for administration.

2. The medication is withheld and the PHCP is called to question the prescription for the client.

A mother of a teenage client with an anxiety disorder is concerned about her daughter's progress during discharge. She states that her daughter "Stashes food, eats all the wrong things that make her hyperactive," and "hangs out with the wrong crowd." While helping the mother prepare for her daughter's discharge, the nurse should make which suggestion? 1. The mother should restrict the daughter's socializing time with her friends. 2. The mother should restrict the amount of chocolate and caffeine products in the home. 3. The mother should keep her daughter out of school until she can adjust to the school environment. 4. The mother should consider taking time off of work to help her daughter readjust to the home environment.

2. The mother should restrict the amount of chocolate and caffeine products in the home.

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply. 1. Slight redness along the incision 2. The presence of purulent drainage 3. A temperature of 98.8° F (37.1° C) 4. The client states that he feels cold. 5. The client states that the incision itches. 6. Tender firmness palpable around the incision.

2. The presence of purulent drainage 6. Tender firmness palpable around the incision.

The nurse obtains a prescription to restrain a client using a belt (safety) restraint and instructs the unlicensed assistive personnel (UAP) to apply the restraint. Which observation, if made by the nurse, indicates unsafe application of the restraint? 1. A safety knot is made in the restraint strap. 2. The restraint straps are safely secured to the side rails. 3. The restraint strap does not tighten when force is applied against it. 4. The restraint is secure, and the client is able to turn from back to side.

2. The restraint straps are safely secured to the side rails.

The nurse is caring for a client dying of cancer. During care, the client states, "If I can just live long enough to attend my daughter's graduation, I'll be ready to die." Which phase of coping is this client experiencing? 1. Anger 2. Denial 3. Bargaining 4. Depression

3. Bargaining

The health education nurse provides instructions to a group of clients regarding measures that will assist with preventing skin cancer. Which instructions should the nurse provide? Select all that apply. 1. Sunscreen should be applied every 8 hours. 2. Use sunscreen when participating in outdoor activities. 3. Wear a hat, opaque clothing, and sunglasses when in the sun. 4. Avoid sun exposure in the late afternoon and early evening hours. 5. Examine your body monthly for any lesions that may be suspicious.

2. Use sunscreen when participating in outdoor activities. 3. Wear a hat, opaque clothing, and sunglasses when in the sun. 5. Examine your body monthly for any lesions that may be suspicious.

The nurse if performing tracheostomy care and changing the dressing on the tracheostomy site. The client coughs and the tube is dislodged. What is the initial nursing action? 1. Call the primary health care provider to reinsert the tube. 2. Ventilate the client using a manual resuscitation bag and facemask. 3. Cover the tracheostomy site with a sterile dressing to prevent infection. 4. Call the respiratory therapy department to reinsert the tracheostomy tube.

2. Ventilate the client using a manual resuscitation bag and facemask.

The intravenous prescription is 1000 mL of 0.9% NaCl (normal saline) to run over 12 hours. The drop factor is 15 gtts/1 mL. The nurse plans to adjust the flow rate to how many gtts/minute?

21 gtts/minute

The intravenous prescription is 3000 mL of 5% dextrose in water (D5W) to run over a 24-hour period. The drop factor is 10 gtts/1 mL. The nurse plans to adjust the flow rate to how many gtts/minute?

21 gtts/minute

A postoperative client has a prescription to receive an intravenous (IV) infusion of 1000 mL normal saline solution over a period of 10 hours. The drop (ggt) factor for the IV infusion is set at 15 gtts/mL. The nurse sets the flow ate at how many drops per minute? Fill in the blank. _____ gtts/minute

25 gtt/min

The nurse is calculating a client's 24-hour fluid intake. The client consumed coffee (8 oz), water (8 oz), and orange juice (6 oz) for breakfast; soup (4 oz) and iced tea (8 oz) for lunch; and milk (10 oz), tea (8 oz), and water (8 oz) for dinner. The client also consumed 24 oz of water during the day. How many milliliters of fluid did the client consume in the 24-hour period? Fill in the blank. _____ mL

2520 mL

The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The nurse asks the nurse if the child should perform range-of-motion (ROM) exercises at this time. The nurse should make which response to the mother? 1. "Avoid all exercise during painful periods." 2. "The ROM exercises must be performed every day." 3. "Have the child perform simple isometric exercises during this time." 4. "Administer additional pain medication before performing the ROM exercises."

3. "Have the child perform simple isometric exercises during this time."

The nurse is explaining causes and reasons of hemophilia A to the parents of a child with the disease. The nurse should make which statement about hemophilia A? 1. "Hemophilia A is a Y-linked heredity disorder." 2. "Hemophilia A results from a deficiency of factor IX." 3. "Hemophilia A results deficiency of factor VIII." 4. "Hemophilia A is always inherited in a recessive manner."

3. "Hemophilia A results deficiency of factor VIII."

An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member indicated that he or she has learned positive coping skills? 1. "I will be more careful to make sure that my father's needs are met." 2. "Now that my father is moving into my home, I will need to change my ways." 3. "I feel better able to care for my father now that I know where to obtain assistance." 4. "I am so sorry and embarrassed that the abusive event occurred, It won't happen again."

3. "I feel better able to care for my father now that I know where to obtain assistance."

The nurse provides information to the parent of a 2-week-old infant who is diagnosed with clubfoot at the time of birth. Which statement by the parent indicates the need for further teaching regarding this disorder? 1. "I understand treatment needs to be started as soon as possible." 2. "I realize my child will require follow-up care until full grown." 3. "I need to bring my child back to the clinic in 1 month for a new cast." 4. "I need to come to the clinic every week with my child for the casting."

3. "I need to bring my child back to the clinic in 1 month for a new cast."

The nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. Which statement made by the client indicates the need for further teaching? 1. "I'll eat a balanced meal plan." 2. "I need to drink diet soft drinks." 3. "I need to buy special dietetic foods." 4. "I will snack on fruit instead of cake."

3. "I need to buy special dietetic foods."

The nurse reinforces home care instructions to a client who is taking lithium carbonate. Which statement by the client indicates a need for further instructions? 1. "I need to take the lithium with meals." 2. "My blood levels must be monitored very closely." 3. "I need to decrease my salt and fluid intake while taking the lithium." 4. "I need to withhold the medication if I have excessive diarrhea, vomiting, or sweating.

3. "I need to decrease my salt and fluid intake while taking the lithium."

The nurse, a Cub Scout leader, is preparing a group of Cub Scouts for an overnight camping trip and instructs them about methods to prevent Lyme disease. Which statement by one of the Cub Scouts indicates a need for further teaching? 1. "I need to bring a hat to wear during the trip." 2. "I should wear long-sleeved tops and long pants." 3. "I should not use insect repellent because it will attract the ticks." 4. "I need to wear closed shoes and socks that can be pulled up over my pants."

3. "I should not use insect repellent because it will attract the ticks."

Fluoxetine is prescribed, and the nurse reinforces instructions to the client regarding the administration of the medication. Which statement made by the client indicates an understanding about the administration of this medication? 1. "I should take the medication with my evening meal." 2. "I should take the medication at noon with an antacid." 3. "I should take the medication in the morning when I first arise." 4. "I should take the medication right before bedtime with a snack."

3. "I should take the medication in the morning when I first arise."

The nurse instructs a client receiving external radiation therapy about skin care. Which statements by the client indicate an understanding of the instructions? 1. "I can lie in the sun as long as I limit the time to 2 hours daily." 2. "I should wear snug clothing to support the irradiated skin area." 3. "I should wash the irradiated area gently each day with a mild soap and water." 4. " After bathing I should dry the area with a patting motion using a clean soft towel." 5. "I should avoid the use of powders, lotions or creams on the skin area being irradiated." 6. "I should avoid removing the markings on the skin when bathing until the entire course of radiation is complete."

3. "I should wash the irradiated area gently each day with a mild soap and water." 4. " After bathing I should dry the area with a patting motion using a clean soft towel." 5. "I should avoid the use of powders, lotions or creams on the skin area being irradiated." 6. "I should avoid removing the markings on the skin when bathing until the entire course of radiation is complete."

A parent with a 6-year-old child diagnosed with enuresis discusses with the nurse the measures that are being taken to help her child. Which statement by the parent indicates a need for further teaching? 1. "I make sure that my child goes potty before going to bed." 2. "I have my child help with changing the wet sheets in the morning." 3. "I take away privileges such as TV time when the bed is wet in the morning." 4. "I make sure that my child does not have anything to drink 2 hours before bedtime."

3. "I take away privileges such as TV time when the bed is wet in the morning."

While collecting data related to the cardiac system on a client, the nurse hears a murmur. Which best describes the sound of a heart murmur? 1. Lub-dub sounds 2. Scratchy, leathery heart noise 3. Gentle, blowing or swooshing noise 4. Abrupt, high-pitched snapping noise

3. Gentle, blowing or swooshing noise

The nurse reinforces home care instructions to the parents of a child with a brace for scoliosis. Which statement by a parent indicates a need for further teaching? 1. "I will inspect the skin under the brace for redness or breakdown." 2. "I will encourage my child to do their exercises to maintain strength." 3. "I understand that my child needs to wear this brace for 12 hours a day." 4. "I understand that this brace is not a cure for scoliosis, it only slows the progression of the curvature."

3. "I understand that my child needs to wear this brace for 12 hours a day."

The nurse instructs a mother of a child who has seizures regarding seizure precautions. Which statement by the mother indicates a need for further teaching? 1. "I will make my child wear a medical identification alert bracelet." 2. "I know that my child will need to have a companion when swimming." 3. "I will need to give antiseizure medications when my child has a seizure." 4. "I will have my child wear a bike helmet when riding a bike or skateboarding."

3. "I will need to give antiseizure medications when my child has a seizure."

The nurse is reinforcing discharge instructions to the parent of a 2-year-old child who has had an orchiopexy to correct cryptorchidism. Which statement by the parent indicates a need for further teaching? 1. "I'll check his temperature." 2. "I'll give him medication so he'll be more comfortable." 3. "I'll let him decide when to return to his play activities." 4. "I'll check his voiding to be sure that there are no problems."

3. "I'll let him decide when to return to his play activities."

A client asks the nurse why her newborn baby needs an injection of vitamin K (phytonadione). The nurse should make which statement to the client? 1. "Your newborn needs vitamin K to develop immunity." 2. "The vitamin K will protect your newborn from becoming jaundiced." 3. "Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." 4. "Newborns have sterile bowels. The vitamin K will give the bowel the necessary bacteria."

3. "Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding."

The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time? 1. "I know you feel 'they are out to get you,' but it's not true." 2. "I can hear the voice, and she wants you to come to dinner." 3. "Sometimes people hear things or voices others can't hear." 4. "I talked to the voices you're hearing and they won't hurt you now."

3. "Sometimes people hear things or voices others can't hear."

A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement? 1. "I would try anything that I could if I had cancer." 2. "No, because it will interact with the chemotherapy." 3. "Tell me what you know about complementary therapies." 4. "You need to ask your primary health care provider about it."

3. "Tell me what you know about complementary therapies."

A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which purpose? 1. "The medication will help dilate the eye to prevent an increase in eye pressure." 2. "The medication will relax the muscles of the eyes and prevent blurred vision." 3. "The medication causes the pupil to constrict and will lower the pressure in the eye." 4. "The medication will help block the responses that are sent to the muscles in the eye."

3. "The medication causes the pupil to constrict and will lower the pressure in the eye."

A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is reinforcing teaching for the client about the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen? 1. "My ulcer will heal because these medications will kill the bacteria." 2. "These medications are only taken when I have pain from my ulcer." 3. "The medications will kill the bacteria and stop the acid production." 4. "These medications will coat the ulcer and decrease the acid production in my stomach."

3. "The medications will kill the bacteria and stop the acid production."

The parent of a 4-year-old child expresses concern because her hospitalized child has started sucking this thumb. The mother states that this behavior began 2 days after hospital admission. Which is the appropriate nursing response? 1. "Your child is acting like a baby." 2. "The doctor will need to be notified." 3. "This is common during hospitalization." 4. "A 4-year-old is too old for this type of behavior."

3. "This is common during hospitalization."

The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further teaching? 1. "We need to encourage adequate fluid intake." 2. "Coughing spells may be triggered by dust or smoke." 3. "We need to maintain respiratory precautions and a quiet environment for at least 2 weeks." 4. "Good hand-washing techniques need to be instituted to prevent spreading the disease to others."

3. "We need to maintain respiratory precautions and a quiet environment for at least 2 weeks."

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bas situation." The most helpful response by the nurse should be which statement? 1. "Why don't you tell your husband about this?" 2. "This is not the best time to make that decision." 3. "What do you find difficult about this situation?" 4. "I agree with you. You should get out of this situation."

3. "What do you find difficult about this situation?"

The nurse observes that a client with a potential for violence is agitated, pacing up and down in the hallway, and making aggressive and belligerent gestures at other clients. Which statement is appropriate to make to this client? 1. "You need to stop that behavior now!" 2. "You will need to be placed in seclusion!" 3. "What is causing you to become agitated?" 4. "You will need to be restrained if you do not change your behavior."

3. "What is causing you to become agitated?"

The nurse is gathering data from a client in a crisis. When determining the client's perception of the precipitating event that led to the crisis, which is the most appropriate question to ask? 1. "With whom do you live?" 2. "Who is available to help you?" 3. "What leads you to seek help now?" 4. "What do you usually do to feel better?"

