N117 Section 1 Exam NCLEX Practice Questions

A nurse is performing an admission assessment on a client. The nurse determine's the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?

16/min The pulse deficit is the difference between the apical and radial pulse rates. It reflects the number of ineffective or nonperfusing heartbeats that do not transmit pulsations to the peripheral pulse points. 84/min - 68/min = 16/min

A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate her body mass index (BMI) and determine whether this client's BMI indicates that she is of a healthy weight, overweight, or obese.

BMI = weight (kg) divided by height (meters squared) BMI = 80 kg divided by (1.6 m x 1.6 m) BMI = 31.25 BMI greater than 30 is considered obese.

A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client? a. "Do not measure the client's temperature rectally." b. "Count the client's radial pulse for 30 seconds and multiply it by 2." c. "Do not let the client know you are counting her respirations." d. "Let the client rest for 5 minutes before you measure her blood pressure."

a. "Do not measure the client's temperature rectally." The greatest risk to a client who has a low platelet count is an injury that results in bleeding. Using a thermometer rectally poses a risk of injury to the rectal mucosa. The low platelet count contraindicates the use of the rectal route for this client.

A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include? a. "Flush the tube before and after each medication." b. "Mix your medications with your enteral feeding." c. "Push tablets through the tube slowly." d. "Mix all the crushed medications prior to dissolving them in water."

a. "Flush the tube before and after each medication." The client should flush the tubing before and after each medication with 15 to 30 mL water to prevent clogging of the tube.

A nurse is performing dietary needs assessments for a group of clients. A blenderized liquid diet is appropriate for which of the following clients? (Select all that apply.) a. A client who has a wired jaw due to a motor vehicle crash. b. A client who is 24 hr postoperative following a temporomandibular joint repair c. A client who has difficulty chewing due to oral surgery. d. A client who has hypercholesterolemia due to coronary artery disease e. A client who is scheduled for a colonoscopy the next morning

a. A client who has a wired jaw due to a motor vehicle crash. b. A client who is 24 hr postoperative following a temporomandibular joint repair c. A client who has difficulty chewing due to oral surgery. A blenderized liquid diet is appropriate for a client who has a wired jaw. A blenderized liquid diet is appropriate for a client following oral surgery. A blenderized liquid diet is appropriate for a client who has difficulty chewing.

A nurse in a provider's office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) a. Capillary refill less than 3 seconds b. 1+ pitting edema in both feet c. Pale nail beds in both hands d. Thick skin on the soles of the feet. e. Numerous light brown macules on the face.

a. Capillary refill less than 3 seconds d. Thick skin on the soles of the feet. e. Numerous light brown macules on the face. The nurse should expect capillary refill in less than 3 seconds as an expected finding. The nurse should expect thicker skin the palms of the hands and the soles of the client's feet. The nurse should expect light brown macules on the face, such as freckles.

A nurse is planning care for an older adult client who is receiving treatment for malnutrition. The client is scheduled for discharge to his home where he lives lone. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) a. Consult social services to arrange home meal delivery. b. Encourage the client to purchase nonperishable boxed meals. c. Advise the client to purchase frozen fruits and vegetables. d. Recommend drinking a supplement between meals. e. Educate the client on how to read nutrition labels.

a. Consult social services to arrange home meal delivery. c. Advise the client to purchase frozen fruits and vegetables. d. Recommend drinking a supplement between meals. e. Educate the client on how to read nutrition labels. The nurse should consult social services to arrange home meal delivery to promote adequate nutrition. The nurse should advise the client to purchase frozen fruits and vegetables to promote adequate nutrition. The nurse should recommend a supplement between meals to promote adequate nutrition. The nurse should educate the client on how to read food labels to promote adequate nutrition.

A nurse is caring for a client who has hypothyroidism. Which of the following is associated with this disorder? a. Decreased metabolic demand b. Weight loss c. Increased heart rate d. Diarrhea

a. Decreased metabolic demand A decreased metabolic demand is associated with hypothyroidism.

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? a. Encourage the client to perform anti embolic exercises every 2 hr. b. Instruct the client to cough and deep breathe every 4 hr. c. Restrict the client's fluid intake. d. Reposition the client every 4 hr.

a. Encourage the client to perform anti embolic exercises every 2 hr. The nurse should encourage the client to perform anti embolic exercises every 1 to 2 hr to promote venous return and reduce the risk of thrombus formation.

