Module 5 Capstone

A nurse is admitting a client who has sustained severe burn injuries in a grease fire. The nurse shades in a diagram indicating the burned surface areas. Using the rule of nines, the nurse should estimate that the client has burned what percentage of body surface area? Round to the answer to the nearest tenth.

Ans 49.5

A nurse is providing dietary teaching to the parents of a newborn who is being breastfed. The nurse should instruct that the transition to whole milk can occur to which of the following ages? a. 12 months b. 10 months c. 8 months d. 6 months

a. 12 months

A nurse is assessing clients in a health clinic for risk factors for contracting hepatitis. Which of the following clients is at risk for developing hepatitis C? a. A client who has multiple tattoos. b. A client who eats raw shellfish c. A client who works in a childcare center d. A client who has recently traveled to an underdeveloped country

a. A client who has multiple tattoos.

A nurse is caring for a client for an 8-hour postoperative following a total knee replacement Which of following actions should the nurse take? a. Apply cool compresses to the affected limb every 6 hr. b. Promote bed rest for 5-7 days. c. Place a pillow under the affected limb. d. Encourage increased fluid intake.

a. Apply cool compresses to the affected limb every 6 hr.

A nurse is preparing dietary instructions for a client who has episodes of biliary colic from chronic cholecystitis. Which of the following instructions should the nurse include in the teaching plan? a. Avoid foods high in fat b.Include foods high in fiber c. Avoid foods high in sodium d. Include foods high in starch and proteins

a. Avoid foods high in fat

A community health nurse is preparing a presentation about complementary and alternative therapies. Which of the following therapies should the nurse describe as a means of manipulating a series of channels to re-establish the flow of vital energy within the body? a. Autogenic training b. Acupuncture c. Reiki d. Biofeedback

b. Acupuncture

A nurse is caring for a child who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take? a. Administer an antiemetic. b. Auscultate bowel sounds c. Insert nasogastric tube. d. Encourage use of the incentive spirometer.

b. Auscultate bowel sounds

A nurse is preparing a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device help clients learn to control physical responses to stress? a. Autogenic training b. Biofeedback c. Reiki d. Acupuncture

b. Biofeedback

A nurse is assessing an 11-month-old infant. Which of the following manifestations is associated with a CNS infection? a. Oliguria b. Bulging fontanel c. Jaundice d. Negative Brudzinski Sign

b. Bulging fontanel

A nurse is planning care for a client who has diverticulitis. Which of the following menu selections should the nurse include in the plan? a. Turkey sandwich with celery sticks. b. Grilled chicken breast with white rice. c. Pork tenderloin with green peas. d. Sliced ham with green salad.

b. Grilled chicken breast with white rice.

A nurse is teaching a client about causes of biliary cirrhosis. Which of the following information should the nurse include in the teaching? a. Hepatotoxic medications b. Obstruction of the bile duct c. Excessive alcohol consumption d. Hepatitis C

b. Obstruction of the bile duct

A nurse is providing anticipatory guidance about Child Development to the parents of a toddler. Which of the following development tasks should the nurse include as expected over toddler? a. Explains the difference between right and the wrong. b. Separates easily form primary care giver for short periods of time. c. Cooperates in doing simple chores. d. Prints letters and numbers.

b. Separates easily form primary care giver for short periods of time.

A nurse is providing care for a client who is 2 days postoperative following abdominal surgery and is about to progress from a clear liquid diet to full liquids. Which of the following items should the nurse tell the client he may now request to have on his meal tray? a. Cranberry juice b. Skim milk c. Chicken broth d. Flavored gelatin

b. Skim milk

A nurse is performing an integumentary assessment for a client. which of the following findings should the nurse identify as a possible squamous cell carcinoma? a. A small macule with a yellow brown scale. b. Yellow white patches growth on the tongue. c. A firm nodule with a hard crust. d. Painless, raised purple nodules on the hard palate.

c. A firm nodule with a hard crust.