3. "What leads you to seek help now?"

A client who is diagnosed with pedophilia and recently has been paroled as a sex offender says, "I'm in treatment and I have served my time. Now this group has posters all over the neighborhood with my photograph and details of my crime." Which is an appropriate response by the nurse? 1. "When children are hurt the way you hurt them, people want you isolated." 2. "You're lucky it doesn't escalate into something scary after your crime." 3. "You understand that people fear for their children, but you're feeling unfairly treated?" 4. "You seem angry, but you have committed serious crimes against several children, so your neighbors are frightened."

3. "You understand that people fear for their children, but you're feeling unfairly treated?"

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is most important to provide to the client? 1. "Herbal substances are not safe and should never be used." 2. "I will teach you how to take your blood pressure so that it can be monitored closely." 3. "You will need to talk to your primary health care provider (HCP) before using an herbal substance." 4. "If you take an herbal substance, you will need to have your blood pressure checked frequently."

3. "You will need to talk to your primary health care provider (HCP) before using an herbal substance."

A client says to the nurse, "I'm going to die, and I wish my family would stop hoping for a 'cure'! I get so angry when they carry on like this! After all, I'm the one who's dying." Which therapeutic response should the nurse make to the client? 1. "Have you shared your feelings with your family?" 2. "I think we should talk more about your anger with your family." 3. "You're feeling angry that your family continues to hope for you to be 'cured'?" 4. "Well, it sounds like you're being pretty pessimistic. After all, years ago people died of pneumonia."

3. "You're feeling angry that your family continues to hope for you to be 'cured'?"

During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted? 1. 80 beats per minute 2. 100 beats per minute 3. 150 beats per minute 4. 180 beats per minute

3. 150 beats per minute

The nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings should the nurse expect to note? Select all that apply. 1. Excessive bubbling in the water-seal chamber 2. Vigorous bubbling in the suction-control chamber 3. 50 mL of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation

3. 50 mL of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation

An older client with hepatic encephalopathy has a serum ammonia level of 120 mcg/dL (72 mcmol/L) and receives treatment with lactulose syrup. The nurse determines that the client has the best response if the level changes to which after medication administration? 1. 2 mcg/dL (1.2 mmol/L) 2. 5 mcg/dL (3 mmol/L) 3. 70 mcg/dL (42 mmol/L) 4. 100 mcg/dL (60 mmol/L)

3. 70 mcg/dL (42 mmol/L)

The nurse is caring for a 5-year-old who has been placed in traction after a fracture of the femur. Which is the most appropriate activity for this child? 1. Blocks 2. A music video 3. A 10-piece puzzle 4. Large picture books

3. A 10-piece puzzle

The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions with regard to avoiding the use of herbal medications? 1. A 60-year-old male client with rhinitis 2. A 24-year-old male client with a lower back injury 3. A 10-year-old female client with a urinary tract infection 4. A 45-year-old female client with a history of migraine headaches

3. A 10-year-old female client with a urinary tract infection

Which client is most likely at risk to become a victim of elder abuse? 1. A 75-year-old man with moderate hypotension 2. A 68-year-old man with newly diagnosed cataracts 3. A 90-year-old woman with advanced Alzheimer's disease 4. A 70-year-old woman with early diagnosed Lyme disease

3. A 90-year-old woman with advanced Alzheimer's disease

A 4-year-old child is admitted to the hospital with suspected acute lymphocytic leukemia (ALL). The nurse should prepare for which diagnostic study that can confirm this diagnosis? 1. A platelet count 2. A lumbar puncture 3. A bone marrow biopsy 4. A white blood cell (WBC) count

3. A bone marrow biopsy

The nurse is monitoring a client receiving glipizide. Which outcome indicated an ineffective response from the medication? 1. A decrease in polyuria 2. A decrease in polyphagia 3. A glycosylated hemoglobin level of 12% 4. A fasting plasma glucose of 100 mg/dL (5.7 mmol/L)

3. A glycosylated hemoglobin level of 12%

The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection? 1. An uninsured man who is homeless 2. A woman newly immigrated from Korea 3. A man who is an inspector for the U.S. Postal Service 4. An older woman admitted from a long-term care facility

3. A man who is an inspector for the U.S. Postal Service

When reinforcing teaching about signs and symptoms of ovarian cancer with a community group of women, the nurse emphasizes which sign/symptom as being a typical manifestation of the disease recognized by persons diagnosed with the condition? 1. Pelvic cramping 2. Sharp abdominal pain 3. Abdominal distention or fullness 4. Postmenopausal vaginal bleeding

3. Abdominal distention or fullness

A client is taking lansoprazole for the chronic management of Zollinger-Ellison syndrome. If prescribed, which medication would be appropriate for the client if needed for a headache? 1. Naprosyn 2. Ibuprofen 3. Acetaminophen 4. Acetylsalicylic acid

3. Acetaminophen

The nurse is caring for a postrenal transplantation client with prescription for cyclosporine. Of the nurse notes an increase in one of the client's vital signs and the client is complaining of a headache, which vital sign is most likely increased? 1. Pulse 2. Respirations 3. Blood pressure 4. Pulse oximetry

3. Blood pressure

A client was just admitted to the hospital to rule out a gastrointestinal bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication should the nurse determine to be the cause of the client's complaint? 1. Doxycycline 2. Atropine sulfate 3. Acetylsalicylic acid 4. Diltiazem hydrochloride

3. Acetylsalicylic acid

The nurse enters a client's room and finds that the waste bucket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action? 1. Call for help. 2. Extinguish the fire. 3. Activate the fire alarm. 4. Confine the fire by closing the room door.

3. Activate the fire alarm.

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon? 1. Immediately inflate the balloon. 2. Insert the catheter 2.5 cm to 5 cm and inflate the balloon. 3. Advance the catheter to the bifurcation and inflate the balloon. 4. Insert the catheter until resistance is met and inflate the balloon.

3. Advance the catheter to the bifurcation and inflate the balloon.

The client has an as needed prescription for loperamide hydrochloride. For which condition should the nurse administer this medication? 1. Constipation 2. Abdominal pain 3. An episode of diarrhea 4. Hematest-positive nasogastric tube drainage

3. An episode of diarrhea

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster? 1. A staff member who has never had roseola 2. A staff member who has never had mumps 3. An unlicensed assistive personnel who has never had chickenpox 4. An unlicensed assistive personnel who has never had German measles

3. An unlicensed assistive personnel who has never had chickenpox

The nurse is assisting with preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. Which instruction should be included in the plan of care? 1. Soak the feet in hot water. 2. Avoid using soap to wash the feet. 3. Apply a moisturizing lotion to dry feet, but not between the toes. 4. Always have a podiatrist cut your toenails, never cut them yourself.

3. Apply a moisturizing lotion to dry feet, but not between the toes.

A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate? 1. Monitor the infant for a fever. 2. Bring the infant back to the clinic. 3. Apply an ice pack to the injection site. 4. Leave the injection site alone, because this always occurs.

3. Apply an ice pack to the injection site.

A client is admitted to the emergency department with complaints of sever chest pain. The client is extremely restless, frightened, and dyspneic. Immediate admission prescriptions include oxygen by nasal cannula at 4L per minute; troponin, creatinine phosphokinase, and isoenzymes blood levels; a chest x-ray, and a 12-lead electrocardiogram (ECG). Which action should the nurse plan to take first? 1. Obtain the 12-lead ECG. 2. Draw the blood specimens. 3. Apply the oxygen to the client. 4. Call radiology to obtain the chest x-ray study.

3. Apply the oxygen to the client.

A client receiving a tricyclic antidepressant arrives at the mental health clinic. Which observation indicates that the client is correctly following the medication plan? 1. Reports not going to work for the past week 2. Complains of not being able to "do anything" anymore 3. Arrives at the clinic neat and appropriate in appearance 4. Reports sleeping 12 hours per night and 3 to 4 hours during the day

3. Arrives at the clinic neat and appropriate in appearance

The nurse is caring for a client who is scheduled for surgery, The client states concern about the surgical procedure. How should the nurse initially address the client's concerns? 1. Tell the client that preoperative fear is normal. 2. Explain all nursing care and possible discomfort that may result. 3. Ask the client to discuss information known about the planned surgery. 4. Provide explanations about the procedures involved in the planned surgery.

3. Ask the client to discuss information known about the planned surgery.

A client is admitted to the psychiatric unit after a serious suicidal attempt by hanging. What is the nurse's most important intervention to maintain client safety? 1. Request that a peer remain with the client at all times. 2. Remove the client's clothing and place the client in a hospital gown. 3. Assign a staff member to the client who will remain with him or her at all times. 4. Admit the client to a seclusion room where all potentially dangerous articles are removed.

3. Assign a staff member to the client who will remain with him or her at all times.

The nurse is preparing a client for the termination phase of the nurse-client relationship. Which task should the nurse appropriately plan for during this phase? 1. Plan short-term goals. 2. Identify expected outcomes. 3. Assist with making appropriate referrals. 4. Assist with developing realistic solutions.

3. Assist with making appropriate referrals.

The client with myasthenia gravis is receiving pyridostigmine. The nurse monitors for signs and symptoms of cholinergic crisis caused by overdose of the medication. The nurse checks the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs? 1. Vitamin K 2. Acetylcysteine 3. Atropine sulfate 4. Protamine sulfate

3. Atropine sulfate

The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question? 1. Betaxolol 2. Pilocarpine 3. Atropine sulfate 4. Pilocarpine hydrochloride

3. Atropine sulfate

A client with Meniere's disease is experiencing severe vertigo. The nurse reinforces instructions to the client to do which to assist with controlling the vertigo? 1. Increase sodium in the diet. 2. Lie still and watch television. 3. Avoid sudden head movements. 4. Increase fluid intake to 3000mL/day.

3. Avoid sudden head movements.

The nurse enters the client's room, and the client immediately demands to be released from the hospital. During review of the client's record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? 1. Call the client's family. 2. Persuade the client to stay a few more days. 3. Contact the primary health care provider (PHCP). 4. Tell the client that discharge is not possible at this time.

3. Contact the primary health care provider (PHCP).

A client has epididymitis as a complication of a urinary tract infection (UTI). The nurse is giving the client instructions to prevent recurrence. The nurse determines that the client needs further teaching if the client states the intention to do which action? 1. Drink an increased amount of fluids. 2. Limit the force of the stream during voiding. 3. Continue to take antibiotics until all symptoms are gone. 4. Use condoms to eliminate risk associated with chlamydia and gonorrhea.

3. Continue to take antibiotics until all symptoms are gone.

An older client has been prescribed digoxin. The nurse determines that which age-related change would place the client at risk for digoxin toxicity? 1. Decrease salivation and gastrointestinal motility 2. Decrease muscle strength and loss of bone density 3. Decreased lean body mass and glomerular filtration rate 4. Decreased cardiac output and decreased efficiency of blood return to the heart

3. Decreased lean body mass and glomerular filtration rate

A newborn has just been circumcised and is being discharged home in 2 hours. Which instructions should be provided by the nurse to the parents? Select all that apply. 1. Use only baby wipes to clean the penis. 2. Remove the yellow exudate which forms by 24 hours post circumcision. 3. Do not wash penis with soap until the circumcision has healed, which takes 5 to 6 days. 4. Change diaper every 4 hours or more often to inspect the penis for drainage or infection. 5. Monitor the circumcision; penis may appear reddened with a small amount of bloody drainage shortly after the procedure.

3. Do not wash penis with soap until the circumcision has healed, which takes 5 to 6 days. 4. Change diaper every 4 hours or more often to inspect the penis for drainage or infection. 5. Monitor the circumcision; penis may appear reddened with a small amount of bloody drainage shortly after the procedure.

The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back to bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident? 1. Place the incident report in the patient's chart. 2. Make a copy of the incident report for the PHCP. 3. Document a complete entry in the client's record concerning the incident. 4. Document in the patient's record that an incident report has been completed.

3. Document a complete entry in the client's record concerning the incident.

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure? 1. Dorsiflex the client's foot while flexing the knee. 2. Plantarflex the client's foot while flexing the knee. 3. Dorsiflex the client's foot while extending the knee. 4. Plantarflex the client's foot while extending the knee.

3. Dorsiflex the client's foot while extending the knee.

The nurse is preparing to care for a dying client and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1. Discourage reminiscing. 2. Make the decisions for the family. 3. Encourage expression of feelings, concerns, and fears. 4. Explain everything that is happening to all family members. 5. Extend touch, and hold the client or family member's hand if appropriate. 6. Be honest and truthful, and let the client and family know that you will not abandon them.

3. Encourage expression of feelings, concerns, and fears. 5. Extend touch, and hold the client or family member's hand if appropriate. 6. Be honest and truthful, and let the client and family know that you will not abandon them.

The nurse is preparing to care for a dying client and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1. Discourage reminiscing. 2. Make the decisions for the family. 3. Encourage expression of feelings, concerns, and fears. 4. Explain everything that is happening to all family members. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know that they will not be abandoned by the nurse.

3. Encourage expression of feelings, concerns, and fears. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know that they will not be abandoned by the nurse.

