NCLEX

The nurse reviews a client's laboratory report and notes that the client's serum phosphate is 1.8 mg/dl. Which condition is most likely to cause the serum phosphate level? 1. Malnutrition 2. Renal insufficiency 3. Hypoparathyroidism 4. Tumor lysis syndrome

1 Hypophosphatemia can be cause by malnutrition, starvation, and the use of aluminum hydroxide-based or magnesium antacids

Under the supervision of the registered nurse, a student nurse changes the dressing of the client with a newly inserted peritoneal dialysis catheter. In which order does the RN expect the student to perform this procedure? *Think aseptic technique

1) First Use clean gloves to remove old dressing to protect nurse. 2) Second Prepare the cotton swabs with providone-iodine. 3) Third Use circular motion going from center to outside area; clean to dirty. 4) Fourth Apply dressing to area. 5) Last Tape dressing in place.

The nurse recognizes which symptoms are early signs of lithium toxicity? Select all that apply. 1. Fine motor tremors. 2. Involuntary muscle movements. 3. Seizures. 4. Nausea and vomiting. 5. Orthostatic hypotension. 6. Diarrhea

1. A symptom of toxicity. 4. An early symptom. 6. An early symptom.

The client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which assessment findings for this client? (Select all that apply.) 1. Hypotension. 2. Low back pain. 3. Wet breath sounds. 4. Fever.5. Urticaria. 6. Severe shortness of breath.

1. hemolytic transfusion reaction will experience a drop in blood pressure 2. hemolytic transfusion reaction will experience low back pain 4. An elevated temperature is expected for the client who experiences a hemolytic transfusion reaction

The nurse cares for the client receiving haloperidol. The nurse anticipates which adverse effects? 1. Blood dyscrasia and extrapyramidal symptoms. 2. Hearing loss and unsteady gait. 3. Nystagmus and vertical gaze palsy. 4. Alteration in level of consciousness and increased confusion.

1. major adverse effects of haloperidol include hematologic problems, primarily blood dyscrasia and extrapyramidal symptoms (EPS)

The parent brings a 9-month-old infant to the pediatric office with a fever of 102.2° F (39° C) and frequent vomiting. The nurse expects to find which reflex? 1. Babinski reflex. 2. Moro reflex. 3. Tonic neck reflex. 4. Grasp reflex.

1. stroking outer sole of foot upward causes toes to hyperextend and fan and great toe to dorsiflex; disappears after 1 year of age

The nurse cares for a client admitted 2 days ago with a diagnosis of closed head injury. If the client develops diabetes insipidus, the nurse will observe which symptoms? Select all that apply. 1. Glucosuria. 2. Cracked lips. 3. Weight gain of 5 lb. 4. BP 160/100, pulse 56. 5. Urinary output of 4 L/24 hours. 6. Urine specific gravity of 1.004.

2. due to dehydration caused by excessive water loss 5. excessive fluid loss is major occurrence of diabetes insipidus. 6. specific gravity very low as urine is not concentrated in the kidney.

The nurse plans discharge teaching for the client after a lumbar laminectomy. Which muscle or muscles does the nurse instruct the client to exercise regularly? 1. Anal sphincter. 2. Abdominal. 3. Trapezius. 4. Rectus femoris.

2. strengthening the abdominal muscles adds support for the muscles supporting the lumbar spine

The RN is planning client assignments for the day. Which is the most appropriate assignment for an assistive personnel? 1. Client requiring a colostomy irrigation 2. Client receiving continuous tube feedings 3. Client who requires urine specimen collection 4. Client with difficulty swallowing food and fluids

3. AP is skilled in this procedure

The client has partial-thickness and full-thickness burns over 75% of the body. The nurse is most concerned if which symptom is observed? 1. Epigastric pain. 2. Restlessness. 3. Tachypnea. 4. Lethargy.

3. body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cool, clammy skin, tachycardia, tachypnea, and pale color

Normal K+

3.5-5.0 mEq/L

The nurse planning care for a refugee considers which health care need a priority for this client? 1. Access to housing 2. Access to clean water 3. Access to transportation 4. Access to mental health services

4. Mental health problems are the primary issue fo this population as a result of tortuous events

The nurse is volunteering with and outreach program to provide basic health care to homeless people. Which finding, if noted, should be addressed first? 1. BP 154/52 mmHg 2. Visual acuity of 20/200 in both eyes 3. Blood glucose 206 mg/dl 4. Complaints of pain with numbness and tingling in both feet

4. Should be addressed first with this particular population

The nurse leads a parenting class for a group of expectant clients. How many extra calories a day does the nurse advise the clients to consume to support breastfeeding? 1. 200. 2. 300. 3. 400. 4. 500.

4. milk production requires an increase of 500 calories per day

Normal ALT

8-40 units

Normal AST

8-40 units/L

Normal Ca

8.5-10.5 mg/dL

What is early deceleration?

Normal; occurs in response to compression of fetal head; uniform shape corresponds to rise in intrauterine pressure as uterus contracts, does not indicate fetal distress

What are social determinants of health?

conditions in which people are born, grow, live, work and age

The nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? 1. Asthma 2. Claustrophobia 3. Sleep Problems 4. Bipolar Disorder 5. Aggressive Behavior 6. ADHD

3,4,5,6

The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium is 5.7 mEq. Which patterns would the nurse watch for on the cardiac monitor as a result of the lab value? 1. ST depression 2. Prominent U waves 3. Tall peaked T waves 4. Prolonged ST segment 5. Widened QRS complex

3,5 ECG changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS segment, and tall peaked T waves.

The 7-year-old child is seen in the clinic with a diagnosis of pituitary dwarfism. Which clinical manifestation is the nurse most likely to observe? 1. Abnormal body proportions. 2. Early sexual maturation. 3. Delicate features. 4. Coarse, dry skin.

3. appear younger in age

The teenage client diagnosed with anorexia nervosa is admitted to the hospital. Which behavior does the nurse expect the client to present? 1. View appearance as "skinny." 2. Be hypoactive and withdrawn. 3. Want to discuss and plan meals. 4. Have a close relationship with a parent.

3. display a marked preoccupation with food

The client in labor is monitored with an internal fetal monitor. The nurse knows which is the most important reason for the fetal monitor? 1. To evaluate the progress of the client's labor. 2. To assess the strength and duration of the client's contractions. 3. To monitor the oxygen status of the fetus during labor. 4. To determine if an oxytocin drip is necessary.

