NCLEX Review

A client is admitted following a severe burn. What changes to fluid status would the nurse anticipate? Select all that apply. A.) Fluid volume excess B.) Hypovolemia C.) Third spacing D.) Increased urine output E.) Low CVP F.) Increased urine specific gravity

B, C, E, F

The nurse is discussing frostbite prevention with a group of teenagers who participate in cold weather activities. What risk factors for developing frostbite will the nurse include? Select all that apply. A.) Alcohol use B.) Dehydration C.) Diabetes D.) Exhaustion E.) Low level altitude

A, B, C, D

What signs/symptoms would lead the nurse to suspect that a client diagnosed with cirrhosis may be developing hepatic coma? Select all that apply. A.) Asterixis B.) Fetor C.) Grey Turner's sign D.) Hyperactive reflexes E.) Squiggly handwriting

A, B, E

Which intervention should the nurse initiate for a client post liver biopsy? Select all that apply. A.) Apply direct pressure to the site immediately after needle is removed B.) Assess puncture site every 15 minutes for 1 hour C.) Position client on left side D.) Keep client NPO for 24 hours E.) Advise client that pain may occur in right shoulder as the anesthetic wears off

A, B, E

Which client diagnosis would require the nurse to initiate droplet precaution? A.) Methicillin-resistant Staphylococcus aureus (MRSA) B.) Varicella C.) Vancomycin-resistant enterococci (VRE) D.) Whooping cough

D

Which member of the multi-disciplinary team oversees and coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client? A.) Clinical nutritionist B.) Primary nurse each shift C.) Primary healthcare provider D.) Case manager

D

A nurse walks into a client's room and discovers the radioactive uterine implant lying on the bed. What action should the nurse take FIRST? A.) Put on gloves B.) Pick up the implant with tongs C.) Place implant in lead lined container D.) Call radiation department to take the implant out of the room

A

A client diagnosed with schizophrenia tells the nurse. "God is going to heal me. I do not need medication." Which response by the nurse would BEST promote compliance with the prescribed medication regimen? A.) Yes, I believe God will heal you B.) Many people of faith believe that one way God works to heal is through medication C.) We are talking about taking your medication right now D.) What if God does not heal you and you should have taken the medication?

B

A client diagnosed with systemic lupus erythematosus (SLE) has been on hydroxychloroquine sulfate to decrease joint pain and swelling. What statement by the client indicates to the nurse the medication teaching has been effective? A.) I will be prone to infections while on this medication B.) I need to see my eye doctor at least once every year C.) I might develop a red rash on my nose and cheeks D.) I can stop this medicine after my symptoms are gone

B

A client has been transferred from the emergency room to the cardiac unit with a diagnosis of anterior MI with elevation ST segment (STEMI). Which initial action by the nurse takes PRIORITY? A.) Obtain the client's vital signs B.) Place client on cardiac monitor C.) Auscultate bilateral lung sounds D.) Perform cardiac output assessment

B

A client is admitted with prolonged nausea and vomiting. The client's admission sodium level is 149 mEq/L. What action by the nurse would be most appropriate at this time? A.) Administer 3% NS at 150 mL/hr B.) Perform neurological assessment C.) Increase oral intake of sodium D.) Decrease fluid intake

B

A client is being treated in the emergency department for dehydration. Which central venous pressure (CVP) reading would the nurse identify as the desired response to treatment? A.) -1 mmHg B.) 4 mmHg C.) 10 mmHg D.) 15 mmHg

B

In what position should the nurse place a client post intracranial surgery? A.) Head of bed elevated 30 degrees B.) Supine C.) Dorsal recumbent D.) Recovery position

A

The nurse in the clinic would recognize which client statement as most indicative of gallbladder disease? A.) Yesterday, when I ate a hamburger and french fries, my belly really hurt B.) I have been gaining a lot of weight lately C.) My stools are darker. Sometimes they are even black D.) When I start hurting, it helps if I drink milk or have a small snack

A

Which medication prescription should the nurse question for a client diagnosed with nephrotic syndrome? A.) Ibuprofen B.) Enalapril C.) Prednisone D.) Cyclophosphamide