A nurse is beginning to complete a bed bath for a client. After removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first? a. Face b. Feet c. Chest d. Arms

a. Face The greatest risk to a client during bathing is the transmission of pathogens from one area of the body to another. The nurse should begin with the cleanest area of the body and proceed to the least clean area. The face is generally the cleanest area, and washing it first follows a systematic head-to-toe approach to client care.

A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.) a. Hold the cane on the right side. b. Keep two points of support on the floor. c. Place the cane 38 cm (15 in) in front of the feet before advancing. d. After advancing the cane, move the weaker leg forward. e. Advance the stronger leg so that it aligns evenly with the cane.

a. Hold the cane on the right side. b. Keep two points of support on the floor. d. After advancing the cane, move the weaker leg forward. The client should hold the cane on the uninjured side to provide support for the injured left leg. The client should keep two points of support on the ground at all times for stability. The client should advance the weaker leg first, followed by the stronger leg.

A school nurse is teaching a high school health class about the possible causes of a negative nitrogen balance. Which of the following causes should the nurse include in the teaching? a. Illness b. Malnutrition c. Adolescence d. Trauma e. Pregnancy

a. Illness b. Malnutrition d. Trauma Illness is a possible cause of negative nitrogen balance. Malnutrition is a possible cause of negative nitrogen balance. Trauma is a possible cause of negative nitrogen balance.

A nurse is teaching a group of women about risk factors for developing osteoporosis. Which of the following risk factors should the nurse include? (Select all that apply.) a. Inactivity b. Family history c. Obesity d. Hyperlipidemia e. Cigarette smoking

a. Inactivity b. Family history e. Cigarette smoking There is an increased risk for osteoporosis due to inactivity. Weight-bearing exercises is a primary prevention measure. A family history of osteoporosis is a risk factor. Cigarette smoking can increase the incidence of osteoporosis.

A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply.) a. Inspect the feet daily. b. Use moisturizing lotion on the feet. c. Wash the feet with warm water and let them air dry. d. Use over-the-counter products to treat abrasions. e. Wear cotton socks.

a. Inspect the feet daily. b. Use moisturizing lotion on the feet. e. Wear cotton socks. Clients who have diabetes mellitus are at increased risk for infection and diminished sensitivity in the feet, so they should inspect them daily. The client should use moisturizing lotions (but not between the toes) to help keep the skin smooth and supple. The client should wear clean cotton socks each day.

A charge nurse is conducting a nutritional class for a group of newly licensed nurses regarding basal metabolic rate (BMR). The charge nurse should inform the class that which of the following factors increases BMR? (Select all that apply.) a. Lactation b. Prolonged stress c. Malnutrition d. Puberty e. Age older than 60 years

a. Lactation b. Prolonged stress d. Puberty The charge nurse should include in the teaching that lactation increases BMR. The charge nurse should include in the teaching that prolonged stress increases BMR. The nurse should include in the teaching that puberty increases BMR.

A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3°C (101°F), pulse rate 114/min, and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (Select all that apply.) a. Obtain culture specimens before initiating antimicrobials. b. Restrict the client's oral fluid intake. c. Encourage the client to rest and limit activity. d. Allow the client to shiver and dispel excess heat. e. Assess the client with oral hygiene frequently.

a. Obtain culture specimens before initiating antimicrobials. c. Encourage the client to rest and limit activity. e. Assess the client with oral hygiene frequently. The provider can prescribe cultures to identify any infectious organisms causing the fever. The nurse should obtain culture specimens before antimicrobial therapy to prevent interference with the detection of the infection. Rest helps conserve energy and decreases metabolic rate. Activity can increase heat production. Oral hygiene helps prevent cracking of dry mucous membranes of the mouth and lips.

A nurse in a senior center is counseling a group of older adults about their nutritional needs & considerations. Which of the following information should the nurse include? (Select all that apply.) a. Older adults are more prone to dehydration than younger adults are b. Older adults need the same amount of most vitamins & minerals as younger adults do c. Many older men & women need calcium supplementation d. Older adults need more calories than they did when they were younger e. Older adults should consume a diet low in carbs

a. Older adults are more prone to dehydration than younger adults are b. Older adults need the same amount of most vitamins & minerals as younger adults do c. Many older men & women need calcium supplementation Sensations of thirst diminish with age, leaving older adults more prone to dehydration. These requirements do not change from middle adulthood to older adulthood. If older adults ingest insufficient calcium in the diet, they need supplements to help prevent bone demineralization (osteoporosis).