3. goal is early detection of mild fetal hypoxia

The client had a kidney transplant yesterday, and the client's adult child has come to visit. The nurse instructs the adult child to take which action? 1. No special actions are necessary. 2. Wear a double mask and gloves. 3. Perform good hand washing. 4. Wear a gown and a mask.

3. good hand washing is the most effective method of reducing infection; very important with immunosuppressed clients

The nurse performs range-of-motion (ROM) exercises for an elderly client recently immobilized. The nurse identifies which statement as correct about range-of-motion? 1. Passive ROM exercises increase muscle strength. 2. A full ROM must be completed for the elderly client. 3. Exercises should be completed to the point of discomfort. 4. ROM assists the elderly to carry out activities of daily living (ADLs).

4. emphasis should be on ROMs that support ADLs

The nurse is assigned to care fir a group of clients. On review of the client's medical records, the nurse determines that which client is most likely at risk for FVD? 1. A client with an ileostomy 2. A client with heart failure 3. A client on long-term corticosteroid therapy 4. A client receiving frequent wound irrigation

1 Presence of an ileostomy of colostomy can cause FVD

The client is receiving imipramine. It is most important for the nurse to instruct the client to immediately report which symptoms? Select all that apply. 1. Fever. 2. Dry mouth. 3. Increased fatigue. 4. Vomiting and diarrhea. 5. Staggering gait. 6. Sore throat.

1, 2, 3, 4, 6

The nurse plans a diet for a child client diagnosed with cystic fibrosis. Which dietary requirement does the nurse consider? (Select all that apply.) 1. High-protein. 2. Low-sodium. 3. High-calorie. 4. Low-protein. 5. Low-carbohydrate. 6. Low-potassium.

1, 3 Impaired intestinal absorption due to cystic fibrosis necessitates a diet high in protein and calories. Because of pancreatic insufficiency, the client will require pancreatic enzymes at the beginning of all meals and snacks. Fat-soluble vitamins (A, D, E, K) must also be supplemented because of malabsorption.

The nurse reviews a client's electrolyte lab report and notes that the K+ level is 2.5 mEq. Which patterns should the nurse watch for on the ECG as a result of this abnormal lab value? 1. U waves 2. Absent P waves 3. Inverted T waves 4. Depressed ST segment 5. Widened QRS segment

1, 3, 4 ECG changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves

The client is admitted for a series of tests to verify the diagnosis of Cushing's syndrome. Which nursing assessment finding supports this diagnosis? Select all that apply. 1. Buffalo hump. 2. Intolerance to heat. 3. Hyperglycemia. 4. Hypernatremia. 5. Intolerance to cold. 6. Irritability.

1, 3, 4 hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections

he nurse cares for a client with a diagnosis of Guillain-Barré syndrome. Which symptoms support this diagnosis? Select all that apply. 1. Respiratory failure. 2. Pulmonary congestion. 3. Hypertension. 4. Flaccid paralysis. 5. Hemiplegia. 6. Urinary retention.

1, 4, 6 classic symptoms include respiratory failure and flaccidity due to paralysis of the muscles and urinary retention due to loss of sensation

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? 1. The acuity level of the clients 2. Specific requests from the staff 3. The clustering of the rooms on the unit 4. The number of anticipated client discharges 5. Client needs and workers' needs and abilities

1, 5

Which health concerns should the nurse be aware of as risk factors for African American clients? 1. Cancer 2. Obesity 3. HTN 4. Heart disease 5. Hypothyroidism 6. Diabetes Mellitus

1,2,3,4,6

Potassium chloride IV is prescribed fir a client with heart failure experiencing experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the K+? 1. Obtain an IV pump 2. Monitor UO during administration 3. Prepare the medication for bolus administration 4. Monitor the IV site for signs of infiltration or phlebitis 5. Ensure that the medication is diluted in the appropriate volume of fluid 6. Ensure that the bag is labeled so that it reads the volume of K+ in the solution

1,2,4,5,6

The nurse cares for the elderly client receiving IV fluids of 0.9% NaCl at 125 mL/h into the left arm. During a routine assessment, the nurse finds the client has distended neck veins, shortness of breath, and crackles in both lung bases. Which action does the nurse take first? 1. Decreases the IV rate to 20 mL/h and notifies the health care provider. 2. Decreases the IV rate to 100 mL/h and continues to monitor the client. 3. Discontinues the IV and starts oxygen at 6 L/min. 4. Assesses for infiltration of the IV solution.

1. 20 mL/h (KVO - keep vein open) will keep access open

The client has a nasogastric tube connected to intermittent low suction. At 07:00, the nurse documents 235 mL of greenish drainage in the suction container. At 15:00, there is 445 mL of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the tube with 30 mL of normal saline. Which is the actual amount of drainage from the nasogastric tube for 07:00 to 15:00? 1. 150 mL. 2. 210 mL. 3. 295 mL. 4. 385 mL.

1. 445 − 235 = 210 − 60 = 150

Which therapeutic communication technique is most helpful when working with transgender persons? 1. Using open-ended questions 2. Using their first name to address them 3. Using pronouns associated with birth sex 4. Anticipating the client's needs an making suggestions

1. Assists in refraining from judgement and allows the client the opportunity to express their thoughts and feelings.

The parent tells the nurse about having had difficulty forming relationships. The parent is worried the 7-year-old child will have the same problem. Which statement by the nurse is best? 1. "Children develop trust from birth to 18 months of age." 2. "Children develop trust from 18 months to three years of age." 3. "Children develop trust from three to six years of age." 4. "Children develop trust from six to twelve years of age."

1. Erikson states that trust results from interaction with dependable, predictable primary caretaker

The nurse cares for the elderly client admitted with a possible fractured right hip. During the initial nursing assessment, which observation of the right leg validates this diagnosis? 1. The leg appears to be shortened and is adducted and externally rotated. 2. Plantar flexion is observed with sciatic pain radiating down the leg. 3. From the hip, the leg appears to be longer and is externally rotated. 4. There is evidence of paresis with decreased sensation and limited mobility.

1. accurate assessments of the position of a fractured hip prior to repair

The health care provider prescribes lithium carbonate 300 mg PO QID for the adult client. The nurse in the outpatient clinic instructs the client about the medication. The nurse encourages the client to maintain an adequate intake of which substance? 1. Sodium. 2. Protein. 3. Potassium. 4. Iron.

1. alkali metal salt acts like sodium ions in the body; excretion of lithium depends on normal sodium levels; sodium reduction causes marked lithium retention, leading to toxicity

Prior to sending a client for a cardiac catheterization, it is most important for the nurse to report which information? 1. The client has an allergy to shellfish. 2. The client has diminished palpable peripheral pulses. 3. The client has cool lower extremities bilaterally. 4. The client is anxious about the pending procedure.

