Nclex Prep Part C

A nurse is caring of a client recently diagnosed with diabetes mellitus (DM). Which of the following is the physiologic basis for the polyuria manifested by individuals with untreated DM? Select one: a. Inadequate secretion of antidiuretic hormone (ADH) b. Early-stage renal failure causes a loss of urine concentrating capacity c. Hyperosmolarity of the extracellular fluids secondary to hyperglycemia d. Chronic stimulation of the detrusor muscle by the ketone bodies in the urine

C.Hyperosmolarity of the extracellular fluids secondary to hyperglycemia

Thirty minutes after admission to the nursery an infant appeared jittery and exhibits a weak, high pitched cry. Which of the following would be the nurse's priority action? Select one: a. Obtain an order for a drug screening blood test b. Feed the infant oral feeding. c. Perform a heel stick to check serum glucose. d. Hold and comfort the infant to stop the crying.

C.Perform a heel stick to check serum glucose.

A client has undergone an aortofemoral bypass for the treatment of peripheral arterial disease. Which of the following findings should be reported to the surgeon immediately? Select one: a. Edema of the affected limb b. Systolic blood pressure 110 mmHg c. Systolic blood pressure 160 mmHg d. Redness of the incision line

C.Systolic blood pressure 160 mmHg

Mark 1.00 out of 1.00 Flag question Question text A laboring client reports suddenly feeling something in her vagina. Upon assessment, the nurse identifies a prolapsed umbilical cord. Place the following interventions in the correct order that they should be performed for this client. A. Prepare the client for a cesarean birth. B. Administer oxygen at 8-10L via face mask. C. Notify primary care provider of the prolapsed cord. D. Reposition the client in either a knee-ches or Trendelenburg position. E. Using a sterile glove insert two fingers into the vagina to reduce pressure off the cord.

C, D, E, B, A

A nurse is educating a client who is scheduled for a nonstress test (NST). Which of the following statements are correct? Select all that apply. Select one or more: a. The NST can easily be performed in an outpatient setting. b. The NST measures the relationship of the fetal heart rate to fetal movement. c. The NST is a primary method of antenatal fetal assessment. d. The NST is not useful after 38 weeks gestation. e. The NST is a useful in calculating gestational age.

a, b, c

What are common factors that lead a personal or family into crisis? Select all that apply. Select one or more: a. Sudden event with no time to prepare b. Life-threatening event c. Perceived loss d. Recognizable control e. Increase family communication

a, b, c

A nurse is caring for a client diagnosed with osteomyelitis. The nurse would expect which of the following findings during the assessment? Select all that apply. Select one or more: a. Elevated erythrocyte sedimentation rate b. Leukocytosis c. Coolness upon palpation d. Positive wound cultures e. Sharp bone pain

a, b, d

A nurse is caring for a client who has MRSA in a wound. Which of the following infection control precautions should be initiated? Select all that apply. Select one or more: a. Use a face shield when irrigating the client's wound. CORRECT. A face shield should be worn during wound irrigation to prevent contamination through splashes. b. Wear a protective gown when entering the client's room. c. Wear sterile gloves when removing the client's wound dressing. d. Don clean gloves when delivering the client's meal tray. e. Wear a particulate respirator mask when administering medications to the client.

a, b, d

A nurse is caring for an infant prescribed digoxin. The client's apical heart rate is 88 beats per minute. Which of the following interventions should the nurse take? Select all that apply. Select one or more: a. Obtain a rhythm strip to assess for heart block. b. Withhold the medication. c. Call an emergency code for the arrest team. d. Administer the medication as ordered. e. Notify the physician.

a, b, e

A nurse is educating a client on how to perform Kegel exercise therapy for urinary incontinence. Which of the following points should be included in teaching? Select all that apply. Select one or more: a. Improvement in incontinence may be seen after 6 weeks of exercise therapy. b. During exercises, tighten pelvic muscles for a count of 10 and then relax for a count of 10. c. While sitting on the toilet, strain down to help identify pelvic muscles. d. Complete exercises in only a sitting position. e. Have a designated time and place for completing therapy.

a, b, e

What are characteristics of the fetus that are reviewed to determine the biophysical profile (BPP) during an ultrasound? Select all that apply. Select one or more: a. Fetal tone b. Fine body movement c. Reactive FHR d. Qualitative amniotic fluid volume e. Fetal tidal volume

a, c, d

An 8-year-old child was admitted to the hospital for possible shunt malfunction. The child has been diagnosed with hydrocephalus since birth. The nurse understands which of the following are symptoms of increased intracranial pressure? Select all that apply. Select one or more: a. Vomiting b. High-pitched cry c. Hypotonic deep tendon reflexes d. Headache e. Increased cluminess

a, d, e

A nurse is educating a parent of a newborn about safety measures. Which of the following statements made by the client would indicate a need for further teaching? Select one: a. "Once my baby begins to roll over it is okay to use a small pillow in the crib." b. "I should never leave my baby unattended with pets or other children." c. "My baby's car seat should be in the back seat facing backwards." d. "I should always support my baby's head when I pick him up."

a. "Once my baby begins to roll over it is okay to use a small pillow in the crib."

A client comes to a mental health clinic after experiencing a crisis in which a fire destroyed the client's home and took the life of a child. The client states, "I am unable to work or sleep and don't see how I can go on after this." Which of the following is the priority nursing intervention for this client? Select one: a. Assess the client for potential suicidal behavior. b. Relocate the client to a more supportive environment. c. Help the client return to a pre-crisis level of functioning. d. Enroll the client in a grief counseling program.

a. Assess the client for potential suicidal behavior.

A nurse is caring for multiple clients on the acute care unit. Which action demonstrates effective time management? Select one: a. Cluster activities that are to be performed on the same client. b. Document all client care activities at the conclusion of the shift. c. Complete difficult tasks after simpler tasks have been completed. d. Avoid delegation of tasks to other members of the health care team.

a. Cluster activities that are to be performed on the same client.

A nurse is assisting a client with an advance directive. Which of the following nursing responsibilities should be included regarding advance directives? Select all that apply. Select one or more: a. Confirm that the advance directive is current. b. Document the client's advance directive in the medical chart. c. Ensure that each family member receives a copy of the advance directive. d. Provide written information to the client about advance directives. e. Inform all members of the client's family of the client's wishes.

a. Confirm that the advance directive is current., b. Document the client's advance directive in the medical chart., d. Provide written information to the client about advance directives.

A nurse is planning discharge interventions designed to promote and maintain independence and maintain health for a child with a spinal cord injury (SCI). Which of the following interventions are appropriate? Select all that apply. Select one or more: a. Encouraging annual flu vaccinations b. Discussing sexuality issues c. Promoting an exercise program d. Evaluating bowel training e. Assessing food choices

a. Encouraging annual flu vaccinations c. Promoting an exercise program d. Evaluating bowel training e. Assessing food choices

A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis (DKA). An intravenous infusion of regular insulin has been started. Which of the following nursing interventions is most appropriate for this client? Select one: a. Ensure glucagon is readily available b. Obtain an arterial blood gas every 2 hours c. Add the prescribed dose of NPH insulin to the IV infusion d. Monitor blood glucose levels every 4 hours

a. Ensure glucagon is readily available

A nurse is caring for a client in Buck's Traction. Which of the following nursing interventions would ensure effective therapy? Select all that apply. Select one or more: a. Ensure that all weights are free hanging. c. Assist the client to roll from side to side. d. Prevent wrinkling of the traction bandage. e. Maintain countertraction with weights.

a. Ensure that all weights are free hanging., d. Prevent wrinkling of the traction bandage

A nurse is providing care for a client with a Jackson-Pratt drain. Which of the following nursing interventions has the highest priority? Select one: a. Keeping the drainage bulb depressed to manual suction. b. Securing the tubing and drainage bulb to the client. c. Cleansing the insertion site of the tube with betadine. d. "Milking" the tubing before emptying the drain.

a. Keeping the drainage bulb depressed to manual suction.

A client is discharged following a cardiac catheterization procedure. Which of the following should the nurse include in the discharge teaching? Select one: a. Limit activity for several days after the procedure. b. Remove dressing the evening of the procedure. c. Tub baths the night following the procedure are acceptable. d. Notify provider if bruising is noted at the site.

a. Limit activity for several days after the procedure.

The nurse is caring for a child with cystic fibrosis. What provider order would the nurse question? Select one: a. Limit physical activity c. Oxygen therapy via nasal cannula at 2 L/min d. Administer the influenza vaccine

a. Limit physical activity

A nurse is preparing to transfer a client from the bed to a stretcher. Which action increases the nurse's risk for injury? Select one: a. Manually lifting the client's full weight. b. Keeping knees slightly flexed. c. Standing with feet wide apart. d. Encouraging the client to assist.

a. Manually lifting the client's full weight.

A client who has been experiencing prolonged vomiting has the following ABG results: pH 7.48; pCO2 40 mm Hg; HCO3 34 mEq/L; pO2 85 mm Hg. The nurse determines that the client is experiencing which of the following imbalance? Select one: a. Metabolic Alkalosis b. Respiratory Alkalosis c. Respiratory Acidosis d. Metabolic Acidosis

a. Metabolic Alkalosis

A nurse has accepted a new position and is attending the general nursing orientation. Which of the following topics will most likely NOT be included in the orientation? Select one: a. Rules of conduct b. Health promotion c. Fire safety d. Accident prevention

a. Rules of conduct

A nurse is preparing a client who speaks limited English for surgery. Which of the following is the most appropriate nursing action in obtaining informed consent from this client? Select one: a. Seek the assistance of a nurse on the floor who is fluent in the client's language. b. The nurse should explain the procedures using pictures and hand gestures. c. Have the nurse respond to the client's concerns so the provider can prepare for surgery. d. Do nothing as this is the provider's primary concern.

a. Seek the assistance of a nurse on the floor who is fluent in the client's language.

A client is prescribed linsinopril. Which of the following findings indicates to the nurse that the client is experiencing an adverse effect of this medication? Select one: a. Serum potassium 5.8 mEq/L b. Creatine kinase (CK) 120 units/L c. Fasting blood glucose 40 mg/dl d. White blood cell count 10,000mm3

a. Serum potassium 5.8 mEq/L

A nurse is caring for a client with a partial hearing impairment. The nurse understands which of the following is the best way to communicate with this client? Select one: a. Speak slowly in a low-pitched voice. b. Provide assessment questions in a written format. c. Conduct only the physical assessment at this time. d. Have a family member present.

a. Speak slowly in a low-pitched voice.

A nurse is taking the health history of a school-age girl. Which statement by the client's mother indicates a need for further teaching regarding the client's nutritional status? Select one: a. "She enjoys helping to prepare her snacks in the kitchen." b. "We allow her to pick out a treat at the grocery store for good behavior." c. "We increase her protein intake when she's playing sports." d. "She eats a large breakfast every morning."

b. "We allow her to pick out a treat at the grocery store for good behavior."

A nurse is planning community education focusing on the principles of first aid. Which of the following strategies is likely to be most effective with adolescent learners? Select one: a. Simple lecture format. b. Actively involve the participants in practice of techniques. c. Teach the most crucial content early in the session. d. Divide the planned program into several sessions over several weeks.

b. Actively involve the participants in practice of techniques.

A client in the behavioral health unit began taking fluoxetine 20 mg per day three days ago for depression. Which of the following should the nurse immediately report to the health care provider? Select one: a. Sexual dysfunction b. Agitation and fever c. Headache and nausea d. Weight gain

b. Agitation and fever

A nurse is using silence to communicate with a client. Which of the following describes a therapeutic purpose of silence? Select one: a. Conveys the nurse's understanding of the client and assists with clarification. b. Allows the client time to gain insights and slows the pace of the interaction. c. Encourages the client to discuss central issues and keeps communication goal-oriented. d. Communicates the nurse's interest and concern for the well-being of the client.

b. Allows the client time to gain insights and slows the pace of the interaction.

A hospital has been notified that possible bioterrorist activity has taken place at a large sporting event nearby. A nurse has been put in charge of preparing a holding area to meet the needs of victims who report headache, dizziness, anxiety and shortness of breath, and are noted to have a bitter almond odor to their breath. What medication should the nurse be prepared to administer? Select one: a. Acetylcysteine b. Amyl Nitrate c. Cyanide vaccine d. Vitamin K

b. Amyl Nitrate

A nurse is caring for an intraoperative client. Which of the following are basic principles of sterile technique? Select all that apply. Select one or more: a. Sterile surfaces may touch other sterile surfaces b. A six-inch perimeter should be maintained around the sterile field. c. Once a sterile package is opened, the edges are considered unsterile d. Hands must stay below waist level once sterile gloves are applied. e. Surgical gowns are sterile from the chest to the level of the sterile field.

a. Sterile surfaces may touch other sterile surfaces., c. Once a sterile package is opened, the edges are considered unsterile., e.Surgical gowns are sterile from the chest to the level of the sterile field.

A nurse is preparing a client for discharge after an anterior-posterior colporrhaphy. Which of the following statements made by the client indicates a need for further teaching? Select one: a. "I will increase my fiber intake to stay regular." b. "I will increase my daily fluid intake." c. "I will tighten my pelvic muscles when coughing." d. "I will avoid standing for prolonged periods of time."

a."I will increase my fiber intake to stay regular."

For which of the following clients would benefit most from use of a walker? Select one: a. A 32-year-old female client who fractured her left tibia. b. An 82-year-old female client post right hip replacement that has had two falls in the past week c. A 43-year-old avid jogger one week status post right knee replacement. d. A 67-year-old male client post cerebrovascular accident with minimal right sided weakness.

b. An 82-year-old female client post right hip replacement that has had two falls in the past week

A nurse is teaching lifestyle modifications to a client diagnosed with hypertension. Which of the following statements made by the client indicates a need for further teaching? Select one: a. "I will substitute mushrooms for the bacon in my daily omelets." b. "We have a glass of wine a couple of times a week with dinner." c. "Losing weight is so hard, but so far I am losing 2 pounds a week." d. "I don't like to walk, but I do aerobics and work out at the gym during the week."

a."I will substitute mushrooms for the bacon in my daily omelets."

A nurse is admitting a client diagnosed with posttraumatic stress disorder (PTD) to the mental health unit. The client is confused and disoriented. When developing a plan of care, which of the following would be the priority intervention for this client? Select one: a. Accept and make the client feel safe. b. Explain unit rules to the client. c. Stabilize the client's psychiatric needs. d. Orient the client to the unit.

a.Accept and make the client feel safe.

A nurse is caring for a client who is experiencing a sodium level of 119 mEq/L. Which nursing action would be most appropriate at this time? Select one: a. Administer 0.9% Normal Saline. b. Provide oral hygiene and comfort measures. c. Encourage water and other fluids. d. Monitor for diminished breath sounds.

a.Administer 0.9% Normal Saline.

A client ingested a full bottle of imipramine hydrochloride. Which of the following toxic effects is most important for the nurse monitor? Select one: a. Arrhythmias b. Hypertension c. Blurred vision d. Photophobia

a.Arrhythmias

A client diagnosed with cervical cancer is prescribed a loop electrosurgical excision procedure (LEEP). Following the procedure, which of the following findings should the nurse instruct the client to report to the provider? Select one: a. Spotting of blood. b. Elevated temperature. c. Mild pelvic pain. d. Clear vaginal drainage.

b. Elevated temperature.

A nurse is caring for a client immediately following an amniotomy. Which of the following interventions are appropriate? Select all that apply. Select one or more: a. Assess maternal intake and urinary output. b. Document any unusual color in the amniotic fluid. c. Assess fetal heart for rate and variable decelerations. d. Prepare for an intrauterine pressure catheter (IUCP) insertion. e. Observe for the presence of an odor in amniotic fluid.

b,c, e

A nurse is caring for a client with respiratory syncytial virus (RSV). The nurse is aware that which of the following strategies would not prevent the spread of infection? Select one: a. Covering the nose and mouth. b. Encouraging children to participate in school activities. c. Discouraging the sharing of eating utensils. d. Performing good hand hygiene.

b. Encouraging children to participate in school activities.

A nurse is caring for a client post aortofemoral bypass surgery. Which of the following interventions would be contraindicated? Select one: a. Monitoring client for changes in blood pressure. b. Encouraging client to sit in high Fowler's position. c. Maintaining NPO status until first postoperative day. d. Coughing and deep breathing every 1 to 2 hours.

b. Encouraging client to sit in high Fowler's position

A nurse is transferring a client with a diagnosis of CVA. Which of the following safety measures should be implemented? Select all that apply. Select one or more: a. Pull on the arm of the client for stabilization. b. Engage locks on wheelchair and bed. c. Assist client to move toward the weaker side. d. Utilize an assistive device to facilitate transfer. e. Detach arm and foot rests from wheelchair.

b. Engage locks on wheelchair and bed., e. Detach arm and foot rests from wheelchair., d. Utilize an assistive device to facilitate transfer.

