NCLEX Prep 3
28.A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include? A. "Avoid driving until the medication's effects are evident." B. "Take the medication on an empty stomach." C. "Stop taking the medication immediately for headache." D. "Diarrhea is an adverse effect of this medication."
A. "Avoid driving until the medication's effects are evident."
25.A nurse is reinforcing teaching with a client who takes diazepam. Which of the following information should the nurse the nurse include? A. "Diazepam can cause drowsiness." B. "A single dose of diazepam is unlikely to cause side effects." C. "Avoid foods that contain tyramine." D. "Grapefruit juice inactivates this medication."
A. "Diazepam can cause drowsiness."
44.A nurse is reinforcing teaching to a client about skin cancer. Which of the following statements by the client indicates a need for further teaching? A. "Eating a high fiber diet will reduce my risk for developing skin cancer." B. "I should check my skin monthly for any changes." C. "I should avoid the use of tanning booths." D. "I should use sunscreen even on cloudy days."
A. "Eating a high fiber diet will reduce my risk for developing skin cancer."
40.A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud's phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching? A. "I will keep my house at a cool temperature." B. "I will try to anticipate and avoid stressful situations." C. "I will complete the smoking cessation program I started." D. "I will wear gloves when removing food from the freezer."
A. "I will keep my house at a cool temperature."
39.A nurse is reinforcing teaching with a client who has iron deficiency anemia and is to start taking ferrous sulfate twice a day. Which of the following statements by the client indicate an understanding of the teaching? A. "I will take the medication with orange juice." B. "I should expect to have loose stools while taking this medication." C. "I will have clay-colored stools while taking this medication." D. "I should take the medication with milk."
A. "I will take the medication with orange juice."
75.A nurse is caring for a 9-year-old child who has a new diagnosis of diabetes mellitus and tells the nurse that he is eager to return to school and participate in sports. The mother tells the nurse that she is afraid to let her take part in physical activities at school. Which of the following responses should the nurse make? A. "Tell me more about how you are feeling about your daughter's activities." B. "You might want to consider teaching your daughter at home." C. "I agree. Her well-being is the most important thing." D. "You sound overprotective. Let's talk about this some more."
A. "Tell me more about how you are feeling about your daughter's activities."
73.Assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry because I think that the client might be doing it just to get attention." Which of the following responses by the nurse is therapeutic? A. "Tell me what makes you feel the client is doing this on purpose?" B. "Next time this happens, tell me and I'll talk to the client about his behavior." C. "You are probably right. Soiling the bed is a way of getting attention from the nursing staff." D. "Why don't you spend more time with the client if you think that she is trying to get attention?"
A. "Tell me what makes you feel the client is doing this on purpose?"
66.A nurse is reinforcing teaching about protecting client health information with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of confidentiality? A. "The courts may require me to discuss confidential information." B. "I am required to provide confidential information to insurance companies." C. "If questioned during a police investigation, I am required to divulge confidential information." D. "I am legally allowed to discuss confidential information with the client's former therapist."
A. "The courts may require me to discuss confidential information."
18.A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby's mouth, which of the following responses by the nurse is appropriate? A. "You should place your nipple and some of the areola into her mouth." B. "Babies know instinctively exactly how much of the nipple to take into their mouth." C. "Your baby's mouth is rather small so she will only take part of the nipple." D. "Try to place the nipple, the entire areola, and some breast tissue beyond the areola into her mouth."
A. "You should place your nipple and some of the areola into her mouth."
58.A nurse is planning to assign care activities to the assistive personnel (AP). Which of the following activities are appropriate for assignment to the AP? (Select all that apply.) A. Accompanying a client who has depression to occupational therapy B. Determining the level of exhaustion in a client who has hypomania C. Checking the position of a client who is in soft wrist restraints D. Setting limits with a client who has mania E. Sitting with a client who has alcohol use disorder whose last drink was 4 days ago
A. Accompanying a client who has depression to occupational therapy C. Checking the position of a client who is in soft wrist restraints E. Sitting with a client who has alcohol use disorder whose last drink was 4 days ago
36.A nurse is assisting with the plan of care for a client who has pneumonia and requires chest percussion, vibration, and postural drainage. Which of the following actions should the nurse plan to complete first? A. Auscultate lung fields. B. Provide mouth care. C. Cup hands and tap on the client's chest repeatedly. D. Position the client so that the lung area to be drained is above the client's trachea.