A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next? a. Decrease environmental stimuli b. Complete a vascular assessment c. Assess the cranial nerves d. Administer an antipyretic

c. Assess the cranial nerves

A nurse is caring for a client who reports throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache? a. Darken the client's room and close the door. b. Administer pain medication. c. Increase fluid intake d. Elevate the head of the bed to 30'

c. Increase fluid intake

A nurse is providing anticipatory guidance about child development to the parents of a preschooler. Which of the following developmental tasks should the nurse include as being expected of a preschooler? a. Builds a collection of cards b. Controls impulsive feelings c. Participate in imaginary play d. Expresses need for privacy

c. Participate in imaginary play

A nurse is performing discharge teaching with a client about the care of a newly created ileal conduit. The nurse should instruct the client to empty the appliance a. Twice a day. b. When the bag is full. c. When the bag is 2/3 full. d. Daily at bedtime.

c. When the bag is 2/3 full.

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching? a. I will use mild soap b. I will test the water on my wrist for temperature before bathing. c. I will use basin during bathing. d. Baby powder will help prevent a diaper rash.

d. Baby powder will help prevent a diaper rash.

A nurse is caring for a client who has a fractured tibia because of a fall. The client x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures? a. Impacted b. Transverse c. Oblique d. Comminuted

d. Comminuted

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? a. Speak loudly to the client. b. Limit client physical activity. c. Leave the television on continuously. d. Provide client supervision

d. Provide client supervision

A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice? a. Begin phototherapy. b. Initiate early feeding. c. Prepare for an exchange blood transfusion. d. Suction excess mucus with a bulb syringe.

a. Begin phototherapy.

Nurse is caring for a client who is breastfeeding and states that her nipples are sore. Which of the following interventions should the nurse suggest? a. Change the newborn's position on the nipples with each feeding. b. Increase the length of time between feedings. c. Keep the nipples covered between breastfeeding sessions. d. Apply mineral oil to the nipples between feedings.

a. Change the newborn's position on the nipples with each feeding.

A nurse is caring for a client whose Papanicolaou (Pap) test cytology results are abnormal. Which of the following procedures should the nurse anticipate for this client? a. Colposcopy b. Rectovaginal palpation by the provider c. Dilation and curettage d. Human chorionic gonadotropin (hCG) test

a. Colposcopy

A nurse is preparing a presentation at a senior center about age-related musculoskeletal change. which of the following changes should the nurse plan to include? a. Decreased muscle mass b. Reduced chest width c. Increased force of isometric contraction d. Thickened vertebral disks

a. Decreased muscle mass

A nurse is caring for a client who had a vaginal delivery 2 hour ago. Which of the following actions should the nurse anticipate in the care of this client? ( Select all that apply) a. Determine whether the fundus is midline. b. Massage a firm fundus. c. Document fundal height. d. Observe the lochia during palpation of fundus. e. Administer methylergonovine maleate if uterus is boggy.

a. Determine whether the fundus is midline. b. Massage a firm fundus. c. Document fundal height. d. Observe the lochia during palpation of fundus.

A nurse is caring for a client who has infective endocarditis. Which of the following manifestation is the priority for the nurse to monitor for? a. Dyspnea b. Fever c. Malaise d. Anorexia

a. Dyspnea

A nurse is presenting information to the public about preventive measures to reduce the risk for contradicting West Nile virus. Which of the following instructions should the nurse include? a. Encourage the use of mosquito repellant. b. Check pets for ticks before bringing them into the home. c. Increase standing pools of water around the home. d. Wait until dusk to go for a walk.

a. Encourage the use of mosquito repellant.

A nurse is teaching a group of male adolescents about testicular self-examination. Which of the following information should the nurse include? a. Examine the testicles after a bath or shower b. Pinch the testicles to feel to feel for abnormalities c. Expect a moderate amount of swelling d. Perform testicular self-examination twice per year.

a. Examine the testicles after a bath or shower

A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take? a. Explain to the client what is about to happen. b. Inform the client that the provider will examine sensitive areas first. c. Make sure the room temperature is cool. d. Provide music as an environmental distraction.

a. Explain to the client what is about to happen.

A nurse is caring for a client who is two days postoperative following creation of an ileal conduit. Which of the following is an unexpected finding associated with this procedure? a. Feces in the drainage appliance b. Urine in the drainage appliance c. Edema of the stoma d. Redness of the stoma

a. Feces in the drainage appliance

A nurse is teaching a client who is perimenopausal and has recurrent lower back pain. Which of the following client statements indicates an understanding of the teaching? a. I should keep my weight within 10 percent of my ideal weight. b. I should sleep lying flat with my legs extended straight. c. I can wear heels up to 2 ½ inches in height. d. I should increase high potassium foods in my diet.

a. I should keep my weight within 10 percent of my ideal weight.