A daughter of a client with a terminal illness pulls a nurse to the side and says, "Although my mother's living will states she is not to be resuscitated, the family wants everything done to save her if she has a cardiac arrest." How should the nurse respond? Select one: a. "Since the living will is a legal document a lawyer will have to make the changes." b. "The living will documents your mother's wishes and must be followed." c. "If your mother has a cardiac arrest, we will begin resuscitation if you wish." d. "I will contact the provider to make him aware of your request."

b. "The living will documents your mother's wishes and must be followed."

The parents of an adolescent client ask the nurse why the meningiococcal conjugate vaccine is recommended before attending college. Which of the following statements best explains the reason why college-aged students should receive this vaccine? Select one: a. Adults who contract meningitis rarely have complications from it. b. Living in a dormitory increases the risk of exposure to the disease. c. Receiving the vaccine provides guaranteed immunity to the disease. d. Upper respiratory infections are more common on college campuses.

b. Living in a dormitory increases the risk of exposure to the disease.

A nurse is providing pin site care for a client with skeletal traction for a tibia-fibula fracture. Which of the following findings should the nurse report to the provider? Select all that apply. Select one or more: a. Muscle spasms b. Loosening of the pins c. +1 edema of skin at the pin sites d. Crusting at the pin sites e. Purulent drainage from the insertion sites

b. Loosening of the pins, e. Purulent drainage from the insertion sites, a.Muscle spasms

A nurse has received an inappropriate assignment. Which of the following actions should the nurse take? Select all that apply. Select one or more: a. Delegate care of the assigned client(s) to another nurse. b. File an unsafe staffing complaint with the appropriate personnel. c. Bring the inappropriate assignment to the attention of the charge nurse. d. Accept the assignment and complete tasks as comfortable. e. Refuse the assignment and report to the nurse manager.

b. File an unsafe staffing complaint with the appropriate personnel. c. Bring the inappropriate assignment to the attention of the charge nurse.

A nurse is caring for an adolescent client who is recovering from a traumatic below the knee amputation. The day after surgery, the client refuses to look at or touch the affected leg. Which of the following nursing interventions would be most beneficial to this client? Select one: a. Avoid discussing the amputation until the client initiates conversation. b. Gently examine and redress the stump without frowning or grimacing. c. Insist that the client participate in bathing and examining his affected leg. d. Remind the client that full mobility is possible once fitted for a prosthesis.

b. Gently examine and redress the stump without frowning or grimacing.

A nurse is caring for a client who has difficulty swallowing following a cerebrovascular accident (CVA). Which of the following interventions should the nurse implement? Select all that apply. Select one or more: a. Encourage client to place food in the front of the mouth. b. Maintain suction equipment at the bedside. c. Elevate the head of the bed 90 degrees before feeding. d. Encourage client to flex head and neck back when swallowing. e. Assess swallowing reflexes before feeding.

b. Maintain suction equipment at the bedside., e. Assess swallowing reflexes before feeding., c. Elevate the head of the bed 90 degrees before feeding.

A nurse is caring for a client taking captopril who has started experiencing a frequent dry cough. What action should the nurse take? Select one: a. Encourage the client to continue taking the medication as prescribed. b. Notify the provider of the client's symptom. c. Instruct the client to decrease the dosage of the medication. d. Encourage the client to use over the counter cough syrup for the cough.

b. Notify the provider of the client's symptom.

A nurse is assessing the health status of an older adult client. Although the client denies a problem, the caregiver explains that the client is alert and oriented but consistently has an unkempt appearance, body odor, and soiled clothing. The nurse understands that the client's behavior is likely related to which of the following? Select one: a. Experiencing side effects from a medication. b. Restricting activities in response to disease symptoms. c. Manifesting typical early symptoms of delirium. d. Exhibiting evidence of asymptomatic pathology.

b. Restricting activities in response to disease symptoms

A client is prescribed warfarin daily. Which of the following statement made by the client indicates to the nurse a need for further teaching? Select one: a. "I have two pairs of anti-embolic stockings so that one pair can be washed each day." b. "I have been eating more salads and other green, leafy vegetables to prevent constipation." c. "Instead of a safety razor, I have been using an electric razor to shave." d. "I will report any sign of Purple Syndrome to my physician."

b."I have been eating more salads and other green, leafy vegetables to prevent constipation."

A nurse is evaluating a client's understanding of lithium. Which statement by the client indicates a need for further education? Select one: a. "I will drink 8-12 glasses of water a day." b. "I should take the medication on an empty stomach." c. "I will contact my provider if I develop diarrhea." d. "I should have my blood level drawn as directed."

b."I should take the medication on an empty stomach."

A nurse is performing initial teaching with a client who will be receiving electroconvulsive therapy (ECT). Which statement by the client indicates a need for further teaching? Select one: a. "Before the procedure, I will have an EKG to assess for heart irregularities." b. "My Dilantin dose will be increased several days before the procedure." c. "I will need to continue taking my regular blood pressure medication." d. "I will stop taking my lithium for 2 weeks prior to my procedure."

b."My Dilantin dose will be increased several days before the procedure."

A nurse is providing education to the mother of a 10-year-old child about to undergo scoliosis screening. Which of the following statements by the mother indicates a need for further teaching? Select one: a. "The examiner will be looking for asymmetry of the ribs and flanks." b. "My child will be asked to stand upright, arms stretched above the head." c. "The examiner will be looking for symmetry in alignment of shoulders or hips." d. "My child should be undressed down to her under wear."

b."My child will be asked to stand upright, arms stretched above the head."

A nurse has provided discharge education to a school age client and his parents following a radius fracture with cast application. Which of the following statements by the client's parent indicates a need for additional teaching? Select one: a. "We will reposition him every 2 hours until the cast is dry." b. "When we get home we will use a hair dryer to finish drying the cast." c. "We will notify the provider if his fingers become swollen and dark." d. "We will keep the cast elevated about his heart for the next 24 hours."

b."When we get home we will use a hair dryer to finish drying the cast."

A nurse is calculating the client's intake and output. Based on the information below, which of the following values correctly represents the client's total output? Sipped 8 oz. clear broth. 100 mL ice chips. Voided 450 mL. IV push pain medication 50 mL. Drank 4 oz. juice and 6 oz. hot tea. Vomited 120 mL and voided 600 mL. Jackson Pratt drain emptied 40 mL. Select one: a. 680 mL b. 1210 mL c. 590 mL d. 1068 mL

b.1210mL

A fire in a first floor operating room is forcing evacuation of clients from a second floor unit to another building. Which of the following clients would have the highest priority for the charge nurse to evacuate? Select one: a. A client post left hip replacement of two days ago whose daughter is visiting. b. A client receiving IV antibiotics every six hours for a leg ulcer. c. A client admitted with pancreatitis with nasogastric tube and PCA pump in place. d. A client semi-comatose after a cerebrovascular accident with an indwelling urinary catheter.

b.A client receiving IV antibiotics every six hours for a leg ulcer.

A client with a recent myocardial infarction is prescribed digoxin. Which of the following findings indicate to the nurse that a therapeutic response to this medication has been attained? Select one: a. A rise in central venous pressure. b. A decrease in pulmonary crackles. c. A decrease in urinary output. d. An increase in apical pulse rate.

b.A decrease in pulmonary crackles.

A nurse is caring for a client who has had a gastric resection to treat peptic ulcer disease. What is the priority intervention when caring for the client in the immediate postoperative period? Select one: a. Auscultate the lungs for adventitious sounds. b. Assess NG tube for patency. c. Monitor pain levels. d. Inspect the operative site for redness or swelling.

b.Assess NG tube for patency.

A nurse is caring for a client on the telemetry unit who is two days post coronary artery bypass grafting (CABG). The nurse recognizes a cardiac rhythm change from normal sinus rhythm to atrial fibrillation. Which of the following should be completed first? Select one: a. Notify the health care provider. b. Assess the client's blood pressure. c. Prepare a diltizem drip. d. Prepare the client for cardioversion.

b.Assess the client's blood pressure.

A client is hospitalized for multiple rib fractures following a motor vehicle accident (MVA). The results of an arterial blood gas (ABG's) are; pH 7.30, pCO2 48, HCO3 26 and pO2 91 on 2 L/min of oxygen per nasal cannula. Which of the following interventions has the highest priority? Select one: a. Administer an anti-anxiety agent to calm the client. b. Assist the client to deep breathe, splinting with a pillow. c. Notify the health care provider of the abnormal ABG's. d. Increase the client's O2 delivery to 4 L/min.

b.Assist the client to deep breathe, splinting with a pillow.

At a well-child visit, the parents report that their toddler occasionally touches and fondles her genital area. The parents ask the nurse if this behavior is something to be concerned about. Which of the following is a correct response? Select one: a. Your child is probably imitating behaviors that she has observed b. Awareness of body structures and sensations is normal and expected c. This is an early emergence of sexual expression that should be discouraged d. This is a possible infection or irritation in the genital area

b.Awareness of body structures and sensations is normal and expected

A client presents to the emergency department with an abdominal stab wound. The nurse visualizes intestines protruding through the wound. Which of the following is an appropriate action for the nurse? Select one: a. Place sterile gauze and an abdominal binder over the wound. b. Cover the wound with warm saline-soaked gauze. c. Irrigate the wound with a normal saline solution. d. Apply pressure to the wound with wet sterile sponges.

b.Cover the wound with warm saline-soaked gauze.

A nurse is providing education to a client diagnosed with glaucoma. The nurse should instruct the client to avoid which of the following medications? Select all that apply. Select one or more: a. Acetazolamide b. Diphenhydramine c. Timolol maleate d. Scopolamine e. Methylphenidate

b.Diphenhydramine, e.Methylphenidate, d.Scopolamine

A nurse is caring for a client when the IV infusion pump malfunctions and delivers 1 Liter of IV fluid over 2 hours. Which intervention is the priority? Select one: a. Monitor urine output. b. Fill out an incident report. c. Report the defective equipment. d. Document the amount of fluid infused.

b.Fill out an incident report.

A charge nurse is planning to utilize a nurse from the hospital's float pool. Which of the following are disadvantages to float pools? Select all that apply. Select one or more: a. Float pool nurses have the flexibility to choose when they want to work. b. Float pool nurses receive a higher rate of pay and typically no benefits. c. Float pools result in a lack of continuity of client care. d. Float pools are not a solution to the long term staffing shortages. e. Float pools are adequate for filling intermittent staffing holes.

c, d

Parents share with a nurse that the beloved pet cat of their preschooler died just before the child was admitted to the hospital. Which of the following statements would be characteristic for a child of this age to make about death? Select one: a. "All cats get old and die. And Fluffy too." b. "It's my fault Fluffy died because I let him out." c. "Fluffy didn't really die. He's just sleeping." d. "What happens to cats after they die?"

c. "Fluffy didn't really die. He's just sleeping."

A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor? Select one: a. "Have you felt fetal movement over the last 24 hours?" b. "What happens to your contractions when you move about?" c. "Have you noticed any bloody show or fluid coming from your vagina?" d. "When did your contractions begin?"

c. "Have you noticed any bloody show or fluid coming from your vagina?"

A nurse has completed medication teaching for flouxetine with a client recently diagnosed with recurring panic attacks. Which of the following statements made by the client indicates a need for further teaching? Select one: a. "It may take up to four weeks or longer before flouxetine takes full effect." b. "When my panic attacks go away and I feel better I must continue taking flouxetine." c. "I can eat whatever I want while I am taking flouxetine." d. "I need to monitor my blood sugar closely while I am taking flouxetine."

c. "I can eat whatever I want while I am taking flouxetine."

A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification? Select one: a. "I should not remove the yellow exudate on the end of the penis." b. "The circumcision will heal completely within a couple of weeks." c. "I can give him a tub bath in two days." d. "I will clean his penis with each diaper change."

c. "I can give him a tub bath in two days."

A client has been prescribed spironolactone for treatment of heart failure. Which statement made by the client would indicate a need for further teaching? Select one: a. "I will weigh myself daily and report any changes in weight." b. "I should take my medication at the same time each day in the morning." c. "I will limit the use of salt in my diet and use a salt substitute instead." d. "I will need to have routine labs drawn while taking this medication."

c. "I will limit the use of salt in my diet and use a salt substitute instead."

A nurse is providing a tour of the labor and delivery unit to expectant parents. Which statement made by the mother indicates a need for further education? Select one: a. "When the baby is born, my thumb print will be taken along with the baby's footprint." b. "We will request to see picture identification badges for all facility staff who care for our baby." c. "We will need to remove the baby's ankle identification band during diaper changes." d. "When the baby is returned to us from the nursery, we should check the baby's identification band."

c. "We will need to remove the baby's ankle identification band during diaper changes

A nurse is orienting a newly licensed nurse to the operating room. Which of the following actions by the new nurse indicates a need for further education about surgical aseptic hand hygiene? Select one: a. Drying with a sterile towel moving from the hands to the elbows. b. Rinsing hands and arms while keeping them lower than elbows. c. Cleaning under nails of both hands with a nail pick while under running water. d. Lathering hand and arms with soap to 5 cm (2 inches) above the elbows

b. Rinsing hands and arms while keeping them lower than elbows.

A client experiences postural hypotension during initial drug therapy with diltiazem. Which of the following would be most important for the nurse to recommend to this client? Select one: a. Drink additional oral fluids each day. b. Rise slowly from a sitting or lying position. c. Eat small, frequent meals during the day. d. Lie down for 30 minutes after taking the medication.

b. Rise slowly from a sitting or lying position.

A newly-licensed nurse is preparing the surgical suite for a client who has a latex allergy. Which action demonstrates a need for further education? Select one: a. Covering IV tubing ports with tape. b. Scheduling the case late in the day. c. Using glass syringes. d. Placing monitoring devices in stockinet.

b. Scheduling the case late in the day.

A nurse is preparing a client who speaks limited English for surgery. Which of the following is the most appropriate nursing action in obtaining informed consent from this client? Select one: a. The nurse should explain the procedures using pictures and hand gestures. b. Seek the assistance of a nurse on the floor who is fluent in the client's language. c. Do nothing as this is the provider's primary concern. d. Have the nurse respond to the client's concerns so the provider can prepare for surgery.

b. Seek the assistance of a nurse on the floor who is fluent in the client's language.

Thirty minutes following initiation of oxytocin infusion a client's contractions are lasting 95 seconds and coming one minute apart. Late decelerations are observed on the fetal monitor. Which of the following is the correct priority nursing intervention? Select one: a. Assess vital signs and apply O2 via facemask. b. Stop oxytocin infusion and assess contractions and fetal heart rate. c. Stop the oxytocin infusion and administer terbutaline 0.25 mg. d. Notify provider and prepare for an emergency cesarean birth

b. Stop oxytocin infusion and assess contractions and fetal heart rate.

A nurse is administering mannitol to the client with increased intracranial pressure. What supplies are necessary when administering this medication? Select one: a. Pressure cuff, 1000mL bag of normal saline b. Syringe, filter needle, IV filter tubing c. Alcohol wipe, syringe, 18 gauge needle d. Pill cup, glass of water, straw

b. Syringe, filter needle, IV filter tubing

A nurse has administered the first DTaP (diphtheria toxoid, tetanus and pertussis) immunization to a two-month-old infant. For which of the following symptoms should the nurse teach the parents to seek immediate medical attention? Select one: a. The baby develops swelling or redness at the injection site b. The baby is crying inconsolably for more than three hours c. The baby has an axillary temperature of 100.4o F. (38o C) d. The baby develops a localized or generalized rash

b. The baby is crying inconsolably for more than three hours

A nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following outcomes best demonstrates that TPN therapy is effective? Select one: a. The client reports less frequent bowel movements. b. The client maintains an albumin level of 5.0 g/100mL. c. The client gains one kilogram per day. d. The client's urinary output increases by 800 mL per day.

b. The client maintains an albumin level of 5.0 g/100mL

The client who is scheduled for a nonstress test (NST) asks the nurse to explain the purpose of the test. Which of the following is the correct response? Select one: a. The purpose of the NST helps to determine gestational age. b. The purpose of the NST is to assess the fetal CNS. c. The purpose of the NST is to determine fetal lie. d. The purpose of the NST is to determine fetal breathing.

b. The purpose of the NST is to assess the fetal CNS.

