NCLEX NGN Pre-Test Questions

A primary health care provider prescribes morphine sulfate, 2.5 mg intravenously stat, for a client with terminal cancer. The medication ampule reads, "Morphine sulfate 10 mg/mL." How many milliliters of medication does the nurse prepare to administer the correct dose? Please enter the number only.

0.25

A nurse is preparing to administer an injection of vitamin K to a newborn. At which site would the nurse select to administer the medication?

3 The preferred injection site for the administration of vitamin K in the newborn is the lateral aspect of the middle third of the vastus lateralis muscle (the newborn's thigh). This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication

A client who was sexually assaulted a year ago is self-contained and calm while discussing the assault. The client says to the nurse, "It still doesn't seem real." The nurse is considering requesting a referral to a mental health professional because which defense mechanism has been used for an extensive period of time? Denial Projection Rationalization Intellectualization

A

A man calls the clinic and tells the nurse that he sustained a bee sting on his leg while working in his yard. The client states that he is not allergic to bees and wants to know how to treat the sting. The nurse tells the client to first take which action? a. Place a cool compress on the sting site b. Apply an antipruritic lotion to the sting site c. Apply a topical corticosteroid to the sting site d. Take an oral antihistamine such as diphenhydramine (Benadryl)

A

A nurse assesses the chest tube drainage system of a client who has undergone thoracic surgery and notes intermittent bubbling in the water seal chamber. One hour later, the nurse notes the presence of continuous bubbling in the chamber. On the basis of this finding, which would the nurse check first? The chest tube connection sites For bubbling in the suction-control chamber The amount of drainage in the collection chamber The amount of suction being applied to the chest tube system

A

A nurse is caring for a client in labor who is receiving an oxytocin infusion. The nurse notes that the client is experiencing uterine hypertonicity. The nurse should take which action immediately? Stop the oxytocin infusion Check the client's blood pressure Contact the primary health care provider Place the client in a side-lying position

A

A nurse is performing an initial assessment of a pregnant adolescent client with diabetes mellitus. The client says to the nurse, "I've stopped my insulin and cut back on my food." Which client concern does the nurse recognize as the priority? Concern about nutritional deficiency Concern about getting stretch marks Concern about being able to care for the infant Concern about what her friends might think about her wearing maternity clothes

A

A nurse stops at the scene of an automobile accident. One of the victims is sitting in the driver's seat, complaining of severe muscle spasms in the neck area. The nurse must take which action first? Stabilize the neck area Firmly massage the neck area Assist the victim out of the automobile and lay the victim on the ground Tell the victim that the nurse is leaving to call an ambulance but will be right back

A

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think that the twins should come to the funeral service for their grandfather. What do you advise?" Which response by the nurse would be therapeutic? "What do you and your husband believe is the right thing for your children?" "By all means have them attend. Keeping them home will only prolong their grief. " "I agree with your mother-in-law. Just tell your children that their grandfather is in heaven." "It's a difficult decision, but given their young age, maybe it would be best to keep them home from the wake and just let them attend the funeral."

A

A nurse is caring for a client who has just undergone cardioversion. Which intervention is the nurse's priority after this procedure. a. Administer oxygen b. Monitoring the BP c. Administering antidysrhythmic medications d. Monitoring the client's LOC

A ABC's of nursing. All other choices are correct, but not priority.

A client has recently been diagnosed with deep vein thrombosis of the right leg. Which of the following interventions of the nurse immediately implement? a. Elevating the foot of the bed 6 inches b. Placing ice packs on and under the right leg c. Documenting the need for hourly calf measurements d. Performing the need for hourly calf measurements

A DVT treatment includes bed rest, leg elevation, and application of warm, moist heat. Elevation decreases the venous pressure with relieves edema and pain. ROM cause cause the thrombus to mobilize to the lungs causing PEs.

A child with osteosarcoma who required amputation of a lower limb is experiencing phantom limb pain. The nurse attempts to comfort the child by providing which explanation? The pain is a normal, temporary condition The pain occurs because nerves have been cut This pain will go away once a prosthesis is used Pain medication may be needed for life to alleviate the discomfort

A Phantom limb pain is a temporary condition that some people who undergo amputation experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the client. The child should be reassured that the condition is normal.