A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make? a. It is caused by the lack of production of aldosterone by the adrenal gland. b. It is caused by the lack of production of insulin by the pancreas. c. It is caused by the over production of parathormone by the parathyroid gland. d. It is caused by the over production of growth hormone by the pituitary gland.

a. It is caused by the lack of production of aldosterone by the adrenal gland.

A nurse is educating new parents about risk factors for sudden infant death syndrome (SIDS). Which of the following statements should indicate to the nurse the need for additional teaching? a. Our baby will sleep in our bed because I am breastfeeding. b. We will place my baby on her back when sleeping. c. We will give my baby a pacifier during naps and bedtime. d. We will remove blankets and toys from the crib.

a. Our baby will sleep in our bed because I am breastfeeding.

A nurse is caring for a client who is 1 day postpartum and is taking a sitz bath. To determine the client's tolerance of the procedure, which of the following assessments should the nurse perform? a. Pulse rate b. Respiratory rate c. Color of lochia d. Bladder distension

a. Pulse rate

A nurse is caring for a client who has traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? a. Restlessness b. Hypotension c. Amnesia d. Tachycardia

a. Restlessness

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). which of the following assessment by the nurse supports this suspicion? a.Restlessness b.Positive kernig's sign c.Nuchal rigidity d.Photophobia

a. Restlessness

A nurse is reviewing the PT, aPTT and INR laboratory values for a client who is experiencing an acute episode disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect? a. The laboratory values are prolonged. b. The laboratory values are within the expected reference range. c. The laboratory values are the same as the previous test values. d. The laboratory values are decreased.

a. The laboratory values are prolonged.

A nurse is observing a new mother bathing her newborn son for the first time. For which of the following actions should the nurse intervene? a. The mother plans to use a cotton tripped swab to clean the nares. b. The mother cleans the newborn's eyes from the inner canthus outwards. c. The mother cleans the umbilical cord with tap water. d. The mother leaves the yellow exudate on the circumcision site.

a. The mother plans to use a cotton tripped swab to clean the nares.

A nurse is assessing a 15-month-old toddler. Which of the following findings should the nurse report to the provider? a. The toddler cannot stand upright without support. b. The toddler cannot build a tower of six to seven cubes. c. The toddler cannot jump with both feet. d. The toddler cannot turn a doorknob.

a. The toddler cannot stand upright without support.

A nurse is providing teaching about dietary recommendations to a client who has iron deficiency anemia. Which of the following dietary recommendations should the nurse include as a food that enhances iron absorption when consumed with nonheme iron? a. Tomato juice b. Milk c. Dried beans d. Tea

a. Tomato juice

66. A nurse is teaching an older adult client who has osteoporosis about beginning a program of regular physical activity. Which of the following recommendations should the nurse make? a. Walk briskly b. High impacted aerobics c. Riding bicycle d. Stretching exercises.

a. Walk briskly

A nurse is talking with a client who is beginning a program of moderate exercise. The client asked the nurse why warm up exercises are necessary. Which of the following responses should the nurse make? a. Warm-up exercises reduce the risk of injury. b. Warm-up exercises reduce the risk for lactic acidosis. c. Warm-up exercises reduce the risk for muscle fatigue. d. Warm-up exercises reduce the risk for tachycardia.

a. Warm-up exercises reduce the risk of injury.

A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply) a. Wash the perineal area using squeeze bottle of warm water after voiding. b. Blot the perineal area dry after cleansing. c. Perform hand hygiene before and after voiding. d. Clean perineal area from front to back. e. Apply ice packs to the perineal area several times daily.

a. Wash the perineal area using squeeze bottle of warm water after voiding. b. Blot the perineal area dry after cleansing. c. Perform hand hygiene before and after voiding. d. Clean perineal area from front to back.

A nurse receives report about a client who is in labor and is having contractions 4 minutes apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? a. Contractions that last for 60 seconds each with a 4 min rest between contractions. b. Contractions that last for 60 seconds each with a 3 min rest between contractions. c. Contractions that last for 45 seconds each with a 3 min rest between contractions. d. A contraction that lasts 4 min followed by a period of relaxation.

b. Contractions that last for 60 seconds each with a 3 min rest between contractions.