A nurse is preparing to complete discharge teaching for a hearing impaired client. Which of the following interventions would best facilitate successful teaching? Select all that apply. Select one or more: a. Provide the client with detailed written instructions. b. Turn off the TV and close the door to the hallway. c. Include the client's spouse in the teaching session d. Sit beside the client to discuss discharge information. e. Speak more loudly when talking to the client.

b. Turn off the TV and close the door to the hallway., a. Provide the client with detailed written instructions., c. Include the client's spouse in the teaching session

A client is admitted to the inpatient care unit with a diagnosis of diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect? Select one: a. Serum glucose 200 mg/dL b. Urine ketones positive c. Serum pH 7.40 d. Low serum osmolality

b. Urine ketones positive

A postpartum client is reporting heavy vaginal blood flow. The nurse correctly understands which of the following assessments has the highest priority? Select one: a. Assessing vital signs both lying and sitting b. Assess the fundus for tone and position c. Assess the client's last voiding d. Assess episiotomy for bleeding

b. assess the fundus for tone and position

A client diagnosed with depression is taking the medication phenelzine, a monoamine oxidase inhibitor (MAOI). What foods should the nurse discuss with the client to avoid the adverse effect of hypertensive crisis? Select all that apply. Select one or more: a. Basil b. Avocados c. Bananas d. Salami e. Oats

b. avacados d. salami c. bananas

A nurse is caring for a client who is neutropenic. Which of the following foods are appropriate for this client? Select one: a. Lettuce and alfalfa sprouts b. Cooked spinach and celery c. Raw cauliflower or broccoli d. Fresh strawberries and carrots

b. cooked spinach and celery

There are different parenting styles that are exhibited within a family. Which of the following parenting styles is exhibited when a parent states, "My child can play video games for one hour a day after his homework is completed"? Select one: a. Permissive b. Democratic c. Dictatorial d. Passive

b. democratic

A nurse is providing dietary education to a client with a new ileostomy. What foods should the nurse instruct the client to avoid in the first weeks after surgery? Select one: a. Cream cheese b. Fresh vegetables c. Lean meats d. Strained fruit juices

b. fresh veggies

A client comes to the emergency department reporting epistaxis. Which of the following medications should the nurse suspect as contributing to the epistaxis? Select one: a. furosemide b. ibuprofen c. alprazolam d. montelukast

b. ibuprofen

Which of the following diseases should the nurse anticipate using droplet precautions? Select all that apply. Select one or more: a. Scarlet Fever b. Mumps C. varicella d. pertussis e. tuberculosis

b. mumps d. pertussis a. scarlet fever

The nurse is providing discharge teaching to a client who is hearing impaired. Which of the following communication strategies would be effective for the nurse to include in the plan of care? Select all that apply. Select one or more: a. Use hand-gestures and symbols to reinforce key points. = b. Speak clearly and slowly. c. Arrange for closed-captioning of video presentations. d. Provide teaching in a quiet room. e. Ask family members to interpret.

b. speak clearly and slowly c. arrange for closed captioning of video presentations d. provide teaching in a quiet room

The nurse manager observes a nurse placing several packages of suction catheters in her pocket to use as the nurse provides treatments to several clients with tracheostomies. Which of the following recommendations should the nurse manager make? Select one: a. Place suction catheters in a treatment tray rather than in a pocket b. Leave suction catheters in the supply room until needed c. Store suction catheters in a dedicated space at client's bedside d. Carry catheters in pocket but note how many catheters are used for each client

c. Store suction catheters in a dedicated space at client's bedside

A nurse is caring for a client recently diagnosed Hepatitis C. He asks the nurse to promise him his wife will find not out about his diagnosis. What is the best response by the nurse? Select one: a. "Your wife has the right to know about your condition because she may be at increased risk." b. "I can't promise you because your provider may inform her anyway." c. "Your medical information is considered confidential to be shared only if you agree." d. "I'll place a note in your chart concerning your request for your wife not to be informed."

c. "Your medical information is considered confidential to be shared only if you agree."

At 0715 the nurse is assigned to care for the following four clients. Which of the following clients should the nurse plan to see first? Select one: a. A client scheduled for a bronchoscopy at the bedside at 0900. b. A client who will be transferred to a skilled care facility at 0930. c. A client with diabetes mellitus type I waiting for a breakfast tray at 0745. d. A client with pneumonia scheduled for a portable chest x-ray at 0730.

c. A client with diabetes mellitus type I waiting for a breakfast tray at 0745.

A nurse is providing dietary teaching to a client diagnosed with ulcerative colitis. Which of the following foods should the nurse instruct the client to avoid? Select one: a. Grilled salmon and cooked apricots. b. Broiled liver and white rice. c. Pork chop and brown rice. d. Roast chicken and cooked spinach.

c. Pork chop and brown rice.

A client diagnosed with chronic obstructive pulmonary disease (COPD) is reporting shortness of breath upon exertion. The client is prescribed oxygen at 3 L/min and his oxygen saturation level is measuring 86%. The nurse understands which of the following is the priority intervention? Select one: a. Increase oxygen from 3L/min to 6 L/min. b. Encourage the client to stop smoking. c. Position the client in the high-Fowlers. d. Teach the client to eat several small meals a day.

c. Position the client in the high-Fowlers.

A nurse is aware that priorities need to be continuously set and reset in order to meet the needs of multiple clients. Which principles of client care should the nurse use for prioritization when giving report? Select all that apply. Select one or more: a. Recognize and respond to transient findings b. Prioritize acute before chronic. c. Prioritize systemic before local. d. Prioritize potential problems before actual. e. Listen carefully and don't assume.

c. Prioritize systemic before local., b. Prioritize acute before chronic., e. Listen carefully and don't assume.

A nurse is helping parent's select appropriate independent activities for their 8-year-old child. Which of the following would be an appropriate activity? Select one: a. Playing touch football b. Allowing the child to play video games c. Providing frequent trips to the library d. Encouraging the child to assume care of the family pet

c. Providing frequent trips to the library

A client with pneumonia has an oxygen saturation of 85%, heart rate of 88, respiratory rate of 22, and blood pressure of 132/88. Which of the following is the priority nursing intervention? Select one: a. Place the client on 2 Liters oxygen b. Immediately notify the provider c. Reassess pulse oximetry d. Administer albuterol inhaler

c. Reassess pulse oximetry

A client has been prescribed bupropion to assist with smoking cessation therapy. Which of the following findings would a nurse report to the health care provider immediately? Select one: a. Photosensitivity b. Nausea and Vomiting c. Seizures d. Dry mouth

c. Seizures

During administration of vancomycin IV, the nurse notices the client's neck and face becoming flushed. Which of the following actions should the nurse take first? Select one: a. Check the client's temperature. b. Obtain an order for an antihistamine. c. Stop the infusion. d. Notify the health care provider.

c. Stop the infusion.

A nurse is educating a client about implementation of bowel training program. Which of the following interventions should be included in the plan of care? Select all that apply. Select one or more: a. Avoid the use of time limits for defecation. b. Drink hot milk before defecation time. c. Take stool softeners daily d. Choose a regular toileting time based on the client's pattern. e. Advise the client to lean forward at the hips while sitting on the toilet.

c. Take stool softeners daily., d. Choose a regular toileting time based on the client's pattern., e. Advise the client to lean forward at the hips while sitting on the toilet.

A client with a digoxin level of 2.4 ng/ml has a heart rate of 39. The health care provider prescribes atropine sulfate. Which of the following best describes the intended action of atropine for this client? Select one: a. To stimulate the SA node and sympathetic fibers to increase the rate. b. To dry oral and tracheobronchial secretions. c. To accelerate the heart rate by interfering with vagal impulses. d. To reduce peristalsis and urinary bladder tone.

c. To accelerate the heart rate by interfering with vagal impulses.

A nurse is educating an older adult about food safety in the home. Which of the following instructions should the nurse include in teaching? Select one: a. The older adult recovers from food poisoning in a few days. b. Food poisoning is usually caused by a fungus. c. When preparing a meal raw and fresh foods should be handled separately. d. Clients at risk for food poisoning should follow a low cholesterol diet.

c. When preparing a meal raw and fresh foods should be handled separately.

A nurse is collecting a diet history for a client with chronic renal failure. Which food choice indicates the client would benefit from further education? Select one: a. Small amounts of kiwi b. Small sweet potato c. Cheddar cheese d. Wheat bread

c. cheddar cheese

A nurse is educating the parents of an infant about symptoms that should be reported to the provider. What finding should be immediately reported? Select one: a. Abdominal distension b. Mild diarrhea c. Decreased urine output d. Difficulty evacuating bowels

c. decreased urinary output

A nurse is educating the parents of an infant about symptoms that should be reported to the provider. What finding should be immediately reported? Select one: a. Abdominal distension b. Mild diarrhea c. Decreased urine output d. Difficulty evacuating bowels

c. decreased urine output

The parent of a two-year-old child reports feeling frustrated with the fact that her son is saying no to everything. The nurse should teach the parent that this behavior is a normal expression of the child's desire to accomplish which of the following? Select one: a. Develop their sense of trust. b. Finish a project they set out to do. c. Increase their independence. d. Gratify their oral fixation.

c. increase their independence

A client in her first trimester is encouraged to increase intake of proteins and folic acid as essential nutrients for basic fetal growth. Which foods would the nurse identify as high in folic acid? Select one: a. Tomatoes b. Avocados c. Lentils d. Fish

c. lentils

A nurse is teaching parents how care for their newborn. Which of the following statements indicates a good understanding of how to use a bulb syringe to suction excess mucous from the infant's airway? Select one: a. "The bulb syringe should be sterilized after each use." b. "I should compress the bulb syringe after I place it in my baby's mouth." c. "I should suction my baby's mouth before the nose." d. "The bulb syringe should reach to the back of my baby's throat."

c."I should suction my baby's mouth before the nose."

A nurse has just taught a client about the side effects of levodopa. Which client statement would indicate to the nurse that further instructions is needed? Select one: a. "I will not eat bananas." b. "I will administer the medication with food." c. "I still can drive." d. "I will get out of bed slowly."

c."I still can drive."

A nurse is taking the health history of a school-age girl. Which statement by the client's mother indicates a need for further teaching regarding the client's nutritional status? Select one: a. "She enjoys helping to prepare her snacks in the kitchen." b. "We increase her protein intake when she's playing sports." c. "We allow her to pick out a treat at the grocery store for good behavior." d. "She eats a large breakfast every morning."

c."We allow her to pick out a treat at the grocery store for good behavior."

A nurse is caring for a client diagnosed with diabetes. The nurse notes that the client has a mild tremor, slight diaphoresis and is fully oriented. Which of the following nursing actions should have the highest priority? Select one: a. Call the lab for a stat glucose level. b. Give the client 4 ounces of orange juice. c. Assess the client's blood glucose level. d. Administer 50% Dextrose via IV push.

c.Assess the client's blood glucose level.

A nurse is teaching a client with gout who is starting allopurinol. Which of the following should the nurse include in the client teaching? Select one: a. Do not take allopurinol within 2-3 weeks of an acute gout attack. b. Sudden onset of muscle pain can result with initiation of this therapy. c. Drink 2-3 liters of fluid per day. d. Take allopurinol on an empty stomach.

c.Drink 2-3 liters of fluid per day.

A nurse is caring for a client after an open radical prostatectomy. Which of the following interventions is the highest priority in the immediate postoperative period? Select one: a. Suggest methods for reducing urinary incontinence, such as Kegel exercises. b. Teach the client how to care for a urinary catheter and leg bag. c. Encourage use of patient-controlled analgesia (PCA) as needed. d. Administer a stool softener to prevent constipation.

c.Encourage use of patient-controlled analgesia (PCA) as needed.

A nurse is caring for a client with diabetes insipidus (DI) who has been prescribed aqueous vasopressin. Which of the following outcomes indicates that treatment has been effective? Select one: a. Blood pressure of 90/50 mm Hg b. Pulse rate of 126 beats/minute c. Fluid intake of 2,400mL in 24 hours d. Urine output of 200mL per hour

c.Fluid intake of 2,400mL in 24 hours

A nurse is reviewing the morning laboratory results while preparing to administer a client their dose of digoxin. Which result would the nurse need to report to the primary care provider? Select one: a. Digoxin level of 0.5 ng/ml b. Sodium level of 133 mEq/l c. Potassium level of 3.4 mEq/l d. Calcium level of 11mg/dl

c.Potassium level of 3.4 mEq/l

When the nurse takes morning medications to a client, the client states "I've never seen that one before." Which of the following is the most appropriate action for the nurse to take? Select one: a. Tell the client that the medication must be new and to go ahead and take it. b. Administer the rest of the medications and recheck the one that was questioned. c. Return to the nurse's station and check all medications against provider orders d. Recheck the medication with the medication administration record (MAR).

c.Return to the nurse's station and check all medications against provider orders

Which of the following should the nurse use to determine the neurological status of a client with a head injury? Select one: a. Manifestations of seizure activity b. Respiratory rate c. The Glasgow Coma Scale d. Client's reported pain scale

c.The Glasgow Coma Scale

A nurse is caring for a client who is prescribed gentamicin sulfate. Which of the following side effects would indicate an adverse reaction to this medication? Select one: a. Muscular cramping in the lower extremities. b. Pruritis in the forearms and upper arms. c. Urinary output of 185 mL in an 8 hour shift. d. Fine tremors in the fingers and hands.

c.Urinary output of 185 mL in an 8 hour shift.

A surgical client in the post anesthesia care unit is receiving intravenous patient controlled analgesia (PCA) of morphine sulfate. Which of the following findings would be evidence of an interaction of anesthetic agents and the PCA infusion? Select all that apply. Select one or more: a. Urine output 60 mL/hr b. Temperature 97.2F c. Respirations 10/min d. SpO2 89% e. BP 154/86

c.respirations 10/min d. SpO2 89%

A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification? Select one: a. "I should not remove the yellow exudate on the end of the penis." b. "I will clean his penis with each diaper change." c. "The circumcision will heal completely within a couple of weeks." d. "I can give him a tub bath in two days."

d. " I can give him a tub bath in two days."

A nurse has completed medication teaching regarding methylphenidate with a client. Which of the following client statements indicates an understanding of the nurse's teaching? Select one: a. "Methylphenidate is a safe drug with very few side effects." b. "If I don't like how I feel on methylphenidate, I may stop it at any time." c. "Weight gain is common if I take methylphenidate long term." d. "Avoiding afternoon doses of methylphenidate will help me sleep better."

d. "Avoiding afternoon doses of methylphenidate will help me sleep better."

The nurse is providing client education regarding the combined use of herbal supplements with prescribed medications. Which of the following statements indicates the client correctly understands the interaction of ginkgo biloba and warfarin? Select one: a. "I should take the warfarin in the morning and the ginkgo at bedtime so that they do not interact." b. "The ginkgo and warfarin work together to help my memory." c. "Ginkgo and warfarin should be taken at the same time during the day." d. "Ginkgo increases the effects of warfarin so I will stop taking the ginkgo."

d. "Ginkgo increases the effects of warfarin so I will stop taking the ginkgo."

During an assessment, an adolescent client whispers to the nurse, "I have to tell you something, but you have to promise you won't tell anyone else." Which of the following is the most appropriate response for the nurse to make? Select one: a. "What is said in this room stays in this room." b. "I am bound by the nurse-client relationship to keep your comments private." c. "I feel that you should share this with your parents first." d. "I cannot make that promise if it affects your or someone else's safety."

d. "I cannot make that promise if it affects your or someone else's safety."

A nurse is caring for a client who has reported difficulty sleeping. Which statement made by the client requires further assessment? Select one: a. "I try not to nap during the day, even though I'm tired." b. "I drink a cup of chamomile tea to help relax at bedtime." c. "I make a point of getting to bed at the same time every night." d. "I have been really stressed out at work lately."

d. "I have been really stressed out at work lately."

A client has recently been diagnosed with inoperable lung cancer and has been referred to hospice. The nurse recognizes that the client has successfully dealt with the anticipated outcome of the disease when the client states which of the following? Select one: a. "I plan on planting a vegetable garden next year." b. "I just don't want to talk with anyone right now." c. "If I can live, I will never smoke a cigarette again." d. "I have reviewed my will and advance directives."

d. "I have reviewed my will and advance directives."

A nurse is completing a dietary evaluation for a client diagnosed with acute glomerulonephritis. Which of the following statements made by the client demonstrates understanding of necessary restrictions? Select one: a. "I should increase my consumption of protein." b. "I should consume a diet low in carbohydrates." c. "I should increase my fluid intake to 8-10 glasses of water a day." d. "I should limit my sodium intake to 4 grams per day."

d. "I should limit my sodium intake to 4 grams per day."

A nurse is educating a client on restful sleep. Which of the following statements by the client would alert the nurse that further teaching is necessary? Select one: a. "I go to bed and get up at the same time each day." b. "I drink some hot milk and take a bath before going to bed." c. "I don't take naps during the day." d. "I watch television until I fall asleep."

d. "I watch television until I fall asleep."