1. allergies to iodine and/or seafood must be reported immediately before a cardiac catheterization to avoid anaphylactic shock during the procedure

The client develops a postoperative infection and receives ceftriaxone sodium IV every day. It is most important for the nurse to monitor for which changes? 1. The surface of the tongue. 2. Hemoglobin and hematocrit. 3. Skin surfaces in skin folds. 4. Changes in urine characteristics.

1. cephalosporin, long-term use of ceftriaxone sodium can cause overgrowth of organisms; monitoring of tongue and oral cavity is recommended

The client with bipolar illness is extremely angry. The client tells the nurse, "I just found out my spouse has filed for divorce. I need to use the phone right now!" Which action by the nurse is most appropriate? 1. Allow the client to use the phone. 2. Confront the client about the anger and inappropriate plan of action. 3. Do not allow the client to use the phone because this is an involuntary admission. 4. Set limits on the client's phone use because of the inability to control behavior.

1. client is able to use phone unless otherwise indicated by court order or health care provider's order

The nurse cares for the client with ataxia. Which action is most important? 1. Supervise ambulation. 2. Measure the intake and output accurately. 3. Consult the speech therapist. 4. Elevate the foot of the bed.

1. client's coordination is poor; the only relevant nursing action is to supervise ambulation

The nurse prepares a teaching plan regarding colostomy irrigation. The nurse includes which information? 1. The colostomy needs to be irrigated at the same time every day. 2. Irrigate the colostomy after meals to increase peristalsis. 3. Insert the catheter about 10 inches into the stoma. 4. The solution should be very warm to increase dilation and flow.

1. colostomy irrigation should be done at same time each day to assist in establishing a normal pattern of elimination

The child is in the early stages of nephrotic syndrome. The nurse discusses which dietary change with the parents? 1. Adequate protein, low sodium intake. 2. Low protein, low potassium intake. 3. Low potassium, low calorie intake. 4. Limited protein, high carbohydrate intake.

1. if child can tolerate the protein intake, then this diet is encouraged to speed healing; sodium is usually restricted

The nurse prepares discharge teaching for the parents of the newborn. Which information does the nurse provide regarding the accuracy of a PKU (phenylketonuria) test? 1. The initial specimen should be collected as close to discharge as possible but not later than 7 days. 2. The infant can have water but should not have formula for 6 hours before the test. 3. The test will need to be repeated at 6 weeks and at the 3-month check-up. 4. Blood will be drawn at three 1-hour intervals; there is no specific preparation.

1. if initial specimen is collected before newborn is 24 hours old, a repeat test should be performed by 2 weeks of age

The client diagnosed with Addison's disease comes to the health clinic. When assessing the client's skin, the nurse expects to make which observation? 1. Darker skin that is more pigmented. 2. Skin that is ruddy and oily. 3. Skin that is puffy and scaly. 4. Skin that is pale and dry.

1. increase in melanocyte-stimulating hormone results in "eternal tan"

The home care nurse visits a new parent and a 2-week-old infant. The client asks the nurse which solid foods to give the child first. Which response does the nurse give? 1. Rice cereal is usually the first solid food and is started around 4 to 5 months. 2. Strained fruits are well tolerated as the first solid food, and infants like them. 3. Introduction of solid foods is not important at this time. 4. Solid foods are usually not started until the infant is around 6 months old.

1. infants are less likely to be allergic to rice cereal than to any other solid food; usually started between 4 and 5 months of age; breast-fed infants may be started on solids even later

The health care provider orders chlorpromazine to control the alcoholic client's restlessness, agitation, and irritability following surgery. The nurse checks the order with the health care provider because of which rationale? 1. The nurse believes the client's symptoms reflect alcohol withdrawal. 2. The nurse does not know if the client is allergic to this medication. 3. The nurse knows the client is not psychotic. 4. The nurse routinely checks on the health care provider's orders.

1. medication is contraindicated for the treatment of alcohol withdrawal symptoms; medication will lower client's seizure threshold and BP, causing potentially serious medical consequences

The nurse cares for the client one day after a thoracotomy. Nursing actions in the care plan include turn, cough, and deep breathe q 2 h. Which does the nurse understand to be the purpose of this nursing action? 1. Promote ventilation and prevent respiratory acidosis. 2. Increase oxygenation and removal of secretions. 3. Increase pH and facilitate balance of bicarbonate. 4. Prevent respiratory alkalosis by increasing oxygenation.

1. primary purpose of this nursing measure is to improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis

A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve which behaviors? 1. Projection and displacement. 2. Sublimation and internalization. 3. Rationalization and intellectualization. 4. Reaction formation and symbolization.

1. projection (attributing one's thoughts or impulses to another) and displacement (shifting of emotion concerning person or object to another neutral or less dangerous person or object)

Which symptoms alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness? Select all that apply. 1. Tremors. 2. Elevated temperature. 3. Depression. 4. Nocturnal leg cramps. 5. Night sweats. 6. Decreased concentration.

1. symptom of withdrawal 2. symptom of withdrawal 4. symptom of withdrawal

The 6-month-old infant has had all of the required immunizations for that age. The nurse knows this includes which immunizations? 1. Three doses of diphtheria, tetanus, and pertussis vaccine. 2. Measles, mumps, and rubella vaccine. 3. One dose of rotavirus. 4. Varicella vaccine.

1. the first dose of the DTaP may be given at 2 months of age; the second is given around 4 months; the third is given around 6 months

The nurse cares for the client admitted with a diagnosis of acute hypoparathyroidism. It is most important for the nurse to have which item available? 1. Tracheostomy set. 2. Cardiac monitor. 3. IV monitor. 4. Heating pad

1. tracheostomy set is the most important for the client's safety due to risk for laryngospasm

The client has a total laryngectomy with a permanent tracheostomy. The nurse plans nutritional intake for the next 3 days. Which action is necessary for the nurse to consider regarding the client's nutrition? 1. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented. 2. The client will be unable to maintain any oral intake as long as the tracheotomy is in place. 3. Nutritional and/or gastric feedings will not be attempted for approximately 3 weeks to decrease the incidence of aspiration. 4. Because the client is dependent on the ventilator, nutritional intake will be delayed.