The nurse caring for a child with aplastic anemia is reviewing the laboratory results and notes a white blood cell (WBC) count of 6,000 mm^3 (6 x 10^9/L) and a platelet count of 20,000 mm^3 (20 x 10^9/L). Which nursing intervention should be incorporated into the plan of care? 1. Encourage naps. 2. Encourage a diet high in iron. 3. Encourage quiet play activities. 4. Maintain strict isolation precautions.

3. Encourage quiet play activities.

The mother of a 6-year-old who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? 1. Hold the next dose of insulin. 2. Come to the clinic immediately. 3. Encourage the child to drink liquids. 4. Administer an additional dose of regular insulin.

3. Encourage the child to drink liquids.

Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. Which is the best rationale for checking gastric residual volume before administering the tube feeding? 1. Observe the digestion of formula. 2. Check fluid and electrolyte status. 3. Evaluate the absorption of the last feeding. 4. Confirm proper nasogastric tube placement.

3. Evaluate the absorption of the last feeding.

The nurse reviews the record of a child who has just seen the primary health care provider (PHCP). The PHCP has documented a diagnosis of suspected aortic stenosis. Which specific sign/symptom of aortic stenosis should the nurse anticipate? 1. Pallor 2. Hyperactivity 3. Exercise intolerance 4. Gastrointestinal disturbances

3. Exercise intolerance

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply. 1. Administer regular insulin. 2. Encourage the child to ambulate. 3. Give the child a teaspoon of honey. 4. Provide electrolyte replacement therapy intravenously. 5. Wait 30 minutes and confirm the blood glucose reading. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

3. Give the child a teaspoon of honey. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

The nurse prepares to care for a client on contact precautions who has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator, which requires frequent suctioning. The nurse should assemble which necessary protective items before entering the client's room? 1. Gloves and a gown 2. Gloves, mask and goggles 3. Gloves, mask, gown and goggles 4. gloves, gown, and shoe protectors

3. Gloves, mask, gown and goggles

A child remarks, "I share my toys and snacks with my friends so they will like me more." The nurse determines the child is in which stage of moral development? 1. Egocentric judgement 2. Law-and-order orientation 3. Good boy-nice girl orientation 4. Social contract and legalistic orientation

3. Good boy-nice girl orientation

The nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in which position postoperatively? 1. Head of bed flat, head and neck midline 2. Head of bed flat, head turned to the nonoperative side 3. Head of bed elevated 30 to 45 degrees, head and neck midline 4. Head of bed elevated 30 to 45 degrees, head turned to the operative side

3. Head of bed elevated 30 to 45 degrees, head and neck midline

Amikacin is prescribed for a client with a diagnosed bacterial infection. The nurse instructs the client to contact the primary health care provider (PHCP) immediately if which occurs? 1. Nausea 2. Lethargy 3. Hearing loss 4. Muscle aches

3. Hearing loss

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1. Right side 2. Low Fowler's position 3. High Fowler's position 4. Supine, with the head flat

3. High Fowler's position

A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right!" Which action should the nurse take? 1. Tell the client that this is not true and that we all have a purpose in life. 2. Remain with the client and sit in silence until the client verbalizes feelings. 3. Identify recent behaviors or accomplishments that demonstrate skill or ability. 4. Reassure the client that you know how the client is feeling and that things will get better.

3. Identify recent behaviors or accomplishments that demonstrate skill or ability.

The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority? 1. Take a set of vital signs. 2. Call the radiology department. 3. Immobilize the leg before moving the client. 4. Reassure the client that everything will be fine.

3. Immobilize the leg before moving the client.

A client has sustained a closed fracture and has just has a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition? 1. Infection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. The newness of the fracture

3. Impaired tissue perfusion

The nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory finding is indicative of the massive cell destruction that occurs with the chemotherapy? 1. Anemia 2. Decreased platelets 3. Increased uric acid level 4. Decreased leukocyte count

3. Increased uric acid level

The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale and swollen and that the IV has stopped running. The nurse determines that which has probably occurred? 1. Phlebitis 2. Infection 3. Infiltration 4. Thrombosis

3. Infiltration

A client who has begun taking fosinopril is very distressed, telling the nurse that he cannot taste food normally since beginning the medication 2 weeks ago. Which suggestion would provide the best support for the client? 1. Tell the client not to take the medication with food. 2. Suggest that the client taper the dose until taste returns to normal. 3. Inform the client that impaired taste is expected and generally disappears in 2 to 3 months. 4. Tell the client that a request will be made to the primary health care provider (PHCP) to change the prescription.

3. Inform the client that impaired taste is expected and generally disappears in 2 to 3 months.

The nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire, but despite the client's efforts, the neighbor died. Which action should the nurse take to enable the client to work through the meaning of the crisis? 1. Identifying the client's ability to function 2. Identifying the client's potential for self-harm 3. Inquiring about the client's feelings that may affect coping 4. Inquiring about the client's perception of the cause of the neighbor's death

3. Inquiring about the client's feelings that may affect coping

The client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. Besides treatment of the lung cancer, the nurse anticipates that which interventions may be prescribed to treat the SIADH? Select all that apply. 1. Increase fluid intake 2. Decrease sodium intake 3. Institute safety measures 4. Frequent monitoring of sodium blood levels 5. Gather data about the neurological status frequently 6. Medication that is antagonistic to antidiuretic hormone (ADH)

3. Institute safety measures 4. Frequent monitoring of sodium blood levels 5. Gather data about the neurological status frequently 6. Medication that is antagonistic to antidiuretic hormone (ADH)

The nurse should expect to note which interventions in the plan of care for a client with hypothyroidism? Select all that apply. 1. Provide a cool environment for the client. 2. Instruct the client to consume a high-fat diet. 3. Instruct the client about thyroid replacement therapy. 4. Encourage the client to consume fluids and high-fiber foods. 5. Inform the client that iodine preparations will be prescribed to treat the disorder. 6. Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur.

3. Instruct the client about thyroid replacement therapy. 4. Encourage the client to consume fluids and high-fiber foods. 6. Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur.

An adult female client has a hemoglobin level of 10.8 g/dL (108 g/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history? 1. Dehydration 2. Heart failure 3. Iron deficiency anemia 4. Chronic obstructive pulmonary disease

3. Iron deficiency anemia

The nurse is caring for an older client who is terminally ill. Which signs indicate to the nurse that death may be imminent? 1. Flushed and warm skin 2. Eupnea and normal body temperature 3. Irregular, noisy breathing and cold, clammy skin 4. Presence of swallowing reflex and active bowel sounds

3. Irregular, noisy breathing and cold, clammy skin

The nurse is caring for a client after a Billroth II (gastrojejunostomy) procedure. During review of the postoperative prescriptions which should the nurse clarify? 1. Leg exercises 2. Early ambulation 3. Irritating the NG tube 4. Coughing and deep breathing exercises

3. Irritating the NG tube

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which characteristics describe this type of a lesion? Select all that apply. 1. Metastasis is rare. 2. It is encapsulated. 3. It is highly metastatic. 4. It is characterized by a local invasion. 5. Lesions is a nevus that has changed in color.

3. It is highly metastatic. 5. Lesions is a nevus that has changed in color.

The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormonal changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen? 1. It maintains the uterine lining for implantation. 2. It stimulates the metabolism of glucose and converts glucose to fat. 3. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts for lactation. 4. It prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.

3. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts for lactation.

The nurse is reinforcing discharge instructions to a client after a gastrectomy. Which measure should the nurse include during client teaching to help prevent dumping syndrome? 1. Ambulate after a meal. 2. Eat high-carbohydrate meals. 3. Limit the fluids taken with meals. 4. Sit in a high Fowler's position during meals.

3. Limit the fluids taken with meals.

A client with tuberculosis is being started on antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse ensures that which baseline study has been completed? 1. Electrolyte levels 2. Coagulation times 3. Liver enzyme levels 4. Serum creatinine level

3. Liver enzyme levels

The nurse is reinforcing instructions to a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) regarding measures to prevent a recurrence. Which instruction is important for the nurse to emphasize? 1. Eat six small meals daily. 2. Test the urine ketone level. 3. Monitor blood glucose level frequently. 4. Receive appropriate follow-up health care.

3. Monitor blood glucose level frequently.

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team-based model of the nursing practice? 1. A task approach method is used to provide care to clients. 2. Managed care concepts and tools are used when providing client care. 3. Nursing staff are led by the nurse when providing care to a group of clients. 4. A single registered nurse is responsible for providing nursing care to a group of clients.

3. Nursing staff are led by the nurse when providing care to a group of clients.

The nursing student is creating a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which intervention in the plan that is not specific to this disorder? 1. Monitor intake and output. 2. Monitor electrolyte levels. 3. Observe for excessive exercise. 4. Monitor for the use of laxatives and diuretics.

3. Observe for excessive exercise.

The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action? 1. Engaging in immoral acts 2. Always reinforcing self-approval 3. Observing rigid rules and regulations 4. Having the need to always make the right decision

3. Observing rigid rules and regulations

The nurse is assisting with caring for a client after a craniotomy. Which are the positions that can be used for the client? Select all that apply. 1. Prone position 2. Supine position 3. Semi-Fowler's position 4. Dorsal recumbent position 5. With the foot of the bed flat 6. With the foot of the bed elevated 30 degrees

3. Semi-Fowler's position 5. With the foot of the bed flat

An intoxicated client is brought to the emergency department by local police. The client is told that the primary health care provider (PHCP) will be in to see the client in about 30 minutes. The client becomes very loud and offensive and wants to be seen by the PHP immediately. The nurse assisting to care for the client should take which appropriate nursing intervention? 1. Watch the behavior escalate before intervening. 2. Attempt to talk with the client to de-escalate the behavior. 3. Offer to take the client to an examination room until he or she can be treated. 4. Inform the client that he or she will be asked to leave if the behavior continues.

3. Offer to take the client to an examination room until he or she can be treated.

An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. Which is the best position to place this infant at this time? 1. A flat position 2. A prone position 3. On his or her left side 4. On his or her right side

3. On his or her left side

The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How should the nurse determine that the restraints are not too constrictive? 1. Observe the skin in the wrist area for redness. 2. Check the temperature of the skin in the hands. 3. Place two fingers under the restraint to determine snugness. 4. Remove the restraint and exercise the extremity in 2 hours.

3. Place two fingers under the restraint to determine snugness.

The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for the child? 1. Keeping the weights hanging freely 2. Ensuring that the ropes are in the pulleys 3. Placing the bed linens on the traction ropes 4. Ensuring that the weights are out of the child's reach

3. Placing the bed linens on the traction ropes

The nurse monitors the 3-day postoperative client who underwent abdominal surgery. Vital signs are: temperature: 37.9° C (100.2° F), pulse 104 beats per minute, respirations 22 breaths per minute, blood pressure 128/74 mm Hg. Oxygen saturation is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which postoperative problem? 1. Hypoxia 2. Atelectasis 3. Pneumonia 4. Fluid overload

3. Pneumonia

The nurse is reviewing the primary health care provider's (PHCP's) prescriptions written for a client admitted with acute pancreatitis. Which PHCP prescription should the nurse verify if noted in the client's chart? 1. NPO status 2. An anticholinergic medication 3. Position the client supine and flat 4. Prepare to insert a nasogastric tube

3. Position the client supine and flat

The child with cryptorchidism is being discharged after orchiopexy, which was performed on an outpatient basis. The nurse should reinforce instructions to the parents about which priority care measure? 1. Measuring intake and output 2. Administering anticholinergics 3. Preventing infection at the surgical site 4. Applying cold, wet compresses to the surgical site

3. Preventing infection at the surgical site

The client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse should determine that this has been confirmed by which finding? 1. Swelling in the genital area 2. Swelling in the lower extremities 3. Punch biopsy of the cutaneous lesions 4. Appearance of reddish-blue lesions on the skin

3. Punch biopsy of the cutaneous lesions

The nurse is observing a parent and child interacting in the clinic waiting room. The child begins to bounce on the couch. The parent removes the child from the couch stating firmly, "Couches are for sitting, not for jumping." The parent then gives the child a toy to play with on the carpet. The child plays with the toy until called by the nurse. The nurse determines the child is acting within which Kohlberg stage of moral development? 1. Egocentric judgement 2. Law-and-order orientation 3. Punishment-obedience stage 4. Good boy-nice girl orientation

3. Punishment-obedience stage

The nurse assists with creating a plan of care for a client with hyperthyroidism receiving calcitonin-human. Which outcome has the highest priority regarding this medication? 1. Relief of pain 2. Absence of side effects 3. Reaching normal serum calcium levels 4. Verbalization of appropriate medication knowledge

3. Reaching normal serum calcium levels

The client has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed? 1. Weight loss 2. Relief of heartburn 3. Reduction of steatorrhea 4. Absence of abdominal pain

3. Reduction of steatorrhea

The nurse is assisting with creating a plan of care for a client with pancytopenia as a result of chemotherapy. The nurse should suggest including which in the plan of care? Select all that apply. 1. Restricting all visitors 2. Restricting fluid intake 3. Restricting fresh fruits and vegetables in the diet 4. Applying a face mask to the client if outside the client room. 5. Inserting an indwelling urinary catheter to prevent skin breakdown

3. Restricting fresh fruits and vegetables in the diet 4. Applying a face mask to the client if outside the client room.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. During data collection about the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

3. Rigid extension and pronation of the arms and legs

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which action should the nurse take? 1. Have one of the client's family members interpret. 2. Have the Spanish-speaking triage receptionist interpret. 3. Seek an interpreter from the hospital's interpreter services. 4. Obtain a Spanish-English dictionary and attempt to triage the client.