A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply.) a. Place the client in semi-Fowler's position. b. Have the client rest an arm across the abdomen. c. Observe one full respiratory cycle before counting the rate. d. Count the rate for 30 sec if it is irregular. e. Count and report any sighs the client demonstrates.

a. Place the client in semi-Fowler's position. b. Have the client rest an arm across the abdomen. c. Observe one full respiratory cycle before counting the rate. Having the client sit upright facilitates full ventilation and gives the students a clear view of chest and abdominal movements. With the client's arm across the abdomen or lower chest, it is easier for the students to see respiratory movements. Observing for one full respiratory cycle before starting to count assists the students in obtaining an accurate count.

A nurse is performing a nutritional assessment on a client. Which of the following clinical findings are suggestive of malnutrition? a. Poor wound healing b. Dry hair c. Blood pressure 130/80 mmHg d. Weak hand grips e. Impaired coordination

a. Poor wound healing b. Dry hair d. Weak hand grips e. Impaired coordination Poor wound healing describes changes reflective of malnutrition. Dry hair describes changes reflective of malnutrition. Weak hand grips describe changes reflective of malnutrition. Impaired coordination describes changes reflective of malnutrition.

A nurse is conducting a nutrition class to a group of women at a local community center. Which of the following information should the nurse include in the teaching? a. Progress toward limited saturated fat to 7% of total daily intake. b. Good bowel function requires 35 g/day of fiber for women. c. Limit cholesterol consumption to 400 mg/day. d. Normal functioning cardiac systems depends on B-complex vitamins.

a. Progress toward limited saturated fat to 7% of total daily intake. The nurse should include for the client's to progress toward limiting saturated fat to 7% of total daily intake.

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply.) a. Request assistance when repositioning a client. b. Avoid twisting your spine or bending at the waist c. Keep your knees slightly lower than your hips when sitting for long periods of time. d. Use smooth movements when lifting and moving clients. e. Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles.

a. Request assistance when repositioning a client. b. Avoid twisting your spine or bending at the waist d. Use smooth movements when lifting and moving clients. To reduce the risk of injury, at least two staff members should reposition clients. Twisting the spine or bending at the waist (flexion) increases the risk for injury. Using smooth movements instead of sudden or jerky muscle movements help prevent injury.

A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following actions should the nurse include in the client's plan of care? a. Schedule rest periods during morning care. b. Discontinue morning care for 2 days. c. Perform all care as quickly as possible. d. Ask a family member to come in to bathe the client.

a. Schedule rest periods during morning care. Planning for rest periods during morning care will help prevent fatigue and continue to foster independence.

A school nurse is teaching a group of students how to read food labels. Which of the following is a required component of food labels that the nurse should include in the teaching? (Select all that apply.) a. Total carbohydrates b. Total fat c. Calories d. Magnesium e. Dietary fiber

a. Total carbohydrates b. Total fat c. Calories e. Dietary fiber The FDA requires certain information be included with packaged foods and beverages. Total carbohydrates are included on food labels. Food labels must include single serving size, number of servings in the package, percent of daily values, and the amount of each nutrient in one serving. Total fat is included on food labels. Calories are included on food labels. Dietary fiber is included on food labels.

A nurse is performing oral care for a client who is unconscious. Which of the following actions should the nurse take? a. Turn the client's head to the side. b. Place two fingers in the client's mouth to open. c. Brush the client's teeth once per day. d. Inject a mouth rinse into the center of the client's mouth.

a. Turn the client's head to the side. The nurse should position the client's head on the side, unless contraindicated, to reduce the risk of aspiration.

A nurse is providing teaching to a client who follows vegan dietary practices. The nurse should instruct the client to ensure he is consuming enough of which of the following nutrients? (Select all that apply.) a. Vitamin D b. Fiber c. Calcium d. Vitamin B12 e. Whole grains

a. Vitamin D c. Calcium d. Vitamin B12 The nurse should instruct the client to ensure he is consuming adequate Vitamin D because most dietary Vitamin D is consumed via fortified milk products. The vegan diet includes plant foods, and excludes all animal-derived products. The nurse should instruct the client to ensure he is consuming adequate calcium because there are few good sources of calcium from plant sources. The vegan diet excludes all animal-derived products. The nurse should instruct the client to ensure he is consuming adequate Vitamin B12 because all reliable sources of Vitamin B12 are in animal products. The vegan diet excludes all animal-derived products.