1. tube feedings frequently started as the initial nutritional intake; prevents trauma to suture area

Normal BUN

10-20 mg/dL

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? 1. Open doors to client rooms 2. Move beds away from windows 3. Close window shades and curtains 4. Place blankets over clients who are confined to bed 5. Relocate ambulatory clients from hallways back into their rooms

2, 3, 4

The client undergoes hospital admission for regulation of insulin dosage. The client takes 15 units of isophane insulin at 0800 every day. At 1600, which nursing observations indicate a complication from the insulin? (Select all that apply.) 1. Acetonic breath. 2. Irritability. 3. Polyuria. 4. Tachycardia. 5. Polydipsia. 6. Diaphoresis.

2, 4, 6 Isophane insulin is an intermediate-acting insulin that peaks from 4 to 12 hours after administration. This is when signs and symptoms of hypoglycemia will occur (e.g., irritability)

The nurse assesses a client diagnosed with a spinal cord injury. Which finding suggests the complication of autonomic dysreflexia? (Select all that apply.) 1. Urinary bladder spasm pain. 2. Severe pounding headache. 3. Profuse sweating. 4. Dysrhythmias. 5. Severe hypotension. 6. Nasal congestion.

2. A severe headache results from rapid onset of hypertension and is one of the classic symptoms of dysreflexia. 3. Profuse sweating, especially on the forehead, is another classic symptom of dysreflexia. 6. Nasal congestion occurs with dysreflexia and piloerection (goose flesh) may also occur.

The nurse provides care for a client with a tracheostomy. Which is the priority nursing diagnosis for this client? 1. Problem with verbal communication. 2. Inadequate airway clearance. 3. Possible skin integrity impairment. 4. Acute pain.

2. Inadequate airway clearance is the top priority for clients with a tracheostomy because loss of the upper airway increases the amount and viscosity of secretions

A newborn client at 32 weeks' gestation weighs 4 lb 10 oz (2.12 kg) and has mottling of the skin and acrocyanosis with irregular respirations of 60 breaths per minute. Which newborn problem does the nurse suspect this client is experiencing? 1. Hypoglycemia. 2. Cold stress. 3. Birth asphyxia. 4. Hypovolemia.

2. Mottling of the skin, acrocyanosis, and irregular respirations at the rate of 60 breaths per minute are symptoms of cold stress.

The nurse observes the student nurse auscultate the right middle lobe (RML) lung of a client. The nurse knows the student nurse is auscultating correctly if the stethoscope is placed in which position? 1. Posterior and anterior base of right side. 2. Right anterior chest between the fourth and sixth intercostal spaces. 3. Left of the sternum, midclavicular, at fifth intercostal space. 4. Posterior chest wall, midaxillary, right side.

2. RML is found in the right anterior chest between the fourth and sixth intercostal spaces.

The nurse administers Rho(D) immune globulin to prevent complications in which client situation? 1. The baby is Rh-negative, the mother is Rh-negative, and the father is Rh-positive. 2. The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs. 3. The mother is Rh-positive and previously sensitized, and the baby is Rh-negative. 4. The mother is Rh-positive, the baby is Rh-negative, and there is a history of one incomplete pregnancy.

2. Rho(D) immune globulin is given to an Rh-negative mother who delivers an Rh-positive baby when the baby has a negative Coombs test

Several days after the delivery of a stillborn, the parents say, "We wish we could talk with other couples who have gone through this trauma." Which response by the nurse is best? 1. "SIDS will provide you with this opportunity." 2. "SHARE will provide you with this opportunity." 3. "RESOLVE will provide you with this opportunity." 4. "CANDLELIGHTERS will provide you with this opportunity."

2. SHARE is a support group for parents who have lost a newborn or have experienced a miscarriage

A client suspects she is pregnant because the last menstrual period began May 8 and ended May 12. Which estimated date of birth (EDB) will the nurse calculate for this client? 1. February 1. 2. February 15. 3. February 19. 4. March 14.

2. When using the Naegele's rule, the nurse adds 7 calendar days to the date of the client's last menstrual period and then subtracts 3 months. For example, May 8 plus 7 days is May 15 minus 3 months is February 15th.

The health care provider inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that which outcome is the primary purpose of the pacemaker? 1. Increases the force of myocardial contraction. 2. Increases the cardiac output. 3. Prevents premature ventricular contractions (PVCs). 4. Prevents systemic overload.

2. acts to regulate cardiac rhythm

The nurse prepares the adult client diagnosed with intellectual delay for discharge. The health care provider ordered warfarin sodium, 5 mg each day. To maintain client safety, which action does the nurse take first? 1. Instructs the significant other about the medication regimen 2. Determines the client's comprehension of the medication administration. 3. Prepackages the medication to encourage correct administration. 4. Encourages a return demonstration of medication self-administration.

2. assessment; intellectually delayed client should be carefully evaluated to ensure complete comprehension of the dosage regimen to prevent overdose and underdose

The nurse cares for the multipara client who delivered an infant 1 hour ago. The nurse observes the client's breasts are soft, the uterus is boggy to the right of the midline and 2 cm below the umbilicus, and there is moderate lochia rubra. It is most important for the nurse to take which action? 1. Perform a straight catheterization. 2. Offer the client the bedpan. 3. Put the baby to breast. 4. Massage the uterine fundus.

2. boggy uterus deviated to right indicates full bladder, encourage client to void

The elderly alcoholic client receives a long-acting benzodiazepine for 2 days for symptom management and reduction. The client states, "Get those bugs off of me and clean them out of here." The nurse knows the client is exhibiting symptoms of which problem? 1. A reaction to the sedative medication. 2. A worsening course of the withdrawal syndrome. 3. An exacerbation of the schizophrenia process. 4. The process of aging and the effects of delirium.

2. client has most probably progressed to another level of abstinence withdrawal from polypharmacy chemical dependence; characteristic symptoms include tremors, increased heart rate, and fever, as well as psychological problems of confusion, delusions, and hallucinations

The client is diagnosed with Cushing syndrome. Which assessment finding does the nurse recognize as pertinent to this diagnosis? 1. Low blood pressure and weight loss. 2. Thin extremities with easy bruising. 3. Decreased urinary output and decreased serum potassium. 4. Tachycardia with reports of night sweats..

2. clients with Cushing syndrome tend to lose weight in their legs and have petechiae and bruising

The nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows which change in the pattern of urinary elimination occurs normally with aging? 1. Decreased frequency. 2. Nocturia. 3. Incontinence. 4. Hematuria.

2. decreased ability to concentrate urine increases urine formation and increased nocturnal urine production leads to need to awaken to void

The nurse cares for a client during an acute manic episode. The nurse identifies which client behaviors as most characteristic of mania? Select all that apply. 1. Paranoia. 2. Grandiose delusions. 3. Somatic difficulties. 4. Difficulty concentrating. 5. Agitation. 6. Distorted perceptions.