A. Auscultate lung fields.
35.A nurse is reinforcing discharge teaching with a client following a cataract extraction. Which of the following should the nurse include in the teaching? A. Avoid bending at the waist. B. Remove the eye shield at bedtime. C. Limit the use of laxatives if constipated. D. Seeing flashes of light is an expected finding following extraction.
A. Avoid bending at the waist.
14.A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following findings are associated with this diagnosis? (Select all that apply.) A. Coughing B. Poor suck reflex C. Sunken abdomen D. Respiratory distress E. Frothy saliva
A. Coughing D. Respiratory distress E. Frothy saliva
69.A nurse is conducting a home health visit for an older adult client who lives with family members. The nurse notices that the client has multiple unusual bruises, and based on several other factors, the nurse suspects that the client has been physically abused. Which of the following actions should the nurse take first? A. Follow the agency's guidelines for reporting suspected abuse. B. Arrange referral for family therapy to deal with home stressors. C. Institute more frequent visits to the client's home. D. Check the bruises at the next visit to the client's home.
A. Follow the agency's guidelines for reporting suspected abuse
23.A nurse is instructing a mother about caring for a child who has impetigo contagiosa. Which of the following directions should the nurse plan to include? A. Give the child his own towel and washcloth to use. B. Wash the child's clothes in tepid water. C. Have family members receive an immunization to prevent acquiring the infection. D. Apply an antifungal ointment to the lesions.
A. Give the child his own towel and washcloth to use.
33.A nurse is preparing a presentation for coworkers about the various herbal remedies clients might report using. Which of the following should she include as an herbal supplement clients might use to treat osteoarthritis of the knee, hip, and wrists? A. Glucosamine B. Feverfew C. Ginger root D. Ginkgo biloba
A. Glucosamine
21.A nurse in a pediatric clinic nurse is talking with a parent of a toddler. The parent tells the nurse that her toddler drinks a quart of milk a day. The nurse should recognize that the toddler is at risk for which of the following disorders? A. Iron-deficiency anemia B. Beriberi C. Diabetes mellitus D. Dehydration
A. Iron-deficiency anemia
43.A nurse is caring for a client who has recurrent herpes simplex type 1 lesions. The nurse should perform a focused assessment of which of the following areas of the client's body? A. Mouth B. Genitalia C. Extremities D. Scalp
A. Mouth
15.A nurse is reinforcing teaching with a client who is pregnant and has phenylketonuria (PKU). Which of the following foods should the nurse instruct the client to eliminate from her diet? A. Peanut butter B. Potatoes C. Apple juice D. Broccoli
A. Peanut butter
6.A nurse is collecting data about reflexes from a newborn. Which of the following actions should the nurse take to elicit the newborn's Moro reflex? A. Perform a sharp hand clap near the infant. B. Hold the newborn vertically, allowing one foot to touch the crib surface. C. Place a finger at the base of the newborn's toes. D. Turn the newborn's head quickly to one side.
A. Perform a sharp hand clap near the infant.
26.A nurse is collecting data from client who has just begun therapy with alprazolam to treat anxiety. The nurse should observe the client for which of the following adverse effects of this medication? A. Sedation B. Bradycardia C. Hearing loss D. Hypertension
A. Sedation
30.A nurse is collecting data from a client who reports taking several herbal supplements. Which of the following supplements should the nurse tell the client can increase sedation in clients who take CNS depressant medications? A. Valerian B. Black cohosh C. Echinacea D. Ginkgo biloba
A. Valerian
72.A nurse is reinforcing discharge teaching with a client who has bipolar disorder and is to begin taking lithium. Which of the following instructions should the nurse include in the teaching? A. "The medication on an empty stomach." B. "Avoid dieting." C. 'Decrease sodium intake." D. "Limit daily fluid intake to less than 1200 milliliters."