3. Seek an interpreter from the hospital's interpreter services.

A client arrives at the health care clinic and tells the nurse that they have been doubling their daily dosage of bupropion hydrochloride to help them get better faster. The nurse understands that the client is now at risk for which problem? 1. Insomnia 2. Weight gain 3. Seizure activity 4. Orthostatic hypotension

3. Seizure activity

A nurse lawyer provides an education session to the nursing staff regarding client rights with emphasis on invasion of client rights. The nurse lawyer asks a staff nurse to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1. Threatening to place the client in restraints 2. Performing a surgical procedure without consent 3. Taking photographs of the client without consent 4. Telling the client that he or she cannot leave the hospital

3. Taking photographs of the client without consent

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on the finding, which nursing action is appropriate? 1. Contact the health care provider. 2. Instruct the client to maintain bed rest for the remainder of the pregnancy. 3. Tell the client that these are common and they may occur throughout the pregnancy. 4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition.

3. Tell the client that these are common and they may occur throughout the pregnancy.

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area? 1. The pharmacy 2. The laboratory 3. The blood bank 4. The risk-management department

3. The blood bank

After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination should the nurse make? 1. This is a normal expectation after episiotomy. 2. The mother should be allowed bathroom privileges only. 3. The bright red bleeding is abnormal and should be reported. 4. The perineal assessment should be performed more frequently.

3. The bright red bleeding is abnormal and should be reported.

The nurse is caring for a client who has just been admitted to the nursing unit after receiving flame burns to the face and chest. The nurse notes a hoarse cough, and the client is expectorating sputum with black flecks. The client suddenly becomes restless and his color is becoming dusky. Based on this data, which interpretation should the nurse make? 1. The client is hypotensive. 2. Pain is present from the burn injury. 3. The burn has probably caused laryngeal edema, which has occluded the airway. 4. The client is afraid and is having a panic attack as a result of the unfamiliar surroundings.

3. The burn has probably caused laryngeal edema, which has occluded the airway.

The parents of a 2-year-old arrive at the hospital to visit their child. The child is in the play room and ignores the parents during the visit. The nurse tells the parents that this behavior in a 2-year-old child indicates which characteristic about the child? 1. The child is withdrawn. 2. The child is upset with the parents. 3. The child is exhibiting a normal pattern. 4. The child has adjusted to the hospitalized setting.

3. The child is exhibiting a normal pattern.

The nurse is monitoring a client with mild gestational hypertension (GH). Which data indicate that GH is a concern? 1. Urinary output is increased. 2. There is no evidence of proteinuria. 3. The client complains of a headache and blurred vision. 4. The blood pressure reading has returned to the prenatal baseline.

3. The client complains of a headache and blurred vision.

The nurse is reading the primary health care provider's (PHCP's) progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss? 1. The client with a draining wound 2. The client with a urinary catheter 3. The client with a fast respiratory rate 4. The client with a nasogastric tube to slow suction

3. The client with a fast respiratory rate

The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse should identify which as a priority concern? 1. The client's report of not eating or sleeping 2. The presence of bruises on the client's body 3. The client's report of self-destructive thoughts 4. The family member is disapproving of the treatment.

3. The client's report of self-destructive thoughts

Morphine sulfate, 2.5 mg, is prescribed for a child. The safe pediatric dose is 0.05 mg/kg/dose to 0.1 mg/kg/dose. The child weighs 50 kg. Which statement accurately describes the prescribed dosage for the child? 1. The dose is too low. 2. The dose is too high. 3. The dose is within the safe dosage range. 4. There is not enough information to determine the safe dosage range.

3. The dose is within the safe dosage range.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a left Sims' position. The nurse explains that this positioning is preferred because of which reason? 1. The nurse is right-handed. 2. The rectal sphincter will relax. 3. The enema will flow into the bowel easily. 4. The client is more likely to retain the enema solution.

3. The enema will flow into the bowel easily.

The registered nurse (RN) reviews the results of the arterial blood gas (ABG) values with the licensed practical nurse (LPN) and tells the LPN that the client is experiencing respiratory acidosis. The LPN should expect to note which on the laboratory result report? 1. pH 7.50, PCO2 52 mm Hg 2. pH 7.35, PCOs 40 mm Hg 3. pH 7.25, PCO2 50 mm Hg 4. pH 7.50, PCO2 30 mm Hg

3. pH 7.25, PCO2 50 mm Hg

The nurse is caring for a client who is taking phenytoin for control of seizures. During data collection, the nurse notes that the client is taking birth control pills. Which information should the nurse provide to the client? 1. Pregnancy should be avoided while taking phenytoin. 2. The client may stop taking the phenytoin if it is causing severe gastrointestinal effects. 3. The potential for decreased effectiveness of the birth control pills exists while taking phenytoin. 4. The increased risk of thrombophlebitis exists while taking phenytoin and birth control pills together.

3. The potential for decreased effectiveness of the birth control pills exists while taking phenytoin.

An ultrasound of the gallbladder is scheduled for the client with a suspected diagnosis of cholecystitis. Which should the nurse explain to the client about this test? 1. The test is uncomfortable. 2. The test requires that the client be NPO. 3. The test requires the client to lie still for short intervals. 4. The test is preceded by the administration of oral tablets.

3. The test requires the client to lie still for short intervals.

The nurse is caring for a client after a thyroidectomy and notes that calcium gluconate is prescribed. The nurse determines that this medication is prescribed for which reason? 1. Treat thyroid storm. 2. Prevent cardiac irritability. 3. Treat hypocalcemic tetany. 4. Stimulate the release of parathyroid hormone.

3. Treat hypocalcemic tetany.

The nurse is working in the emergency department and is caring for a child who has been diagnosed with epiglottitis. Which is an indication that the child may be experiencing airway obstruction? 1. Retractions and coughing 2. Nasal flaring and bradycardia 3. Tripod positioning and dyspnea 4. A low-grade fever and complaints of a sore throat

3. Tripod positioning and dyspnea

The nurse is assisting with caring for a client with abruptio placentae. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first? 1. Monitor the urinary output. 2. Monitor the maternal pulse. 3. Turn the client to her side. 4. Monitor the maternal blood pressure.

3. Turn the client to her side.

Which intervention should be implemented for the older client with presbycusis who has a hearing loss? 1. Speak louder 2. Speak more slowly 3. Use low-pitched tones 4. Use high-pitched tones

3. Use low-pitched tones

A client with prostatitis resulting from kidney infection has received instructions on management of the condition at home and prevention of recurrence. Which statement indicates that the client understood the instructions? 1. Stop antibiotic therapy when the pain subsides. 2. Exercise as much as possible to stimulate circulation. 3. Use warm sitz baths and analgesics to increase comfort. 4. Keep fluid intake to a minimum to decrease the need to void.

3. Use warm sitz baths and analgesics to increase comfort.

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? Select all that apply. 1. Fatigue 2. Drowsiness 3. Uterine hyperstimulation 4. Late decelerations of the fetal heart rate 5. Early decelerations of the fetal heart rate

3. Uterine hyperstimulation 4. Late decelerations of the fetal heart rate

A client with severe acne is seen in the clinic and the primary health care provider (PHCP) prescribes isotretinoin. The nurse reviews the client's medication record and would contact the PHCP if the client is also taking which medication? 1. Digoxin 2. Phenytoin 3. Vitamin A 4. Furosemide

3. Vitamin A

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client? 1. Wear gloves only. 2. Wear a mask and gloves. 3. Wear a gown and gloves. 4. Avoid touching the client's clothes.

3. Wear a gown and gloves.

The nurse should institute which interventions for a client diagnosed with Clostridium difficile? Select all that apply. 1. Wear a mask if within 3 feet of the client. 2. Place a mask on the client when the client is outside the room. 3. Wear gloves and gown while in the room caring for the client. 4. Use soap and water, not alcohol-based hand rub, for hand hygiene. 5. Keep the door of the room shut except when entering or exiting the client's room.

3. Wear gloves and gown while in the room caring for the client. 4. Use soap and water, not alcohol-based hand rub, for hand hygiene.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which signs should the nurse expect to note in the health record when collecting data related to the respiratory system for this client? 1. Stridor and cyanotic tips 2. Diminished breath sounds and fever 3. Wheezes and use of accessory muscles 4. Pleural friction rub and inspirational chest pain

3. Wheezes and use of accessory muscles

The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. Which is the accurate response the nurse could make? 1. The organ of copulation 2. Where the fetus develops 3. Where fertilization occurs 4. The organ that secretes estrogen and progesterone

3. Where fertilization occurs

A hospitalized client is taking clozapine for the treatment of a schizophrenic disorder. Which laboratory study for the client should the nurse specifically review to monitor for an adverse effect associated with the use of this medication? 1. Platelet count 2. Cholesterol level 3. White blood cell count 4. Blood urea nitrogen level

3. White blood cell count

The client with trigeminal neuralgia is being treated with carbamazepine. Which laboratory result indicates that the client is experiencing an adverse effect of the medication? 1. Sodium level, 14 mEq/L (140 mmol/L) 2. Uric acid level, 5.0 mg/dL (0.3 mmol/L) 3. White blood cell count, 3000 mm^3 (3 x 10^9/L) 4. Blood urea nitrogen (BUN) level, 15 mg/dL (5.4 mmol/L)

3. White blood cell count, 3000 mm^3 (3 x 10^9/L)

The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement? 1. "My medications won't make me anxious." 2. "I'll go to a support group and talk so that I won't hurt anyone." 3. "I won't get anxious or heat things if I get enough sleep and eat well." 4. "I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone."

4. "I can call my therapist when I'm hallucinating so I can talk about my feelings and plans and not hurt anyone."

The nurse is caring for an older client with a diagnosis of myasthenia gravis and has reinforced self-care instructions. Which statement made by the client indicates a need for further teaching? 1. "I rest each afternoon after my walk." 2. "I cough and deep breathe many times during the day." 3."If I get abdominal cramps and diarrhea, I should call my doctor." 4. "I can change the time of my medication on the mornings that I feel strong."

4. "I can change the time of my medication on the mornings that I feel strong."

The nurse reinforces home care instructions to the mother of a child recovering from Reye's syndrome. which statement by the mother indicates a need for further teaching? 1. "I need to check for jaundiced skin and eyes every day." 2. "I need to have my child nap during the day to provide rest." 3. "I need to decrease the stimuli at home to prevent intracranial pressure." 4. "I need to give frequent, small, nutritious meals if my child starts to vomit."

4. "I need to give frequent, small, nutritious meals if my child starts to vomit."

During the prenatal visit, the nurse is explaining dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective when the client makes which statement? 1. "I can eat more sweets now because I need more calories." 2. "I need more fat in my diet so that the baby can gain enough weight." 3. "I need to eat a high-protein, low-carbohydrate diet now to control my blood glucose." 4. "I need to increase the fiber in my diet to control my blood glucose and prevent constipation."

4. "I need to increase the fiber in my diet to control my blood glucose and prevent constipation."

The nurse has provided instructions to the mother of a child who has been diagnosed with bacterial conjunctivitis. Which statement by the mother would indicate the need for further teaching? 1. "I need to wash my hands frequently." 2. "I need to clean the eye, as prescribed." 3. "I need to give the eye drops, as prescribed." 4. "I need to use hot compresses to relieve the eye irritation."

4. "I need to use hot compresses to relieve the eye irritation."

The nurse is reinforcing discharge teaching to a client diagnosed with tuberculosis who has been taking medication for 1.5 weeks. The nurse knows that the client understood the information if which statement is made? 1. "I can't stop at the mall for the next 6 months." 2. "I need to continue my medication therapy for 2 months." 3. "I can return to work if a sputum culture comes back negative." 4. "I should not be contagious after 2 to 3 weeks of medication therapy."

4. "I should not be contagious after 2 to 3 weeks of medication therapy."

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia. Which statement by the client indicates a correct understanding of Humulin N insulin and exercise? 1. "I should not exercise after lunch." 2. "I should not exercise after breakfast." 3. "I should not exercise in the late evening." 4. "I should not exercise in the late afternoon."

4. "I should not exercise in the late afternoon."

The nurse reinforces home care instructions to the parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further teaching? 1. "I will supervise my child closely." 2. "I will pad the corners of the furniture." 3. "I will remove household items that can easily fall over." 4. "I will avoid immunizations and dental hygiene treatments for my child."

4. "I will avoid immunizations and dental hygiene treatments for my child."

A licensed practical nurse is precepting a student assigned to care for a client with chronic pain. Which statement, if made by the student, indicates the need for further teaching regarding pain management? 1. "I will be sure to ask my client what their pain level is on a scale of 0 to 10." 2. "I know that I should follow-up after giving medication to make sure it is effective." 3. "I know the pain in the older client might manifest as sleep disturbance or depression." 4. "I will be sure to cue in to any indicators that the client may be exaggerating their pain."

4. "I will be sure to cue in to any indicators that the client may be exaggerating their pain."

The nurse reviews measures to prevent tick bites with a parent of a child with Rocky Mountain spotted fever. Which statement by the parent indicates a need for further teaching? 1. "I will have my child wear long sleeves and long pants to keep covered up." 2. "I will have my child stay on well-worn paths and will not stray into tall grass." 3. "I will check my child for ticks after being exposed to a high-risk tick-infected area." 4. "I will have my child wear dark colored clothing so the tick will not be attracted to the colors."