A nurse is talking with young adult clients who has a family history of osteoporosis. Which health promotion activity should the nurse recommend as a possible preventive measure? a. Drink a cup of coffee each morning. b. Engage in weight-bearing exercise regularly c. Increase sodium intake. d. Have a bone density scan each year.

b. Engage in weight-bearing exercise regularly

A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1 + station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse take? a. Have the client to the bathroom to void. b. Have the client pant during the next few contractions. c. Assist the client into a comfortable position. d. Observe the perineum for signs of crowning.

b. Have the client pant during the next few contractions.

A nurse is an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report. a. Seeing bright flashes of light and floaters. b. Having a decreased ability to perceive colors. c. Loss of central vision. d. Having a loss of peripheral vision.

b. Having a decreased ability to perceive colors.

A nurse is providing teaching to a client who has stomatitis. Which of the following statements by the client indicates a need for further teaching? a. I will rinse my mouth with baking soda and water frequently. b. I will season foods with dried spices before cooking c. I will eat frozen bananas as a snack. d. I will drink liquids through a straw.

b. I will season foods with dried spices before cooking

39. A nurse in a burn treatments center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? a. This procedure involves placing the client into a shower and removing the dead tissue. b. Large incision will be made in the eschar to improve circulation. c. Dead tissue will be non-surgically removed. d. A piece of healthy skin will be removed from an unburned area and grafted over the burned area.

b. Large incision will be made in the eschar to improve circulation.

A nurse is caring for a client who is menopausal and ask the nurse about the use of herbal therapies to reduce her discomfort. Which of the following statements should the nurse make? a. Herbal therapies have no benefits and will not help your discomfort. b. Many herbal products have not undergone long-term testing for safety and efficacy c. You should begin immediately as they will help you. d. There are no ill effects associated with the use of herbal therapies.

b. Many herbal products have not undergone long-term testing for safety and efficacy

A nurse is teaching a group of clients who are in their first trimester about exercise during pregnancy. Which of the following statements should the nurse include in the teaching? a. It is recommended to rest for 30 minutes before each new exercise. b. Moderate exercise improves circulation. c. It is recommended to increase your weight-bearing exercises. d. Refrain from exercises that include stretching.

b. Moderate exercise improves circulation.

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions require intervention by the charge nurse? a. Auscultates bowel sounds for 3 to 5 min. b. Palpates the abdomen prior to performing auscultation. c. Perform auscultation between meals. d. Clamps the NG tube during auscultation.

b. Palpates the abdomen prior to performing auscultation.

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take? a. Hold the client's arms and legs from moving. b. Place the client on his side. c. Insert a tongue blade in the client's mouth. d. Place the client back in bed.

b. Place the client on his side.

A nurse is planning care for a client who has viral hepatitis. Which of the following actions should the nurse include in the plan of care? a. Administer acetaminophen for pain. b. Provide a high carbohydrate diet. c. Include high protein snack. d. Encourage eating three large meals daily.

b. Provide a high carbohydrate diet.

A nurse is caring for a client who is 1-day postoperative following a left radical mastectomy. Which of the following behaviors should the nurse to the possibility that the client is having difficulty adjusting to the loss of her breasts? a. Asking questions about the information on her postoperative care pamphlet. b. Refusing to look at dressing or surgical incision. c. Asking for pain medication every 3 hr. d. Performing arm exercise once or twice a day.

b. Refusing to look at dressing or surgical incision.

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing intervention is the highest priority? a. Monitor the client's electrolyte levels. b. Suction saliva from the client's mouth. c. Record the client's intake and output. d. Perform passive range of motion each extremity.

b. Suction saliva from the client's mouth.

A nurse is providing discharge teaching to a client who has implantable cardioverter/ defibrillator (ICD). Which of the following information should the nurse include? a. The client travel by air due to security screening. b. The client should hold his cell phone the side opposite the ICD c. The client should avoid the use of small electric devices. d. The client can carry his ICD in a small pocket.

b. The client should hold his cell phone the side opposite the ICD

A nurse is assessing a 10-month-old infant. Which of the following findings should the nurse report to the provider? a. The infant cannot build a tower or three or four cubes. b. The infant does not sit steadily without support. c. The infant is unable to imitate animal sounds. d. The infant cannot turn pages in a book.

b. The infant does not sit steadily without support.