B. "Avoid dieting."
7.A nurse is caring for a newborn who was delivered by vacuum extraction and has swelling on his head that crosses the suture line. The newborn's mother asks about the swelling on her newborn's head. Which of the following responses should the nurse make? A. "This is a Mongolian spot, which is found on many newborns." B. "This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor." C. "This is a cephalhematoma, which will resolve on its own in 3 to 5 days." D. "This is erythema toxicum, which is a transient allergic reaction that causes edema in the skin."
B. "This is a caput succedaneum, which is a collection of fluid from pressure of the vacuum extractor."
1.A nurse is caring for a client during a nonstress test (NST). The nurse observes two decelerations of 15/min in the fetal heart rate during a period of fetal movement. Each deceleration lasts 20 seconds. Which of the following results are indicated by these findings? A. A negative test B. A nonreactive test C. A positive test D. A reactive test
B. A nonreactive test
68.A nurse in an assisted-living facility is caring for a client who is in early stages of dementia. The client has been oriented to name and place and is usually cooperative. Which of the following nursing actions is appropriate if the client refuses to take morning medications? A. Crush the pills, if not contraindicated, and hide them the client's in applesauce. B. Ask the client to express her reasons for refusing the morning medications and document the event. C. Try to talk the client into adherence by telling her the possible implications of missing a dose. D. Notify the charge nurse of the need for evaluation of the client's level of competence.
B. Ask the client to express her reasons for refusing the morning medications and document the event.
76.A nurse is caring for a client who has substance use disorder and undergoing detoxification for alcohol use. Which of the following medications should the nurse administer to minimize the client's craving for alcohol? A. Chlordiazepoxide B. Atenolol C. Clonidine D. Carbamazepine
B. Atenolol
47.A nurse is caring for a client who is postoperative and has an incision. To support tissue, repair the nurse should recommend that the client increase his dietary intake of which of the following? A. Fats B. Complex carbohydrates C. Fiber D. Vitamin E
B. Complex carbohydrates
13.A nurse on the postpartum unit is collecting data from a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize this client is at risk for which of the following postpartum complications? A. Amniotic fluid embolism B. Disseminated intravascular coagulation (DIC) C. Preeclampsia D. Puerperal infection
B. Disseminated intravascular coagulation (DIC)
54.A nurse is caring for a client who has widespread psoriasis. The nurse should prepare the client for which of the following treatments? A. Radiation therapy B. Exposure to photochemotherapy C. Topical application of antibiotic ointment D. Administration of isotretinoin
B. Exposure to photochemotherapy
31.A nurse is collecting data from a client who reports taking several herbal supplements. Which of the following supplements should the nurse tell the client can increase anticoagulation effects and thus increase risk for bleeding? A. Valerian B. Feverfew C. St. John's wort D. Saw palmetto
B. Feverfew
10.A nurse is collecting data from a client who is 12 hr postpartum. Which of the following findings should the nurse expect? A. Fundus soft, to the right of the umbilicus B. Fundus firm, at the level of the umbilicus C. Fundus firm, 2 fingerbreadths above the umbilicus D. Fundus soft, 2 fingerbreadths below the umbilicus
B. Fundus firm, at the level of the umbilicus
29.A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparin's effects? A. Vitamin K B. Protamine sulfate C. Acetylcysteine D. Deferoxamine
B. Protamine sulfate
20.A nurse at a pediatric hotline receives a call from a mother who plans to administer aspirin to a toddler for a fever and wants to know the dosage. Which of the following statements by the nurse is an appropriate response? A. "You'll have to call your physician." B. "Give her no more than three baby aspirin every 4 hours." C. "Give her acetaminophen, not aspirin." D. "Follow the directions on the aspirin bottle for her age and weight."