A child who is HIV-positive is scheduled to receive a mumps, measles, and rubella (MMR) vaccine. The laboratory results show the CD4+ as 1000 cells/mm3. Which nursing action is appropriate? Administering the vaccine Contacting the primary health care provider Asking the laboratory to repeat the CD4+ test Informing the child's mother that the vaccine must not be administered at this time

A The normal CD4+ count is 500 to 1600 cells/mm3. Because this child's CD4+ count is 1000 cells/mm3, the nurse would administer the vaccine.

A nurse of the telemetry unit is caring for a client who has had a MI and is now attached to a cardiac monitor. The nurse is monitoring the client's cardiac rhythm and nots ventricular fibrillation. Which nursing intervention should the nurse take first? a. Calling the rapid response team b. Preparing the client for cardioversion c. Asking the client to bear down and cough d. Preparing to administer diltiazem

A The pattern of ventricular fibrillation is identified and can be a result after a patient with an MI. VF makes the patient feel faint, then loses consciousness and becomes pulseless and apneic (BP and heart sounds absent). Treatment is to terminate VF and covert it into a rhythm via defibrillation-> call a rapid and initiate CPR. Cardioversion is used for ventricular or supraventricular tachydysrhythmias.

A nurse on the day shift receives the client assignment for the day. In which order will the nurse assess the assigned clients? A client who was admitted during the night because of congestive heart failure A client who has been fitted with a closed chest tube drainage system A client with a nasogastric tube who underwent bowel resection 2 days ago A client on nothing-by-mouth (NPO) status who is scheduled for a barium enema at 10 a.m.

A client who was admitted during the night because of congestive heart failure A client who has been fitted with a closed chest tube drainage system A client with a nasogastric tube who underwent bowel resection 2 days ago A client on nothing-by-mouth (NPO) status who is scheduled for a barium enema at 10 a.m.

A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis through an internal AV fistula in the RA. Which intervention should the nurse implement in caring for the client? SATA a. Assessing the radial pulse in the right extremity b. Using the LA ti take BP readings c. Drawing pre-dialysis blood specimens from the LA d. Assessing the area over the AV fistula for a bruit and three each shift e. Placing a pressure dressing over the site after each dialysis treatment f. Administering IV fluids through the venous site of the AV fistula as needed

A, B, C, D

A nurse is caring for the client who is in bed and begins to exhibit seizure activity. Which actions does the nurse implement to care for the client? Select all that apply. Observing and timing the seizure Loosening any restrictive clothing Turning the client's head to the side Removing the pads on the side rails Inserting an airway into the client's mouth Removing objects that might injure the client from the vicinity

A, B, C, F

A nurse provides instructions to a pregnant woman about foods that contain calcium. The nurse realizes the client understands instructions if the client selects which products? Select all that apply. Cheese Yogurt Spinach Sardines Shellfish

A, B, D

A pregnant woman is being admitted to the maternity unit. The woman tells the nurse that she felt a large gush of fluid from her vagina on the way to the hospital. The nurse detects a fetal heart rate of 90 beats/min. On physical examination, the nurse finds that the umbilical cord is protruding from the vagina. Which actions should the nurse perform? Select all that apply. Placing the woman in knee-chest position Administering oxygen at 2 to 4 L/min by nasal cannula Administering terbutaline to stop contractions With two gloved fingers, exerting upward pressure, into the vagina, on the presenting part Wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline solution

A, C, D Oxygen should be administered at 8-10 L/min via face mask

A nurse provides instruction to a client with COPD about home oxygen therapy. Which statement made by the client indicates need for further instruction? a. I should limit activity as much as possible b. If I have trouble breathing, I need to call the doctor c. I need to drink lots of fluids to keep my mucus thin d. I can apply petroleum jelly to my nose if the oxygen dries it out e. I should wear a scarf over my nose and mouth in cold weather f. If I get a flu shot, I do not have to worry about being around people with colds

A, D, F

A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail in my coffin." Which response by the nurse is therapeutic? "Do you think that having asthma will kill you?" "You seem very distressed at learning that you have asthma." "I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your coffin.'" "Asthma is a very treatable condition, but it's important to learn how to properly administer your medications. Let's practice with your inhalant."