A nurse educator is teaching a class on culture and food to a group of newly hired nurses. Which of the following statements by a nurse indicates an understanding of the teaching? a. "Clients who practice Roman Catholicism do not drink caffeinated beverages." b. "Clients who practice Orthodox Judaism do not eat meat with daily products." c. "Clients who are Mormon eat only the protein of animals that are slaughtered under strict guidelines." d. "Clients who practice Hinduism do not eat dairy products."

b. "Clients who practice Orthodox Judaism do not eat meat with daily products." Clients who practice Orthodox Judaism do not eat meat with daily products.

A nurse is providing teaching for a client who has a new diagnosis of hypertension and a prescription for a low-sodium diet. Which of the following client statements indicate an understanding of the teaching? (Select all that apply.) a. "I should select organic canned vegetables." b. "I need to read food labels when grocery shopping." c. "I will stop eating frozen dinners for lunch at work." d. "I know that deli meats are usually high in sodium." e. "I can refer to the American Heart Association's website for dietary guidelines."

b. "I need to read food labels when grocery shopping." c. "I will stop eating frozen dinners for lunch at work." d. "I know that deli meats are usually high in sodium." e. "I can refer to the American Heart Association's website for dietary guidelines." Reading food labels provides the client with information about the food's sodium content. Frozen dinners are usually high in sodium and are therefore a poor choice for a client on a sodium-restricted diet. Deli meats are usually high in sodium and are therefore a poor choice for a client on a sodium-restricted diet. The American Heart Association is a recommended health association for continued client education on dietary guidelines related to cardiac disorders such as hypertension.

A nurse is teaching an adult client how to administer ear drops. Which of the following statements should the nurse identify as an indication that client understands the proper technique? a. "I will straighten my ear canal by pulling my ear down and back." b. "I will gently apply pressure withe my finger to the front part of my ear after putting in the drops. c. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in." d. "After the drops are in, I will place a cotton ball all the way into my ear canal."

b. "I will gently apply pressure withe my finger to the front part of my ear after putting in the drops. The client should gently apply pressure with the finger to the trigs of the ear after administering the drops to help the drops go into the ear canal.

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching. (Select all that apply.) a. "My line of gravity should fall outside my base of support." b. "The lower my center of gravity, the more stability I have." c. "To broaden my base of support, I should spread my feet apart." d. "When I lift an object, I should hold it as close to my body as possible." e. "When pulling an object, I should move my front foot forward."

b. "The lower my center of gravity, the more stability I have." c. "To broaden my base of support, I should spread my feet apart." d. "When I lift an object, I should hold it as close to my body as possible." Being closer to the ground lowers the center of gravity, which leads to greater stability and balance. Spreading the feet apart increases and widens the base of support. Holding an object as close to the body as possible helps avoid displacement of the center of gravity and thus prevent injury and instability.

A nurse is evaluating teaching on a client who has a new prescription for a sequential compression device. Which of the following client statements should indicate to the nurse the client understands the teaching? a. "This device will keep me from getting sores on my skin." b. "This thing will keep the blood pumping through my leg." c. "With this thing on, my leg muscles won't get weak." d. "This device is going to keep my joints in good shape."

b. "This thing will keep the blood pumping through my leg." Sequential pressure devices promote venous return in the deep veins of the legs and thus help prevent thrombus formation.

A nurse is educating a client who is taking iron supplements about foods which aid in iron absorption. Which of the following foods is the best choice for the client to make? a. 1 baked potato b. 1/2 cup orange juice c. 1/2 cup low-fat milk d. 2 cups boiled green beans

b. 1/2 cup orange juice Vitamin C aids in the absorption of iron, and 1/2 cup orange juice has 62 mg of vitamin C. This is the best food choice for the client to make.

A nurse is caring for several clients in an extended care facility. Which of the following clients is the highest priority to observe during meals? a. A client who has decreased vision b. A client who has Parkinson's disease c. A client who has poor dentition d. A client who has anorexia

b. A client who has Parkinson's disease A client who has Parkinson's disease is at risk for aspiration. Due to this safety risk, this client is the highest priority to observe during meals.