C. "Give her acetaminophen, not aspirin."
63.A nurse in a long-term care facility is reinforcing teaching with a newly licensed nurse about methods to reduce the cost of client care. Which of the following statements indicates an understanding of the teaching? A. "I should discourage clients from taking as-needed pain medications." B. "I should perform perineal care on a client with an indwelling urinary catheter once a day." C. "I should encourage clients to receive an annual influenza immunization." D. "I should use clean gauze to cover a client's open wound."
C. "I should encourage clients to receive an annual influenza immunization."
56.A nurse is reinforcing teaching about self-management strategies with a client who has emphysema. Which of the following client statements indicates that the client understands the instructions? A. "I will inhale slowly through pursed lips to help me breathe better." B. "I will drink about 34 ounces of fluid every day." C. "I will follow a diet high in calories and protein." D. "I will lie on my stomach to practice abdominal breathing every day."
C. "I will follow a diet high in calories and protein."
38.A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following a renal transplant. Which of the following statements by the client indicates an understanding of the teaching? A. "I will take this medication until my BUN returns to normal." B. "This medication will help my new kidney make adequate urine." C. "I will need to take this medication for the rest of my life." D. "This medication will boost my immune system."
C. "I will need to take this medication for the rest of my life."
3.A nurse in a provider's office is caring for a client who is at 36 weeks of gestation and is scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following responses by the nurse is appropriate? A. "This will determine if there is more than one fetus." B. "It is useful for estimating fetal age." C. "It assists in identifying the location of the placenta and fetus." D. "This is a screening tool for spina bifida."
C. "It assists in identifying the location of the placenta and fetus."
49.A nurse is caring for the client who has Ménière's disease. When asked by the client if he is allowed to ambulate independently, which of the following responses should the nurse make? A. "You are free to move around your room as you wish, but you should avoid the hallways." B. "You are on strict bed rest and must not be up." C. "Please call for assistance when you wish to get out of bed." D. "Why would we not allow you to walk if you wanted?"
C. "Please call for assistance when you wish to get out of bed."
60.A nurse is caring for a client who is scheduled for a surgery. The client states, "I have changed my mind and I don't want the surgery." Which of the following responses should the nurse give? A. "Many clients have had no complications with this surgery." B. "You will feel much better after the surgery." C. "You can change your mind about the surgery at any time." D. "If you do not have the surgery, your condition will worsen."
C. "You can change your mind about the surgery at any time."
65.A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to see first? A. A client who wants a bath B. A client who needs a referral for home health services C. A client who requests pain medication D. A client who asks to review the instructions he received about his new prescription
C. A client who requests pain medication
77.A nurse is selecting a toy for a 7-month-old infant. Which of the following toys should the nurse choose? A. A set of blocks to build a block tower B. A colorful crib mobile that plays music C. A soft toy that squeaks or crackles when squeezed D. A wooden farm animal puzzle with large pieces
C. A soft toy that squeaks or crackles when squeezed
62.A charge nurse overhears a provider speaking to a staff nurse in anger concerning incorrect supplies that are available. Which of the following actions by the charge nurse displays conflict resolution? A. Use aggressive communication skills. B. Assist the provider in identifying alternative solutions. C. Address the situation as soon as possible. D. Foster closed communication.
C. Address the situation as soon as possible
48.A nurse is checking the laboratory tests for a client who has glomerulonephritis. The nurse should expect to find an increase in which of the following test results? A. Creatinine clearance B. RBC C. BUN D. Specific gravity
C. BUN
59.A nurse mistakenly administers a dose of metformin within 1 hr of the previous dose. Which of the following findings should alert the nurse that the client is experiencing an adverse effect from the medication error? A. Confusion and lethargy B. Rapid and deep respirations C. Diaphoresis and tachycardia D. Nausea and abdominal cramping
C. Diaphoresis and tachycardia
5.A nurse is caring for a newborn immediately after birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn? A. Placing the newborn on a warm surface B. Preventing air drafts C. Drying the newborn's skin thoroughly D. Maintaining ambient room temperature at 24° C (75° F.)