A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching? Select one: a. "My partner should leave an empty space at the tip." b. "My partner will put the condom on while his penis is erect." c. "I can use spermicidal gels or creams to increase effectiveness." d. "I will remove the condom 30 minutes after intercourse."

d. "I will remove the condom 30 minutes after intercourse."

A 3-month-old infant has just undergone a cheiloplasty. The nurse is conducting an assessment following the procedure and needs to complete a pain assessment. Which of the following pain assessment tools will the nurse use to conduct this pain assessment? Select one: a. Numeric scale b. Oucher c. FACES d. FLACC

d. FLACC

A nurse applies restraints to a mental health client who is refusing to take his antipsychotic medication. The nurse may be charged with which of the following intentional torts? Select one: a. Assault b. Malpractice c. Negligence d. False Imprisonment

d. False Imprisonment

A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls? Select one: a. Place bedside table in close proximity. b. Demonstrate how to use the call light. c. Use of a night-light. d. Hourly rounding by the nurse.

d. Hourly rounding by the nurse

A nurse is caring for a client of the Buddhist faith who has just given birth to a stillborn infant. Which of the following interventions is most appropriate? Select one: a. Remain in the room and answer any questions the parents may have about the stillbirth. b. Remove the infant from the room and allow the parents a period of time to grieve. c. Gently inform the parents about the hospital procedures for handling a stillborn infant. d. Inquire about any rituals the parents would like to perform at this time.

d. Inquire about any rituals the parents would like to perform at this time.

A nurse is caring for a client with severe peripheral arterial disease of the right lower extremity. Which intervention is appropriate? Select one: a. Apply cold compresses to the affected extremity. b. Apply warm compresses to the affected extremity. c. Keep the affected extremity above the level of the heart. d. Keep the affected extremity below the level of the heart.

d. Keep the affected extremity below the level of the heart.

A nurse is charting the morning assessments on the computer when a client calls for assistance from his room. What actions should the nurse take next? Select one: a. Take the computer to the client's door while assisting him. b. Complete the charting before assisting the client. c. Have an assistive personnel stay with the computer. d. Log off of the computer before responding.

d. Log off of the computer before responding.

A nurse is caring for a newborn diagnosed with a neonatal infection. Which of the following risk factors is most important to the care of this client? Select one: a. Increased size of neonate's heart. b. Documented birth trauma. c. A decreased number of functional alveoli. d. Maternal history of cytomegalovirus.

d. Maternal history of cytomegalovirus.

The nurse is caring for a client admitted with diverticulitis. The client reports severe abdominal pain and assessment reveals that the client's abdomen is rigid and tender. The client's vital signs are: T: 101.8 F (38C); HR: 120; B/P: 100/50. Urine output was less than 300 ml during the previous eight hours. The client states the pain is "worse than before". What is the priority nursing intervention for this client? Select one: a. Administer bisacodyl suppository as needed b. Encourage the client to increase fluids c. Administer the prescribed scheduled antibiotic d. Notify the client's health care provider

d. Notify the client's health care provider

A nurse is caring for a client with dementia who has just returned from the postanesthesia care unit (PACU). Which of the following would be appropriate during the initial pain assessment? Select one: a. Asking the client to rate the pain using a faces scale. b. Asking the client to rate the pain on a scale of one to ten. c. Assessing the client's vital signs. d. Observing the client's facial expressions.

d. Observing the client's facial expressions.

A client is admitted to the hospital for suspected infective endocarditis. The client is reporting chills, fatigue, myalgia and dyspnea upon exertion. When assessing the client the nurse notes a heart murmur and a temperature of 102.3 F (38.2 C). Which of the following orders should the nurse implement first? Select one: a. Administer IV Penicillin G, 2 million units b. Administer acetaminophen 325 mg by mouth c. Order the EKG d. Obtain the blood cultures from three sites

d. Obtain the blood cultures from three sites

A nurse is positioning a client on the operating room table in preparation for a cesarean birth. Which of the following is the correct position? Select one: a. Lithotomy position with a foam wedge behind the shoulders. b. Modified Trendelenburg position with a foam wedge under the legs. c. Left lateral position with a foam wedge between the legs. d. Supine position with foam wedge positioned under one hip.

d. Supine position with foam wedge positioned under one hip

A client in the early postpartum period is talkative and enjoys recounting the details of her labor and birth. The nurse recognizes that the behaviors must likely indicate which of the following? Select one: a. Postpartum role transition. b. The taking-hold phase of maternal psychosocial adaptation. c. Positive mother-infant bonding. d. The taking-in phase of maternal postpartum adjustment.

d. The taking-in phase of maternal postpartum adjustment.

A client diagnosed with preterm labor has been prescribed nifedipine. The client asks the nurse why this particular medication has been prescribed. Which of the following statements by the nurse is correct? Select one: a. To promote development of your baby's lungs b. To decrease the intensity of your pain c. To lower your blood pressure d. To relax your muscles of your uterus

d. To relax your muscles of your uterus

A nurse is providing prenatal education to a group of pregnant women. The nurse is teaching clients when to contact their provider. Which of the following should be included? Select all that apply. Select one or more: a. Chloasma b. Dimming vision c. Epigastric pain d. Evening lower extremity edema. e. Severe continuous headeaches

e, b, c

A nurse is administering magnesium sulfate to a client diagnosed with preeclampsia. Which of the following signs and symptoms would indicate possible magnesium toxicity? Select all that apply. Select one or more: a. Prolonged PR interval b. Hypertension c. Diminished tendon reflexes d. Hyperactive tendon reflexes e. Hypotension

e, c, a

A nurse is caring for a neonate who is 34 weeks gestation. The nurse correctly understands which of the following are consistent with prematurity? Select all that apply. Select one or more: a. Inner eye canthus level with pina b. Mongolian spots on shoulders c. Large amount of vernix present d. Prominent clitoris and labia minora e. Abundant lanugo

e, d, c

A nurse is part of an interprofessional team. What qualities will the nurse use to implement effective collaboration. Select all that apply. Select one or more: a. Structured decision-making b. Critical Thinking c. Agressive reasoning d. Coercive behavior e. Assertive communication

e. Assertive communication, b. Critical Thinking, a. Structured decision-making

The nurse will need to wear a standard mask when caring for a client with which of the following disorders? Select all that apply. Select one or more: a. Respiratory viral influenza b. Meningococcal pneumonia c. Hepatitis A Virus d. Tuberculosis e. Pharyngeal diphtheria

e. pharyngeal diptheria a. resp viral influenza b. meningococcal pneumonia

An older adult client with a history of heart failure is admitted to the hospital with a diagnosis of digoxin toxicity. Which of the following assessment findings should the nurse expect? Select all at apply. Select one or more: a. Constipation b. Increased appetite c. Yellow vision d. Heart rate of 52 bpm e. Digoxin level 1.5 ng/ml

e.Digoxin level 1.5 ng/ml, d. Heart rate of 52 bpm, c. Yellow vision

A nurse is caring for a client who is beginning a warfarin regimen. What education should be provided to the client about this medication? Select all that apply. Select one or more: a. Intake of foods that are high in Vitamin K should be monitored. b. Protamine sulfate will be administered in cases of warfarin overdose. c. Concurrent use of glucocorticoids should be avoided while taking warfarin. d. Warfarin can be used safely in pregnancy. e. Oral contraceptives will decrease anticoagulant effects.

e.Oral contraceptives will decrease anticoagulant effects., a.Intake of foods that are high in Vitamin K should be monitored., c.Concurrent use of glucocorticoids should be avoided while taking warfarin.

A client asks "Why can't I take Prednisone every day for my arthritis like my grandmother did?" The nurse correctly explains that corticosteroids can have which of the following adverse effects when used continuously? Select all that apply. Select one or more: a. Truncal obesity b. Susceptibility to infection c. hypoglycemia d.bronze coloration of the skin e.osteoporosis

e.Osteoporosis, a.Truncal obesity, b.Susceptibility to infection

A nurse is evaluating a client who is exhibiting violent behavior. Which of the following should the nurse consider before applying restraints? Select all that apply. Select one or more: a. Nurse Practitioners can prescribe restraints. b. The most restrictive restraint should be used for a violent client. c. Restraints should be applied immediately to avoid client injury. d. Use the smallest amount of force necessary when applying a restraint. e. Restraints must be released according to the protocol.

e.Restraints must be released according to the protocol. d. Use the smallest amount of force necessary when applying a restraint.

A nurse is working in the Emergency Department (ED). In which order should the following clients be triaged? 1. 30-year-old male reporting shortness of breath. 2. 18-year-old male with a possible fractured tibia. 3. 24-year-old female with a swollen and bruised ankle. 4. 40-year-old female with high fever and productive cough.

1, 4, 2, 3

A nurse is caring for a client experiencing an anaphylactic reaction. List the following interventions to be taken by the nurse in order beginning with highest priority. 1. Administer epinephrine IVP 2. Teach the client to carry an EpiPen at all times 3. Begin an intravenous infusion with 0.9% sodium chloride 4. Establish a patent airway. 5. Administer diphenhydramine IVP

4, 3, 1, 5, 2

A nurse is working in the Emergency Department (ED). In which order should the following clients be triaged? A. 30 year old male reporting shortness of breath. B. 18 year old male with a possible fractured tibia. C. 24 year old female with a swollen and bruised ankle. D. 40 year old female with high fever and productive cough.

A, D, B, C

A client is prescribed iron dextran intramuscularly using the Z-track method. Place the following steps in the order the nurse should take them to administer this medication. A. Discard the needle used to draw up the irone. B. Pull the skin and subcutaneous tissues sideways away from the muscle. C. Aspirate to determine needle placement. D. Release the skin and subcutaneous tissue. E. Place a new needle on the syringe. F. Insert the needle deeply into the muscle. G. Administer medication and quickly withdraw the needle.

A, E, B, F, C, G, D

Place in order of priority, which clients the nurse will visit first to last. A. A client receiving IV chemotherapy and the infusion pump is alarming. B. A client who is ordered to be discharged. C. A client who is one day post chest tube insertion for pneumothorax. D. A client in wrist restraints who has a sitter in the room. E. A client admitted via the Emergency Department three hours ago with the diagnosis of "acute abdomen".

A, E, C, D, B

A nurse is caring for a client who has been prescribed magnesium sulfate as tocolytic therapy. Several hours after the infusion was started, contractions ceased. Which of the following is the best analysis of this data? Select one: a. The drug is having a therapeutic effect b. Deep tendon reflexes should be assessed c. The medication dose should be increased d. The medication dose should be decreased

A. The drug is having a therapeutic effect

A breastfeeding mother develops engorgement on her second postpartum day. Which of the following statements by the client indicates a need for further teaching? Select one: a. I will offer my baby a bottle following each feeding. b. I will apply warm packs to each breast prior to feeding. c. I will use a breast pump if my breasts do not soften. d. I will feed my baby every 2 hours.

A.I will offer my baby a bottle following each feeding.

A nurse is performing a fundal assessment on the client's second postpartum day. Which of the following should the nurse expect if the client is experiencing normal involution? Select one: a. The fundus will be one centimeter below the umbilicus. b. The fundus will be one centimeter above the umbilicus c. The fundus will be two centimeters below the umbilicus. d. The fundus will be at the level of the umbilicus.

A.The fundus will be one centimeter below the umbilicus.

A nurse is teaching a client the correct use a diaphragm as a method of contraception. Which of the following statements is correct? Select one: a. Douche promptly after removing the diaphragm b. Leave diaphragm in place for at least 6 hours post coitus c. Insert diaphragm at least 8 hours prior to sexual intercourse d. Do not use any cream or jelly with the diaphragm

B.Leave diaphragm in place for at least 6 hours post coitus

A client diagnosed with atrial fibrillation has a pacemaker set at a ventricular rate of 70 beats per minute. Which of the following findings should the nurse immediately report to the provider? Select one: a. HR= 76 beats/minute and irregular b. HR= 96 beats/minute and irregular c. HR= 60 beats /minute and regular d. HR= 96 beats /minute and regular

C. HR= 60 beats /minute and regular

A nurse is assessing a client during her first prenatal visit. The client reports that her last normal period began on April 22. Use Nagele's rule to calculate this client's expected date of birth (EDB). Use the MMDD format to enter exactly four numerals, with no spaces or punctuation between the numbers. Select one: a. 0722 b. 0729 c. 0122 d. 0129

D. 0129

A nurse is caring for a client diagnosed with pre-eclampsia. The client is receiving Magnesium Sulfate IV. Which of the following assessment findings is the first sign of Magnesium toxicity? Select one: a. Visual blurring b. Nausea and vomiting c. Respiratory depression d. Decreased deep tendon reflexes

D. DECREASED DEEP TENDON REFLEXES

A client diagnosed with pregnancy induced hypertension (PIH) has been receiving a Magnesium Sulfate infusion for three days. Serum drug levels have been between 8-10 mg/dl. Which of the following finding should the nurse expect to assess in the infant after delivery? Select one: a. Hyperactivity and irritability b. Hypothermia and bradycardia c. Tachycardia and respiratory distress d. Lethargy and respiratory depression

D. LETHARGY AND RESP DEPRESSION

A nurse is caring for a client who is intubated and receiving ventilatory assistance. The high pressure alarm is sounding on the ventilator. Which of the following would have the highest priority? Select one: a. Check the endotracheal tube (ETT) to be sure there is no disconnection. b. Administer sedation to calm the client's fears. c. Assess the ETT cuff for proper inflation. d. Assess the clients need for suctioning.

D.Assess the clients need for suctioning.

A nurse is caring for a neonate who exhibits abstinence syndrome and demonstrates clinical manifestations of the condition. Which assessment finding is associate with this condition? Select one: a. Increased drowiness b. Negative Startle reflex c. Diminished tendon reflexes d. Hypothermia

D.Hypothermia

During a family therapy session, a client diagnosed with bipolar disorder states, "My family does not understand my bipolar disease." The client's family expresses concern to the nurse that the client may not be responding to the prescribed medication. Place the following interventions for promoting positive outcomes to therapy in the order of priority. A. Assist the client and family to find strengths on which to capitalize. B. Provide therapeutic and medication education. C. Identify and clarify concerns of both the client and family D. Assess further as to why the family feels the client is not responding to the medication. E. Provide a non-manipulative and decentralized communicative environment.

E, C, D, A, B

A nurse is teaching a client with right-sided hemiparesis to ambulate with a quad cane. Which instructions are appropriate? Select one: a. Place quad cane in left hand, extend left hand with quad cane, and right lower extremity followed by left leg. b. Place quad cane in left hand, extend left hand with quad cane, and then left leg followed by right leg. c. Place quad cane in right hand, extend left lower extremity, and then right hand with quad cane and left lower extremity. d. Place quad cane in right hand, extend right hand with quad cane and left lower extremity.

Place quad cane in left hand, extend left hand with quad cane, and right lower extremity followed by left leg.

A nurse is caring for an adolescent client admitted to the nursing unit three days ago. The client is withdrawn, unwilling to eat, and does not interact with the staff. The nurse correctly understands which of the following would provide the best support for this client? Select one: a. A visit with friends from school. b. A visit with a parent. c. An opportunity to view a popular DVD. d. A call from the client's sibling.

a. A visit with friends from school.

A client diagnosed with schizophrenia and experiencing frequent auditory hallucinations is admitted to an inpatient psychiatric unit. Which of the following would be the most effective, initial strategy for the nurse to implement? Select one: a. Ask the client to describe the components of the hallucination. b. Ask the client to rest in a quiet area until the voices are gone. c. Agree with the client that the voices are audible. d. Explain to the client that the hallucination is not real.

a. Ask the client to describe the components of the hallucination.

During a group therapy session on a psychiatric unit, the nurse leader observes that one of the clients frequently interrupts the session. Which of the following nursing actions is the most appropriate for this situation? Select one: a. Ask the client to speak privately with a nurse after the meeting. b. Encourage another group member to reprimand the client. c. Discuss this observation during the post-meeting evaluation. d. Tell the client that the interrupting behavior must be discontinued.

a. Ask the client to speak privately with a nurse after the meeting.

A client who is 32 weeks pregnant presents to the emergency room with bright red vaginal bleeding for the last 3 hours. The client reports feeling fetal movement since the bleeding started. Which of the following is the nurse's priority action? Select one: a. Assess maternal vital signs b. Administer a 500 mL fluid bolus c. Assess fetal heart tones d. Perform a vaginal exam

a. Assess maternal vital signs

Two staff members have called in sick on the medical-surgical unit and no additional help is available. The remaining team members consist of an RN, an LPN and unlicensed assistive personnel (UAP). Which of the following should be considered by the nurse when making client assignments? Select all that apply: Select one or more: a. Assess the health status and complexity of care required by the client. b. Evaluate client needs to determine if assigned nurse can meet plan of care outcomes. c. Identify what tasks are appropriate to delegate for each specific client. d. Assess and verify the competency of the health care team. e. Continually provide supervision, either directly or indirectly, to the team.

a. Assess the health status and complexity of care required by the client. c. Identify what tasks are appropriate to delegate for each specific client. d. Assess and verify the competency of the health care team.