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? a. Instruct the client not to perform the Vasalva maneuver. b. Apply elastic stockings. c. Review laboratory values for total protein level. d. Place pillows under the client's knees and lower extremities. e. Assist the client to change position often.

b. Apply elastic stockings. e. Assist the client to change position often. Elastic stockings promote venous return and prevent thrombus formation. Frequent position changes prevents venous stasis.

A nurse who is admitting a client who has a fractured femur obtains a blood pressure reading of 140/94 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first? a. Request a prescription for an antihypertensive medication. b. Ask the client if she is having pain. c. Request a prescription for an antianxiety medication. d. Return in 30 min to recheck the client's blood pressure.

b. Ask the client if she is having pain. The first action the nurse should take using the nursing process is to assess the client for pain which can cause multiple complications, including elevated blood pressure. Therefore, the nurses's priority is to perform a pain assessment. If the client's blood pressure is still elevated after pain interventions, the nurse should report this finding to the provider.

A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? a. Pull down and out at the back of the upper denture to remove. b. Brush the dentures with a toothbrush and denture cleaner. c. Rinse the dentures with hot water after cleaning them. d. Place the dentures in a clean, dry storage container after cleaning them.

b. Brush the dentures with a toothbrush and denture cleaner. Brushing the dentures thoroughly with a toothbrush and denture cleaner removes debris that accumulates on and between the teeth.

A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? a. Pallor b. Cyanosis c. Jaundice d. Erythema

b. Cyanosis The priority finding when using the airway, breathing, circulation (ABC) approach to care is cyanosis, which an indication of hypoxia (inadequate oxygenation). Therefore, the nurse should immediately report this finding to the provider.

A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? a. Macaroni and cheese b. Fresh fruit and whole wheat toast. c. Bread pudding and yogurt d. Roast chicken and white rice

b. Fresh fruit and whole wheat toast. A high fiber diet promotes normal bowel elimination. The nurse should recommend the client consume fresh fruits and vegetables with whole grain carbohydrates to provide the highest fiber option.

A nurse is assisting a client who has a prescription for a mechanical soft diet with food selections. Which of the following are appropriate selections by the client? (Select all that apply.) a. Dried prunes b. Ground turkey c. Mashed carrots d. Fresh strawberries e. Cottage cheese

b. Ground turkey c. Mashed carrots e. Cottage cheese Ground meats require minimal chewing before swallowing and are therefore appropriate for a mechanical soft diet. Mashed carrots require minimal chewing before swallowing and are therefore appropriate for a mechanical soft diet. Cottage cheese requires minimal chewing before swallowing and is therefore appropriate for a mechanical soft diet.

A nurse is caring for a client who has had diarrhea for 4 days. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.) a. Bradycardia b. Hypotension c. Elevated temperature d. Poor skin turgor e. Peripheral edema

b. Hypotension c. Elevated temperature d. Poor skin turgor Prolonged diarrhea leads to dehydration. The nurse should expect the client to have a decrease in blood pressure. Prolonged diarrhea leads to dehydration. The nurse should expect the client to have an increased temperature. Prolonged diarrhea leads to dehydration. The nurse should expect the client to have poor skin turgor.

A young adult client in a provider's office tells the nurse that she uses fasting for several days each week to help control her weight. The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that results from fasting puts her at risk for medication toxicity? a. Increasing the metabolism of the medications over time b. Increasing the protein-binding response c. Increasing medications' transit time through the intestines d. Decreasing the excretion of medications

b. Increasing the protein-binding response Inadequate nutrition, such as starvation, can affect the protein-binding response of medications. It increases their response and thus increases the risk for medication toxicity.

A nurse is caring for a client who is at risk for aspiration. Which of the following actions should the nurse take? a. Give the client thin liquids. b. Instruct the client to tuck her chin when swallowing. c. Have the client use a straw. d. Encourage the client to lie down and rest after meals.

b. Instruct the client to tuck her chin when swallowing. Tucking the chin when swallowing allows food to pass down the esophagus more easily.