C. Drying the newborn's skin thoroughly
19.A nurse is assisting with the care of a client who is multigravid and in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following is the appropriate nursing response? A. Assist the client into a comfortable position. B. Assess the perineum for signs of crowning. C. Have the client pant during the next few contractions. D. Help the client to the bathroom to empty her bladder.
C. Have the client pant during the next few contractions.
12.A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following treatments should the infant receive? A. Hepatitis B immune globulin at 1 week followed by the hepatitis B vaccine monthly for 6 months B. The hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen C. Hepatitis B immune globulin and the hepatitis B vaccine within 12 hr of birth D. The hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days
C. Hepatitis B immune globulin and the hepatitis B vaccine within 12 hr of birth
2.A nurse in a clinic is reviewing the medical records of a group of clients who are pregnant. The nurse should anticipate that the provider will order an amniotic fluid alpha-fetoprotein screening for which of the following clients? A. Has mitral valve insufficiency B. Has been exposed to AIDS C. History of delivering a child with a neural tube defect D. History of preterm labor
C. History of delivering a child with a neural tube defect
80.A nurse is caring for a child who has idiopathic thrombocytopenic purpura and is experiencing a nosebleed. Which of the following actions should the nurse take? A. Apply warm pack to the bridge of the child's nose. B. Move the child into a supine position. C. Insert cotton into each of the child's nostrils. D. Tilt the child's head back.
C. Insert cotton into each of the child's nostrils.
4.A nurse is assisting in the care of a client who is scheduled for a cesarean birth based on the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature? A. Phosphatidylglycerol (PG) absent B. Biophysical profile score of 8 C. Lecithin/sphingomyelin (L/S) ratio of 2:1 D. Nonstress test is reactive
C. Lecithin/sphingomyelin (L/S) ratio of 2:1
11.A nurse is caring for a postpartum client who saturates a perineal pad in 10 min. Which of the following actions should the nurse take first? A. Check the client's blood pressure. B. Observe for pooling of blood under the buttocks. C. Massage the client's fundus. D. Administer oxytocin.
C. Massage the client's fundus.
61.A client has been waiting for discharge medications from the pharmacy for more than 2 hr. Which of the following actions should the nurse identify as an opportunity for performance improvement in this area? A. Suggesting to the nurse supervisor that the pharmacy deliver discharge medications faster B. Having pharmacy and nursing staff attend a seminar about performance improvement C. Participating on a work team that includes pharmacy and nursing staff D. Discussing delivery of discharge medications with the pharmacy manager
C. Participating on a work team that includes pharmacy and nursing staff
45.A nurse is caring for a client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40% by face tent. The client's SiO2 is 89 %. ABG results are: pH 7.31, PaO2 93 mm Hg, PCO2 50 mm Hg, HCO3 25 mEq/L. Which of the following is an appropriate action by the nurse? A. Switch oxygen to a nonrebreather mask. B. Increase oxygen to 70%. C. Place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing. D. Position the client prone and have the respiratory therapist perform postural drainage.
C. Place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing.
16.A nurse is assisting with the care of a client who is at 37 weeks of gestation and has placenta previa. Which of the following risks is the primary reason the nurse should avoid performing a pelvic examination? A. Infection B. Preterm labor C. Profound bleeding D. Rupture of the fetal membranes
C. Profound bleeding
41.A nurse is caring for a client who has suspected superficial spreading melanoma. When collecting data about the client's lesion, which of the following is an expected finding? A. Pain B. Pruritus C. Purplish in color D. Purulent drainage
C. Purplish in color
51.A nurse in a clinic is caring for a client who is postmenopausal and has risk factors for osteoporosis. The nurse anticipates the client will be prescribed which of the following medications? A. Levothyroxine B. Calcitonin C. Raloxifene hydrochloride D. Escitalopram oxalate
C. Raloxifene hydrochloride
53.A nurse is reinforcing teaching with a client who has herpes zoster. The nurse should include which of the following statements in the teaching? A. Herpes zoster is only contagious to others who have had chickenpox. B. The client is contagious only if the lesions are draining. C. Recurrence of infection can be triggered by stress or trauma. D. Recovery occurs in 6 to 8 weeks.