4. "I will have my child wear dark colored clothing so the tick will not be attracted to the colors."

The nurse provides skin care instructions to the client who is receiving external radiation therapy. Which statement by the client indicates the need for further teaching? Select all that apply. 1. "I will handle the area gently." 2. "I will wear loose-fitting clothing." 3. "I will avoid the use of deodorants." 4. "I will limit sun exposure to 1 hour daily." 5. "I will apply moisturizer with a cotton tipped applicator for itching."

4. "I will limit sun exposure to 1 hour daily." 5. "I will apply moisturizer with a cotton tipped applicator for itching."

The nurse reinforces instructions to the parent of a child with meningococcal meningitis. Which statement by the parent indicates a need for further teaching? 1. "I can give my child acetaminophen for fever." 2. "I will watch for any hearing loss that may occur." 3. "I know that I will need to watch for any rash that my child may develop." 4. "I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is only 3 months."

4. "I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is only 3 months."

The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action? 1. Monitor the vital signs. 2. Elevate the head of the bed. 3. Increase the intravenous flow rate. 4. Administer oxygen by face mask, as prescribed.

4. Administer oxygen by face mask, as prescribed.

The nurse is providing discharge instructions to the parents of a 14-year-old child who is undergoing radiation for Hodgkin's disease. Which statement by a parent indicates the need for further teaching? 1. "I need to watch for diarrhea, so my child does not get dehydrated." 2. "I think that once my child's hair starts to fall out that I can keep a hat on him." 3. "I understand that the radiation will cause nausea and vomiting and I need to keep my child hydrated." 4. "I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days."

4. "I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days."

The nurse is reviewing instructions to a parent of a 6-year-old on how to prevent influenza. Which statement by the parent indicates a need for further teaching? 1. "I will get the flu shot and I will have my child get a flu shot too." 2. "I will avoid having my child come into contact with sick children." 3. "I will have my child wash her hands frequently during the flu season." 4. "I will not let my child play with other children who have the flu unless they are taking acetaminophen."

4. "I will not let my child play with other children who have the flu unless they are taking acetaminophen."

When the nurse is reinforcing instructions to a client who has been newly diagnosed with type 1 diabetes mellitus, which statement by the client would indicate that teaching has been effective? 1. "I will stop taking my insulin if I'm too sick to eat." 2. "I will decrease my insulin dose during times of illness." 3. "I will adjust my insulin dose according to the level of glucose in my urine." 4. "I will notify my primary health care provider if my blood glucose is consistently greater than 250."

4. "I will notify my primary health care provider if my blood glucose is consistently greater than 250."

The nurse reinforces discharge instructions to a postoperative client who is taking warfarin sodium. Which statement made by the client reflects the need for further teaching? 1. "I will take my pills every day at the same time." 2. "I will be certain to avoid alcohol consumption." 3. "I have already called my family to pick up a MedicAlert bracelet." 4. "I will take enteric-coated aspirin for my headaches because it is coated."

4. "I will take enteric-coated aspirin for my headaches because it is coated."

The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement? 1. "I know I can never have another child." 2. "I am glad I won't have to have these shots if I have another child." 3. "I will have to have an injection once a month until the baby is born." 4. "I will tell the nurse at the hospital that I had an Rh shot during pregnancy."

4. "I will tell the nurse at the hospital that I had an Rh shot during pregnancy."

The home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL (9.95 mmol/L). The client is taking cholestyramine. Which statement made by the client indicates the need for further teaching? 1. "Constipation and bloating might be a problem." 2. "I'll continue to watch my diet and reduce my fats." 3. "Walking a mile each dat will help the whole process." 4. "I'll continue my nicotinic acid from the health food store."

4. "I'll continue my nicotinic acid from the health food store."

A client is taking nicotinic acid for hyperlipidemia, and the nurse reinforces instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions? 1. "It is not necessary to avoid the use of alcohol." 2. "The medication should be taken with meals to decrease flushing." 3. "Clay-colored stools are a common side effect and should not be of concern." 4. "Ibuprofen taken 30 minutes before the nicotinic acid should decrease the flushing."

4. "Ibuprofen taken 30 minutes before the nicotinic acid should decrease the flushing."

The nurse provides homecare instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin. Which statement by a parent indicates a need for further teaching? 1. "I will not mix the medication with food." 2. "If more than one dose is missed, I will call the doctor." 3. "I will take my child's pulse before administering the medication." 4. "If my child vomits after medication administration, I will repeat the dose."

4. "If my child vomits after medication administration, I will repeat the dose."

The parents of a newborn have been told that their child was born with bladder exstrophy and the parents ask the nurse about his condition. Which response should the nurse give to the parents about bladder exstrophy? 1. "It is a hereditary disorder that occurs in every other generation." 2. "It is caused by the use of medications taken by the mother during pregnancy." 3. "It is a condition in which the urinary bladder is abnormally located in the pelvic cavity." 4. "It is extrusion of the urinary bladder to the outside of the body though a defect in the lower abdominal wall."

4. "It is extrusion of the urinary bladder to the outside of the body though a defect in the lower abdominal wall."

A client is admitted to the in-patient unit and is being considered for electroconvulsive therapy (ECT). The client appears calm, but the family is hypervigilant and anxious. The client's mother begins to cry and states, "My child's brain will be destroyed. How can the doctor do this?" The nurse should make which therapeutic response? 1. "It sounds as though you need to speak to the psychiatrist." 2. "Perhaps you'd like to see the ECT room and speak to the staff." 3. "Your child has decided to have this treatment. You should be supportive of the decision." 4. "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

4. "It sounds as though you have some concerns about the ECT procedure. Why don't we sit down together and discuss any concerns you may have?"

A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which client statement indicates an understanding of this stress reduction measure? 1. "This will help only if I play music at the same time." 2. "This will work for me only if I am alone in a quiet area." 3. "I need to do this only when I lie down in case I fall asleep." 4. "The best thing about this is that I can use it anywhere, anytime."

4. "The best thing about this is that I can use it anywhere, anytime."

The nurse determines a child is in the "preoperational" phase of Piaget's cognitive developmental theory when the child makes which statement? 1. "I know all my multiplication tables by memory." 2. "The ball is gone," when a ball disappears out of sight. 3. "I'll use a map to help me find my way in a new town." 4. "The moon follows me, and goes to bed when I go to bed."

4. "The moon follows me, and goes to bed when I go to bed."

The nurse reinforces medication instructions to a client with peptic ulcer disease. Which statement by the client indicates the best understanding of the medication therapy? 1. "Antacids will coat my stomach." 2. "Omeprazole will coat the ulcer and help it heal." 3. "Sucralfate will change the fluid in my stomach." 4. "The nizatidine will cause me to produce less stomach acid."

4. "The nizatidine will cause me to produce less stomach acid."

A client with acute muscle spasms has been taking baclofen. The client calls the clinic nurse because of continuous feelings of weakness and fatigue and asks the nurse about discontinuing the medication. The nurse should make which appropriate response to the client? 1. "You should never stop the medication." 2. "It is best that you taper the dose if you intend to stop the medication." 3. "It is okay to stop the medication if you think that you can tolerate the muscle spasms." 4. "Weakness and fatigue commonly occur and will diminish with continued medication use."

4. "Weakness and fatigue commonly occur and will diminish with continued medication use."

A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, "I don't feel any better than I did before the surgery." Which response by the nurse is most appropriate? 1. "You will feel better in a week or two." 2. "It's only the second day postop. Cheer up." 3. "This is a normal frustration. It'll get better." 4. "You are concerned that you don't feel any better after surgery?"

4. "You are concerned that you don't feel any better after surgery?"

The nurse is caring for an older client who has recently lost her husband. The client says, "No one cares about me anymore. All the people I loved are dead." Which response by the nurse is therapeutic? 1. "Right! Why not just 'pack it in'?" 2. "That seems rather unlikely to me." 3. "I don't believe that, and neither do you." 4. "You must be feeling all alone at this point."

4. "You must be feeling all alone at this point."

During a conversation with a depressed client on a psychiatric unit, the nurse says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client? 1. "Have you talked to your family about this?" 2. "Everyone feels this way when they are depressed." 3. "You will feel better once your medication begins to work." 4. "You sound very upset. Are you thinking of hurting yourself?"

4. "You sound very upset. Are you thinking of hurting yourself?"

A pregnant woman has a positive history of genital herpes, but she has not had any lesions during her pregnancy. The nurse plans to provide which information to the client? 1. "You will be isolated from your newborn after delivery." 2. "There is little risk to your baby during your pregnancy, birth, and after delivery." 3. "Vaginal deliveries can reduce neonatal infection risk, even if you have an active lesion at birth." 4. "You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."

4. "You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."

A client with a diagnosis of depression says to the nurse, "I should have died. I've always been a failure." The nurse should make which therapeutic response to the client? 1. "I see a lot of positive things in you." 2. "You still have a great deal to live for." 3. "Feeling like a failure is part of your illness." 4. "You've been feeling like a failure for some time now?"

4. "You've been feeling like a failure for some time now?"

The client arrives at the emergency department after a burn injury that occurred in their home basement and an inhalation injury is suspected. which should the nurse anticipate as being prescribed for the client? 1. Oxygen via nasal cannula at 10 L 2. Oxygen via nasal cannula at 15 L 3. 100% oxygen via an aerosol mask 4. 100% oxygen via a tight-fitting, nonrebreather face mask

4. 100% oxygen via a tight-fitting, nonrebreather face mask

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that the fetal movements will be noted between which weeks of gestation? 1. 6 and 8 weeks' gestation 2. 8 and 10 weeks' gestation 3. 10 and 12 weeks' gestation 4. 16 and 20 weeks' gestation

4. 16 and 20 weeks' gestation

A client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level. When reviewing the client's results, the nurse determines that which requires a call to the primary health care provider for intervention? 1. 75 mg/dL (4.2 mmol/L) 2. 92 mg/dL (5.3 mmol/L) 3. 120 mg/dL (6.9 mmol/L) 4. 240 mg/dL (13.7 mmol/L)

4. 240 mg/dL (13.7 mmol/L)

A client received 20 units of NPH insulin subcutaneously at 8:00 AM. The nurse should check the client for a potential hypoglycemic reaction at which time? 1. 9:00 AM 2. 12:00 NOON 3. 1:00 PM 4. 5:00 PM

4. 5:00 PM

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition? 1. An infectious disease of the central nervous system 2. An inflammation of the brain as a result of a viral illness 3. A congenital condition that results in moderate to severe retardation 4. A chronic disability characterized by impaired muscle movement and posture

4. A chronic disability characterized by impaired muscle movement and posture

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first? 1. A client scheduled for a chest x-ray 2. A client requiring daily dressing changes 3. A postoperative client preparing for discharge 4. A client receiving oxygen who is having difficulty breathing

4. A client receiving oxygen who is having difficulty breathing

A client who has been drinking alcohol on a regular basis admits to having "a problem" and is asking for assistance with the problem. The nurse should encourage the client to attend which community group? 1. Al-Anon 2. Fresh Start 3. Families Anonymous 4. Alcoholics Anonymous

4. Alcoholics Anonymous

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client? 1. A client complaining of muscle ache, headache and malaise 2. A client who twisted their ankle when they fell in-line skating 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

4. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

The nurse is planning the client assignment for the day and has another licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP) on the nursing team. Which client should the nurse most appropriately assign to the LPN? 1. A client with stable heart failure who has early-stage Alzheimer's disease 2. A client who is scheduled for an electrocardiogram and a chest radiograph 3. A client who was treated for dehydration and is weak and needs assistance with bathing 4. A client with emphysema who is receiving oxygen by nasal cannula and becomes dyspneic during exertion

4. A client with emphysema who is receiving oxygen by nasal cannula and becomes dyspneic during exertion

The nurse is assisting with creating a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which about a crisis response? 1. A crisis state indicates that the individual is suffering from a mental illness. 2. A crisis state indicates that the individual is suffering from an emotional illness. 3. Presenting symptoms in a crisis situation are similar for all individuals experiencing a crisis. 4. A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

4. A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person.

The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding? 1. An increased hematocrit level 2. An increased hemoglobin level 3. A decline of the temperature to normal 4. A decrease in oozing from the puncture sites and gums

4. A decrease in oozing from the puncture sites and gums

The nurse is assigned to assist with caring for a client with esophageal varices who has a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside? 1. An obturator 2. A Kelly clamp 3. An irrigation set 4. A pair of scissors

4. A pair of scissors

Phenazopyridine hydrochloride is prescribed for a client for symptomatic relief of pain resulting from a lower urinary tract infection. Which should the nurse reinforce to the client? 1. Take the medication at bedtime. 2. Take the medication before meals. 3. Discontinue the medication if a headache occurs. 4. A reddish-orange discoloration of the urine may occur.

4. A reddish-orange discoloration of the urine may occur.

The client with diagnosed acquired immunodeficiency disease (AIDS) and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101° F (38.3° C). The nurse continues to monitor the client, knowing that this sign would most likely indicate which condition? 1. The dose of the medication is too low. 2. The client is experiencing toxic effects of the medication. 3. The client has developed inadequacy of thermoregulation. 4. A result of another infection caused by the leukopenic effects of the medication.