A

A home care nurse is completing an initial assessment on an elderly client living alone. What normal effects of aging would the nurse expect to find? Select all that apply. A.) Loss of skin elasticity B.) Decline in sensory system C.) Decreased enjoyment of intimacy D.) Forgetfulness E.) Desire to remain at home

A, B

The emergency department nurse is monitoring a client being admitted in diabetic ketoacidosis (DKA). Which ABG values would be expected? Select all that apply. A.) pH 7.32 B.) PaCO2 32 C.) HCO3 25 D.) PaO2 78 E.) SaO2 82

A, B

A Hispanic mother and her child visit the PCP's office due to a fever that the child has been having for two or three days. Upon entering the room, the nurse immediately asks what is happening with the child and begins to check the temperature. Which response is likely by the mother? A.) Accepts the treatment of the nurse and think that it is appropriate B.) Takes offense to the abrupt nature of the treatment C.) Thinks that the nurse is busy and needs to rush D.) Thinks that the nurse is very efficient

B

The nurse is teaching a group of clients about SSRIs. Which comment by a client in the group indicates adequate understanding of the effects/side effects of the medications? A.) My weight may decrease while taking this drug B.) I may expect increased sweating while taking this drug C.) I may actually feel more depressed while taking this medication D.) I should feel better within a couple of days after beginning the medication

B

What is the BEST position for the nurse to place a client for a thoracentesis of the right lung? A.) Lying supine with pillow removed and head of bed flat B.) Sitting on side of bed and leaning over the bedside table C.) Lying on the right side with the head of the bed at 45 degrees D.) Lying supine with the left arm raised over the head

B

The nurse is educating a client diagnosed with cirrhosis about the functions of the liver. What functions should the nurse include? Select all that apply. A.) Removes old RBCs from the body B.) Produces clotting factors C.) Detoxifies the body D.) Releases digestive enzymes E.) Breaks down medications

B, C, E

A client admitted to the Coronary Care Unit (CCU) following a myocardial infarction expresses fear of the equipment and noise on the busy unit. What is the MOST therapeutic response by the nurse? A.) Everyone gets scared here at first B.) Why are you afraid of equipment C.) This all seems frightening to you D.) You won't have to be here very long

C

A client admitted with a diagnosis of portosystemic encephalopathy secondary to Laennec's cirrhosis is scheduled for the insertion of a pigtail catheter. The family asks the nurse the purpose of the catheter. What should the nurse tell the family? A.) Obtain an hourly assessment of urinary output B.) Instills antibiotics to decrease internal bacteria C.) Drains excess fluid from the abdominal cavity D.) Obtains liver tissue for a diagnostic biopsy

C

Which laboratory test should be assessed by the nurse prior to administering radioactive iodine (RAI) to a female client? A.) Thyroid scan B.) Serum calcium C.) Pregnancy test D.) Metanephrine test

C

A client has been started on IV gentamicin for osteomyelitis. The nurse informs the client frequent blood work will be done to monitor the amount of medication in the body. The nurse knows what labs are a priority to check every three days for this client? A.) BUN and creatinine B.) Liver function studies C.) Hemoglobin and hematocrit D.) Peak and trough levels

D

What does the nurse need to remember when caring for clients on the oncology unit who have a radiation implant? Select all that apply. A.) Nursing assignments should be rotated weekly B.) The nurse should care for no more than 3 clients with a radiation implant per shift C.) Limit visitors to 60 minutes per day D.) Wear film badge throughout assigned shift E.) Educate visitors to stay at least 6 feet from the client

D, E

What signs/symptoms does the nurse expect to see in a client diagnosed with schizophrenia? Select all that apply. A.) Auditory hallucinations B.) Grandiose delusions C.) Religious preaching all the time D.) Flat affect E.) Abstract reasoning

A, B, C, D

A palliative care client is suffering from persistent diarrhea. What foods should the nurse suggest? Select all that apply. A.) Applesauce B.) Rice C.) Bananas D.) Tea E.) Yogurt

A, B, C

In what position should the nurse place a client post lumbar puncture? A.) Reverse trendelenburg B.) Prone C.) Side-lying D.) Supine HOB elevated 45 degrees