A nurse is assessing an older adult client who has significant tenting of the skin over his forearm. Which of the following factors should the nurse consider as a cause for this finding? (Select all that apply.) a. Thin, parchment-like skin b. Loss of adipose tissue c. Dehydration d. Diminished skin elasticity e. Excessive wrinkling

b. Loss of adipose tissue c. Dehydration d. Diminished skin elasticity Tenting is a delay in the skin returning to its normal place after pinching. Tenting is a manifestation of aging skin and loss of subcutaneous tissue that provides recoil in younger skin. Tenting is a delay in the skin returning to its normal place after pinching. Dehydration can cause the skin to tent, which can easily develop in the older adult client. Tenting is a delay in the skin returning to its normal place after pinching. Tenting in the older adult client is a manifestation of aging skin and loss of elasticity.

A nurse on an orthopedic unit is reviewing data for a client who sustained trauma in a motor-vehicle crash. Which of the following values indicates the client is in a catabolic state (using protein faster than protein is being synthesized)? a. Serum albumin 3.5 g/dL b. Negative nitrogen balance c. BMI of 18.5 d. Serum prealbumin 15 mg/dL

b. Negative nitrogen balance A negative nitrogen balance indicates protein is used at a greater rate than it is synthesized as in starvation or a catabolic state following injury or disease.

To promote adherence with medication self‑administration, a nurse is making recommendations for an older adult client. Which of the following instructions should the nurse include? (Select all that apply.) a. Adjust dosages according to daily weight. b. Place pills in daily pill holders. c. Ask for liquid forms if the client has difficulty swallowing pills. d. Ask a relative to assist periodically. e. Request child‑resistant caps on medication containers.

b. Place pills in daily pill holders. c. Ask for liquid forms if the client has difficulty swallowing pills. d. Ask a relative to assist periodically. Organizing medications in daily pill holders promotes medication adherence. Providing a form of medication that is easier for the client to swallow promotes medication adherence. Including the client's support system promotes medication adherence.

A nurse is caring for a client who is to receive a Level 2 dysphagia diet due to a recent stroke. Which of the following dietary selections is most appropriate? a. Turkey sandwich b. Poached eggs c. Peanut butter crackers d. Granola

b. Poached eggs A Level 2 diet requires foods that moist and semi-solid, such as a poached egg.

A nurse is discussing health problems associated with nutrient deficiencies with a group of adolescents. The nurse should include that which of the following conditions is associated with a deficiency of vitamin C. a. Dysrhythmias b. Scurvy c. Pernicious anemia d. Megaloblastic anemia

b. Scurvy Scurvy is associated with vitamin C deficiency

A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take? a. Use a 22-gauge needle. b. Select a site on the client's abdomen. c. Spread the skin with the thumb and index finger. d. Observe for bleb formation to confirm proper placement.

b. Select a site on the client's abdomen. For a subcutaneous injection, the nurse should select a site that has an adequate fat-pad size (abdomen, upper hips, lateral upper arms, thighs).

A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? a. Supine b. Semi-Fowler's c. Semi-prone d. Trendelenburg

b. Semi-Fowler's In the semi-Fowler's position, the client lies supine with head of the bed elevated 15° to 45° (typically 30°). This position helps prevent regurgitation and aspiration by clients who have difficulty swallowing. This is the safest position for clients receiving enteral tube feedings.

A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should include which of the following? (Select all that apply.) a. Range of motion b. Skin color c. Edema d. Skin lesions e. Skin temperature

b. Skin color c. Edema e. Skin temperature The nurse should assess the peripheral vascular system to verify adequate circulation to the client's legs, which includes skin color. Pallor and cyanosis reflect inadequate circulation. The nurse should assess the peripheral vascular system to verify adequate circulation to the client's legs, which includes edema. Edema reflects inadequate venous circulation. The nurse should assess the peripheral vascular system to verify adequate circulation to the client's legs, which includes skin temperature. Coolness of the extremity compared with the nonoperative extremity indicates inadequate circulation.

A nurse is caring for a client who has multiple sclerosis and requires liquids with honey-like thickness. Which of the following foods can the client consume without adding a thickening agent? a. Ice cream b. Yogurt c. Buttermilk d. Cream of chicken soup

b. Yogurt The nurse should identify yogurt as a honey-like liquid, because it can be eaten with a spoon but not sipped with a straw. This client can also safely receive spoon-thick liquids.