2. delusions of grandeur are common during mania. 4. due to excessive activity 5. clients are constantly in motion.

The client is scheduled for electromyography (EMG). Which information does the nurse tell the client about the procedure? 1. "Your hair will be carefully washed prior to the procedure." 2. "This is a noninvasive procedure that takes about 30 minutes." 3. "A sedative will be given to you shortly before the procedure." 4. "You will not be allowed to eat 4 to 6 hours before the procedure."

2. electrodes are attached to muscles, length of time for impulse transmission is measured

The school nurse observes a group of preschool children in the playroom. The nurse recognizes which activity as appropriate behavior for the 5-year-old child? 1. The child plays with a large truck with another child. 2. The child talks on a toy telephone and imitates same-sex parent. 3. The child works on a puzzle with several other children. 4. The child holds and cuddles a large stuffed animal.

2. imitative behavior seen at this age

The nurse cares for the client diagnosed with a pneumothorax resulting from a motor vehicle accident three days ago. The client has a chest tube connected to a three-chamber water-seal drainage system with 20 cm suction. The nurse determines the lung has re-expanded if which observation is made? 1. There is no drainage in the collection chamber for 3 hours. 2. The fluid in the water-seal chamber does not fluctuate with respirations. 3. There is continuous bubbling in the water-seal chamber. 4. There is gentle bubbling in the suction-control chamber.

2. indicates no more air leaking into pleural space

The nurse cares for a 3-month-old infant scheduled for a barium swallow in the morning. Prior to the procedure, it is most appropriate for the nurse to take which action? 1. Offer the infant only clear liquids. 2. Make the infant NPO for 3 hours. 3. Feed the infant regular formula. 4. Maintain the infant NPO for 6 hours.

2. infant should be NPO 3 hours prior to the procedure

Which observation suggests to the nurse the client has developed an Addisonian crisis? 1. Muscular weakness and fatigue. 2. Restlessness and rapid, weak pulse. 3. Dark pigmentation of the skin. 4. Gastrointestinal disturbances and anorexia

2. may be signs of shock related to an Addisonian crisis

The nurse in the outpatient clinic assists with the application of a cast to the left arm of the preschool-aged child. After the cast is applied, the nurse takes which action first? 1. Petals the edges of the cast to prevent irritation. 2. Elevates the child's left arm on two pillows. 3. Applies cool, humidified air to dry the cast. 4. Asks the client to move the fingers to maintain mobility.

2. minimizes swelling, elevated for first 24 to 48 hours, protects from pressure and flattening of cast

The health care provider writes an order for a stat dose of morphine 4 mg IV for pain. Three hours later the client again reports pain, and the nurse administers a second injection of morphine. Which bestdescribes the nurse's liability? 1. The nurse administered the medication appropriately; there is no liability. 2. There is no order for a second dose of medication; the nurse is liable. 3. The client was not injured; if injury did not occur, then the nurse is not liable. 4. The nurse should have waited at least 4 hours; then there would be no liability.

2. order for a stat dose is for a one time administration; nurse practice act addresses scope of practice; by administering a second dose the nurse was prescribing the medication, something only a healthcare provider with prescriptive ability can do; nurse was practicing medicine, not nursing and was outside of scope of practice

The nurse recognizes which symptoms as characteristic of a panic attack? Select all that apply. 1. Decreased blood pressure. 2. Palpitations. 3. Decreased perceptual field 4. Bradycardia5. Diaphoresis 6. Fear of going crazy

2. the heart rate increases and palpitations occur 3. the visual field narrows; part of the fight or flight reaction. 5. neurological changes cause diaphoresis 6. clients fear they are going crazy; part of the neurological changes

The client is diagnosed with right-sided weakness. The nurse instructs the client how to walk down stairs using a cane. Which client behavior indicates the teaching is successful? 1. The client puts the right leg on the step, then the cane, followed by the left leg. 2. The client leads with the cane, followed by the right leg and then the left leg. 3. The client advances the right leg, followed by the left leg and the cane. 4. The client puts the cane on the step and advances the left leg, followed by the right leg.

2. to go down stairs, advance cane and weak leg, then strong leg; memory trick: the good goes up, the bad goes down

The client is diagnosed with pneumonia secondary to chronic pulmonary disease. Which nursing goal is most appropriate? 1. Maintain and improve the quality of oxygenation. 2. Improve the status of ventilation. 3. Increase oxygenation of peripheral circulation. 4. Correct the bicarbonate deficit.

2. to improve the quality of ventilation refers to levels of carbon dioxide and oxygen

The nurse is caring for a female client in the ED who presents with a complaint of fatigue and shortness of breath. Which physical assessment findings, if noted by the nurse, require followup? 1. Reddened sclera of the eyes 2. Dry flaking of the scalp 3. Reddish purple mark on the neck 4. A scaly rash noted on the elbows and knees

3. Client should be screened for abuse. Battered women experience bruises, particularly around eyes, or red-purple marks on the neck, sprained or broken wrists, chronic fatigue, shortness of breath, muscle tension, involuntary shaking, changes in eating and sleeping, sexual dysfunction, and fertility issues

A continent adult client undergoes admission to the hospital with a diagnosis of hepatitis A. Which precautions does the nurse include in the client's overall care during hospitalization? 1. Contact precautions. 2. Airborne precautions. 3. Standard precautions. 4. Droplet precautions.

3. Standard precautions should be used on everyone. Hepatitis A is usually transmitted person-to-person through the fecal-oral route or consumption of contaminated food or water. Contact precautions would only be required if the client was incontinent or diapered.

The nurse in the pediatric office observes the child in the waiting room. The child can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet. Which does the nurse identify as the child's chronological age? 1. 1 year old. 2. 2 years old. 3. 3 years old. 4. 5 years old.

3. able to jump with both feet and stand on one foot momentarily at 30 months

The client is admitted with a tentative diagnosis of late stage AIDS dementia complex. The nursing assessment is most likely to reveal which finding? 1. Hyperactive deep tendon reflexes. 2. Peripheral neuropathy affecting the hands. 3. Disorientation to person, place, and time. 4. Impaired concentration and memory loss.

3. approximately 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debilitation; late stage is typified by cognitive confusion and disorientation

The client receives tetracycline. The nurse includes which information in the teaching plan? 1. Take the medication with milk or antacids to decrease GI problems. 2. The medication should always be taken with meals. 3. Use a maximum-protection sunscreen when outdoors. 4. Crackers and juice will help decrease gastric irritation.