A nurse is caring for a client who is receiving intermittent tube feedings. What intervention reduces the risk of aspiration? Select one: a. Assessing gastric residual volume immediately before administering the feeding b. Instructing the client to cough forcefully as the feeding is started. c. Assisting the client into a supine position in preparation for the feeding. d. Performing nasotracheal suctioning before initiation of the feeding.

a. Assessing gastric residual volume immediately before administering the feeding

A nurse is caring for a client with a spinal cord injury who has an indwelling catheter. Which of the following is the highest priority when providing perineal care for this client? Select one: a. Avoid inadvertently advancing the catheter into the bladder. b. Examine condition of catheter and drainage tubing c. Assess the client's knowledge of importance of perineal hygiene. d. Assess for perineal pain or discomfort.

a. Avoid inadvertently advancing the catheter into the bladder.

A nurse is obtaining a sterile specimen from an indwelling urinary catheter. Place the following steps in the order the nurse should use to obtain this specimen: A. Remover clamp to resume drainage. B. Drain the cathether's tubing of urine. C. Place urine sample in sterile container. D. Clamp the catheter's tubing below port for 20 minutes. E. Clean the injection port cap of the catheter drainage tubing with antiseptic. F. Attach a sterile syringe to the port and aspirate quantity of urine required.

a. B, D, E, F, C, A

Following a TURP (transuretheral resection of the prostate) with CBI (continuous bladder irrigation), the client states he has severe lower abdominal cramping. Which of the following actions should the nurse take first? Select one: a. Check the catheter for kinks b. Irrigate the catheter c. Discontinue the bladder irrigation d. Increase the flow of the irrigate

a. Check the catheter for kinks

A graduate nurse is performing ostomy care for a client with a new colostomy. Which intervention performed by the nurse indicates the need for more education? Select one: a. Cleansing the peristomal skin with alcohol. b. Positioning the client standing or supine. c. Measuring and assessing the stoma. d. Changing the pouch before a meal.

a. Cleansing the peristomal skin with alcohol.

A client diagnosed with bipolar disorder and prescribed lithium carbonate is being discharged from the hospital. Which of the following medication prescriptions should the nurse should question? Select one: a. Furosemide 20 mg by mouth twice per day b. Captopril 25 mg by mouth twice per day c. Valproic acid 250 mg by mouth three times per day d. Ranitidine 150 mg by mouth daily

a. Furosemide 20 mg by mouth twice per day

The nurse is attempting to comfort parents who just experienced the death of their premature infant. The parents are angry and blaming the nurses and doctors for the death of their child. Which of the following is the most appropriate nursing intervention? Select one: a. Grant time for the parents and family to hold and be with their infant. b. Refer the parents to grief support group to deal with the loss of their infant. c. Provide a more detailed explanation for why their infant passed away. d. Remind the parents that the nurses and doctors did all they could for their infant.

a. Grant time for the parents and family to hold and be with their infant.

The nurse is conducting a physical examination of a 2-month-old with suspected pyloric stenosis. Which finding indicates pyloric stenosis? Select one: a. Hard, moveable "olive-like mass" in the upper right quadrant b. Perianal fissures and skin tags c. Sausage-shaped mass in the upper mid abdomen d. Abdominal pain and irritability

a. Hard, moveable "olive-like mass" in the upper right quadrant

The parent of a two-year-old child reports feeling frustrated with the fact that her son is saying no to everything. The nurse should teach the parent that this behavior is a normal expression of the child's desire to accomplish which of the following? Select one: a. Increase their independence. b. Develop their sense of trust. c. Finish a project they set out to do. d. Gratify their oral fixation.

a. Increase their independence.

A client who is suffering from delusions states, "I can't stay in group today. I am expecting the governor to be here any minute!" The nurse leading the group responds, "I understand, but right now it is time for group and we expect everyone to attend." Which of the following explains why the nurse's statement would be considered therapeutic? Select one: a. It articulates what is expected without reinforcing the delusion b. It sets limits on manipulative behavior without creating a confrontation c. It demonstrates to all group members that the nurse is in control d. It discourages other group members from trying to avoid group

a. It articulates what is expected without reinforcing the delusion

A nurse is caring for four laboring clients. Each of the clients is requesting an epidural. Which of the following clients should receive her epidural first? Select one: a. Mulitipara with contractions occurring every 3 minutes, lasting 45 seconds. The cervical os is dilated 5 cms. b. Mulitipara with contractions occurring every 2 minutes, lasting 130 seconds. The cervical os is dilated 8 cms. c. Primipara with contractions occurring every 2 minutes, lasting 90 seconds. The cervical os is dilated 10 cms. d. Primipara with contractions occurring every 10-15 minutes, lasting 15 seconds. The cervical os is dilated 3 cms.

a. Mulitipara with contractions occurring every 3 minutes, lasting 45 seconds. The cervical os is dilated 5 cms.

One hour ago, a nurse administered morphine sulfate 4 mg IVP to a client who reported pain of 9 on a scale of 10. The client now reports pain of a 7 on a scale of 10. What is the priority intervention at this time? Select one: a. Notify the provider of client's report. b. Administer antiemetic as prescribed. c. Reposition the client. d. Reassess pain level in 30 minutes.

a. Notify the provider of client's report.

The family of a 14-year-old client with Attention-Deficit Hyperactivity Disorder (ADHD) is requesting the nurse's assistance in implementing strategies in the client's management of ADHD. Which of the following strategies should be discussed in the management of ADHD for an adolescent client? Select all that apply. Select one or more: a. Offer verbal instruction combined with visual cues. b. Plan structured activities in the afternoon. c. Use charts to assist with organization. d. Model positive behaviors. e. Introduce new situations slowly.

a. Offer verbal instruction combined with visual cues., c. Use charts to assist with organization., d. Model positive behaviors.

According to the American Hospital Association's Patient Care Partnership, the nurse understands that client rights in the health care setting include which of the following? Select all that apply. Select one or more: a. Preparation for discharge b. Help with billing and filing insurance claims c. Assistance with childcare arrangements d. Client involvement in the plan of care e. Arrangements for home follow-up visits

a. Preparation for discharge b. Help with billing and filing insurance claims d. Client involvement in the plan of care

A nurse is managing client care. Which of the following should be implemented when prioritizing care? Select all that apply. Select one or more: a. Prepare a written list. b. Avoid delegation of difficult tasks. c. Postpone items that do not have immediate deadlines. d. Take on a task when inspired. e. Respond to needs as soon as they arise.

a. Prepare a written list., c. Postpone items that do not have immediate deadlines.

The nurse is observing sibling adaptation behaviors to the newborn infant during a family visit. To facilitate sibling acceptance, which action by the parents can assist with bonding? Select one: a. Provide the sibling a stuffed animal that they care for while the parents nurture the newborn. b. Discuss with the sibling the importance of being more independent. c. Encourage the sibling to spend time primarily with the babysitter. d. Create new traditions and routines.

a. Provide the sibling a stuffed animal that they care for while the parents nurture the newborn.

A nurse is supervising a graduate nurse. The nurse evaluates the client care the graduate nurse provides by doing which of the following? Select all that apply. Select one or more: a. Provides feedback to the nurse. b. Evaluates the nurse's goals. c. Reinforces client education. d. Intervenes if necessary. e. Determines if client outcomes were met.

a. Provides feedback to the nurse. d. Intervenes if necessary. e. Determines if client outcomes were met.

A nurse is caring for a client diagnosed with an acute anxiety disorder. Which of the following is the priority nursing intervention? Select one: a. Remain with the client during the crisis period. b. Evaluate coping mechanisms for controlling anxiety. c. Encourage to attend a behavioral therapy group. d. Administer prescribed selective serotonin inhibitor (SSRI).

a. Remain with the client during the crisis period.

A nurse has administered the first DTaP (diphtheria toxoid, tetanus and pertussis) immunization to a two-month-old infant. For which of the following symptoms should the nurse teach the parents to seek immediate medical attention? Select one: a. The baby is crying inconsolably for more than three hours b. The baby develops a localized or generalized rash c. The baby has an axillary temperature of 100.4o F. (38o C) d. The baby develops swelling or redness at the injection site

a. The baby is crying inconsolably for more than three hours

A nurse is preparing to discharge an older adult client to the home of a family member while recovering from hip surgery. Which of the following may negatively affect the client's adjustment to living with family members? Select one: a. The family is insisting on maintaining financial control for the client. b. The family is actively involved in the discharge plans. c. The client is unable to complete all ADLs. d. Older clients often recover more quickly when encouraged to interact with family.

a. The family is insisting on maintaining financial control for the client.

A nurse correctly understands which of the following characteristics is a possible developmental delay for a 3-month-old client? Select one: a. The infant does not raise his head when placed on his abdomen b. The infant demonstrates stranger anxiety c. The infant is unable to point to objects d. The infant is unable to sit with support

a. The infant does not raise his head when placed on his abdomen

A nurse is caring for a terminally ill client of the Muslim faith and observes the client to be unconscious and having Cheyne-Stokes respirations. The family has repositioned the bed so that the client is on the right side facing toward the wall. The nurse does not question this action because of which of the following? Select one: a. This positioning has religious significance for the client and family. b. This positioning is preferred for a client with respiratory distress. c. The religious practice of concealing the face of the dying client should be supported. d. The nurse should support the family in their efforts to make the client comfortable.

a. This positioning has religious significance for the client and family.

A nurse is caring for a client diagnosed with hyperemesis gravidarum. Which of the following are expected findings for this client? Select all that apply Select one or more: a. Persistent diarrhea b. Dehydration c. Increased blood pressure d. Weight loss e. Ketosis

b, d, e

A nurse is delegating client care. Which of the following leadership functions are associated with delegation? Select all that apply. Select one or more: a. Use delegation as a time management strategy. b. Function as a resource person in delegating tasks to subordinates. c. Communicate insistently when delegating tasks. d. Identify situations appropriate for delegation. e. Display indifference to how a cultural phenomenon affects transcultural delegation.

a. Use delegation as a time management strategy. b. Function as a resource person in delegating tasks to subordinates. d. Identify situations appropriate for delegation.

A nurse is to administer morphine sulfate 10 mg intramuscular (IM) to an adult client for post-operative pain. Which injection site is the most appropriate? Select one: a. Ventrogluteal b. Dorsogluteal c. Epidural d. Deltoid

a. Ventrogluteal

A nurse is assisting a client with bowel training. When should the nurse instruct the client to attempt defecation? Select one: a. When the client has the urge to defecate. b. When the client feels abdominal cramping. c. Every hour while awake. d. Immediately before meals.

a. When the client has the urge to defecate

A nurse is providing dietary education for a client with cholecystitis. Which of the following food choices made by the client indicates a need for further teaching? Select one: a. Broccoli with cheese sauce b. Wheat bread c. Baked potato d. Chicken breast

a. broccoli with cheese sauce

A nurse is monitoring a client undergoing electroconvulsive therapy (ECT). Which of the following assessments should be completed by the nurse during this therapy? Select all that apply. Select one or more: a. Duration of the seizure b. Respiratory rate and effort c. Long-term memory loss d. Intestinal obstruction e. Hypotension or hypertension

a. duration of the seizure b. respiratory rate and effort e. hypotension or hypertension

A nurse is caring for a child who has leukemia. What discharge teaching would be provided to the parents prior to discharge? Select one: a. How to properly use vascular access devices. b. Report developmental delays to the provider. c. Side effects of radiation therapy. d. Encourage parents not to palpate the stomach

a. how to properly use vascular access devices

A nurse is caring for a client with Crohn's Disease. Which of the following foods can be included in this client's diet? Select all that apply. Select one or more: a. Pasta b. Wild rice c. fresh celery d. raisins e. eggs

a. pasta e. eggs

A nurse is caring for a client with chronic renal failure. When assessing this client, the nurse should be alert for which of the following that may indicate hypocalcemia? Select all that apply. Select one or more: a. Trousseau's sign b. Constipation c. Seizures d. Decreased clotting time e. Fractures

a. trousseau sign c.seizures e.fractures

A nurse is caring for a client who is reporting lower abdominal pain. The client has a positive pregnancy test and is estimated to be 10 weeks pregnant. Which of the following best support a possible ectopic pregnancy? Select one: a. Unilateral stabbing abdominal lower abdominal pain. b. Steady bleeding with lower abdominal pain. c. Absence of fetal heart tones and fetal movement. d. Edematous face, hands, and ankles.

a. unilateral stabbing abdominal lower abdominal pain

A client is admitted to the medical unit from the convalescent center for treatment of urosepsis. The client's adult daughter reports to the nurse, "I don't know what to do. I love my mom and would like to have her live in my home, but I just can't be with her every minute, and that's what she needs now." Which of the following would be the best approach to improve integration of the elderly mother into the family structure? Select one: a. Determine if the daughter would consider having the client visit in her home one day a week. b. Suggest that the daughter move the client into the family home on a trial basis for several weeks. c. Assist the daughter in finding a caregiver who can assist the client in the convalescent center. d. Offer to refer the daughter to a counselor in an effort to better deal with her feelings of guilt.

a.Determine if the daughter would consider having the client visit in her home one day a week.

A nurse is caring for a client following a spinal cord injury (SCI). Which of the following findings would alert the nurse to the development of neurogenic shock? Select one: a. Hypotension b. Hyperglycemia c. Hypertension d. Hypoglycemia

a.Hypotension

A clinic nurse is preparing to administer a Penicillin IM injection to a client who has never taken the medication before. Which of the following interventions should be included in the plan of care? Select one: a. Instruct the client to sit in the clinic for 30 minutes after the injection. b. Ask the client if they are allergic to shell fish before administering. c. Inject the client with a small test dose of Penicillin subcutaneously. d. Instruct the client to expect a slight rash to develop at the injection site.

a.Instruct the client to sit in the clinic for 30 minutes after the injection.

A client has just returned to the surgical unit after an open cholestectomy. A nurse notes the abdominal dressing is saturated with sanguineous drainage. Which of the following is the most appropriate intervention? Select one: a. Reinforce the dressing with additional gauze. b. Outline the drainage size with a marker. c. Document the assessment findings. d. Remove the dressing to assess the incision.

a.Reinforce the dressing with additional gauze.

A nurse is caring for a toddler who is being treated for hypovolemia. Which of the following demonstrates to the nurse the desired response to fluid replacement? Select one: a. Specific Gravity 1.025 b. Central Venous Pressure 2 mm Hg c. Urine output 48 mL for the past 4 hours d. Apical heart rate 130 beats/min

a.Specific Gravity 1.025

A nurse is caring for a client prescribed omeprazole. What information should the nurse provide to the client regarding administration of this medication? Select one: a. Take the medication in the morning before breakfast. b. Take the medication at bedtime. c. You may crush the medication for easier swallowing. d. Take the medication after a meal twice daily.

a.Take the medication in the morning before breakfast.

A nurse is to administer nitroglycerin to a client for the treatment of angina. Which of the following should the nurse first advise the client? Select one: a. To sit or lie down. b. Dizziness may occur. c. To rise slowly d. A headache may occur.

a.To sit or lie down.

A nurse is providing care for an older adult client. Which of the following findings indication fluid imbalance? Select all that apply. Select one or more: a. Sunken eyes b.oliguria c.moist mucus membranes d. tenting of skin on the back of the hand e.cap refill greater than 5 sec

a.sunken eyes b.oliguria e.cap refill greater than 5 sec

A nurse is teaching a new mother breastfeeding techniques. Which of the following teaching tips are appropriate to discuss with a new mother who is breastfeeding? Select all that apply. Select one or more: a. Burp the newborn between each breast. b. Avoid a specific length of time to breastfeed. c. Dark, firm stools are the norm. d. Avoid use of a pacifier to prevent nipple confusion. e. Two to three wet diapers per day are the norm.

b, a, d

A nurse is providing instructions for car seat safety to parents of an infant. The nurse should include which of the following? Select all that apply. Select one or more: a. When placing the infant in the front seat, the air bag should be off. b. A five point restraint system is recommended for car seats. c. Infants should be rear facing until they weigh 9.1kg (20 lbs). d. Used car seats should be inspected by the health deparment. e. The infant should be rear facing until 6 months of age.

b, c,

A nurse is caring for a neonate diagnosed with a congenital heart defect. Which of the following signs and symptoms would the nurse note if the client was experiencing heart failure? Select all that apply. Select one or more: a. Bounding pulses b. Tachypnea c. Feeding difficulties d. Mottling e. Hyperglycemia

b, c, d

A nurse is caring for a client with MRSA. In which order should the nurse don Personal Protective Equipment (PPE)? Place the following items in the correct order. A. Goggles B. Gown C. Gloves D. Mask

b, d, a, c

A nurse has completed medication teaching for disulfiram with an adult child of an alcoholic parent. Which of the following statements made by the adult child indicate an understanding of the nurse's teaching? Select one: a. "Before being discharged from the hospital, dad will have at least one supervised alcohol-drug reaction." b. "Dad may have to take this medication for a long time until he gains self-control over alcohol use." c. "My dad's last drink was eight hours ago, so he may take his the first dose immediately." d. "I am so glad my dad has agreed to take this drug, I want it to cure his drinking problem."

b. "Dad may have to take this medication for a long time until he gains self-control over alcohol use."