B

What discharge instruction should a nurse provide to a client diagnosed with Hepatitis B to provide adequate nutrition? A.) Suggest client eat several small meals a day, with the largest at breakfast B.) Recommend eating meals in a semi-recumbent position C.) Administer metoclopramide 1 hour after meals D.) Avoid fruit juices and carbonated beverages

A

A child is admitted to the hospital with a temp of 102.2 F, lethargic, and no urinary output in 6 hours. Which prescription would be PRIORITY for the nurse to initiate for this child? A.) Blood cultures times two B.) Ceftriaxone 250 mg IV every 12 hours C.) Start IV and monitor site D.) 1/2 NS at 40 mL/hr

A

A client diagnosed with depression asks the nurse, "What is causing me to be depressed so often?" What is the BEST response by the nurse? A.) There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain B.) You experience depression because of your elevated levels of thyroid hormone C.) The PCP will have to explain to you what is causing your depression D.) Tell me what you think causes you to be depressed

A

A client has a prescription for digoxin 0.125 mg IV push every morning. Prior to administering digoxin, the nurse that the digoxin level drawn this morning was 0.9 ng/mL. Which action would be MOST important for the nurse to take? A.) Administer the digoxin B.) Hold the digoxin C.) Notify the PCP D.) Repeat the digoxin level

A

A client has been taking enoxaparin 40 mg subcutaneous once a day for 1 week. Which action should the nurse take? Labs: - Hgb: 15 g/dL - Hct: 43% - Platelets: 110,000 mm3 - aPTT: 110 seconds - INR: 1.2 A.) Administer protamine sulfate 50 mg over 10 minutes B.) Type and cross match for 2 units PRBCs C.) Increase enoxaparin dose to increase INR D.) Give the scheduled dose of enoxaparin

A

A client has terminal cancer tells the nurse that the opioid prescription, which is at the highest recommended dose, is not relieving the pain. What should the nurse tell the client? A.) I will ask your primary healthcare provider to increase your dose of medication B.) You cannot have a higher dose of pain medication since you are at the maximum dose C.) Opioid addiction is a major concern. You don't want to take too much of this medication D.) Let's try some lemon essential oils to decrease your pain level

A

A client is admitted to the cardiac floor in heart failure. The lung sounds reveal crackles bilaterally and the BP is 160/98. The client has been on diuretics at home and the potassium level is 3.3 mEq/L. Which diuretic would the nurse anticipate being prescribed for this client to minimize potassium loss? A.) Spironolactone B.) Furosemide C.) Bumetanide D.) Hydrochlorothiazide

A

A client is experiencing a panic attack. What PRIORITY action should the nurse take? A.) Instruct client to deep breathe with the nurse B.) Teach relaxation techniques C.) Inform client that symptoms will be gone in 20-30 minutes D.) Hold the client gently for 5 minutes

A

A client who is suicidal confused to the night nurse, "I will try again when I get out of this place." What is the nurse's BEST response? A.) What do you plan to do? B.) You will try what again? C.) Why would you want to do that? You have everything to live for D.) Are you trying to get back at your family for sending you here?

A

A client who was hospitalized with a diagnosis of schizophrenia tells the nurse. "My veins have turned to stone and my heart is solid!" How would the nurse identify this statement? A.) Depersonalization B.) Echopraxia C.) Neologism D.) Concrete thinking

A

A client with chronic liver disease has ascites and is being treated with an albumin infusion. What should the nurse anticipate and monitor in this client? A.) Fluid volume excess B.) Cellular edema C.) Severe hypotension D.) Decreasing CVP

A

A client with mania has repeatedly interrupted group session with the counselor. The client explains that they already know this information about family roles and paces around the room. What should the nurse do at this time? A.) Ask the client to take a walk with you and make another pot of coffee B.) Ask the client to reflect on their behavior to determine if it is appropriate C.) Ask the group to tell the client how they feel when they are interrupted D.) Tell the client to perform jumping jacks and count out loud

A

A client with type II diabetes reports normal blood glucose levels at bedtime and high blood glucose levels in the morning for the past week. What instruction would the nurse give the client? A.) Monitor blood sugar around 2 cm B.) Decrease bedtime snacking C.) Decrease intermediate acting insulin D.) Increase intermediate acting insulin