C. Recurrence of infection can be triggered by stress or trauma.
37.A nurse is reviewing the medical record of a client and identifies a serum potassium 6.8 mEq/L. Which of the following medications should the nurse expect to administer? A. Lactulose B. Triamterene C. Sodium polystyrene D. Acetylcysteine
C. Sodium polystyrene
24.A nurse is reinforcing teaching with a client who uses a nitroglycerine patch to treat angina. The client now has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include? A. Swallow the tablet whole with an 8 oz glass of water. B. Store the medication in a pill box at the bedside. C. Take the medication at the first indication of chest pain. D. Remove the nitroglycerine patch before taking the sublingual tablet.
C. Take the medication at the first indication of chest pain.
71.A nurse is caring for a client with has schizophrenia and is taking haloperidol. The nurse should monitor the client for which of the following adverse effects? A. Increased salivation B. Serotonin syndrome C. Tardive dyskinesia D. Increased menstrual bleeding
C. Tardive dyskinesia
55.A nurse is assisting with the development of a teaching plan for a client who has psoriasis. Which of the following statements should the nurse include in the plan? A. Wash the affected area with hot water. B. Treatment will focus on pain management. C. Treatment will include coal tar preparations. D. Apply warm moist compresses to the affected areas.
C. Treatment will include coal tar preparations.
57.A nurse is reinforcing teaching with a newly licensed nurse about limit-setting for a client who exhibits manipulative behaviors. Which of the following responses by the newly licensed nurse indicates further teaching is needed? A. "Consistency among staff is important." B. "I will set limits each time I see a dysfunctional behavior from a client." C. "I understand that setting limits counteracts resistance." D. "I will bargain with the client about consequences."
D. "I will bargain with the client about consequences."
78.During a routine well-child visit, a nurse is reinforcing teaching with the parents of a preschool-age child whom they have difficulty getting to sleep. Which of the following statements by the parents indicates an understanding of the teaching? A. "I will allow my child to watch TV to help him go to sleep." B. "I will let my child fall asleep with me, and then move him to his own bed." C. "I will make sure the room is dark when placing my child in bed." D. "I will encourage my child to fall asleep with his favorite toy."
D. "I will encourage my child to fall asleep with his favorite toy."
52.A nurse in a clinic is reinforcing teaching to a client who is postmenopausal about the prevention of osteoporosis. Which of the following statements by the client requires clarification of the teaching? A. "I will decrease the amount of sodium in my diet." B. "I will eat a moderate amount of high-fiber foods." C. "I will decrease the number of cups of coffee I drink daily." D. "I will include vitamin E rich foods in my diet."
D. "I will include vitamin E rich foods in my diet."
74.A nurse is caring for a client who has cancer. The client states that she wants to try nontraditional treatments instead of the chemotherapy recommended by her provider. Which of the following responses should the nurse make? A. "Using nontraditional treatments is not a good Idea. I'd rather you avoid that route." B. "A lot of people think nontraditional treatments will work, and they find out too late that they made the wrong choice." C. "Your doctor is very knowledgeable. If he prescribes chemotherapy, it's the best treatment for you." D. "Tell me more about your concerns about chemotherapy."
D. "Tell me more about your concerns about chemotherapy."
79.A nurse is assisting with a parenting class and is approached by a parent of a 2-year-old toddler who asks what to do when the toddler throws a tantrum. Which of the following instructions should the nurse give? A. Place the child in time-out for 3 min. B. Distract the child by buying a toy. C. Calmly tell the child to stop. D. Appear to ignore them.