A client reports awaking from sleep by contractions that are occurring every five minutes and lasting 30-40 seconds. Which of the following questions should the nurse ask to assess for true labor versus false labor? Select one: a. "What happens to your contractions when you move about?" b. "Have you noticed any bloody show or fluid coming from your vagina?" c. "When did your contractions begin?" d. "Have you felt fetal movement over the last 24 hours?"

b. "Have you noticed any bloody show or fluid coming from your vagina?"

A client is seeking treatment for stress related to unexpected loss of employment and is engaging in the stress management technique of cognitive reframing. Which of the following statements would indicate to the nurse that the client understands this stress management technique? Select one: a. "When I do my daily yoga exercises, I feel so much better." b. "I have excellent job skills; I just need to find a new employer." c. "Once I decided what was most important to me, things got easier." d. "I can visualize the perfect interview and being offered a new job."

b. "I have excellent job skills; I just need to find a new employer."

A nurse is caring for a client with newly diagnosed diabetes mellitus. Which of the following client statements demonstrates understanding of self-blood glucose monitoring? Select one: a. "I only need to check my blood sugar when I feel dizzy." b. "I will check my blood sugar at the same times each day." c. "I can use my wife's blood glucose meter as long as I use my test strips." d. "I will check my blood sugar before dinner each day."

b. "I will check my blood sugar at the same times each day."

A nurse is caring for a client who is scheduled for an electroencephalogram (EEG). Which statement by the client indicates a need for further education? Select one: a. "I should wash my hair on the morning of the test." b. "I will not eat or drink anything after midnight." c. "I will expect the procedure to be painless." d. "A tracing will be obtained to evaluate my brain activity."

b. "I will not eat or drink anything after midnight."

A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching? Select one: a. "I can use spermicidal gels or creams to increase effectiveness." b. "I will remove the condom 30 minutes after intercourse." c. "My partner will put the condom on while his penis is erect." d. "My partner should leave an empty space at the tip."

b. "I will remove the condom 30 minutes after intercourse."

A nurse concludes that additional teaching about the Diabetic Sick Rule is needed when the mother of the child states which of the following? Select one: a. "I will encourage my child to sugar-free, non-caffeinated liquids." b. "I will take my child blood sugar every 6 hours." c. " I will notify my health care provider if vomiting occurs more than once." d. "I will continue to give my child the oral antidiabetic agent."

b. "I will take my child's blood sugar every 6 hours."

A nurse is caring for a client who is taking furosemide for heart failure. Which of the following statements by the client indicates a need for further instruction? Select one: a. "I will eat an orange each day with my breakfast." b. "I will take my medication before I go to bed." c. "I will call my provider if I gain 2 pounds in one day." d. "I will drink at least 8 ounces of water with each meal."

b. "I will take my medication before I go to bed."

A nurse is providing discharge instructions to a client following cataract surgery. Which of the following statements by the client indicates the need for further teaching? Select one: a. "I will report a yellow or green discharge." b. "I will wear my bi-focal glasses when sitting outside on the deck." c. "I will report pain accompanied with nausea/vomiting." d. "I will avoid rapid, jerky movements such as vacuuming."

b. "I will wear my bi-focal glasses when sitting outside on the deck."

A client is prescribed digoxin. Which of the following statements by the client indicates to the nurse the need for further teaching? Select one: a. "I will take my medication at the same time each day." b. "If I see halos around lights there is no need to notify my provider." c. "I will check my pulse every day before taking my medication." d. "I should eat bananas and drink orange juice when I am on this medication."

b. "If I see halos around lights there is no need to notify my provider."

The nurse is assessing the family dynamics of a widow with end stage terminal cancer. Which statement made between the adult children would best indicate the need for further teaching? Select one: a. "The doctors have told us that it is time for us to make some tough decisions." b. "It does not matter what we think, the living will says 'do not resuscitate'." c. "If daddy were alive, he would be making these hard decisions, not us." d. "Since you are the oldest child, you have the responsibility to decide."

b. "It does not matter what we think, the living will says 'do not resuscitate'." `

A client being admitted to a nursing unit asks the nurse, "My friend has carpal tunnel syndrome and said I would probably get it too because of my work. What can I do to prevent it?" Which of the following statements would be the nurse's best response? Select one: a. "Consider asking for a different job if your wrists start to bother you." b. "Keep your wrists in a neutral position or wear wrist braces for support." c. "Find out if other family members have it because it is hereditary." d. "Begin a supervised exercise program to strengthen both of your wrists."

b. "Keep your wrists in a neutral position or wear wrist braces for support."

A nurse is teaching a community health class on communicable diseases to adolescents. During the discussion on infectious mononucleosis, which statement would lead the nurse to conclude that further teaching is needed? Select one: a. "Mononucleosis can be confirmed by a blood test." b. "Mononucleosis is a bacterial infection." c. "A person with mononucleosis would have flu-like symptoms including a low grade fever, sore throat and fatigue." d. "A person with mononucleosis is at risk for a ruptured spleen."

b. "Mononucleosis is a bacterial infection."

A client experiencing pain has been prescribed meperidine 30mg IM every three hours, as needed for pain. The vial available is merperidine 75mg/1 mL. How much merperidine should the nurse administer? Select one: a. 0.5 ml b. 0.4 ml c. 1.4 ml d. 2.5 ml

b. 0.4 ml

A client is prescribed phenytoin 5 mg/kg/day in 3 divided doses. The client weighs 36 lb. The drug is available at 50mg/mL. What is the total daily dosage in milliliters for this client? Select one: a. 7.8 mL b. 1.6 mL c. 2.6 mL d. 0.5 mL

b. 1.6 mL

A client has an order for an IV of 1000 ml of lactated ringers with 20 mEq of potassium/L to infuse at 40 ml/hr. The drip factor is 15 drops/ml. The nurse calculates the flow rate to be: ______ gtt/min. Select one: a. 9 drops/min b. 10 drops/min c. 11 drops/min d. 12 drops/min

b. 10 drops/min

A nurse notes the following prescription for a client with thrombophlebitis: Heparin sodium 25,000 units in 500 mL of D5W to infuse at 1,200 units/hour. What is the flow rate in mL per hour? Select one: a. 50 ml/hr b. 24 ml/hr c. 25 ml/hr d. 10 ml/hr

b. 24 ml/hr

When suctioning a client with a tracheostomy tube, a nurse would perform the following steps: (Place in order of priority: may use each answer more than once) Check the suction source and adjust pressure dial to 80-120 mm HG. Assess breath sounds. Wash hands. Hyperoxygenate with 100% oxygen. Set up sterile field. Quickly insert catheter until resistance is met. Document procedure and client's response. Explain procedure to the client. Withdraw catheter using intermittent suction.

b. 3, 2, 8, 1, 5, 4, 6, 9, 4, 2, 3, 7

A client diagnosed with diabetes mellitus reports feeing shaky. Further assessment reveals diaphoresis, tachycardia, and a glucose level of 70 mg/dL. Which of the following should the nurse administer to prevent a hypoglycemia reaction? Select one: a. 2 pieces whole grain toast b. 6 ounces of orange juice c. 1 tablespoon of peanut butter d. 1 cup of whole milk

b. 6 ounces of orange juice

The following clients have been assessed in the emergency department. Which of the following clients requires immediate attention? Select one: a. A 6 year-old client with an open tibial fracture that occurred two hours ago after being hit by a car. b. A 48 year-old male complaining of chest pain, cardiac monitor showing sinus tachycardia with occasional PVC's. c. An 81 year-old client with a history of heart failure and new onset pneumonia with a respiratory rate of 32 and a temp of 101 F (38). d. A 19 year-old client who is vomiting and complaining of new onset right lower quadrant pain with rebound tenderness.

b. A 48 year-old male complaining of chest pain, cardiac monitor showing sinus tachycardia with occasional PVC's.

Which of the following situations demonstrate a violation of the ethical principle veracity? Select one: a. A nurse does not allow a client to refuse a treatment. b. A nurse tells a client that a medication will relieve pain when she knows that it will not. c. A nurse attempts an IV insertion at a site where no vein is seen or felt. d. A nurse tells a client that she will be back at 9am but doesn't return until 11am.

b. A nurse tells a client that a medication will relieve pain when she knows that it will not.

A nurse is caring for a client who is 11 weeks pregnant. Which of the following is an appropriate psychological task for the client? Select one: a. Verbalize concerns about the health care facility b. Accept the fact that she is pregnant c. View morning sickness as tolerable d. Begin to think about names for the baby

b. Accept the fact that she is pregnant

A nurse is managing the nursing staff on a medical-surgical unit. When evaluating client care, which of the following statements represents correct implementation of the five rights of delegation by the nursing staff? Select one: a. A licensed practical nurse creates the nursing care plan for a client experiencing post-operative pain 2 days after an appendectomy. b. An RN asks the assistive personnel to record the intake and output of a client who is admitted to the unit with heart failure. c. A licensed practical nurse delegates to the assistive personnel to teach the client about ambulating with a walker before discharge. d. An RN asks the licensed practical nurse to administer total parenteral nutrition to a client who had minor surgery 2 days ago.

b. An RN asks the assistive personnel to record the intake and output of a client who is admitted to the unit with heart failure.

At a well-child visit, the parents report that their toddler occasionally touches and fondles her genital area. The parents ask the nurse if this behavior is something to be concerned about. Which of the following is a correct response? Select one: a. This is a possible infection or irritation in the genital area b. Awareness of body structures and sensations is normal and expected c. Your child is probably imitating behaviors that she has observed d. This is an early emergence of sexual expression that should be discouraged

b. Awareness of body structures and sensations is normal and expected

A nurse is caring for a client with a tracheostomy. In which order should the following interventions be performed when providing tracheostomy care? A. Document the type and amount of secretions. B. Suction the tracheostomy. C. Clean the inner cannula with hydrogen peroxide followed by sterile saline. D. Apply an oxygen source loosely to prevent desaturation. E. Change tracheostomy ties if soiled. F. Apply a split 4X4 dressing around the tracheostomy.

b. B, D, C, F, E, A

A nurse is collecting data on a 5-month-old infant. Which of the following is an expected finding? Select one: a. Stepping reflex present b. Babinski reflex present c. Pulse rate 70 to 80/min d. Respirations 21 to 24/min

b. Babinski reflex present

A nurse is caring for a client recovering from an abdominal aortic aneurysm (AAA) repair. Which of the following findings would have the highest priority? Select one: a. Respiratory rate 12 breaths/minute. b. Blood pressure 136/90 mmHg c. Urine output 28 ml/hour d. Pedal pulse amplitude 2+.

b. Blood pressure 136/90 mmHg

A client is prescribed 10 units of regular insulin and 30 units of NPH daily. What order will the nurse complete the below insulin administration steps. (Place the following steps in the correct order). A. Inject air into the vial of regular insulin B. Using the same syringe, withdraw 10 units of regular insulin C. Wash hands and roll the vial of NPH D. Wipe the top of the vials with an alcohol pad E. Using the same syringe withdraw 30 units of NPH

b. C, D, A, B, E

A nurse is preparing a bolus tube feeding for a client with a gastrostomy tube. Which of the following would be an appropriate action? Select one: a. Assess the blood glucose before administering the feeding. b. Check gastric pH to assess placement of gastrostomy tube. c. Flush tubing with a small amount of saline before feeding. d. Don sterile gloves when adding feeding to the system.

b. Check gastric pH to assess placement of gastrostomy tube.

A provider informs the wife of a comatose client with terminal cancer that she will need to sign the consent for insertion of a gastrostomy feeding tube. The nurse knows this is against the client's wishes. What is the appropriate action by the nurse? Select one: a. Inform the wife she cannot sign the consent b. Consult the hospital's ethics committee. c. Ask the provider for an order for a NG tube instead. d. Prepare the consent for the wife to sign.

b. Consult the hospital's ethics committee.

A client is admitted to the hospital for treatment of an acute asthma attack. The client is receiving an aminophylline infusion. Which of the following assessment findings indicate the client is experiencing the desired effect of aminophylline? Select one: a. Decreased heart rate b. Decreased wheezing c. Increased blood pressure d. Increased mucous production

b. Decreased wheezing

A nurse is providing the family of a client with acquired immunodeficiency syndrome (AIDS) education in preparation for discharge. A family member asks about appropriate clean up of blood or body fluids. Which of the following is the correct response by the nurse? Select one: a. Disinfect the area with 70% isopropyl alcohol after initial cleaning. b. Disinfect the area with a 10% bleach solution after initial cleaning. c. Clean the area with soap and water and rinse thoroughly with ammonia. d. Use soap and water to clean, rinse thoroughly, and allow the area to air dry.

b. Disinfect the area with a 10% bleach solution after initial cleaning.

A nurse is caring for a client with a new onset bowel obstruction. What assessment finding would be anticipated when completing an abdominal assessment? Select one: a. Absent bowel sounds. b. Hyperactive bowel sounds. c. Normal bowel sounds. d. Hypoactive bowel sounds.

b. Hyperactive bowel sounds.

A client is prescribed TPN (total parenteral nutrition) to be infused through a single lumen PICC (peripherally inserted central catheter). Which of the following actions should the nurse take if the client is prescribed intravenous antibiotic therapy? Select one: a. Administer the antibiotic through the TPN line. b. Identify alternative methods of administration. c. Request the provider insert a second PICC line. d. Stop the TPN to administer the antibiotic as ordered.

b. Identify alternative methods of administration.

The client asks the nurse to explain the difference between true and false labor. Which of the following is an example of true labor? Select one: a. In true labor contractions are felt in the abdomen above the umbilicus b. In true labor the cervix will dilate and efface c. In true labor the presenting part is engaged d. In true labor walking will cause contractions to slow down

b. In true labor the cervix will dilate and efface

A client is admitted to the hospital with a diagnosis of Grave's disease. Which of the following findings should be reported to the provider immediately? Select one: a. Hyperactive deep tendon reflexes b. Increase in temperature from 99.5 F to 100.5 F c. Increase in white blood cell count from 6,000 mm3 to 8,000 mm3 d. Increased number of stools

b. Increase in temperature from 99.5 F to 100.5 F

A nurse is caring for a client who is in diabetic ketoacidosis (DKA). Which of the following outcomes would the nurse expect to find in this client? Select all that apply. Select one or more: a. Kussmaul breathing b. Increased serum potassium c. Decreased blood glucose d. Increased urinary sodium e. Decreased serum pH

b. Increased serum potassium a. Kussmaul breathing e. Decreased serum pH

A nurse is evaluating placement of a nasogastric (NG) tube. Which of the following is the least reliable method to determine correct NG tube placement? Select one: a. Aspirate to collect gastric content. b. Inject air into tube and listen over abdomen. c. Test pH of gastric contents. d. Ask the client to talk.

b. Inject air into tube and listen over abdomen.

A client diagnosed with diabetes mellitus consumed less than 50% of the lunch tray and reports feeling shaky. Which of the following is the first action the nurse should take? Select one: a. Provide a low carbohydrate snack b. Obtain a blood glucose reading c. Observe for signs of hypoglycemia d. Notify the charge nurse

b. Obtain a blood glucose reading

A charge nurse is managing a conflict between co-workers. Which of the following are effective management functions for conflict resolution? Select all that apply. Select one or more: a. Suppress the need for closure and follow-up to negotiation. b. Obtain needed unit resources through effective negotiation strategies. c. Pursue alternative dispute resolutions when conflict cannot be resolved. d. Avoid facilitating conflict resolution involving subordinates. e. Create a work environment that minimizes the conditions for conflict.

b. Obtain needed unit resources through effective negotiation strategies. c. Pursue alternative dispute resolutions when conflict cannot be resolved. e. Create a work environment that minimizes the conditions for conflict.