A

A client, admitted to the surgical unit post left thoracotomy, is drowsy. Vital signs on admit are T 99.8 F, HR 94, RR 16/shallow, BP 100/68. ABGs are pH 7.33, PCO2 48, HCO3 24. Which action should the nurse initiate? A.) Have the client take deep breaths B.) Administer naloxone C.) Tell the patient to breathe faster D.) Medicate for pain

A

A farm worker comes into the clinic reporting headache, dizziness, and muscle twitching after working in the fields. What condition does the nurse suspect? A.) Pesticide exposure B.) Heat stroke C.) Anthrax poisoning D.) Gastroenteritis

A

A home care nurse is preparing to perform venipuncture on the client to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. How should the nurse communicate with this client? A.) Use simple words B.) Speak loudly to the client C.) Do not speak to the client at the time D.) Use open ended questions to ask what is wrong

A

A newly admitted client with schizophrenia tells the nurse, "The doctor is trying to steal my organs for science." Which response by the nurse would be the MOST therapeutic? A.) Are you feeling afraid now? B.) I am here with you C.) Let's discuss something else D.) You know that is not true

A

A nurse is caring for a client that is undergoing outpatient psychiatric treatment for somatization disorder. Which statement by the client indicates that teaching has been successful? A.) I will keep a diary of times of stress and the appearance of physical symptoms B.) I will simply ignore any physical symptoms I get from now on C.) The best way for me to stop having physical symptoms is to avoid all the stress in my life D.) I will take a sedative when I start having physical symptoms

A

A nurse observes a psychiatric client sitting alone. The client is talking, but occasionally stops and leans to the side as if listening to someone. The client then laughs. What is this client MOST likely experiencing? A.) Auditory hallucinations B.) Delusions C.) Catatonic excitement D.) Anergia

A

A teenage client asks the nurse, "Do you think I should tell my parents about my sexuality?" What is the nurse's BEST response? A.) What do you think you should do B.) Absolutely, I think you should tell your parents C.) Don't you think your parents have the right to know about your sexuality D.) I do not think now is the right time to tell your parents. Wait until you are 21

A

After completing several rounds of chemotherapy, a client's laboratory results indicates severe neutropenia. Following admission assessment, what is the nurse's PRIORITY action for this client? A.) Notify dietary no fresh, unpeeled fruits or vegetables B.) Avoid all venipunctures or IM injections C.) Have client wear mask when leaving room D.) Instruct client to use a soft toothbrush

A

After reviewing the client assignments, the LPN tells the RN that the assignment is very unfair and requests that some of the clients be redistributed to the other staff. What should the RN do FIRST? A.) Ask the LPN how the client assignment should be adjusted B.) Assign one of the LPN clients to another nurse C.) Encourage the LPN to use teamwork skills in caring for the clients D.) Develop a strategic plan to assist with client assignments

A

All of the beds in a 10 bed Labor, Delivery, Recovery, Postpartum Unit (LDRP) are full when one of the nurses assigned that day calls in sick. A nurse from the Med surg unit is transferred to the LDRP unit. Which client should the charge nurse assign to this nurse? A.) Client at 32 weeks gestation on oral terbutaline with 4 contractions/hour B.) One hour postpartum client with a continuous trickle of vaginal bleeding. C.) 2 hours postpartum client reporting intense perineal pain D.) Client at 36 weeks gestation with a blood pressure of 148/92

A

Arterial blood gases (ABGs) reflect a pH of 7.28, PaCo2 of 30, and HCO3 of 18. To which client would these ABGs MOST likely belong? A.) Weight loss of 20% in past month B.) Highly anxious with a panic attack C.) Alzheimer's with recent overdose of acetylsalicylic acid D.) Post-op with gastric suction

A

The client is worried and distracted, and explains to the nurse that because of the direct admission from the primary healthcare provider's office, there was no preparation to be away from home. The client is concerned about the length of stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client? A.) I will speak to the charge nurse about your needs so a case manager can be notified to help you with your concerns. B.) I know how you feel. I will be sure to tell your night nurse in shift report that you will probably need something to help you sleep tonight. C.) An unexpected hospital admission can be very stressful. Is there anyone who I can call for you? D.) can call your primary healthcare provider for you and ask if you could go home today, then schedule another date for your hospital admission.