B

A client with diabetes mellitus who is scheduled to have blood drawn for determination of the glycosylated hemoglobin (HbA1c) level asks the nurse why the test is necessary if he is performing blood glucose monitoring at home. Which is the best response for the nurse to provide? a. Detect diabetic complications b. Assess long-term glycemic control c. Determine whether the client is at risk for hypoglycemia d Determine whether the prescribed insulin dosage is correct

B

A female client is examined in the clinic, and gonorrhea is diagnosed. The nurse provides information to the client about the disease and provides which information? Condoms will not help prevent transmission of the infection Healthcare providers are legally responsible for reporting all cases of gonorrhea to the health authorities It is not necessary for sexual partners to be examined, because the disease is not highly communicable Treatment includes the administration of an antibiotic, but it is not necessary for sexual partners to be treated

B

A nurse is caring for a hospitalized child with newly diagnosed type 1 diabetes mellitus who received NPH and regular humulin insulin at 7:30 a.m. At 11 a.m. the child suddenly complains of dizziness, headache, and a shaky feeling. The nurse immediately takes which action? a. Contacts the physician b. Gives the child milk to drink c. Arranges to have the child's lunch tray delivered early d. Prepares to administer intravenous 5% dextrose solution

B

A nurse provides information to a pregnant client about foods that are high in iron. Which food, suggested by the client after this discussion, indicates that the client requires further instruction? Spinach Tomatoes Lima beans Whole-grain bread

B

A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his belongings from where he always kept them. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic? "I know just how you feel, because I lost my husband last summer." "It's OK to grieve and be angry with your daughter and anyone else for a time." "You need to focus on the many good years you enjoyed together and move on." "I know it's a troubling time for you, but try to focus on your children and grandchildren."

B

As a nurse is providing care, the client suddenly experiences a tonic-clonic seizure. The nurse would immediately take which action first? Call the physician Turn the client to the side Restrain the client's limbs Insert an airway in the client's mouth

B

During a preoperative assessment, a nurse notices the client is crying. In light of this observation, which statement by the nurse is appropriate? "You seem upset. Would you rather be alone?" "You're crying. Tell me more about how you are feeling." "Your surgeon is the best and has done many of these operations." "Crying before a serious operation is common, but everything will be okay."

B

A nurse performing a fundal assessment after a vaginal birth notes that the fundus is above the umbilicus and displaced from the midline. What should the nurse do first? Massage the fundus Help the client void Document the findings Help the client ambulate

B A distended bladder can cause the fundus to deviate from midline

A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should take which action first? a. Asses the clear fluid for protein b. Check the clear fluid for glucose c. Place cotton calls or dry gauze loosely in the ears d. Use an otoscope to assess the tympanic membrane for rupture

B CSF contains glucose not protein.

A nurse provides home care instructions to an adolescent with sickle cell disease about measures to prevent vaso-occlusive crisis. The nurse should emphasize which priority instruction? Restrict fluid intake Contact your primary health care provider if you have a fever. Take acetylsalicylic acid (aspirin) immediately if a fever develops Be sure to spend plenty of time in the fresh air and sun each day

B Fevers can initiate a vaso-occlusive crisis. Others should also be avoided.

After a non-immunocompromised client undergoes a Mantoux test for TB infection, an area of induration 6 mm wide developed. The client asks the nurse what this result means. Which is the best response? a. We'll have to repeat the test because the result was inconclusive b. The swollen area is small, so that means your test result is negative c. You've been exposed to TB so you will need to have a chest x-ray d. You need to get started on medication right away because you have TB

B Indurations less than 10 mm (non-immunocompromised) and 5 mm (immunocompromised) is considered a negative result after 48-72 hrs. Results greater indicate exposure and possible TB infection. Morse testing (x-ray) will be needed.