D. Appear to ignore them.
27.A nurse is preparing to use the Z-track technique to administer a medication to a client. Which of the following actions should the nurse plan to take? A. Pull the skin 1.3 cm (1/2 inch) to the side. B. Insert the needle slowly and gently. C. Use a 45° angle of insertion. D. Aspirate for 5 to 10 seconds.
D. Aspirate for 5 to 10 seconds.
9.A nurse is collecting data from a postpartum client and notes the client's fundus is boggy and displaced to the right. Which of the following actions should the nurse take? A. Encourage the client to perform Kegel exercises. B. Position the client on her left side. C. Ask the client to rate her pain. D. Assist the client to the bathroom to void.
D. Assist the client to the bathroom to void.
67.A nurse is collecting data from a client who has schizophrenia and is taking fluphenazine. The nurse observes that the client's tongue is protruding and he has irregular movements of his limbs. The nurse should identify that the client is exhibiting manifestations of which of the following? A. A reaction to drinking grapefruit juice with the medication. B. Missing a dose of the medication. C. Early symptoms of a psychotic episode. D. Early symptoms of tardive dyskinesia.
D. Early symptoms of tardive dyskinesia.
17.A nurse is assisting in the care of a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take? A. Instruct the client to apply mineral oil to the nipples after each feeding. B. Encourage the client to keep the nipples covered when not breastfeeding. C. Instruct the client to limit feedings to 10 min on each breast. D. Encourage the client to change the newborn's position with each feeding.
D. Encourage the client to change the newborn's position with each feeding.
32.A nurse is collecting data from a client who reports she takes ma huang to help her lose weight. The nurse should collect data regarding which of the following adverse effects of ma huang? A. Immunosuppression B. Rheumatoid arthritis C. Hyperpyrexia D. Hypertension
D. Hypertension
46.A nurse is caring with the plan of care for a client who is scheduled for a transurethral resection of the prostate (TURP). Which of the following interventions should the nurse include in the plan of care? A. Discuss with the client that surgery will result in impotence. B. Inform the client that fluids are limited to 100 mL per day for the first 3 days after surgery. C. Limit the client's intake of high-fiber foods following surgery. D. Inform the client to expect insertion of a large indwelling urinary catheter following surgery.
D. Inform the client to expect insertion of a large indwelling urinary catheter following surgery
70.A nurse in a mental health facility is caring for a client who is readmitted for schizophrenia after 2 weeks following the previous discharge. The nurse notices that the client's appearance is unkempt, and the client is mumbling to himself constantly. Which of the following assessments is the nurse's priority? A. Mental status B. Anxiety level C. Perception of reality D. Physical health needs
D. Physical health needs
34.A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects the client's wound is infected because the drainage from the dressing is yellow and thick. Which of the following findings should the nurse report as the type of drainage found? A. Sanguineous B. Serous C. Serosanguineous D. Purulent
D. Purulent
50.A nurse is caring for a client who has chronic glomerulonephritis. The nurse would expect to find a decrease in which of the following serum laboratory values? A. Potassium B. Phosphate C. Creatinine D. RBC
D. RBC
42.A nurse is reinforcing teaching with a client who has a superficial lesion. A biopsy indicates malignant melanoma. Which of the following treatment choices should the nurse include in the teaching? A. Cryosurgery B. Chemotherapy C. Radiation therapy D. Surgical excision
D. Surgical excision
64.A nurse is providing change-of-shift report to the oncoming nurse. Which of the following information should the nurse include in the report? A. The client in room 105 had a bath. B. The client in room 106 is doing poorly. C. The family of the client in room 107 seems upset. D. The client in room 108 has been prescribed a new pain medication
D. The client in room 108 has been prescribed a new pain medication
22.A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion? A. Prone B. Supine C. Side-lying D. Upright
D. Upright
8.A nurse is caring for a postpartum client following a vaginal birth of a newborn weighing 4252 g (9 lb 6 oz). The nurse should identify that this client is at risk for which of the following postpartum complications? A. Puerperal infection B. Retained placental fragments C. Thrombophlebitis D. Uterine atony
D. Uterine atony