A

The client who had a cerebral vascular accident (CVA) is now having Cheyne-Stokes respirations ranging from 12-30 breaths/minute. BP 158/108, HR 46. Based on this assessment, which acid/base imbalance does the nurse anticipate that this client will develop? A.) Respiratory acidosis B.) Respiratory alkalosis C.) Metabolic acidosis D.) Metabolic alkalosis

A

The home health nurse is assessing a client whose spouse died in a motor vehicle accident 6 months ago. The client says, "I feel all alone now." Which response by the nurse is therapeutic? A.) You are feeling all alone B.) Why do you say you are lonely C.) Your feelings of loneliness will decrease D.) I know other people who lost someone feel this way

A

The nurse assessing clients in a pediatric clinic would refer which child for further assessment? A.) A 20 month old who only says "no" B.) A 1 year old who says 3 words C.) A 9 month old who says "dada" and "mama" D.) A 4 month old who laughs out loud

A

The nurse has been educating a client on a new prescription for amitriptyline 25 mg PO twice a day. The nurse recognizes that teaching has been successful when the client makes which statement? A.) I will wear long sleeves and a hat when I go for my afternoon walks B.) I will limit my alcohol intake to one glass of red wine with supper C.) I need to limit my fluid intake in order to avoid fluid retention D.) I need to maintain a high calorie diet and eat 6-8 small meals a day

A

The nurse is assessing a client who is being treated with a non-steroidal anti-inflammatory medication (NSAID) for an acute flare-up of gout. Which finding is expected in the assessment? A.) Dramatic decrease in pain after beginning medications B.) Severe abdominal pain following medication administration C.) Decrease plasma uric acid levels D.) Low-grade fever and rash

A

The nurse is assigned to triage a client presenting to the emergency department who is suspected to have exposure to inhaled anthrax. What assessment findings are expected? A.) Abrupt onset of dyspnea, fever B.) Small papule of skin resembling an insect bite C.) Pustular vesicles on skin D.) Fatigue

A

The nurse is planning to discuss pain management with a client who experiences chronic pain. How should the nurse BEST begin this discussion? A.) Please tell me how I can best help you control your pain B.) It is my job to teach you how to deal with your pain C.) I will be teaching you how to use guided imagery to decrease your pain D.) Your primary healthcare provider has prescribed pain medication for your pain. I will teach you about this medication.

A

The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse recognizes that teaching was successful when the women identify which hormone as causing amenorrhea? A.) Progesterone B.) Estrogen C.) Follicle-stimulating hormone (FSH) D.) Human chorionic gonadotropin (hCG)

A

The nurse walks into a client's room and finds the client exposed while the UAP is giving the bath. After covering the client with a sheet, what should the nurse do FIRST? A.) Tell the UAP to keep the client covered at all times B.) Talk with the UAP about providing appropriate care for all clients C.) Providing teaching to the UAP about privacy for clients D.) Use the call light to ask for additional assistance in the room

A

What action should the nurse take when caring for a client who has a subarachnoid screw? A.) Keep connections tight B.) Use clean technique when caring for screw C.) Clean daily with hydrogen peroxide D.) Maintain a wet to dry dressing around site

A

Which action, if done by the nurse, needs to be interrupted by the charge nurse? A.) Mixes diazepam and hydromorphone in one syringe B.) Administers diazepam before meals C.) Raises side rails after administering hydromorphone D.) Instructs client to call for assistance getting out of bed after administration of diazepam

A

Which client in the Labor, Delivery, Recovery and Postpartum (LDRP) should the nurse see FIRST? A.) Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke" B.) Multigravida at term who is dilated to six centimeters and at minus one station with moderate contractions every five to ten minutes C.) Primipara at 38 weeks gestation who is dilated to five centimeters and at zero station with strong contractions every four minutes D.) Multigravida at 38 weeks gestation with pregestational diabetes in for a biophysical profile for fetal well being