A nurse is preparing to teach a parent how to care for a child who has impetigo contagiosa. Which of the following information should the nurse plan to include in the teaching? a. Immunize household contacts for the disease. b. Wash clothing in hot water. c. Keep the child on droplet precautions at home. d. Give the child a chlorine bath twice daily.

b. Wash clothing in hot water.

A nurse is providing nutritional teaching to a client who has osteoporosis. Which of the following foods should the nurse recommend as being the highest calcium? a. 1 cup carrot strips b. 1 plain baked potato c. 3 oz canned salmon d. 1 cup chopped chicken breast

c. 3 oz canned salmon

A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? a. A grey colored, non-purpuric popular rash. b. Pitting edema of the hands and fingers. c. A dry, red rash across the bridge of the nose and on the cheeks. d. Subcutaneous nodules on the ulnar side of the arm.

c. A dry, red rash across the bridge of the nose and on the cheeks.

A nurse is teaching a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following client food choices reflect the client's understanding of these dietary instructions? a. Eggs b. Liver c. Beans d. Milk

c. Beans

A nurse Midwife is examining a client who is primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor? a. Brownish vaginal discharge b. Amniotic fluid in the vaginal vault c. Cervical dilation d. Report of pain above the umbilicus

c. Cervical dilation

68. A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk? a. Handrails are present in the bathroom. b. Electric cords are placed along the walls. c. Scatter rugs are present in the kitchen. d. Uses a microwave for cooking. A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be including in the plan of care? a. Position the newborn to promote extension of muscles. b. Use fingertips when calming the newborn. c. Cluster the newborn's care activities. d. Keep the newborn in a well-lit nursery.

c. Cluster the newborn's care activities.

A nurse at a pediatrician's office is contacted by a parent whose child just ingested half a bottle of vitamins with added fluorosis sulfate. Which of the following instruction should the nurse provide to the parent? a. Provide a high-carbohydrate meal. b. Give the child syrup of ipecac. c. Contact the poison control center. d. Bring the child to the office for a rapid infusion of deferoxamine.

c. Contact the poison control center.

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? a. Bilateral weakness of extremities b. Tachypnea c. Decreased level of consciousness d. Hypotension

c. Decreased level of consciousness

A nurse is caring for a newborn whose mother is positive for the Hepatitis B surface antigen. Which of the following should the infant receive? a. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen. b. Hepatitis B vaccine at 24 hr followed by Hepatitis B immune globulin every 12 hr for 3 days. c. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth. d. Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months.

c. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth.

A nurse is providing discharge teaching to a client who has gastroesophageal reflux disease. Which of the following statements by the client indicates an understanding of the teaching? a. I will eat a snack just before going to bed. b. I will sleep on my left side. c. I will sleep with the head of my bed elevated. d. The type of foods I eat does not affect this condition.

c. I will sleep with the head of my bed elevated.

A nurse is teaching a group of clients about osteoarthritis. Which of the following recommendations should the nurse include in the teaching? a. Apply ice to the joint before exercising. b. Use Echinacea to manage joint pain. c. Maintain a recommended body weight d. Reduce the amount of purine in the diet.

c. Maintain a recommended body weight

A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and lightheaded. After applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the nurse take? a. Tilt the client onto her right side with her legs elevated to at least 30' b. Insert an indwelling urinary catheter. c. Massage the client's fundus to promote contractions. d. Administer oxytocin by continuous IV infusion.

c. Massage the client's fundus to promote contractions.

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort? a. Rub the client's feet briskly for several minutes. b. Place a moist heating pad under the client's feet. c. Obtain a pair of slipper socks for the client. d. Increase the client's oral fluid intake.

c. Obtain a pair of slipper socks for the client.

A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take? a. Gently restrain the client's extremities. b. Apply a face mask for oxygen administration. c. Place a pillow under the client's head. d. Insert a padded tongue blade into the client's mouth.

c. Place a pillow under the client's head.

A nurse is providing post-operative teaching with a client who had a surgical correction of hallux valgus. Which of the following information should the nurse include in the teaching? a. Expect the foot to be numb for several days postoperatively. b. Walk primarily on the heel to relive pressure on the toes. c. Rest frequently with your foot elevated. d. Expect the foot to take at least 3 weeks to heal.

c. Rest frequently with your foot elevated.