3. because of problems related to photosensitivity, client should wear sunscreen, wide-brimmed hats, and long sleeves when at risk for sun exposure

The client is to have an intravenous pyelogram (IVP). Nursing management includes which action? 1. A fat-free meal the evening before the examination and radiopaque tablets at bedtime. 2. Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter. 3. Cleansing enemas the evening before to provide for adequate visualization of the urinary tract. 4. Explaining the importance of following directions regarding voiding during the test.

3. because of the need to visualize the abdominal area, cleansing enemas the evening before an IVP are usually ordered

The client is diagnosed with obsessive-compulsive disorder manifested by the compulsion of hand-washing. The nurse knows which behavior best describes the client's need for repetitive acts of hand-washing? 1. Hand-washing represents an attempt to manipulate the environment to make it more comfortable. 2. Hand-washing externalizes the anxiety from a source within the body to an acceptable substitute outside the body. 3. Hand-washing helps the client avoid undesirable thoughts and maintain some control over guilt and anxiety. 4. Hand-washing helps maintain the client in an active state to resist the effects of depression.

3. compulsive behavior is an unconscious attempt to control and/or relieve the tension and anxiety the client is experiencing

The nurse cares for the client the first day postoperative after a transurethral prostatectomy (TURP). The client has a continuous bladder irrigation (CBI). The client's spouse asks why the client has the CBI. Which response by the nurse is best? 1. "The CBI prevents urinary stasis and infection." 2. "The CBI dilutes the urine to prevent infection." 3. "The CBI enables urine to keep flowing." 4. "The CBI delivers medication to the bladder."

3. continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client

The client has a history of hypertension and angle-closure glaucoma. Which medication order does the nurse question? 1. Propranolol 80 mg PO QID. 2. Verapamil 40 mg PO TID. 3. Tetrahydrozoline 2 drops in each eye TID. 4. Timolol 1 drop in each eye once daily.

3. contraindicated; ophthalmic vasoconstrictor, contraindicated with angle-closure glaucoma; use cautiously with hypertension

The client diagnosed with metastatic lung cancer is admitted to the hospital. The client's orders include do not resuscitate (DNR) and morphine 2 mg/h by continuous IV infusion. The client's BP is 86/50, respirations are 8, and the client is nonresponsive. Naloxone hydrochloride 0.4 mg IV is ordered stat. It is important for the nurse to consider which action? 1. The BP and respirations will need to increase before a second dose of naloxone can be given. 2. Naloxone should not be given to the client because of the DNR status. 3. A dose of naloxone may need to be repeated in 2 to 3 minutes. 4. Naloxone is effective in treating respiratory changes caused by opiates, barbiturates, and sedatives.

3. half-life of naloxone is short; may go back into respiratory depression; may need to be repeated

The nurse obtains the client's temperature of 103° F (39.4° C). The nurse knows body compensatory mechanisms include which mechanism? 1. Decreased respiratory rate and bradycardia. 2. Normal blood pressure and pulse. 3. Increased respiratory rate and tachycardia. 4. Diaphoresis with cool, clammy skin.

3. hyperthermia increases the oxygen requirements, which results in faster breathing as well as an increase in the pulse rate

The health care provider diagnoses Graves' disease for the client. The nurse expects the client to exhibit which symptom? 1. Lethargy in the early morning. 2. Sensitivity to cold. 3. Weight loss of 10 lb in 3 weeks. 4. Reduced deep tendon reflexes.

3. increased metabolic rate causes weight loss even with increased appetite

The client has a diagnosis of a ruptured lumbar disc. The nurse anticipates which assessment finding? 1. Sensation loss in an upper extremity. 2. Clonic jerks in the affected foot. 3. Paresthesia in the affected leg. 4. Chorea in the upper and lower extremities.

3. lumbar lesions can cause paresthesia, pain, muscle weakness, and atrophy in the lower extremities

The client at 16 weeks gestation has an amniocentesis. The client asks what will be learned from this procedure. The nurse responds that which condition can be detected? 1. Tetralogy of Fallot. 2. Talipes equinovarus. 3. Hemolytic disease of the newborn. 4. Cleft lip and palate.

3. maternal antibodies destroy fetal RBCs; bilirubin secreted because of hemolysis

The nurse cares for the child diagnosed with pediculosis capitis (head lice) who is being treated with permethrin 1% cream rinse. The nurse includes which information when instructing the child's parents? 1. Apply the cream rinse every other day for 1 week. 2. Wash the child's clothing and personal belongings in soap and cool water. 3. Repeat the application of the cream rinse in 7 days if nits are still present. 4. Comb the child's hair weekly with a nit comb.

3. may be repeated 7 days after first application

The client is diagnosed with an obsessive-compulsive ritual. The nurse recognizes the client is attempting to achieve which psychological status? 1. Control of other people. 2. Increased self-esteem. 3. Avoid severe levels of anxiety. 4. Express and manage anxiety.

3. obsessive-compulsive rituals are an attempt to avoid or alleviate increasing levels of anxiety; client is not trying to increase self-esteem or control others with the ritualistic behaviors; these behaviors do not have a significant impact on others; client does not want to repeat the act but feels compelled to do so

The nurse cares for the client several days after an above-knee amputation (AKA). Which symptom is characteristic of an infected residual limb wound? 1. The client is anxious and restless. 2. There is a small amount of dark drainage on the dressing. 3. The client reports persistent pain at the operative site. 4. The skin is cool above the operative site.

3. pain is characteristic of inflammation and infection

The client is returned to the unit after surgery with a cuffed tracheostomy tube in place. The nurse knows the purpose of the cuff on the tracheostomy tube includes which reason? 1. Guarantees secure placement of the tracheostomy tube in the airway. 2. Prevents ischemia of the tracheal wall by distributing the pressure applied to it. 3. Decreases the chance of aspiration into the trachea. 4. Protects the trachea from ischemia and edema.

3. seals trachea, helps to prevent aspiration

In the process of a normal adjustment to a terminal illness, the nurse knows that the client's initial denial and isolation will give way to the second stage. The second stage is characterized by which behavior? 1. Acceptance. 2. Bargaining. 3. Anger. 4. Depression.

3. second stage is characterized by anger

The nurse checks the incision of the client 48 hours after surgery for a hernia repair. Which finding indicates a possible complication? 1. There is swelling under the sutures. 2. There is crusting around the incision line. 3. The incision line is red. 4. The incision line is approximated.