A nurse is planning care for a client who has mechanical fixation of the jaw following a motorcycle crash. Which of the following actions should the nurse include in the plan of care. (Select all that apply.) a. Thicken liquids to honey consistency. b. Educate the client about the use of a nasogastric tube. c. Assist the client to use a straw to drink liquids. d. Ensure that the client receives ground meats. e. Encourage intake of fluids between meals.

c. Assist the client to use a straw to drink liquids. e. Encourage intake of fluids between meals. The nurse should recommend the use of a straw to drink liquids. The nurse should help the client determine where to insert the straw through the space between the jaws. The client who has a mechanical fixation of the jaw will have the jaws wired shut and is only able to consume liquids. The nurse should encourage supplemental and nutrient-rich liquids to maintain adequate hydration and nutrition.

A nurse in a nutritional clinic is calculating body mass index (BMI) for several clients. Which of the following BMI represents an overweight client? a. BMI of 24 b. BMI of 30 c. BMI of 27 d. BMI of 32

c. BMI of 27 Overweight is defined as an increased body weight in relation to height, indicated by a BMI of 25 to 29.9.

A nurse is caring for a client who is transitioning to an oral diet following a partial laryngectomy. Which of the following actions should the nurse take to reduce the client's risk for aspiration? a. Requires to have the client's oral medications provided in liquid form. b. Instruct the client to follow each bite of food with a drink of water. c. Encourage the client to tuck the chin when swallowing. d. Consult with the dietician about providing the client with a thin liquid diet.

c. Encourage the client to tuck the chin when swallowing. Tucking the chin when swallowing helps to close off the trachea and reduces the risk for aspiration.

A nurse is caring for a client who is 1 day postoperative following a total knee arthroplasty. The client states his pain level is 10 on a scale of 0 to 10. After reviewing the client's medication administration record, which of the following medications should the nurse administer? a. Meperidine 75 mg IM b. Fentanyl 50 mcg/hr transdermal patch c. Morphine 2 mg IV d. Oxycodone 10 mg PO

c. Morphine 2 mg IV The nurse should administer IV morphine because the onset is rapid, and absorption of the medication into the blood is immediate, which provides the optional response for a client who is reporting pain at a level of 10.

A nurse is caring for an Asian client who has hypertension. Which of the traditional Asian dietary patterns places the client at risk for this condition? a. Incorporation of plant based foods in the diet b. Consumption of raw fruits c. Preparation of foods using sodium d. Focus on shellfish in the diet

c. Preparation of foods using sodium The preparation of foods using sodium places the client at risk for hypertension. Many spices in the Asian diet contain sodium, or it is used as a preservative. The client should reduce sodium consumption.

A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? a. Decreased subcutaneous fat. b. Muscle atrophy c. Pressure ulcer d. Fecal impaction

c. Pressure ulcer The greatest risk to this client is injury from skin breakdown due to unrelieved pressure over a bony prominence from prolonged sitting in a chair. The nurse should instruct the client to shift his weight every 15 min and reposition the client after 1 hr.

A nurse is assisting a client with selecting food choices on a menu. Which of the following actions by the nurse demonstrates ethnocentricity? a. Asking the client what he likes to eat b. Notifying the dietitian to complete the menu c. Recommending one's own favorite foods d. Asking the client's family to fill out the menu

c. Recommending one's own favorite foods Recommending one's own favorite foods is an example of ethnocentrism, which is the belief that one's own cultural practices are the only correct behaviors/beliefs.

A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night? a. Lie on her back with her head and shoulder on a pillow. b. Lie flat on her stomach with her head to one side. c. Sit on the side of her bed and rest her arms over pillows on top of her bedside table. d. Lie on her side with her weight on her hip and shoulder with her arm flexed in front of her.

c. Sit on the side of her bed and rest her arms over pillows on top of her bedside table. The client is describing the orthopneic position. This position allows for chest expansion and is especially beneficial for clients who have COPD.

A nurse is teaching a client who is lactating about taking medications. Which of the following actions should the nurse recommend to minimize in the entry of medication into breast milk? a. Drink 8 oz of milk with each dose of medication. b. Use medications that have an extended half-life. c. Take each dose right after breastfeeding. d. Pump breast milk and freeze it prior to feeding to the newborn.

c. Take each dose right after breastfeeding. Taking medication immediately after breastfeeding helps minimize medication concentration in the next feeding

A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? a. Cooked barley b. Pureed broccoli c. Vanilla custard d. Lentil soup

c. Vanilla custard A low-residue diet consists of foods that are low in fiber and easy to digest. Dairy products and eggs, such as custard and yogurt, are appropriate for a low-residue diet.