A client is receiving chemotherapy and reports that the tubing has pulled apart and notices a puddle on the floor. Which of the following is the priority nursing action to take after ensuring the client is stable and appropriate tubing disposal? Select one: a. Complete an incident report about the spill. b. Obtain the spill kit specifically designated for this type of spill and use it. c. Soak up the spill with a towel and dispose of it in a biohazard bag. d. Notify housekeeping of the spill.

b. Obtain the spill kit specifically designated for this type of spill and use it.

A nurse is caring for a client hospitalized with Guillain-Barré Syndrome who has been in the intensive care unit on a ventilator for four days. Which of the following would be most appropriate in assessing for complications of immobility? Select all that apply. Select one or more: a. Assess rate and depth of respiratory effort. b. Performing range of motion on the client's ankles, knees, and hips. c. Assessing the client's ability to move lower extremities. d. Assess the character of bowel sounds and frequency of stools. e. Observe skin color over sacral, heels, and scapulae areas.

b. Performing range of motion on the client's ankles, knees, and hips., d. Assess the character of bowel sounds and frequency of stools., e. Observe skin color over sacral, heels, and scapulae areas.

A client has been prescribed lithium carbonate to control the symptoms of bipolar II disorder. The client presents to the clinic reporting symptoms of lethargy, generalized discomfort, and a poor appetite. Which of the following would be the nurse's priority action? Select one: a. Question the client for concomitant alcohol use b. Prepare the client for lab work to measure lithium levels c. Assess the client to rule out possible flu syndrome d. Ask the client if they have experienced episodes of mania

b. Prepare the client for lab work to measure lithium levels

A client is admitted to the surgical unit after sustaining a compound fracture of the left femur. The client is alert and oriented with the following vital signs: T 99.4 F, P 88, R 20, B/P 94/58. The nurse notes a 4 cm. area of bright red blood on the pressure dressing on the left lower extremity. The client is receiving intravenous fluids of normal saline at 150 ml/hr. One hour after being admitted to the unit, the nurse finds the client confused and combative. Which of the following is the most likely cause of the change in the client's condition? Select one: a. Fluid overload related to aggressive isotonic volume replacement b. Hypoxia related to fat embolism from the fractured bone. c. Infectious process related to contamination of the open wound. d. Hypovolemic shock related to hemorrhage from the open wound

b.Hypoxia related to fat embolism from the fractured bone.

A nurse is caring for a client who has just undergone a bone marrow transplant. Neutropenic precautions are implemented to prevent infection. Which of the following is not a precautionary neutropenic measure? Select one: a. Restrict foods that may be contaminated with bacteria b. Monitor platelets c. Screen visitors d. Frequent, thorough hand hygiene

b.Monitor platelets

A nurse is caring for a client following a right below the knee amputation. Which of the following should the nurse include in the plan of care to prevent infection? Select one: a. Encourage the client to lie supine for 20-30 minutes several times a day. b. Position the affected limb in a dependent position. c. Position the affected limb elevated on a pillow. d. Encourage the client to lie prone for 20-30 minutes several times a day.

b.Position the affected limb in a dependent position.

The nurse is planning care for a client who is prescribed antiembolic stocking following abdominal surgery. Which of the following interventions should the nurse include? Select one: a. Ensure stockings are loose fitting over client's calves. b. Remove stockings one to three times per day for skin care and inspection. c. Encourage client to only wear stockings when out of bed. d. Remove stocking every 2 hours then reapply after 1 hour off.

b.Remove stockings one to three times per day for skin care and inspection.

A nurse is caring for a client with a diagnosis of sepsis with a temperature of 40.8 C (105.5 F). The provider has ordered a cooling blanket. Which intervention is appropriate to delegate to an Unlicensed Assistive Personnel (UAP)? Select one: a. Bathe the client to keep the skin damp b. Report shivering by the client c. Obtain a fan for the client's use d. Assess the client's skin for any reddened

b.Report shivering by the client

A client is admitted to the emergency room after falling outside his home. The client is complaining of a severe headache with pain above his left eye. The client is restless and intermittently losses consciousness. Pupils are dilated; pulse 56 and BP 168/98. An x-ray of the head confirms a skull fracture. Which of the following is a priority assessment? Select one: a. Pupillary changes b. Respiratory Status c. Blood alcohol and toxicology screening d. Changes in level of consciousness

b.Respiratory Status

A nurse is providing staff development. The nurse understands that which of the following may impede learning? Select one: a. Self-directed. b. Self-confidence. c. Proven learner. d. Intrinsic motivatio

b.Self-confidence.

A client with Type 1 diabetes has the following values from the morning laboratory testing: fasting plasma glucose = 115 mg/dL and HgA1C = 7.5%. How would a nurse interpret these values with regard to the client's glucose control? Select one: a. Short term values elevated, long-term values normal b. Short term values normal, long-term values elevated c. Short term values normal, long term values normal d. Short term values elevated, long term values elevated

b.Short term values normal, long-term values elevated

A client diagnosed with depression has been prescribed fluoxetine. Which of the following information should the nurse emphasize? Select one: a. Avoid foods high in tyramine b. Take the medication in the morning c. Take the medication at bedtime d. Maintain an adequate fluid and sodium balance

b.Take the medication in the morning

A nurse is caring for a client with a history of rheumatoid arthritis who is receiving methotrexate. Which of the following should be included in client education? Select one: a. Methotrexate will decrease the risk of developing cancer. b. The complete blood count (CBC) will be monitored. c. Methotrexate can be administered during pregnancy d. Daily monitoring of blood glucose is recommended

b.The complete blood count (CBC) will be monitored.

During a home visit, a 10-day postpartum client reports pain and tenderness with redness and swelling to her right breast. A localized hard mass is also noted upon palpation. How should the nurse respond to this client? Select one: a. This is normal breast engorgement and should subside within another week or two. b. These symptoms suggest an inflammatory or infectious process and require immediate notification to your health care provider (HCP). c. You will need to stop breastfeeding immediately until the swelling and redness subside. d. Please mention this to your HCP at your 2-week check-up.

b.These symptoms suggest an inflammatory or infectious process and require immediate notification to your health care provider (HCP).

A client with a history of duodenal ulcer is admitted to the hospital with status asthmaticus. Which of the following medications should the nurse question? Select all that apply. Select one or more: a. sucralfate b. naproxen c. furosemide d. prednisone e. lisinopril

b.naproxen, d.prednisone

A nurse is caring for a client who is being treated with internal radiation. Which nursing interventions are appropriate for this client? Select all that apply. Select one or more: a. Discard bed linens daily. b. Assign the client to a private room with a private bath. c. Always face the radiation source. d. Encourage visitors to stay at least 6 feet from the client. e. Limit visitors to 30 minutes twice daily.

c, b, d

A nurse is caring for a newborn client who is experiencing severe hyperbilirubinemia. Which of the following are symptoms of kernicterus? Select all that apply. Select one or more: a. Temperature instability Incorrect choice. b. Lethargy c. Backward arching of the neck and trunk d. Hypotonic e. Low birth weight Incorrect choice.

c, b`

A nurse is planning care for a client newly admitted to an inpatient mental health unit for treatment of a gambling addiction. The client is having difficulty concentrating and is worried about the future. Which initial intervention will maximize the client's success for recovery? Select one: a. Arrange for the client to attend Gamblers Anonymous. b. Suggest the client replace work out on the treadmill. c. Administer an anti-anxiety medication to the client. d. Recommend the client participate in group discussion.

c. Administer an anti-anxiety medication to the client.

A client who has undergone a mastectomy expresses concern about her body image. What nursing interventions would be appropriate for this client? Select all that apply. Select one or more: a. Advise to avoid taking blood pressure from the arm on the affected side. b. Educate the client about breast prostheses including properly fitting of prosthesis. c. Arrange for someone from a local support group to come and meet with the client. d. Refer the client to home health services to provide for needs following discharge. e. Encourage the client to discuss reconstruction alternatives with the surgeon.

c. Arrange for someone from a local support group to come and meet with the client. b. Educate the client about breast prostheses including properly fitting of prosthesis e. Encourage the client to discuss reconstruction alternatives with the surgeon.

The nurse is assisting the parents of a school-aged child with a plan to prepare him for the impending death of a family member. What would be the potential behavior of the school-aged child when faced with this stressor? Select one: a. Accepting behavior of this situation b. Uncooperative behavior c. Believe that death is temporary d. Same emotional demonstration as his parents

c. Believe that death is temporary

A nurse is caring for a client who underwent a right below the knee amputation yesterday. Which of the following findings should the nurse report to the provider immediately? Select one: a. White blood cell count of 10,000 mm3 b. Quarter size spot of blood on dressing c. Blood glucose 200 mg/dL d. Redness of the incision site

c. Blood glucose 200 mg/dL

A nurse is caring for a post-operative client who underwent thoracic surgery 7 hours prior, and now has in place a chest tube for drainage. What finding would require the nurse to contact the provider immediately? Select one: a. Diminished breath sounds auscultated in left lower lobe. b. Client complains of left-sided chest pain of 7 on pain scale when performing incentive spirometry. c. Chest tube drainage measures 80 mls an hour of red blood. d. Chest tube and tubing become disconnected during client transfer.

c. Chest tube drainage measures 80 mls an hour of red blood.

A client with gestational diabetes gave birth to a 9 pound neonate 12 hours ago. The neonate is presenting with a high pitched cry and jitteriness. Which of the following is the nurse's priority intervention? Select one: a. Administer subcutaneous insulin b. Place the neonate under a radiant warmer c. Offer the neonate breast milk or formula d. Provide oxygen via oxyhood

c. Offer the neonate breast milk or formula

A client with chronic obstructive pulmonary disease (COPD) has oxygen therapy ordered. Which principle should guide the nurse in managing the delivery of oxygen to this client? Select one: a. The concentration of oxygen should be high since the stimulus to breathe in clients with COPD is an elevated PaCO2. b. The concentration of oxygen should be low since the stimulus to breathe in clients with COPD is an elevated PaCO2. c. Clients with COPD should receive low concentrations (2-3 L) of oxygen since the stimulus to breathe is their low PaO2. d. Clients with COPD require higher concentrations (6-8 L) of oxygen since hypoxemia is their stimulus to breathe.

c. Clients with COPD should receive low concentrations (2-3 L) of oxygen since the stimulus to breathe is their low PaO2.

A nurse is reinforcing teaching with a client who has been recently diagnosed with osteoporosis. Which of the following should be included? Select one: a. Walking for one to two hours daily is recommended. b. Increase intake of dietary calcium c. Eliminate safety hazards in the home d. Long-term estrogen replacement therapy will be required.

c. Eliminate safety hazards in the home

A nurse is triaging clients after a tornado disaster. A 22-year-old client being triaged has asymmetrical chest movement, shortness of breath and absent lung sounds on the left side. What category of triage should the nurse place this client at? Select one: a. Expectant Class IV b. Urgent Class II c. Emergent Class I d. Nonurgent Class III

c. Emergent Class I

A nurse is admitting a client diagnosed with schizophrenia. In order to establish a therapeutic nurse-client relationship with the client, the nurse's initial actions should include which of the following? Select one: a. Provide confidentiality b. Maintain consistency c. Establish trust d. Develop a contract

c. Establish trust

A nurse is providing education to a client with coronary artery disease. Which of the following cholesterol values should the nurse identify as a goal for this client? Select one: a. LDL-C level 120 mg/dL b. HDL-C level 20 mg/dL c. HDL-C level 60 mg/dL d. LDL-C level 98 mg/dL

c. HDL-C level 60 mg/dL

A nurse is monitoring client compliance with the diabetes mellitus treatment regimen. Which of the following values best indicates compliance with the regimen? Select one: a. Pre-meal glucose of 140 mg/dL b. Fasting blood glucose level of 127 mg/dL c. Hemoglobin A1c of 5% d. Blood glucose level of 125 mg/dL

c. Hemoglobin A1c of 5%

A client is prescribed digoxin 1mg by mouth QID. The client states that the objects in his room have a yellowish tinge and he is nauseated. Select the most appropriate nursing action at this time. Select one: a. Count the apical pulse; if it is regular and above 60, administer the drug as ordered. b. Administer the medication and observe the client for further nausea. c. Hold the drug and call the health care provider. d. Hold the medication and count the apical pulse before the next dose is to be given.

c. Hold the drug and call the health care provider.

A client is undergoing cystoscopy. Which of the following interventions should the nurse include in the client's plan of care? Select one: a. Educate client on the need for anticoagulant therapy. b. Increase oral fluid intake to flush contrast dye from system. c. Monitor for infection for 48-72 hours following procedure. d. Provide education on home urinary catheter care.

c. Monitor for infection for 48-72 hours following procedure.

A nurse is providing discharge instructions for a client who is taking atenolol. Which instructions should the nurse give to the client to prevent postural hypotension? Select one: a. Take the medication immediately after awakening b. Lie down if dizziness or lightheadedness occurs c. Move slowly when changing from lying to standing d. Take the medication with plenty of fluids

c. Move slowly when changing from lying to standing

A client is receiving chemotherapy for the treatment of breast cancer. Which of the following findings should be reported to the provider immediately? Select one: a. Absolute neutrophil count 8,000/mm3 b. Alopecia c. Temperature 38.1°C d. Mucositis

c. Temperature 38.1°C

A nurse is caring for a client who has been committed to an acute Mental Health facility with an involuntary emergency commitment order. What should the nurse include when orienting the client to the facility? Select one: a. Length of stay at the facility will be determined by the courts. b. The client can leave the facility at any time if they sign a medical release form. c. The client has the right to refuse treatment, unless he has been judged to be incompetent. d. Family will not be able to visit until their provider grants the visitation privileges.

c. The client has the right to refuse treatment, unless he has been judged to be incompetent.

A nurse is caring for a client who has been prescribed magnesium sulfate for pregnancy induced hypertension. On admission the client's B/P is 160/90 mm Hg and urine output is 25mL/hr. Following initiation of magnesium sulfate, which of the following symptoms should be reported to the provider? Select one: a. The client is voiding 40 mL/hr b. The client reports feeling flushed and warm c. The client is drowsy and difficult to rouse d. The client's blood pressure is 130/70 mm Hg

c. The client is drowsy and difficult to rouse

A nurse correctly understands which of the following characteristics is a possible developmental delay for a 3-month-old client? Select one: a. The infant is unable to point to objects b. The infant is unable to sit with support c. The infant does not raise his head when placed on his abdomen d. The infant demonstrates stranger anxiety

c. The infant does not raise his head when placed on his abdomen

An adult is seen in the healthcare provider's office with multiple bruises and lacerations consistent with physical abuse. During the nursing assessment, the client reports that the injuries were intentionally inflicted by the spouse and verbalizes fear that it will happen again. Which of the following statements would indicate that the nurse's initial counseling has been effective? Select one: a. "I'll go home and pack my bag, putting it out in the open so my spouse understands that I'm serious about leaving." b. "The next time the hitting starts, I will tell my spouse to stop immediately or I'll be forced to call the police." c. "I'll tell my spouse that I have spoken with you and that I have decided we need to start counseling soon as a couple." d. "I will take some money, clothes, and important papers to my parents' home and go there if things start to get bad again."

d. "I will take some money, clothes, and important papers to my parents' home and go there if things start to get bad again."

A nurse is educating a parent of a newborn about safety measures. Which of the following statements made by the client would indicate a need for further teaching? Select one: a. "I should never leave my baby unattended with pets or other children." b. "I should always support my baby's head when I pick him up." c. "My baby's car seat should be in the back seat facing backwards." d. "Once my baby begins to roll over it is okay to use a small pillow in the crib."

d. "Once my baby begins to roll over it is okay to use a small pillow in the crib."

A nurse is providing a tour of the labor and delivery unit to expectant parents. Which statement made by the mother indicates a need for further education? Select one: a. "When the baby is returned to us from the nursery, we should check the baby's identification band." b. "We will request to see picture identification badges for all facility staff who care for our baby." c. "When the baby is born, my thumb print will be taken along with the baby's footprint." d. "We will need to remove the baby's ankle identification band during diaper changes."

d. "We will need to remove the baby's ankle identification band during diaper changes."

A client expresses to the nurse that her husband is an alcoholic and has trouble keeping a job for longer than three months. Which of the following is the nurse's best response? Select one: a. "This seems to worry you. May I contact the Hospital Chaplain?" b. "Have you tried to contact Al-Anon? I can help if you want." c. "I'm so sorry to hear that. Why do you think he drinks?" d. "What have you done in the past to help deal with this problem?"

d. "What have you done in the past to help deal with this problem?"