3. should be pink, not red; indicates possible infection; other signs include increased warmth, tenderness, pain, and purulent or odorous drainage

The client experiences inflammation due to rheumatoid arthritis. Which nursing statement is correct? 1. "If you are having a 'bad' day, postpone your exercises until the next day." 2. "Passive exercises are better for you than active exercises." 3. "When inflammation is severe, decrease the number of repetitions of the exercise." 4. "You can substitute your normal household tasks for your exercises to provide variety."

3. should reduce repetitions when client experiences more pain

A postoperative cataract client is cautioned about not making sudden movements or bending over. The nurse understands that the rationale for this recommendation is to prevent which complication? 1. Impairment of cerebral blood flow and headaches. 2. Increased intracranial pressure. 3. Pressure on the ocular suture line. 4. Displacement of the lens implant.

3. sudden changes in position, constipation, vomiting, stooping, or bending over increase the intraocular pressure and put pressure on the suture line

The client returns from surgery. There is a fine, reddened rash around the area where providone iodine prep was applied prior to surgery. The nursing notation in the client's record includes which observation? 1. Time and circumstances under which the rash was noted. 2. Explanation given to the client and family of the reason for the rash. 3. Notation on an allergy list and notification of the health care provider. 4. The need for application of corticosteroid cream to decrease inflammation.

3. suspected reaction to substances should be reported to the health care provider and noted on list of possible allergies

The nurse on a psychiatric unit of the hospital declines the client's request to organize a party on the unit for the client's friends. The client becomes angry and uses abusive language toward the nurse. Which statement indicates the nurse has an understanding of the client's behavior? 1. Allowing the client to use abusive language will undermine the authority of the nurse. 2. Responding in kind to a client who uses abusive language will perpetuate the behavior. 3. Abusive language is one of the behaviors symptomatic of the client's illness. 4. The nurse should model acceptable behavior and language for all clients.

3. symptoms will respond to treatment

The nurse cares for the postoperative client diagnosed with type 2 diabetes controlled with oral antihyperglycemic agents. The client asks why the health care provider ordered subcutaneous insulin injections after surgery. The nurse's response is based on knowing which physiological process? 1. Tissue injury after surgery decreases blood glucose. 2. Anesthesia acts to increase glycogen stores. 3. Being NPO inhibits normal blood glucose control. 4. Surgery often leads to insulin dependency.

3. temporary control by insulin is needed due to inability to control diabetes mellitus by diet and oral agents, surgically induced metabolic changes, being NPO both before and after surgery, and the infusion of intravenous fluids

The parents of a child diagnosed with hemophilia ask the nurse to explain the cause of the disease. Which response by the nurse is best? 1. "The father transmits the gene to the son." 2. "Both the mother and the father carry a recessive trait." 3. "The mother transmits the gene to her son." 4. "There is a 50% chance that the mother will pass the trait to each of the daughters."

3. the disorder is sex-linked

The client has been taking propranolol 40 mg bid and furosemide 40 mg daily for several months. Two weeks ago, the health care provider added verapamil 80 mg tid to the client's medication regimen. It is most important for the nurse to assess the client for which symptom? 1. Tachycardia. 2. Diarrhea. 3. Peripheral edema. 4. Impotence.

3. verapamil is a calcium channel blocker, depresses myocardial contractility, decreases work of ventricles and O2 demand, dilates coronary arteries; when used with other antihypertensives can cause hypotension and heart failure

The nurse prepares the older client for an intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response is based on which explanation? 1. The health care provider is able to directly observe the kidney pelvis. 2. An IVP assesses the glomerular filtration rate. 3. The health care provider is able to examine the urinary tract by x-ray. 4. Medication is injected into the urinary system.

3. x-rays of entire urinary tract taken, evaluates kidney function

The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dl. Which patterns would the nurse watch for on the ECG? 1. U waves 2. Widened T wave 3. Prominent U wave 4. Prolonged QT interval 5. Prolonged ST segment

4, 5 Risk for hypocalcemia, which causes ECG changes such as prolonged QT interval and prolonged ST segment

Which client is at risk for the development of a potassium level of 5.5 mEq? 1. Client with colitis 2. Client with Cushing's syndrome 3. Client who has been overusing laxatives 4. Client who has sustained a traumatic burn

4. Clients who experience cellular shifting of K+ in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis

The nurse employed in an ED is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign highest priority to which client? 1. A client complaining of muscle aches, headaches, and history of seizures. 2. A client who twisted her ankle when rollerblading and is requesting medication for pain 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 he just ate pizza that was made with a very spicy sauce.

4. Clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, and acute neurological deficits and those who have sustained chemical splashes to the eyes are classified as emergent and are highest priority

The nurse supervises an LPN/LVN administering an enema to a client. The nurse determines the LPN/LVN's actions are appropriate if which action is observed? 1. The LPN/LVN places the solution 20 inches above the anus. 2. The LPN/LVN adjusts the temperature of the solution. 3. The LPN/LVN inserts the tube 6 inches. 4. The LPN/LVN positions the client left Sims' position.

4. Sim's encourages solution to flow downward along the natural curve of the sigmoid colon and rectum, which improves retention of solution

The client takes phenelzine. The nurse observes the client eat another client's lunch. After a few minutes, the client reports headache, nausea, and rapid heartbeat, and begins to vomit. The nurse anticipates administering which medication? 1. Buspirone. 2. Fluoxetine. 3. Prochlorperazine. 4. Nifedipine.

4. antihypertensive; client experiencing hypertensive crisis due to ingesting tyramine; adverse effects include dizziness, headache, nervousness

The nurse identifies which finding has the greatest impact on the elderly client's ability to complete activities of daily living (ADLs)? 1. Perseveration. 2. Aphasia. 3. Mnemonic disturbance. 4. Apraxia.

4. apraxia is loss of purposeful movement in the absence of motor or sensory impairment; when it affects an ADL, such as dressing, the client may not be able to put clothes on properly

The client receives aminophylline IV. The client has clear lung sounds and unlabored breathing. Which is the most appropriate nursing action if the client's IV infiltrates? 1. Apply warm soaks to the infiltration site, start a new IV, and continue IV medications. 2. Wait 2 hours, reassess the client, and restart the IV if the client has wheezing or labored breathing. 3. Restart the IV and continue the previous medication schedule. 4. Call the health care provider and recommend the IV medication be changed to PO.

4. before a new IV is started on this client, health care provider should be called and PO medications recommended

Which action is the best way for the nurse to assess the fluid balance of an elderly client? 1. Assess the client's blood pressure. 2. Check the client's tissue turgor. 3. Determine if the client is thirsty. 4. Maintain an accurate intake and output.