A nurse is teaching a client about taking multiple oral medications at home to include time-release capsules, liquid medications, enteric-coated pills, and opioids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I can open the capsule with the beads in it and sprinkle them into my oatmeal." b. "If I am having difficulty swallowing, I will add the liquid medication to a batch of pudding." c. "I can crush the pills with the coating on them.: d. "I will eat two crackers with the pain pills."

d. "I will eat two crackers with the pain pills." The client should take irritating medications, such as analgesics, with small amounts of food. It can help prevent nausea and vomiting.

A nurse in an outpatient clinic is teaching a client who is in her first trimester of pregnancy. Which of the following statements should the nurse make? a. "You will need to get a rubella immunization if you haven't had one prior to pregnancy." b. "You can safely take over-the-counter medications." c. "You should avoid any vitamin preparations containing iron." d. "Your provider can prescribe medication for nausea if you need it."

d. "Your provider can prescribe medication for nausea if you need it." Providers can prescribe medications to treat nausea and other discomforts of pregnancy.

A nurse is discussing foods that are high in vitamin D with a client who is unable to be out in the sunlight. Which of the following should be included in the teaching? a. 1 cup steamed long-grain brown rice b. 6 medium raw strawberries c. 1/2 cup boiled Brussels sprouts d. 2 large, poached eggs

d. 2 large, poached eggs The nurse should include eggs as a food that is high in vitamin D.

A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? a. Fat b. Protein c. Glycogen d. Carbohydrates

d. Carbohydrates Carbohydrates are the body's greatest energy source; providing energy for cells is their primary function. They provide glucose, which burns completely and efficiently without end products to excrete. They are also a ready source of energy, and they spare proteins from depletion.

A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? a. Obtain a walker for the client to use to transfer back to bed. b. Call for additional staff to assist with the transfer. c. Use a transfer belt and assist the client back to bed. d. Determine the client's ability to help with the transfer.

d. Determine the client's ability to help with the transfer. The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should determine the client's ability to help with transfers and then proceed with a safe transfer.

A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles? (Select all that apply.) a. Acne b. Warts c. Psoriasis d. Herpes simplex e. Varicella

d. Herpes simplex e. Varicella Herpes simplex lesions are vesicles, which are circumscribed fluid-filled skin elevations. Eczema and impetigo also cause vesicles to appear on the skin. Varicella (chickenpox) lesions are vesicles, which are circumscribed fluid-filled skin elevations. Eczema and impetigo also cause vesicles to appear on the skin.

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? a. Have the client hold his breath briefly and bear down. b. Discontinue the fluid instillation. c. Remind the client that cramping is common at this time. d. Lower the enema fluid container.

d. Lower the enema fluid container. To relieve the client's discomfort, the nurse should slow the rate of instillation by reducing the height of the enema solution container.

A nurse is caring for a client who will perform a fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client? a. Eating more protein is optimal prior to testing. b. One stool specimen is sufficient for testing. c. A red color change indicates a positive test. d. The specimen cannot be contaminated with urine.

d. The specimen cannot be contaminated with urine. For fecal occult blood testing, the nurse should warn the client not to contaminate the stool specimens with water or urine.

A nurse is caring for a client who is prescribed warfarin. The nurse should teach the client that which of the following vitamins can interfere with this medication? a. Vitamin A b. Vitamin D c. Vitamin E d. Vitamin K

d. Vitamin K Vitamin K assists in blood clotting, is used as an antidote for excess anticoagulants, and can interfere with warfarin. The nurse should instruct the client to avoid increasing sources of vitamin K through supplements or in the diet.

A nurse is caring for a client who follows a vegan diet. Which of the following foods should the nurse offer the client? a. Bagel with cream cheese b. Fried egg c. Fruit with yogurt d. Wheat toast with peanut butter

d. Wheat toast with peanut butter A client who follows a vegan diet does not eat animal products. Peanut butter and wheat bread are plant-based.

A nurse is caring for a client following an appendectomy. The nurse verifies the postoperative prescription, which reads "discontinue NPO status; advance diet as tolerated." Which of the following are appropriate for the nurse to offer the client? a. Applesauce b. Chicken broth c. Sherbet d. Wheat toast e. Cranberry juice

e. Cranberry juice Cranberry juice is a clear liquid, which is appropriate as an initial selection for a client who is postoperative.