The nurse is observing a new nurse employee perform an otoscopic examination of an adult client. The nurse determines the new nurse employee understands the procedure if the new nurse employee takes which action? Uses a small speculum to decrease the discomfort Pulls the pinna up and back before inserting the speculum Tilts the client's head forward before inserting the speculum Pulls the earlobe down and back before inserting the speculum

B Old= up Young= down

A nurse developing a plan of care for a client with a spinal cord injury includes measures to prevent autonomic dysreflexia (hyperreflexia). Which intervention does the nurse incorporate into the plan to prevent this complication? a. Keeping the fan running in the client's room b. Keeping the linens wrinkle free under the client c. Limiting bladder catheterization to once every 12 hours d. Avoiding the administration of enemas and rectal suppositories

B The most frequent cause of autonomic dysreflexias are a distended bladder and impacted feces. Other causes include stimulation of the skin by tactile, thermal, or painful stimuli. The nurse renders care in such a way as to minimize these risks.

A client with skeletal traction applied to the right leg complains of severe pain in the leg. The nurse realigns the client's position, but this intervention does not relieve the pain. Which action would the nurse take next? Providing pin care Calling the primary health care provider Removing some of the traction weights Medicating the client with the prescribed analgesic

B The nurse realigns the client and, if this is ineffective, calls the primary health care provider. The nurse never removes traction weights unless this is specifically prescribed by the primary health care provider. Severe leg pain, once traction has been established, indicates a problem. The client should be medicated after an attempt has been made to identify and treat the cause of the pain.

A primigravida is admitted to the labor unit. During assessment, the client's membranes rupture spontaneously. What is the priority nursing action? Checking the amniotic fluid Checking the fetal heart rate Assessing the contraction pattern Preparing for immediate delivery

B When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord.

The nurse is participating in a facility's planning committee to deal with possible bioterrorism threats. The nurse should recommend implementing which infection control measures to be used for clients in whom smallpox is diagnosed? Select all that apply. Enteric Droplet Contact Standard Protective isolation

B, C, D Smallpox is transmitted from person to person in infected aerosols and air droplets spread by way of face-to-face contact with an infected person after fever has begun, especially if the infected person is also coughing. The disease can also be transmitted in contaminated clothes and bedding, although the risk of infection from this source is much lower. Therefore droplet and contact precautions are necessary. Standard precautions are implemented for the care of all clients. Enteric precautions are implemented if the infectious agent is transmitted by way of contact with feces. Protective isolation is implemented when the client is neutropenic and needs to be protected from infection.

A nurse is preparing client assignments for the day. Which assignments would be appropriate for a registered nurse who is pregnant? Select all that apply. A client with active herpes virus lesions in the perianal area A client who requires frequent abdominal wound irrigations A client with a solid sealed implanted radiation source who is restricted to bed rest A client with methicillin-resistant Staphylococcus aureus (MRSA) under contact precautions A client undergoing mechanical ventilation through a tracheostomy who requires frequent suctioning

B, D, E

A nurse caring for a client with acquired immunodeficiency syndrome is monitoring the client for signs of complications. Which of the following would cause the nurse to suspect infection with Pneumocystis jirovec? SATA a. Diarrhea b. Tachypnea c. Pedal edema d. Intermittent fever e. Dyspnea with ambulating f. Expectoration of frothy mucus

B, D, E A opportunistic respiratory infection associated with AIDs that causes dyspnea, nonproductive cough, intermittent fever, fatigue, anorexia, tachypnea, wt. loss.

A client who is delusional says to the nurse, "Terrorists have been sent here to kill me." How should the nurse respond to the client? "No one is going to kill you." "Your medication is making you feel like this." "Are you worried that people are trying to hurt you?" "What makes you think that terrorists were sent to hurt you?"

C

A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. Which is the first action on the part of the nurse? a. Calling the physician b. Inserting an oral airway c. Turning the client on her side d. Noting the time of the seizure

C

A nurse completes an initial assessment of a client admitted to the mental health unit. Which assessment finding is the priority concern? Bruises on the client's neck The client's report of not sleeping well The client's report of suicidal thoughts The spouse's statement "I don't approve of this treatment."