4. A result of another infection caused by the leukopenic effects of the medication.

The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the client's record? 1. Blurred vision 2. Pain in the effected eye 3. A yellow discoloration of the sclera 4. A sense of a curtain falling across the field of vision

4. A sense of a curtain falling across the field of vision

The nurse notes that the primary health care provider (PHCP) has documented a diagnosis of presbycusis on the client's chart. Which explanation should the nurse give to the client to explain this condition? 1. Tinnitus that occurs with aging 2. Nystagmus that occurs with aging 3. A conductive hearing loss that occurs with aging 4. A sensorineural hearing loss that occurs with aging

4. A sensorineural hearing loss that occurs with aging

The client with myasthenia gravis becomes increasingly weak. The primary health acre provider (PHCP) prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which change in condition indicates that the client is in cholinergic crisis? 1. No change in the condition 2. Complaints of muscle spasms 3. An improvement of the weakness 4. A temporary worsening of the condition

4. A temporary worsening of the condition

The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse? 1. Bradypnea 2. Diaphoresis 3. Decreased blood pressure (BP) 4. A weight gain of 1 lb in 1 day

4. A weight gain of 1 lb in 1 day

A client arrives at the emergency department and has experienced frostbite to the right hand. What should the nurse expect to find when inspecting the client's hand? 1. A pink, edematous hand 2. Fiery red skin with edema in the nail beds 3. Black fingertips surrounded by an erythematous rash 4. A white color of the skin which is insensitive to touch

4. A white color of the skin which is insensitive to touch

The nurse is assisting with the administration of immunizations at a health care clinic. The nurse should understand that immunization provides which protection? 1. Protection from all diseases 2. Innate immunity from disease 3. Natural immunity from disease 4. Acquired immunity from disease

4. Acquired immunity from disease

Heparin sodium is prescribed for the client. Which laboratory result indicates that the heparin is prescribed at a therapeutic level? 1. Thrombocyte count of 100,000 mm^3 2. Prothrombin time (PT) of 21 seconds 3. International normalized ratio (INR) of 2.3 4. Activated partial thromboplastin time (aPPT) of 55 seconds

4. Activated partial thromboplastin time (aPPT) of 55 seconds

A 16-year-old is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which intervention is most appropriate to facilitate normal growth and development? 1. Encourage the child to rest and read. 2. Encourage the parents to room-in with the child. 3. Allow the family to bring in favorite computer games. 4. Allow the child to participate in activities with other individuals in the same age group when condition permits.

4. Allow the child to participate in activities with other individuals in the same age group when condition permits.

The nurse should plan which to encourage autonomy in the client who is a resident in a long-term care facility? 1. Choosing meals 3. Decorating the room 3. Scheduling haircut appointments 4. Allowing the client to choose social activities

4. Allowing the client to choose social activities

A client with chronic kidney disease has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now has mental cloudiness, dementia, and complains of bone pain. Which does this data indicate? 1. Advancing uremia 2. Phosphate overdose 3. Folic acid deficiency 4. Aluminum intoxication

4. Aluminum intoxication

The nurse who is caring for a client with kidney failure notes that the client is dyspneic and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom should the nurse expect to note in this client? 1. Rapid weight loss 2. Flat hand and neck veins 3. A weak and thready pulse 4. An increase in blood pressure

4. An increase in blood pressure

Which individual is least at risk for the development of Kaposi's syndrome? 1. A kidney transplant client 2. A male with a history of same-sex partners 3. A client receiving antineoplastic medications 4. An individual working in an environment where exposure to asbestos exists

4. An individual working in an environment where exposure to asbestos exists

A licensed practical nurse (LPN) attends a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the need for further teaching about anthrax? 1. Anthrax is treated with antibiotic medications. 2. The most lethal form of anthrax is contacted by inhalation of the spores. 3. Anthrax can be transmitted by the consumption of meat from an infected animal. 4. Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis.

4. Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis.

A topical corticosteroid is prescribed by the health care provider for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream? 1. Apply the cream over the entire body. 2. Apply a thick later of cream to the affected areas only. 3. Avoid cleansing the area before application of the cream. 4. Apply a thin layer of cream and rub it into the area thoroughly.

4. Apply a thin layer of cream and rub it into the area thoroughly.

The nurse is reinforcing instructions to a client receiving external radiation therapy. The nurse determines that the client needs further teaching if the client states an intention to take which action? Select all that apply. 1. Eat a high-protein diet. 2. Avoid exposure to sunlight. 3. Wash the skin with a mild soap and pat it dry. 4. Apply pressure on the radiated area to prevent bleeding. 5. Avoid standing within 6 feet of persons under the age of 18 years.

4. Apply pressure on the radiated area to prevent bleeding. 5. Avoid standing within 6 feet of persons under the age of 18 years.

The nurse is planning care for a client who is being hospitalized because the client has been displaying violent behavior and is at risk for potential harm to others. The nurse should avoid which intervention in the plan of care? 1. Facing the client when providing care 2. Ensuring that a security officer is within the immediate area 3. Keeping the door to the client's room open when with the client 4. Assigning the client to a room at the end of the hall to prevent disturbing the other clients

4. Assigning the client to a room at the end of the hall to prevent disturbing the other clients

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? 1. Immediately before swimming 2. 5 minutes before exposure to the sun 3. Immediately before exposure to the sun 4. At least 30 minutes before exposure to the sun

4. At least 30 minutes before exposure to the sun

RH0(D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her baby from which condition? 1. Having Rh-positive blood 2. Developing a rubella infection 3. Developing physiological jaundice 4. Being affected by Rh incompatibility

4. Being affected by Rh incompatibility

A child is brought to the emergency room and the mother reports that the child accidentally swallowed paint thinner after mistaking it for water. The nurse should perform which action first? 1. Begin resuscitation. 2. Terminate exposure to the poison. 3. Take measures to prevent absorption to the poison. 4. Check the circulation, airway and breathing status of the child.

4. Check the circulation, airway and breathing status of the child.

A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription? 1. Obtains a weight 2. Takes the temperature 3. Takes the blood pressure 4. Checks the amount of urine output

4. Checks the amount of urine output

The nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which meal best illustrates the most appropriate diet for a client with cystic fibrosis? 1. Veggie salad and a caramel apple 2. Strawberry jelly sandwich and pretzels 3. Plate of nachos and cheese and a cupcake 4. Chicken tenders and a baked potato with butter

4. Chicken tenders and a baked potato with butter

Which clients would the nurse determine is at risk for development of metabolic alkalosis? 1. Client with emphysema 2. Client who is hyperventilating 3. Client with chronic kidney disease 4. Client who has been vomiting for 2 days 5. Client receiving oral furosemide 40mg daily 6. Client admitted with acetylsalicylic acid overdose

4. Client who has been vomiting for 2 days 5. Client receiving oral furosemide 40mg daily

A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing? 1. Uncaps the distal end of the tubing 2. Uncaps the spike portion of the tubing 3. Opens the roller clamp on the IV tubing 4. Closes the roller clamp on the IV tubing

4. Closes the roller clamp on the IV tubing

The nurse is caring for a client at home who has chronic obstructive pulmonary disease (COPD) and is receiving oxygen at 2L per minute, The client's respiratory rate is 22 breaths per minute, and the client is complaining of increased dyspnea. The nurse should take which initial action? 1. Determine the need to increase the oxygen. 2. Call emergency services to come to the home. 3. Reassure the client that there is no need to worry. 4. Collect more information about the clients' respiratory status.

4. Collect more information about the clients' respiratory status.

The client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse should perform which essential action when caring for this client? 1. Providing a standard bed frame 2. Removing the weights to reposition the client 3. Removing the weights if the client is uncomfortable 4. Comparing the amount of prescribed weights with the amount in use

4. Comparing the amount of prescribed weights with the amount in use

Tamoxifen is prescribed for the client with metastatic breast carcinoma. The nurse understands that which is the primary action of this medication? 1. Increase DNA and RNA synthesis. 2. Promote the biosynthesis of nucleic acids. 3. Increase estrogen concentration and estrogen response. 4. Compete with estradiol for binding to estrogen in tissues containing high concentrations of receptors.

4. Compete with estradiol for binding to estrogen in tissues containing high concentrations of receptors.

The client diagnosed with acquired immunodeficiency syndrome (AIDS) has begun therapy with zidovudine. The nurse should monitor which laboratory result during treatment with this medication? 1. Blood culture 2. Blood glucose level 3. Blood urea nitrogen 4. Complete blood count

4. Complete blood count

While assisting with the measurement of fundal height, the client at 36 weeks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of which reason? 1. A full bladder 2. Emotional instability 3. Insufficient iron intake 4. Compression of the vena cava

4. Compression of the vena cava

The nurse is assigned to care for an infant with cryptorchidism. One testis cannot be palpated. The nurse anticipates that which diagnostic study will be prescribed to determine where the undescended testis is located in the body? 1. Cystoscopy 2. Abdominal x-ray 3. Urodynamic study 4. Computed tomography scan

4. Computed tomography scan

A client with Parkinson's disease develops akinesia while ambulating, increasing the risk for falls. Which suggestion should the nurse provide to the client to alleviate this problem? 1. Use a wheelchair to move around. 2. Stand erect and use a cane to ambulate. 3. Keep the feet close together while ambulating and use a walker. 4. Consciously think about walking over imaginary lines on the floor.

4. Consciously think about walking over imaginary lines on the floor.

A client with chronic kidney disease is receiving ferrous sulfate. The nurse should monitor the client for which common side effect associated with this medication? 1. Diarrhea 2. Weakness 3. Headache 4. Constipation

4. Constipation

Isosorbide mononitrate is prescribed for a client with angina pectoris. The client tells the nurse that the medication is causing a chronic headache. Which action should the nurse suggest to the client? 1. Cut the dose in half. 2. Discontinue the medication. 3. Take the medication with food. 4. Contact the primary health care provider (PHCP).

4. Contact the primary health care provider (PHCP).

The nurse is collecting data from a client who has had benign prostatic hyperplasia (BPH) in the past. To determine whether the client is currently experiencing exacerbation of BPH, the nurse should ask the client about the presence of which early symptom? 1. Nocturia 2. Urinary retention 3. Urge incontinence 4. Decreased force in the stream of urine

4. Decreased force in the stream of urine

The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations. Based on this data, which action is most appropriate for the nurse to take initially? 1. Listen to the client's heart sounds 2. Determine whether the client has a pulse deficit 3. Instruct the client to use an incentive spirometer 4. Determine the client's ability to follow verbal commands

4. Determine the client's ability to follow verbal commands

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. During admission, which action should the nurse take initially? 1. Estimate the fetal size. 2. Check pelvic adequacy. 3. Administer an analgesic. 4. Determine the maternal and fetal vital signs.

4. Determine the maternal and fetal vital signs.

A client arrives at the emergency department and states she was just raped. In preparing a plan of care, which is the priority intervention? 1. Reinforcing instructions for medical follow-up 2. Obtaining appropriate counseling for the victim 3. Providing anticipatory guidance for police investigations, medical questions, and court proceedings 4. Exploring safety concerns by obtaining permission to notify significant others who can provide shelter

4. Exploring safety concerns by obtaining permission to notify significant others who can provide shelter

The client with ovarian cancer is being treated with vincristine. The nurse monitors the client, knowing that which adverse effect is specific to this medication? 1. Diarrhea 2. Hair loss 3. Chest pain 4. Extremity numbness

4. Extremity numbness

The nurse is assisting with developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care? 1. Decrease the amount of salt in the diet. 2. Decrease fluid intake to control the intraocular pressure. 3. Avoid reading the newspaper and watching television. 4. Eye medications may need to be administered for the rest of your life.

4. Eye medications may need to be administered for the rest of your life.

A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client? 1. Soft custard 2. Orange juice 3. Clam chowder 4. Fat-free beef broth

4. Fat-free beef broth

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which occurrence indicates an abnormal physical finding that necessitates further testing? 1. Quickening 2. Braxton Hicks contractions 3. Consistent increase in fundal height 4. Fetal heart rate of 180 beats per minute

4. Fetal heart rate of 180 beats per minute

The nurse reinforces instructions to the parents of a child with sickle cell anemia regarding the precipitating factors related to pain crisis. Which, if identified by a parent as a precipitating factor, indicates the need for further teaching? 1. Stress 2. Trauma 3. Infection 4. Fluid overload

4. Fluid overload

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note? 1. Sweating and tremors 2. Hunger and hypertension 3. Cold, clammy skin and irritability 4. Fruity breath odor and decreasing level of consciousness

4. Fruity breath odor and decreasing level of consciousness

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance? 1. Twitching 2. Positive Trousseau's sign 3. Hyperactive bowel sounds 4. Generalized muscle weakness

4. Generalized muscle weakness

Following a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action? 1. Call the client's family. 2. Place the client in seclusion immediately. 3. Inform the client that seclusion has not been prescribed. 4. Get a written prescription from the primary health care provider (PHCP) and obtain an informed consent.