The nurse is caring for four clients receiving chemotherapy. Which of the following clients should the nurse see first? Select one: a. A client with cervical cancer and a hemoglobin level of 8.2 mg/dL b. A client with endometrial cancer and a potassium level of 5.0 mEq/L c. A client with ovarian cancer with a white blood cell count of 4,500 cells/mcL d. A client with breast cancer and a sodium level of 115 mEq/L

d. A client with breast cancer and a sodium level of 115 mEq/L

A client is recovering from acute respiratory distress syndrome (ARDS). Which clinical manifestation requires immediate attention by the nurse? Select one: a. A decrease in temperature b. Increase in pulse rate c. Increased oxygen saturation d. A decrease in blood pressure

d. A decrease in blood pressure

A client is scheduled for surgery. Which of the following findings should the nurse report to the provider prior to surgery? Select one: a. Serum potassium of 3.8 mEq/L b. Increased anxiety level c. A missing identification band d. A decrease in blood pressure

d. A decrease in blood pressure

A nurse is caring for a client is recovering from a surgical procedure. Which of the following indicates that the client is experiencing orthostatic hypotension? Select one: a. Client reports leg discomfort when ambulating. b. A client reporting feelings of weakness when standing for the first time after surgery. c. An increase in diastolic pressure when changing positions. d. A decrease in systolic pressure when changing positions.

d. A decrease in systolic pressure when changing positions.

An elderly client is three days post-operative an anterior and posterior colporrhaphy. Which of the following assessments has the highest priority in this client's care? Select one: a. Breath sounds decreased with fine crackles audible at bilateral bases. b. Apical pulse 90 and slightly irregular. c. Oral temperature 100.8 F (38.2 C). d. Abdomen firm and tender to palpation above the symphysis pubis.

d. Abdomen firm and tender to palpation above the symphysis pubis.

A client is a Jehovah's Witness and is scheduled for an elective hysterectomy secondary to prolonged and heavy menses. Which medication would the nurse anticipate being ordered prior to surgery for this client? Select one: a. Retrovir b. Interferon c. Methylergonovine d. Epoetin Alfa

d. Epoetin Alfa

An 87-year-old client has been admitted repeatedly to the acute care setting for pneumonia. The client's family asks what measures can help prevent recurrent respiratory issues. Which of the following measures should the nurse discuss to prevent respiratory issues? Select all that apply. Select one or more: a. Reassure the client during respiratory distress. b. Administer a prior dosage of antibiotics when the client has a cough. c. Encourage a diet high in protein. d. Ambulate the client regularly, daily. e. Use a humidifier to moisten the air in the client's room, when needed.

d. Ambulate the client regularly, daily., e. Use a humidifier to moisten the air in the client's room, when needed., a. Reassure the client during respiratory distress.

A client is having an exercise electrocardiography (stress test) performed. The nurse recognizes the need to stop the test if which of the following occurs? Select one: a. The client begins to breathe harder b. The client experiences an increase in heart rate. c. QRS complexes begin to occur more frequently. d. An ST segment depression or T wave inversion on the EKG.

d. An ST segment depression or T wave inversion on the EKG.

A client with an ileostomy calls the clinic reporting stomal swelling along with decreased drainage of ileostomy contents. The nurse instructs the client to do which of the following? Select all that apply. Select one or more: a. Drink hot tea. b. Lie down in a supine position. c. Ensure the pouch is attached correctly. d. Apply moist towels to the abdomen. e. Begin abdominal massage.

d. Apply moist towels to the abdomen., e. Begin abdominal massage., a. Drink hot tea.

A nurse needs to determine a client's strength before ambulating. Which of the following should the nurse do? Select one: a. Assess pedal pulses and feet for edema. b. Ask the client if they have been up before. c. Assess how strong the client feels today. d. Ask the client to plantar flex the feet against resistance

d. Ask the client to plantar flex the feet against resistance.

A client has fallen in the bathroom. Which of the following is the priority nursing action? Select one: a. Notify the healthcare provider b. Assist the client back to bed c. Obtain the client's vital signs d. Assess the client's level of consciousness

d. Assess the client's level of consciousness

A nurse is caring for a client who is one month post bariatric surgery and has been diagnosed with dumping syndrome. Which of the following recommendations is appropriate? Select all that apply. Select one or more: a. Eat small, frequent meals during the day. b. Reduce the amount of protein and fat in the diet. c. Sit up for at least an hour after each meal. It is contraindicated for the client with Dumping Syndrome to sit up after eating, as that position will speed movement of gastric contents into the duodenum and may trigger the symptoms of Dumping Syndrome. d. Avoid consuming milk, sweets, and sugars. e. Eliminate liquids with meals, and for one hour before and after meals. .

d. Avoid consuming milk, sweets, and sugars., a. Eat small, frequent meals during the day., e. Eliminate liquids with meals, and for one hour before and after meals.

A client experiencing intermittent chest pain has been admitted to the hospital. Which of the following laboratory values should the nurse report to the health care provider immediately? Select one: a. C-reactive protein (CRP) 0.2 mg/dL b. Creatine kinase (CK) 90 units/L c. Total myoglobin 60 mcg/L d. Cardiac troponin T 1.2 ng/mL

d. Cardiac troponin T 1.2 ng/mL

A client has a new tracheostomy. Which of the following interventions should the nurse include when performing tracheostomy care? Select one: a. Remove soiled dressing with sterile gloves. b. Clean disposable inner cannula with hydrogen peroxide. c. Suction the tracheostomy before beginning care. d. Change tracheostomy ties when soiled.

d. Change tracheostomy ties when soiled.

A nurse is triaging clients following a mass casualty event. The nurse should place a client who has sustained fatal injuries in which of the following triage categories? Select one: a. Emergent Category (Class I) b. Urgent Category (Class II) c. Nonurgent Category (Class III) d. Expectant Category (Class IV)

d. Expectant Category (Class IV)

A client at 35 weeks gestation is admitted to the birthing unit with preterm labor. Which of the following assessments would require the nurse to immediately notify the provider? Select one: a. B/P 138/80mmHg, contractions every 3-4 minutes b. B/P 110/60mmHg, trace protein, contractions every 3-4 minutes c. FHR 140 b/min: good variability, contractions every 3-4 minutes d. FHR 120 b/min with late decelerations, contractions- every 1-2 minutes

d. FHR 120 b/min with late decelerations, contractions- every 1-2 minutes

A community based nurse receives a client referral. Which of the following actions should be performed first? Select one: a. Educate the client about the community resources that are available b. Encourage the client to contact appropriate agencies. c. Obtain information about community resources accessible to the client. d. Collaborate with the health care team and the referring agency to assess client needs.

d. Collaborate with the health care team and the referring agency to assess client needs.

A nurse is feeding a client with dysphagia. Which of the following should the nurse do to prevent aspiration? Select all that apply. Select one or more: a. Position the client in an upright, seated position in a chair. b. Place food on the weaker side of the mouth. c. Assist the client to flex the head to a chin-down position d. Consult with a speech pathologist for evaluation. e. Provide a brief rest period before eating.

d. Consult with a speech pathologist for evaluation., a. Position the client in an upright, seated position in a chair., c.Assist the client to flex the head to a chin-down position.

A nurse is preparing a client with terminal illness for discharge to a nursing home when he states: "I don't want to go to a nursing home to die. I would rather die at home." What would be the most appropriate action by the nurse? Select one: a. Continue to make the discharge arrangements. b. Inform the provider of the client's decision. c. Assess the client's reasons for feeling this way. d. Contact the client's case manager.

d. Contact the client's case manager.

A charge nurse is delegating a task. The nurse understands which of the following represents effective delegation? Select all that apply. Select one or more: a. Monitoring how the delegated task is being accomplished. b. Referring to the ANA Code of Ethics for effective delegation practices. c. Delegating a task that should be assigned to a manager. d. Delineating the desired outcomes of the delegation. e. Asking the nurse if they are capable of completing the delegated task

d. Delineating the desired outcomes of the delegation., a. Monitoring how the delegated task is being accomplished., e. Asking the nurse if they are capable of completing the delegated task.

A graduate nurse is caring for a client who is on neutropenic precautions. Which of the following actions by the nurse would require further teaching by the charge nurse? Select one: a. Taking a blood pressure cuff to the bedside of a client on neutropenic precautions. b. Disposing of a used needle and syringe in the biohazard box in the client's room. c. Taking an infusion pump from the bedside of a client to the dirty utility room. d. Discarding an empty blood bag and blood tubing in the client's beside trash can.

d. Discarding an empty blood bag and blood tubing in the client's beside trash can.

A school-aged child has been recently diagnosed with attention deficit hyperactivity disorder (ADHD). What activities can the school nurse provide to the parents to help improve school performance? Select one: a. Insist that the child read quietly to himself until he understands the instructions. b. Allow the child to work when they feel like it. c. Encourage the child to sit at the dining room table until all homework is done d. Divide tasks into small projects, allowing frequent breaks.

d. Divide tasks into small projects, allowing frequent breaks.

A nurse is changing a dressing on a preschool-aged child who has a healing wound on a lower extremity. Which of the following nonpharmacologic comfort measures would be most appropriate for this child? Select one: a. Promising the child a special treat in exchange for cooperation. b. Assisting the child to take deep breaths and focus on relaxing. c. Teaching the child how to go 'to a different place' using their imagination. d. Encouraging the child to watch a favorite cartoon on television.

d. Encouraging the child to watch a favorite cartoon on television.

A nurse is changing a dressing on a preschool-aged child who has a healing wound on a lower extremity. Which of the following nonpharmacologic comfort measures would be most appropriate for this child? Select one: a. Promising the child a special treat in exchange for cooperation. b. Teaching the child how to go 'to a different place' using their imagination. c. Assisting the child to take deep breaths and focus on relaxing. d. Encouraging the child to watch a favorite cartoon on television.

d. Encouraging the child to watch a favorite cartoon on television.

Which of the following client care assignments is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Select all that apply. Select one or more: a. Transport a client who is utilizing oxygen and has a peripheral IV catheter. b. Provide initial food by mouth for a client who has experienced a brain attack. c. Apply a dressing to a superficial laceration on the client's arm. d. Obtain vital signs every 4 hours for a client with ulcerative colitis. e. Assist a client with a new transurethral prostectomy with perineal care.

d. Obtain vital signs every 4 hours for a client with ulcerative colitis., e. Assist a client with a new transurethral prostectomy with perineal care., a. Transport a client who is utilizing oxygen and has a peripheral IV catheter.

A client admitted with an acute exacerbation of asthma has been prescribed methylprednisolone sodium succinate IV. Which of the following findings should the nurse report to the provider immediately? Select one: a. Increased hunger b. Blood glucose 120 mg/dL c. Mild wheezing d. Oral temperature of 100.5 F◦

d. Oral temperature of 100.5 F◦

An adult client is seen in the emergency department and is accompanied by a sibling who reports that the client is incapable of performing self-care activities. The client states, "Freeze thumping lasting circus going." The client appears suspicious and reports hearing threatening voices. The nurse recognizes that the client is exhibiting signs of which disorder? Select one: a. Bipolar disorder I b. Dissociative fugue c. Generalized anxiety disorder d. Paranoid schizophrenia

d. Paranoid schizophrenia

A nurse is caring for a client with heart failure. Which of the following interventions should the nurse take if the client is experiencing dyspnea? Select one: a. Obtain serial ABGs every 8 hours. b. Place client in the reverse trendelenberg position. c. Perform coughing and deep breathing exercises every 8 hours. d. Place client in high Fowler's position.

d. Place client in high Fowler's position.

A nurse is caring for a client who is having difficulty swallowing. Which intervention is effective in preventing injury? Select one: a. Discourage visitors at meal time. b. Weigh the patient weekly. c. Observe for evidence of aspiration. d. Position in High Fowler's for meals.

d. Position in High Fowler's for meals.

A nurse is caring for a client taking captopril. Which finding would require immediate attention for this client? Select one: a. Blood pressure 96/48 b. Pulse 56 c. Sodium 133 d. Potassium 5.8

d. Potassium 5.8

A nurse is caring for a client at risk for atelectasis. Which of the following should the nurse monitor for manifestations of atelectasis? Select one: a. Daily weight b. Lung sounds c. Intake and output d. Pulse oximetry

d. Pulse oximetry

A nurse is positioning a client for a urinary catheterization. Which of the following nursing actions would be best in preventing musculoskeletal injuries during the procedure? Select one: a. Narrowing the base of support. b. Using the non-dominant hand to insert the catheter. c. Positioning the client using a draw sheet. d. Raising the bed to a comfortable height.

d. Raising the bed to a comfortable height.

A client is prescribed lisinopril. Which of the following is most important for the nurse to assess before administering this medication to the client? Select one: a. Body temperature. b. Breath sounds. c. Peripheral edema. d. Serum electrolytes.

d. Serum electrolytes.

A distracted 7-year-old student is sent to the school nurse by his teacher. When the nurse checks his hair and scalp, the nurse notes the evidence of pediculosis capitis. What are recognizable signs of this form of skin infestation? Select one: a. Flaking of the scalp with pink, irritated skin exposed b. Multiple tiny pustules on the scalp with no abnormal findings on the hair shafts. c. Scaly, circumscribed patches on the scalp, with mild alopecia in these areas. d. Small white spots that adhere to the hair shaft, close to the scalp.

d. Small white spots that adhere to the hair shaft, close to the scalp.

A nurse is instructing a client with a right fractured tibia on the correct technique for using a three-point gait with crutches. Which of the following should be included in teaching? Select one: a. Weight is evenly distributed, with each leg being moved alternately with the opposing crutch. b. Weight is placed on both legs, and crutches are placed one stride in front and then legs swing to the crutches. c. Partial weight is placed on the right foot moving the crutch at the same time as the right leg. d. Weight is distributed on both crutches and then on the unaffected leg with the sequence being repeated.

d. Weight is distributed on both crutches and then on the unaffected leg with the sequence being repeated.

A nurse is assessing a client in the immediate postpartum period. The fundus is boggy and deviated to the left of the umbilicus. Which of the following is the most appropriate intervention? Select one: a. Begin an oxytocin infusion b. Assess lochia c. Reassess client in 30 minutes d. Assist client to void

d. assist the client to void

A nurse is teaching a client about dietary modifications to help control blood pressure. Which of the following food choices by the client indicates an understanding of the teaching? Select one: a. Chicken bouillon and crackers b. Vegetarian wrap with chips c. French onion soup and salad d. Grilled chicken salad with fresh salsa

d. grilled chicken salad with fresh salsa

A client is diagnosed with rheumatic fever. Which clinical manifestation would the nurse recognize associated with the presentation of rheumatic fever? Select one: a. Irritability, poor concentration and behavioral problems b. Cough c. Purulent nasal discharge d. Polyarthritis

d. polyarthritis

A nurse is educating a client who observes Kosher laws of food preparation. When planning menus with this client, which of the following would not be an appropriate food choice? Select one: a. Eggs b. Spinach c. Tuna d. Rabbit

d. rabbit

A nurse is providing discharge education for a female client diagnosed with Chlamydia. Which statement made by the client would indicate the need for further instruction? Select one: a. "Symptoms of reinfection may include yellow vaginal discharge." b. "I will refrain from sexual intercourse until completion of antibiotics." c. "Possible complications to monitor for include pelvic inflammatory disease." d. "I will return to the clinic in one month for re-screening."

d."I will return to the clinic in one month for re-screening."

A nurse is providing education for a client prescribed digoxin. Which of the following statements by the client demonstrates an understanding? Select all that apply. Select one or more: a. "I will contact my provider if I experience excessive nausea". b. "I will contact my provider if I experience visual changes." c. "This medication will change the color of my urine." d. "This medication will cause my heart to beat slower." e. "I understand I need weekly laboratory testing."d.

d."This medication will cause my heart to beat slower.", b."I will contact my provider if I experience visual changes.", a."I will contact my provider if I experience excessive nausea".

A nurse is caring for a client being discharge home who has hemophilia. Which of the following points would be taught to the parents prior to discharge? Select one: a. Provide heat to control bleeding episodes. b. Report to the provider a pink, nonpruritic macular rash. c. Encourage child to participate in team activity sporting events. d. Dress toddlers in extra layers of clothing.

d.Dress toddlers in extra layers of clothing.

A nurse is reviewing a client's lab results. Which finding would lead the nurse to suspect the client is experiencing dehydration? Select one: a. BUN 20mg/100mL b. Serum sodium 130 mEq/L c. Urine specific gravity of 1.025 d. Hematocrit 55%

d.Hematocrit 55%

A nurse is caring for a client with Addison's disease. Which of the following diets should the nurse teach the client to follow? Select one: a. Low Sodium, high calcium and decreased fluids. b. High Sodium, low calcium and increased fluids. c. Low Sodium, high potassium and decreased fluids. d. High Sodium, low potassium and increased fluids.

d.High Sodium, low potassium and increased fluids.