C

A nurse is assessing a client during her first prenatal visit to the clinic. The nurse takes the client's temperature: 100.8°F (38.2°C). Which of the following actions on the part of the nurse is appropriate? Documenting the temperature Retaking the temperature rectally Notifying the primary health care provider Informing the client that a temperature of 100.8°F is normal during pregnancy

C

A nurse is preparing to administer digoxin to a client with heart failure. When assessing the client, the nurse notes an apical pulse rate of 58 beats/min. Also, the client complains of anorexia and nausea. Which action should the nurse take first on the basis of these assessment findings? a. Contact the primary health care provider b. Administer an as-needed antiemetic c. Check the most recent digoxin level d. Administer the digoxin with an antacid

C

A nurse reviewing the record of a child with suspected acute poststreptococcal glomerulonephritis notes that the child recently had a streptococcal throat infection that was treated with antibiotics. Which diagnostic test will confirm the presence of acute poststreptococcal glomerulonephritis does the nurse expect to find? Throat culture Blood urea nitrogen (BUN) Antistreptolysin (ASO) titer White blood cell (WBC) count

C

A postpartum nurse is caring for a client who had a placenta previa. Which nursing intervention does the nurse, reviewing the plan of care, identify as the priority for this client? Fundal assessment Monitoring of urine output Frequent assessment of lochia Inclusion of iron in every meal

C

An emergency department nurse is caring for an older client who may have been physically abused by her caregiver. In planning care for the client, the nurse takes which priority action? Notifying the police department Obtaining psychiatric help for the caregiver Contacting adult protective services to investigate the situation Telling the caregiver that he or she is not allowed to care for the client

C

A nurse provides information to the mother of a child with diarrhea about signs and symptoms that indicate the need to call the primary health care provider. Which statement by the mother indicates the need for further instruction? "I'll call the doctor if she gets dizzy and acts sick." "I'll call the doctor if she has severe stomach cramps." "I'll call the doctor if her temperature is 102°F (38.9°C) or higher." "I'll call the physician if she goes longer than 6 hours without urinating."

C Call doctor at temperature above 100.

A nurse provides home care instructions to a client who has been fitted with a halo device to treat a cervical fracture. Which statement by the client indicates the need for further teaching? a. I need to get more fluids and fiber into my diet b. I should cut my food into small pieces before I eat c. I need to put powder under the vest twice a day to prevent sweating d. I have to check the pin sites everyday and watch for signs of infection

C Cleanse the skin under the wool liner each day to prevent rashes and soars.

In caring for a child admitted to the hospital with Kawasaki disease, the nurse should monitor the child most closely for signs which complication? Anemia Renal failure Thrombus formation Gastrointestinal disturbances

C Kawasaki disease, also called mucocutaneous lymph node syndrome, is an acute febrile exanthematous illness of children with a generalized vasculitis of unknown origin. A generalized immune response affects the smooth muscle cells of the vascular walls. These vascular changes, along with the increase in platelets that occurs as part of the disease, can cause thrombus formation, myocardial infarction, and death in some children.

A rubella titer is performed on a woman who has just been told that she is pregnant. The results of the titer indicate that the mother is not immune to rubella. The nurse realizes the patient understands patient teaching if the patient makes which statement? "I may need to get a therapeutic abortion." "I will need an immunization against rubella immediately." "Immunization against rubella is required after delivery." "Antibiotics will be prescribed to prevent the infection."

C MMR vaccines are contraindicated in pregnancy

A client who is 8 weeks pregnant reads her electronic medical record via a patient portal. She contacts the clinic and asks the nurse to explain a "positive Hegar sign." Which is the best answer for the nurse to provide? "You are able to feel fetal movement." "A soft blowing sound can be heard with a stethoscope." "The lower part of your uterus is softer than when you are not pregnant." "You are experiencing irregular painless contractions during the pregnancy."

C Softening and compressibility of the lower uterine segment, occurring around the sixth week of pregnancy, is called the Hegar sign.

A nurse is assessing a client who has undergone radical neck dissection for the treatment of cancer. The nurse hears stridor when auscultating over the trachea. On the basis of this finding, which is the priority nursing action? a. Assess the client's pulse oximetry Incorrect b. Place the client in a supine position c. Contact the primary health care provider d. Administer a nebulizer treatment with the use of a bronchodilator

C Stridor indication there is an obstruction and the HCP should be notified immediately. The patient should be placed in high Fowlers and pulse oximetry can be completed by is not the priority.