A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion? a. Would it help to discuss your feelings about this hospitalization? b. Would you tell me about all of your medical issues? c. What brought you to the hospital? d. Do you want to talk about your health concerns?

c. What brought you to the hospital?

The nurse is providing discharge teaching for a client who has chronic pancreatitis. which of the following statements should the nurse make? a. You should decrease your caloric intake when abdominal pain is present. b. You should intake fat intake when experiencing loose stools. c. You should increase your daily intake of protein. d. You should limit alcohol intake 2-3 drinks per week.

c. You should increase your daily intake of protein.

A nurse is caring for a client who is 1-day postoperative following spinal fusion. which of the following actions should the nurse take? a. Elevate the client's legs when he is sitting in a chair. b. Expect clear drainage on the spinal dressing. c. log roll the client every 2 hr. d. Assist the client to sit upright in a chair for 4 hr at a time.

c. log roll the client every 2 hr.

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client? a. Perform vaginal examinations frequently. b. Remind the client to bear down with each contraction. c. Maintain the client in the lithotomy position. d. Encourage the client to empty her bladder every 2 hr.

d. Encourage the client to empty her bladder every 2 hr.

A nurse is reinforcing teaching about food choices with the mother of an 8-month-old infant. Which of the following statements by the mother indicates a need for further teaching? a. I will give my child applesauce and green peas. b. I will give my child pureed liver and strained peas. c. I will give my child rice cereal and crackers. d. I will give my child strained carrots and mashed egg yolks.

d. I will give my child strained carrots and mashed egg yolks.

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns? a. Cause of the burn b. Age of the client c. Associated medical history d. Location of the burn

d. Location of the burn

A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize when the client a. Display compulsive and ritualistic behaviors. b. Reminisces about the past. c. Refuses to leave home to see a provider. d. Makes up stories when he is unable to remember actual events.

d. Makes up stories when he is unable to remember actual events.

A nurse is caring for a client who is receiving peritoneal dialysis. the nurse should monitor the client for which of the following manifestations of peritonitis? a. Bradycardia. b. Increased urinary output. c. Hyperactive bowel sounds. d. Nausea and vomiting.

d. Nausea and vomiting.

A nurse is caring for a client whose throat culture is positive for a group A streptococcus 24 hr after rapid strep test (RST) was negative. Which of the following actions is the nurse's priority? a. Instruct the client to take antipyretics as directed for elevated temperature. b. Ask the client to identify friends and family who have been in close contact. c. Reinforce teaching about gargling with warm saline several times daily. d. Notify the client to return to the clinic for initiation of antibiotic therapy.

d. Notify the client to return to the clinic for initiation of antibiotic therapy.

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? a. Administer a nitrate antihypertensive. b. Obtain the client's heart rate. c. Assess the client for bladder distension. d. Place the client in a high Fowler's position.

d. Place the client in a high Fowler's position.

A nurse is providing teaching to the parent of a toddler about appropriate snacks. Which of the following foods should the nurse include? a. Peanut butter b. Raw celery c. Grapes d. Sliced bananas

d. Sliced bananas

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support? a. Keep family members aware of his condition. b. Rotate nursing staff so he can have varied interactions. c. Assign assistive personnel to keep his room neat and clean. d. Talk with the client during wound care.

d. Talk with the client during wound care.

A nurse is preparing to administer a vaccine to a 4-year-old child. Which of the following vaccines should the nurse administer? a. Hepatitis B (HepB) b. Hemophilus influenza type b (HibB) c. Meningococcal (MCV4) d. Varicella (VAR)

d. Varicella (VAR)

A nurse is assisting an older adult client who is sedentary plan a new exercise regimen. Which of the following activities should the nurse recommend? a. Jumping rope b. Tennis c. Running d. Walking

d. Walking

A nurse is providing teaching to the parents of a newborn. Which of the following information should the nurse include? a. Your baby should receive the pneumococcal conjugate vaccine on his first birth. b. Your baby will receive the first diphtheria, tetanus, pertussis vaccine at the 2-week well-baby visit. c. Your baby should receive the measles, mumps, rubella vaccine at 6 months. d. Your baby should receive a hepatitis B vaccine prior to discharge.

d. Your baby should receive a hepatitis B vaccine prior to discharge.