4. best indicator of fluid status

The nurse provides care for a client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting. It is most important for the nurse to take which action? 1. Assess drainage from site drains. 2. Observe dressings for signs of excessive bleeding. 3. Elevate the residual limb for no less than 40 hours. 4. Provide cast care on the affected extremity.

4. cast applied to provide uniform compression, prevents pain and contractures

The client is diagnosed with a hiatal hernia. Which information is the nursing assessment most likely to reveal? 1. A bulge in the lower right quadrant. 2. Pain at the umbilicus radiating down into the groin. 3. A burning sensation in the midepigastric area each day before lunch. 4. Reports of awakening at night with heartburn

4. classic symptom of hiatal hernia associated with reflux

The client is diagnosed with myasthenia gravis. It is most important for the nurse to consider which action? 1. Prevent accidents from falls as a result of vertigo. 2. Maintain fluid and electrolyte balance. 3. Control situations that could increase intracranial pressure and cerebral edema. 4. Assess muscle groups toward the end of the day.

4. client has increased muscle fatigue, needs more assistance toward end of day

The nurse collects the following data: anger directed by client toward staff in the form of frequent sarcastic or crude comments, increased wringing of hands, and purposeless pacing, particularly after the client has used the telephone. On the basis of the data, the nurse makes which nursing diagnosis? 1. Social interaction impairment. 2. Potential activity intolerance. 3. Powerlessness. 4. Difficulty with coping.

4. client is displaying evidence of anger and anxiety and an inability to directly deal with concerns, which is inability to cope

The nurse cares for the client after an electroconvulsive therapy (ECT) treatment. The nurse reports which observation to the health care provider? 1. Headache. 2. Disruption in short- and long-term memory. 3. Transient confusional state. 4. Backache.

4. client undergoing ECT needs to be instructed about what could be experienced during and after ECT; expected effects include headache, disrupted memory (short- and long-term), and general confused state; backache is not a usual effect; thorough description of the pain in relation to severity, duration, location, and what makes pain better needs to be assessed and reported to the health care provider

The nurse cares for the client admitted with a diagnosis of a stroke and facial paralysis. Nursing care is planned to prevent which complication? 1. Inability to talk. 2. Loss of the gag reflex. 3. Inability to open the affected eye. 4. Corneal abrasion.

4. client will be unable to close eye voluntarily; when facial nerve (cranial nerve VII) is affected, the lacrimal gland will no longer supply secretions that protect the eye

The 18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB). During the initial assessment, the nurse expects to find which early symptoms? 1. Kussmaul respirations and bradycardia. 2. Elevated temperature and slow respiratory rate 3. Expiratory wheezing and substernal retractions. 4. Inspiratory stridor and restlessness.

4. condition is characterized by edema and inflammation of upper airways

The newborn is diagnosed with fetal alcohol syndrome. The nurse knows which action is an important consideration for this newborn? 1. Prevent iron deficiency anemia. 2. Decrease touch to prevent over stimulation. 3. Provide feedings via gavage to decrease energy expenditure. 4. Replace vitamins depleted as a result of poor maternal diet.

4. frequently, maternal diet is poor and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS functio

The nurse cares for clients in a drug rehabilitation facility. Which complication of IV drug abuse is the nurse most likely to observe? 1. Jaundice. 2. Rash. 3. Bruising. 4. Cellulitis.

4. most narcotic addicts do not inject sterile purified material with aseptic techniques; cellulitis is a common complication because of skin popping or using an infected drug apparatus

The nurse knows which mood-altering drug is most often associated with an increased risk for HIV infection related to intravenous drug use? 1. Benzodiazepines. 2. Marijuana. 3. Barbiturates. 4. Narcotics.

4. narcotics are most often used intravenously

Which assessment information indicates to the nurse the client has hypocalcemia? 1. Constipation. 2. Depressed reflexes. 3. Decreased muscle strength. 4. Positive Trousseau's sign.

4. positive Trousseau's sign is indicative of neuromuscular hyperreflexia associated with hypocalcemia

The nurse observes the student nurse care for the client. The student nurse wears a gown and gloves in addition to following standard precautions. The nurse determines care is appropriate if the student nurse performs which activity? 1. Gives isoniazid to a client with tuberculosis. 2. Administers an IM injection to a client with rubella. 3. Delivers a food tray to a client with hepatitis. 4. Changes the dressing for a client with a draining abscess.

4. requires contact precautions

The client is brought to the emergency department after being raped in the home. The client asks the nurse to call the spouse to come to the emergency department. The nurse knows the most common reaction of the significant other to a rape victim is reflected in which behavior? 1. Supportive and helpful to the victim. 2. Disconnected from and apathetic toward the victim. 3. Frustrated and feeling vulnerable, but denying the need for help. 4. Emotionally distressed and needing assistance.

4. sexual assault by rape is a crisis situation for victim and family members and friends

The client with type 1 diabetes asks the nurse why the health care provider prescribed short-acting insulin instead of intermediate-acting insulin. Which response by the nurse is best? 1. "More injections are required with intermediate-acting insulin than with short-acting insulin." 2. "Hypoglycemia and hyperglycemia are more common with intermediate-acting insulin." 3. "Development of eye and kidney damage is less likely with short-acting insulin." 4. "Blood glucose levels can be controlled more accurately with short-acting insulin."

4. tighter blood glucose control occurs with short-acting insulin, especially initially

The nurse administers oral verapamil to a client. Which assessment does the nurse make before administering the medication? 1. The client's electrolytes. 2. The client's urine output. 3. The client's weight. 4. The client's heart rate.

4. verapamil is indicated for the treatment of supraventricular tachycardia, so the client's heart rate should be checked prior to administration

What is myasthenia gravis?

An autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatigue

What is culture competence?

a necessary ability to be able to provide care

What is Meniere's syndrome?

an inner-ear condition that can cause vertigo, a specific type of dizziness in which you feel as though you're spinning. It also can cause ringing in your ear ( tinnitus), hearing loss that comes and goes, and a feeling of fullness or pressure in your ear

What are "vulnerable" populations in healthcare?

groups the typically experience health disparities and inequities - include people of color, those that are uninsured, those living in poverty, homeless, chronic illnesses, disabled persons, immigrants, refugees, those with limited English proficiency, incarcerated, and members of the LGBTQ community

What is a Miller Aboott tube?

provides for intestinal decompression (removes fluid and gases); intestinal tube is often used for treatment of paralytic ileus

During the mother's fourth stage of labor, the nurse palpates the client's fundus in which location?

uterus is normally contracted and palpable at the umbilicus