A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes an audible wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. After immediately disconnecting the suction source from the catheter, which intervention does the nurse implement next? Calling a code Administering an inhaled bronchodilator Connecting oxygen to the suction catheter Encouraging the client to take deep breaths

C The inability to remove a suction catheter is a critical situation. This finding, along with the client's symptoms presented in the question, indicates bronchospasm and bronchoconstriction. The nurse must immediately disconnect the suction source from the catheter but leave the catheter in the trachea. The nurse then connects the oxygen source to the catheter, because the client is at risk for hypoxia.

A nurse responds to an external disaster in a large city involving an explosion at a shopping mall. Numerous victims require treatment. Which victim will the nurse attend to first? A victim with multiple bruises who is alert and oriented A victim who has sustained multiple lacerations with minor bleeding A victim who is alert and wandering around yelling that he cannot see A victim with a crush injury to the abdomen who has no pulse or blood pressure

C The victim who must be treated immediately because of the threat to life, limb, or vision is categorized as emergent and is the priority.

A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux (GER) would expect to note documentation of which other issue? Refusal to suck Frequent diarrhea Recurrent otitis media Inability to pass stools

C Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media resulting from pooling of secretions in the nasopharynx during sleep are characteristics of all types of GER.

Zidovudine is prescribed for a client with AIDS. The nurse tells the client that it is important to report back to the clinic as scheduled for which follow-up diagnostic? a. Blood glucose checks b. Blood pressure checks c. Complete blood counts (CBC) d. Electrocradiographic studies

C Zidovudine is an antiviral medication that cause cause agranulocytosis and anemia.

A contraction stress test is scheduled, and the nurse provides instructions to the client regarding the test. Which pieces of information should the nurse give to the client? Select all that apply. An internal fetal monitor is attached. The client will walk on a treadmill until contractions begin. A positive test result indicates a need for further evaluation. Special body movements will be performed to stimulate contractions. The client may be asked to massage one or both nipples to stimulate uterine contractions.

C, E he fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother, and a 20- to 30-minute baseline strip is recorded. The uterus is stimulated to contract either with the administration of a dilute dose of oxytocin (Pitocin) or by having the mother stimulate the nipples until three palpable contractions with a duration of 40 seconds or more in a 10-minute period have been achieved. Frequent maternal blood pressure readings are taken, and the client is monitored closely if increasing doses of oxytocin are given. A positive contraction stress test result indicates that the fetus may be compromised and requires continued monitoring and further evaluation. A negative result indicates fetal well-being.

A pregnant client complains of heartburn, and the nurse provides instruction regarding measures to alleviate the problem. The nurse tells the client to take which action? Lie down right after meals Take antacids as often as necessary Eat three meals a day and avoid eating between meals Sleep with an extra pillow under the head and shoulders

D

A nurse on the day shift is assigned to care for four clients. In which order will the nurse assess the clients after receiving report from the night shift. A client scheduled for an electrocardiogram (ECG) at 11 a.m. A client on nothing-by-mouth (NPO) status who is for bronchoscopy at 9 a.m. A client who has undergone above-the-knee amputation who is scheduled for discharge home A client who had a seizure at 2 a.m. and was treated with intravenous (IV) diazepam and phenytoin

D

A nurse provides dietary instructions to the mother of a child with iron-deficiency anemia. The nurse realizes the mother understands the instructions if the mother states she will increase which food in the child's diet? Milk Cheese Orange juice Cream of Wheat

D

A client hospitalized on a mental health unit with schizophrenia tells the nurse, "The voices in my head say that I'm worthless and that I don't deserve to be alive." What is the nurse's priority concern for this client? Ineffective coping skills Perceptual disturbances Chronic low self-esteem Risk for self-directed violence

D

A client in a manic state emerges from her room wearing provocative clothing and quickly enters the dayroom. She announces to the group that she is the star of a burlesque show and will begin her performance shortly. Which is the priority nursing action? Ask the client to go to her room and to change her clothes Tell the client firmly that burlesque shows are not allowed in the nursing unit Tell the client that her bathroom privileges are being suspended because of her behavior Quietly and firmly assist the client to her room and help her dress in appropriate clothes

D

A client with a manic disorder monopolizes group therapy. What should the nurse leading the group say to the client? "Leave the room." "Go to the nurses' station until our group therapy session is finished." "I will recommend that group therapy be eliminated from your treatment plan." "Thank you for your comments. Now, try to stop talking and listen to the others."