4. Get a written prescription from the primary health care provider (PHCP) and obtain an informed consent.

A client is having problems with blood clotting,. Which food item should the nurse encourage the client to eat? 1. Legumes 2. Citrus fruits 3. Vegetable oils 4. Green, leafy vegetables

4. Green, leafy vegetables

The client with myasthenia gravis is suspected of having cholinergic crisis. Which sign/symptom indicates this crisis is taking place? 1. Ataxia 2. Mouth sores 3. Hypothermia 4. Hypertension

4. Hypertension

The nurse is monitoring a client who abuses alcohol for signs of alcohol withdrawal delirium. The nurse should monitor for which symptoms? 1. Hypotension, ataxia, vomiting 2. Stupor, agitation, muscular rigidity 3. Hypotension, bradycardia, agitation 4. Hypertension, disorientation, hallucinations

4. Hypertension, disorientation, hallucinations

Carbidopa-levodopa is prescribed for a client with Parkinson's disease, and the nurse monitors the client for adverse effects of the medication. Which sign/symptom indicates the client is experiencing an adverse effect? 1. Pruritis 2. Tachycardia 3. Hypertension 4. Impaired voluntary movements

4. Impaired voluntary movements

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use? 1. Gurgling respirations 2. Increased blood pressure 3. Decreased hematocrit level 4. Increased specific gravity of the urine

4. Increased specific gravity of the urine

The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing BP 2. Decreasing temperature, decreasing pulse, increasing respirations, decreasing BP 3. Decreasing temperature, increasing pulse, decreasing respirations, increasing BP 4. Increasing temperature, decreasing pulse, decreasing respirations, increasing BP

4. Increasing temperature, decreasing pulse, decreasing respirations, increasing BP

A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed? 1. Irrigation of the ear 2. Instillation of antibiotic eardrops 3. Instillation of corticosteroid ointment 4. Instillation of mineral oil or diluted alcohol

4. Instillation of mineral oil or diluted alcohol

The client arrives at the health care clinic and states to the nurse that they were just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that they removed the tick and flushed it down the toilet. Which nursing action is appropriate? 1. Refer the client for a blood test immediately. 2. Inform the client that there is not a test available for Lyme disease. 3. Tell the client that testing is not necessary unless arthralgia develops. 4. Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable.

4. Instruct the client to return in 4 to 6 weeks to be tested, because testing before this time is not reliable.

The client is in her second trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse should recommend which measure to help relieve both discomforts? 1. Lie on the left side with the feet dorsiflexed. 2. Soak the feet in hot water after performing 10 pelvic tilt exercises. 3. Lie on the right side with the feet elevated on a pillow and a heading pad on the back. 4. Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.

4. Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.

After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side lying position. The nurse understands that the purpose of this intervention is to accomplish which? 1. Promote bile flow 2. Limit client discomfort 3. Promote hepatic glucose storage 4. Limit bleeding from the biopsy site

4. Limit bleeding from the biopsy site

The client with spinal cord injury is prone to experiencing automatic dysreflexia. The least appropriate measure to minimize the risk of automatic dysreflexia is which action? 1. Strictly adhering to a bowel retraining program 2. Keeping the linen wrinkle-free under the client 3. Avoiding unnecessary pressure on the lower limbs 4. Limiting bladder catheterization to once every 12 hours

4. Limiting bladder catheterization to once every 12 hours

A client with diabetes mellitus who has been controlled with daily insulin has been placed on atenolol for the control of angina pectoris. Because of the effects of atenolol, the nurse determines that which is the most reliable indicator of hypoglycemia? 1. Sweating 2. Tachycardia 3. Nervousness 4. Low blood glucose level

4. Low blood glucose level

A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement? 1. Breastfeed only during the daytime hours. 2. Apply cold compresses to the breasts before feeding. 3. Avoid the use of a bra while the breasts are engorged. 4. Massage the breasts before feeding to stimulate let-down.

4. Massage the breasts before feeding to stimulate let-down.

The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to document that the fundus of the uterus is located at which area? 1. At the umbilicus 2. Just above the symphysis pubis 3. At the level of the xiphoid process 4. Midway between the symphysis pubis and the umbilicus

4. Midway between the symphysis pubis and the umbilicus

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor the skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with shields or patches.

4. Monitor the skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with shields or patches.

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L (5.4 mmol/L). What should the nurse look for on the cardiac monitor as a result of this laboratory value? 1. ST elevation 2. Peaked P waves 3. Prominent U waves 4. Narrow, peaked T waves

4. Narrow, peaked T waves

The client has an as needed prescription for ondansetron. For which condition should the nurse administer this medication? 1. Paralytic ileus 2. Incisional pain 3. Urinary retention 4. Nausea and vomiting

4. Nausea and vomiting

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) solution? 1. Potassium infusion 2. NPH insulin infusion 3. 5% dextrose infusion 4. Normal saline infusion

4. Normal saline infusion

A child is diagnosed with infectious mononucleosis. The nurse reinforces homecare instructions to the parents about the care of the child. Which instruction should the nurse provide to the parents? 1. Maintain the child on bed rest for 2 weeks. 2. Maintain respiratory precautions for 1 week. 3. Notify the pediatrician if the child develops a fever. 4. Notify the pediatrician if the child develops abdominal or left shoulder pain.

4. Notify the pediatrician if the child develops abdominal or left shoulder pain.

The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9° C). Which is the appropriate nursing action? 1. Apply cool packs to the abdomen. 2. Continue to monitor the temperature. 3. Remove the blanket from the client's bed. 4. Notify the registered nurse (RN), who will then contact the primary health care provider (PHCP).

4. Notify the registered nurse (RN), who will then contact the primary health care provider (PHCP).

The nurse is providing instructions to a client who will be self-administering eyedrops. To minimize the systemic effects that eyedrops can produce, the client is instructed to perform which action? 1. Eat before instilling the drops. 2. Swallow several times after instilling the drops. 3. Blink vigorously to encourage tearing after instilling the drops. 4. Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops.

4. Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops.

A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's poor nutritional intake. Which nursing intervention related to poor nutrition should be the initial choice? 1. Weigh the client three times per week, before breakfast. 2. Explain to the client the importance of a good nutritional intake. 3. Report the nutritional concern to the psychiatrist and obtain a nutritional consent as soon as possible. 4. Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.

4. Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.

The client with a gastric ulcer has a prescription for sucralfate 1 g by mouth four times daily. The nurse should schedule the medication to be administered at which times? 1. With meals and at bedtime 2. Every 6 hours around the clock 3. One hour after meals and at bedtime 4. One hour before meals and at bedtime

4. One hour before meals and at bedtime

The client with small cell lung cancer is being treated with etoposide and the nurse is assisting with caring for the client during administration. The client gets up to use the bathroom and is dizzy and very weak. The nurse understands these symptoms are likely as a result of which side/adverse effect that is specifically associated with this medication? 1. Alopecia 2. Chest pain 3. Pulmonary fibrosis 4. Orthostatic hypotension

4. Orthostatic hypotension

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse monitors this client for which signs/symptoms of this disorder? 1. Edema and purpura of the left arm 2. Warmth, redness, and pain in the left hand 3. Aching pain, pallor, and edema of the left arm 4. Pallor, diminished pulse, and pain in the left hand

4. Pallor, diminished pulse, and pain in the left hand

The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method should be used to monitor the client for crepitus? 1. Auscultating the posterior breath sounds 2. Asking the client about pain upon inspiration 3. Placing the hands over the rib area and observing expansion 4. Palpating the skin around the chest and neck for a cracking sensation

4. Palpating the skin around the chest and neck for a cracking sensation

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. What should the nurse expect to find when checking the client's sacral area? 1. Intact skin 2. The presence of tunneling 3. A deep, crate-like appearance 4. Partial-thickness skin loss of the epidermis

4. Partial-thickness skin loss of the epidermis

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of tasks? 1. Document that the task was completed. 2. Assign the tasks that were not completed to the next nursing shift. 3. Allow each staff member to make judgements when performing the tasks. 4. Perform follow-up with each staff member regarding the performance and outcome of the task.

4. Perform follow-up with each staff member regarding the performance and outcome of the task.

The nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further teaching if the nurse observes the client doing which activity? 1. Pulling up on the trapeze 2. Flexing and extending the feet 3. Doing quadriceps-setting and gluteal-setting exercises 4. Performing active range of motion (ROM) to the right ankle and knee

4. Performing active range of motion (ROM) to the right ankle and knee

Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse contacts the primary health care provider (PHCP) who prescribed the medication if which condition is documented in the client's medical history? 1. Hypotension 2. Hypothyroidism 3. Diabetes mellitus 4. Peripheral vascular disease

4. Peripheral vascular disease

The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse should suspect DIC if which is observed? 1. Rapid clotting times 2. Pain and swelling of the calf of one leg 3. Laboratory values that indicate increased platelets 4. Petechiae, oozing from injection sites, and hematuria

4. Petechiae, oozing from injection sites, and hematuria

The client is hospitalized for the insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. Which is the immediate nursing action? 1. Reinsert the implant into the vagina. 2. Call the primary health care provider (PHCP). 3. Pick up the implant with gloved hands and flush it down the toilet. 4. Pick up the implant with long-handled forceps and place into a lead container.

4. Pick up the implant with long-handled forceps and place into a lead container.

A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm^3 (300x 10^9/L). The nurse should take which action after seeing the laboratory results? 1. Report the abnormally low count. 2. Report the abnormally high count. 3. Place the client on bleeding precautions. 4. Place the normal report in the client's medical record.

4. Place the normal report in the client's medical record.

A mother is breastfeeding her newborn. The mother complains to the nurse that she is experiencing sever nipple soreness. The nurse should provide which suggestion to the client? 1. Avoid rotating breastfeeding positions so that the nipple will toughen. 2. Stop nursing during the period of nipple soreness to allow the nipples to heal. 3. Nurse the newborn infant less frequently and substitute a bottle feeding until the nipples become less sore. 4. Position the newborn infant with the eat, shoulder, and hip in straight alignment and with the baby's stomach against the mother's.

4. Position the newborn infant with the eat, shoulder, and hip in straight alignment and with the baby's stomach against the mother's.

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional sign/symptom should the nurse expect to note in this client if hyponatremia is present? 1. Intense thirst 2. Slow bounding pulse 3. Dry mucous membranes 4. Postural blood pressure changes

4. Postural blood pressure changes

The nurse is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation? 1. Provide the client with a walker. 2. Remove the telemetry equipment. 3. Encourage the client to cough and deep breathe. 4. Premedicate the client with an analgesic before ambulating.

4. Premedicate the client with an analgesic before ambulating.

The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse should perform which action? 1. Check the vital signs every 4 hours. 2. Measure the fundal height every 4 hours. 3. Prepare a heat pack for application to the area. 4. Prepare an ice pack for application to the area.

4. Prepare an ice pack for application to the area.

The nurse has just administered ibuprofin to a child with a temperature of 38.8° C (102° F). The nurse should also take which action? 1. Withhold oral fluids for 8 hours. 2. Sponge the child with cold water. 3. Plan to administer salicylate in 4 hours. 4. Remove excess clothing and blankets from the child.

4. Remove excess clothing and blankets from the child.

The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. On the basis of this diagnosis, the nurse would plan which action? 1. Reassure the client 2. Apply perineal pressure 3. Monitor fundal height 4. Prepare the client for surgery

4. Prepare the client for surgery

A client with diabetes mellitus has a glycosylated hemoglobin A1C level of 9%. On the basis of this test result, the nurse plans to reinforce teaching the client about the need for which measure? 1. Avoiding infection 2. Taking in adequate fluids 3. Preventing and recognizing hypoglycemia 4. Preventing and recognizing hyperglycemia

4. Preventing and recognizing hyperglycemia

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes and the mother asks the nurse why this is done. The nurse should give which response to the client? 1. Prevents cataracts in the neonate born to a woman who is susceptible to rubella 2. Protects the neonate's eyes from possible infection acquired while hospitalized 3. Minimizes the spread of microorganisms to the neonate from invasive procedures during labor 4. Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

4. Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

The nurse is instructing a client about pursed lip breathing and the client asks the nurse about its purpose. The nurse should tell the client that the primary purpose of pursed lip breathing is which? 1. Promote oxygen intake 2. Strengthen the diaphragm 3. Strengthen the intercostal muscles 4. Promote carbon dioxide elimination

4. Promote carbon dioxide elimination

The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse occurred? 1. Dark and bluish 2. Sunken and hidden 3. Narrowed and flattened 4. Protruding and swollen

4. Protruding and swollen

A child is diagnosed with Reye's syndrome. The nurse assists with developing a nursing care plan for the child and should include which intervention in the plan? 1. Assess hearing loss 2. Monitor urine output 3. Change body position every 2 hours 4. Provide a quiet atmosphere with dimmed lighting

4. Provide a quiet atmosphere with dimmed lighting

The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client knowing which about the placenta? 1. Cushions and protects fetus 2. Maintains the body temperature of the fetus 3. Surrounds the fetus and allows for fetal movement 4. Provides an exchange of nutrients and waste products between the mother and the fetus

4. Provides an exchange of nutrients and waste products between the mother and the fetus

A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction has which primary function? 1. Allows bony healing to begin before surgery 2. Provides rigid immobilization of the fracture site 3. Lengthens the fractured leg to prevent severing of blood vessels 4. Provides comfort by reducing muscle spasms and provides fracture immobilization

4. Provides comfort by reducing muscle spasms and provides fracture immobilization

The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation? 1. Poor dietary choices 2. Lack of exercise and poor diet 3. Inadequate dietary intake and dehydration 4. Psychomotor retardation and side effects of medication

4. Psychomotor retardation and side effects of medication

The client is suspected of having systemic lupus erythematous (SLE). The nurse monitors the client, knowing that which is one of the initial characteristic signs of SLE? 1. Weight gain 2. Subnormal temperature 3. Elevated red blood cell count 4. Rash on the face across the nose and on the cheeks

4. Rash on the face across the nose and on the cheeks

The nurse is collecting data regarding a client after a thyroidectomy and notes the development of a hoarse and weak voice. Which nursing action is appropriate? 1. Check for signs of bleeding. 2. Administer calcium gluconate. 3. Notify the registered nurse immediately. 4. Reassure the client that this is usually a temporary condition.

4. Reassure the client that this is usually a temporary condition.

A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action? 1. Show acceptance of feelings. 2. Provide information needed for decision making. 3. Suggest a referral to a mental health professional. 4. Remain with the family member without discussing funeral arrangements.

4. Remain with the family member without discussing funeral arrangements.

The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed the same occurrence several times. Based on the nurse practice act, the observing nurse should plan to take which action? 1. Report the information to the police. 2. Call the impaired nurse organization. 3. Talk to the nurse who gave the medication. 4. Report the information to a nursing supervisor.

4. Report the information to a nursing supervisor.

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action? 1. Call the hospital lawyer 2. Call the nursing supervisor 3. Refuse to float to the pediatric unit. 4. Report to the pediatric unit and identify tasks that can be safely performed.

4. Report to the pediatric unit and identify tasks that can be safely performed.

The nurse is told that the arterial blood gas (ABG) results indicate a pH of 7.50 and a PCO2 of 32 mm HG. The nurse determines that these results are indicative of which acid-base disturbance? 1. Metabolic Acidosis 2. Metabolic Alkalosis 3. Respiratory Acidosis 4. Respiratory Alkalosis

4. Respiratory Alkalosis

The mother of a toddler with mumps asks the nurse what she needs to watch for in her child with this disease. The nurse bases the response on the understanding that mumps is which type of communicable disease? 1. Skin rash caused by a virus 2. Skin rash caused by a bacteria 3. Respiratory disease caused by a virus involving the lymph nodes 4. Respiratory disease caused by a virus involving the parotid gland

4. Respiratory disease caused by a virus involving the parotid gland

The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria? 1. Is grossly bloody in appearance and has a pH of 6 2. clumps together on the dressing and has a pH of 7 3. Is clear in appearance and tests negative for glucose 4. Separates into concentric rings and tests positive for glucose

4. Separates into concentric rings and tests positive for glucose

The nurse is assigned to care for a client diagnosed with cytomegalovirus retinitis and acquired immunodeficiency disease (AIDS) who is receiving foscarnet. The nurse should monitor the results of which laboratory study while the client is taking this medication? 1. CD4+ count 2. Lymphocyte count 3. Serum albumin level 4. Serum creatinine level

4. Serum creatinine level

The nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis. The nurse knows that the client understands the information if the client verbalizes which early sign of exacerbation? 1. Fever 2. Fatigue 3. Weight loss 4. Shortness of breath

4. Shortness of breath

The client is having a lumbar puncture (LP) performed. The nurse should place the client in which position for the procedure? 1. Supine, in semi-Fowler's 2. Prone, in slight Trendelenburg's 3. Prone, with a pillow under the abdomen 4. Side-lying, with legs pulled up and chin to the chest

4. Side-lying, with legs pulled up and chin to the chest

The nurse is reinforcing instructions to a hospitalized client with a diagnosis of emphysema about the positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position should the nurse instruct the client to assume? 1. Side-lying in bed 2. Sitting up in a recliner chair 3. Sitting up in bed at a 90 degree angle 4. Sitting on the side of the bed leaning on an overbed table

4. Sitting on the side of the bed leaning on an overbed table

The nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse should plan to perform which action? 1. Try to manually reduce the fracture. 2. Assist the person with getting up and walking to the sidewalk. 3. Leave the person for a few moments to call an ambulance. 4. Stay with the person and encourage the person to remain still.

4. Stay with the person and encourage the person to remain still.

The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure at the site with which item? 1. Band-aid 2. Alcohol swab 3. Betadine swab 4. Sterile 2x2 gauze

4. Sterile 2x2 gauze

A client is receiving acetylcysteine, 20% solution diluted in 0.9% normal saline by nebulizer. The nurse should have which item available for a possible adverse event after giving this medication? 1. Ambu bag 2. Intubation tray 3. Nasogastric tube 4. Suction equipment

4. Suction equipment

The nurse is caring for a postoperative client who has been NPO and the primary health care provider (PHCP) has prescribed a clear liquid diet. When planning to initiate this diet, which priority item should the nurse place at the client's bedside? 1. A straw 2. Code cart 3. Blood pressure cuff 4. Suction equipment

4. Suction equipment

A child has a basilar skull fracture. Which primary health care provider's prescription should the nurse question? 1. Restrict fluid intake. 2. Insert an indwelling urinary catheter. 3. Keep an intravenous (IV) line patent. 4. Suction via the nasotracheal route as needed.

4. Suction via the nasotracheal route as needed.

The client who is being prepared for a cesarean section delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse should place the client in which position? 1. Prone position 2. Semi-Fowler's position 3. Trendelenburg's position 4. Supine position with a wedge under the right hip

4. Supine position with a wedge under the right hip

The nurse has received the client assignment for the day. Which client should the nurse attend to first? 1. The client who has a nasogastric tube attached to intermittent suction 2. The client who needs to receive subcutaneous insulin before breakfast 3. The client who is 2 days postoperative and is complaining of incisional pain 4. The client who has a blood glucose level of 50 mg/dl (2.85 mmol/L) and complains of blurred vision

4. The client who has a blood glucose level of 50 mg/dl (2.85 mmol/L) and complains of blurred vision

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing? 1. The client with sepsis 2. The client with cirrhosis 3. The client with kidney failure 4. The client with diabetes mellitus

4. The client with diabetes mellitus

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L (130mmol/L). The nurse expects that this sodium level would be noted in a client which which condition? 1. The client with watery diarrhea 2. The client with diabetes insipidus 3. The client with an inadequate daily water intake 4. The client with the syndrome of inappropriate secretion of antidiuretic hormone

4. The client with the syndrome of inappropriate secretion of antidiuretic hormone

The nurse is caring for a newborn diagnosed with Down syndrome. The parents are asking questions about the disorder. The nurse should provide which information when discussing Down syndrome? 1. The condition is characterized by above-average intellectual functioning with deficits in adaptive behavior. 2. The condition is characterized by average intellectual functioning with the absence of deficits in adaptive behavior. 3. The condition is characterized by subaverage intellectual functioning with the absence of deficits in adaptive behavior. 4. The condition is congenital and results in moderate to severe retardation and has been linked to an extra chromosome 21 (group G).

4. The condition is congenital and results in moderate to severe retardation and has been linked to an extra chromosome 21 (group G).

The nurse is assisting a primary health care provider (PHCP) during an examination of an infant with hip dysplasia. The PHCP performs the Ortolani maneuver. Which data should the nurse expect to note during the examination? 1. Full range of motion of the legs 2. Marked asymmetry on the affected side 3. The unstable femoral head pops out of the acetabulum 4. The dislocated femoral head pops back into the acetabulum

4. The dislocated femoral head pops back into the acetabulum

A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. The nurse should tell the client which information about the test? 1. The test may be painful. 2. Fluids will be restricted after the test. 3. The test takes approximately 2 to 3 hours. 4. The dye injected may cause a warm, flushing sensation.

4. The dye injected may cause a warm, flushing sensation.

The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse recognizes that these types of delusions are characteristic of which thoughts? 1. The false belief that one is a very powerful person 2. The false belief that one is a very important person 3. The false belief that one's partner is being unfaithful 4. The false belief that one is being singled out for harm by others

4. The false belief that one is being singled out for harm by others

A client being discharged from the hospital to home with a diagnosis of tuberculosis is worried about the possibility of infecting family members and others. Which information should reassure the client that contaminating family members and others is not likely? 1. The family does not need therapy, and the client will not be contagious after 1 month of medication therapy. 2. The family does not need therapy, and the client will not be contagious after 6 consecutive weeks of medication therapy. 3. The family will receive prophylactic therapy, and the client will not be contagious after 1 continuous week of medication therapy. 4. The family will receive prophylactic therapy, and the client will not be contagious after 3 continuous weeks of medication therapy.

4. The family will receive prophylactic therapy, and the client will not be contagious after 3 continuous weeks of medication therapy.

Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information should the nurse provide to the client about Leopold's maneuvers? 1. The maneuvers measure the height of the maternal fundus. 2. The maneuvers determine the "lie" and "attitude" of the fetus. 3. The maneuvers are a systematic method for palpating the fetus through the maternal back. 4. The maneuvers are a systematic method for palpating the fetus through the maternal wall.

4. The maneuvers are a systematic method for palpating the fetus through the maternal wall.

The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time? 1. The client is taken in for spinal x-rays. 2. The family comes to visit after surgery. 3. The nurse needs to provide physical care. 4. The primary health care provider (PHCP) reviews the x-ray results.

4. The primary health care provider (PHCP) reviews the x-ray results.

The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother which about cord care? 1. Alcohol is the only agent used to clean the cord. 2. It takes 21 days for the cord to dry up and fall off. 3. Cord care is done only at birth to control bleeding. 4. The process of keeping the cord clean and dry will decrease bacterial growth.

4. The process of keeping the cord clean and dry will decrease bacterial growth.

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client? 1. The inverted uterus returning to normal 2. The gradual reversal of the uterine muscle into the abdominal cavity 3. The descent of the uterus into the pelvic cavity, which occurs at a rate of 2 cm/day 4. The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

4. The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

The nurse observes that a client with a nasogastric tube connected to continuous gastric suction is mouth breathing, has dry mucous membranes, and has a foul breath odor. When planning care, which nursing intervention would be best to maintain the integrity of this client's oral mucosa? 1. Offer small sips of water frequently. 2. Encourage the client to suck on sour, hard candy. 3. Use lemon glycerin swabs to provide oral hygiene. 4. Use diluted mouthwash and water to swab the mouth after brushing teeth.

4. Use diluted mouthwash and water to swab the mouth after brushing teeth.

The nurse is providing an education class to healthy older adults. Which exercise will best promote health maintenance? 1. Gardening everyday for an hour 2. Sculpting one a week for 40 minutes 3. Cycling three times a week for 20 minutes 4. Walking three to five times a week for 30 minutes

4. Walking three to five times a week for 30 minutes

A health care provider has prescribed oxygen as needed for a 10-month-old infant with heart failure (HF). In which situation should the nurse administer oxygen to the child? 1. When the child is sleeping 2. When changing the child's diapers 3. When the mother is holding the child 4. When drawing blood for electrolyte levels

4. When drawing blood for electrolyte levels

Disulfiram is prescribed for a client and the nurse is collecting data on the client and is reinforcing instructions regarding the use of this medication. Which is most important for the nurse to determine before administration of this medication? 1. A history of hyperthyroidism 2. A history of diabetes insipidus 3. When the last full meal was consumed 4. When the last alcoholic drink was consumed

4. When the last alcoholic drink was consumed

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for monitoring by the nurse? 1. Glucose level of 99 mg/dL (5.5 mmol/L) 2. Platelet level of 300,000 mm^3 (300 x 10^9/L) 3. Magnesium level of 1.5 mEq/L (0.75 mmol/L) 4. White blood cell count of 3000 mm^3 (3.0 x 10^9/L)

4. White blood cell count of 3000 mm^3 (3.0 x 10^9/L)

The nurse is assisting in performing pediculosis capitis (head lice) checks. Which finding indicates that a child has a "positive" head check? 1. Maculopapular lesions behind the ears 2. Lesions on the scalp that extend to the hairline or neck 3. White flaky particles throughout the entire scalp region 4. White sacs attached to the hair shafts in the occipital area

4. White sacs attached to the hair shafts in the occipital area

The nurse monitors a 5-year-old child admitted to the hospital for a neuroblastoma for signs and symptoms related to the location of the tumor in the adrenal gland. Which descriptions would the nurse expect to document in the child's record specific to this tumor? Select all that apply. 1. Respiratory impairment 2. Anorexia and weight loss 3. Pallor, weakness, irritability 4. Supraorbital ecchymosis and periorbital edema 5. Firm, nontender, irregular mass in the abdomen 6. Urinary frequency or retention from compression of the bladder

5. Firm, nontender, irregular mass in the abdomen 6. Urinary frequency or retention from compression of the bladder

The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student needs further teaching if which responses are made? Select all that apply. 1. Allows for fetal movement 2. Is a measure of kidney function 3. Surrounds, cushions, and protects the fetus 4. Maintains the body temperature of the fetus. 5. Prevents large particles such as bacteria from passing to the fetus 6. Provides an exchange of nutrients and waste products between the mother and the fetus

5. Prevents large particles such as bacteria from passing to the fetus 6. Provides an exchange of nutrients and waste products between the mother and the fetus

The primary health care provider (PHCP) has prescribed phenobarbital sodium, 25 mg orally twice daily, for a child with febrile seizures. The medication label reads as follows: "Phenobarbital sodium, 20 mg/5 mL." The nurse has determined that the dose prescribed is a safe dose for the child. How many milliliters per dose should the nurse administer to the child?

6.25 mL