D

A nurse has provided dietary instructions to a pregnant client with diabetes mellitus. Which patient statement indicates the patient understands the teaching? "I should increase my fat intake to ensure that the baby gains weight." "I'll need to start a high-protein, high-fat diet to help control the blood glucose level." "I should add extra glucose to the diet because additional calories are needed during pregnancy." "I will need to increase fiber in the diet to help control the blood glucose level and prevent constipation."

D

A nurse is monitoring a client in precipitous labor. The nurse would contact the primary health care provider on noting which concern? Fetal descent of 1 cm/hr A reassuring fetal monitoring pattern Cervical dilation of 2 to 4 cm/hr during the active phase Shortening periods of uterine relaxation between contractions

D

A nurse is providing care to a client with a closed chest tube drainage system. When the nurse assists the client in turning onto his side, the chest tube is accidentally dislodged from the insertion site. The nurse must immediately take which action? Reinsert the chest tube Turn the client onto his back Contact the primary health care provider Apply pressure over the chest tube insertion site

D

A nurse is monitoring the neurological status of a client who underwent craniotomy 3 days ago. Which signs or symptoms would prompt the nurse to notify the primary health care provider immediately? a. Disorientation to date b. Pupils equal and reactive at 4 mm c. Mild headache relieved by acetaminophen with codeine d. Pain with forward flexion of the neck onto the chest

D A complication of cranial surgery is meningitis.

A nurse is assigned to conduct an admission assessment of a client who was treated in the emergency department after attempting suicide by cutting her wrists with a razor blade. When the client arrives at the nursing unit, the nurse should take which action first? a. Ask the client to sign a no-harm contract b. Ask the client to report any suicidal thoughts immediately c. Place the client under suicide precautions with 15-minute checks d. Check the dressings that were placed over the client's wrists in the emergency department

D First assess the physical state of the patient for safety then implement precautions.

A nurse performs a bedside glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of (2.164 mmol/L)35 mg/dL. The nurse would take which action first? Ask the mother to breastfeed the newborn Bottle-feed the newborn with diluted glucose Start an intravenous line for the administration of glucose Ask the laboratory to perform a blood glucose test immediately

D Normal newborn levels are 40 mg/dL or greater. Glucose levels of less than (2.22-2.298 mmol/L))40 to 45 mg/dL measured with bedside glucose screening should be reported and verified in the laboratory. Although feeding is an intervention, the result of a bedside glucose must be verified by the laboratory. Some infants need IV glucose to maintain glucose balance and prevent damage to the brain.

A nurse is caring for a client with increased intracranial pressure. In which position should the nurse maintain the client? a. Supine with the head extended b. Side lying with the neck flexed c. Supine with the head turned to the side d. Head midline and elevated 30-45 degrees

D Proper positioning promotes venous drainage from the cranium to minimize ICP.

A clients arterial blood gases are analyzed; pH 1.49, paO2 97 mmHg, HCO3- 22 mEq/L. Which acid base balance disturbance does the nurse identify from these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

D RAcidosis: paCo2 >45 mmHg and RAlkalosis is paCo2 <35 mmHg. MAcidosis is HCO3- is less than 22 mEq/L and MAlkalosis is HCO3- greater than 26 mEq/L.

A nurse is evaluating outcomes for a client with Guillain-Barre syndrome. Which outcome does the nurse recognize as optimal respiratory outcomes for the client? a. Normal deep tendon reflexes b. Improved skeletal muscle tone c. Absences of paresthesias in the lower extremities d. Clear sound in the lower lung fields bilaterally e. pO2 of 85 mmHg and pCO2 of 40 mmHg

D, E