A

Which client should the charge nurse assign to a new RN? A.) Child needing pre-operative medication prior to reduction of a fracture B.) Adult client reporting abdominal pain after being beaten up in a fight C.) Adolescent with sickle cell disease requesting more medication via the PCA device D.) Child admitted with cystic fibrosis 2 hours ago

A

Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult? A.) Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery B.) Twelve year old admitted 5 days ago receiving total parenteral nutrition (TPN) C.) Two year old taking only clear liquids since admission 24 hours ago D.) Nine month old admitted 2 days ago for diarrhea and now on 1/2 strength formula

A

The nurse at the wellness clinic is teaching a client newly diagnosed with insulin-dependent diabetes mellitus. The client asks about beginning an exercise program. The nurse bases the response on the fact that exercise has what effect on the body? Select all that apply. A.) Lowers the blood glucose B.) Provides more energy C.) Increases insulin need D.) Reverses complication of diabetes E.) Increases the workload of the liver

A, B

The nurse is caring for a client with chronic renal failure who receives dialysis treatment. Which findings would indicate to the nurse that the client's AV shunt is patent? Select all that apply. A.) A bruit is heard with a stethoscope B.) A thrill is felt upon palpation C.) There is a blood return on the venous side of the shunt D.) Urine output greater than 30 mL/hr E.) There is a strong radial pulse in the arm with the AV shunt

A, B

The nurse is preparing a class on cancer prevention. Which risk factor should the nurse discuss with the class as being a preventable risk factor? Select all that apply. A.) Smoking tobacco B.) Drinking alcohol C.) Eating a high fiber diet D.) Increasing fish consumption E.) Protect skin from sunlight by using tanning beds

A, B

Which signs/symptoms should the nurse assess for the presence of in a client diagnosed with valvular heart disease? Select all that apply. A.) Orthopnea B.) Paroxysmal nocturnal dyspnea C.) Petechiae on the trunk D.) Increasing CVP with decreasing BP E.) Pericardial friction rub F.) Widening pulse pressure

A, B

A client diagnosed with a brain injury continues to attempt to get out of the bed without assistance. Which nursing interventions would the nurse implement? Select all that apply. A.) Ask a familiar person to stay with the client B.) Apply position change sensor to the bed C.) Move client closer to the nursing station D.) Reinstruct the client to not get out of the bed E.) Provide positive and negative reinforcement

A, B, C

A client is admitted with a diagnosis of myasthenia gravis. What interventions should the nurse include to manage this client's swallowing and chewing impairment? Select all that apply. A.) Provide foods that are soft and tender B.) Allow client to rest between bites C.) Encourage the client to drink thickened liquids D.) Position upright with head tilted slightly backwards E.) Dissolve the cholinesterase inhibitor medication in water

A, B, C

A client is admitted with atrial fibrillation and heart failure secondary to chronic hypertension. Current medications include: Digoxin, Captopril, Carvedilol, Furosemide and Warfarin. Based on this profile, what lab work is ESSENTIAL for the nurse to monitor? Select all that apply. A.) Digoxin level B.) Potassium level C.) PT/INR D.) aPTT E.) CPK-MB

A, B, C

A client is suspected of having a pheochromocytoma. The nurse is explaining the process of a VMA (Vanillylmandelic acid) urine test to be completed at home. What statement made by the client indicates the need for further teaching? Select all that apply. A.) I need to keep the urine in the fridge during the 24 hours B.) I will have to stay well-hydrated to get enough urine to test C.) It does not matter what I eat or drink during this process D.) I need to throw away my first voiding after I start this test E.) I should void at the end of the 24 hours and keep that urine

A, B, C

The client with a new diagnosis of hypertension has been instructed to maintain a low sodium diet. Which foods does the nurse plan to teach the client to include on a low sodium diet? Select all that apply. A.) Lemonade B.) Broccoli C.) Apple D.) Smoked sausage E.) Boiled shrimp F.) Tomato soup

A, B, C

The nurse is talking with a parent regarding childhood immunizations. What vaccination is recommended for children to receive at 6 months? Select all that apply. A.) Diptheria B.) Hib C.) Influenza D.) Measles E.) Mumps F.) Rubella

A, B, C

The nurse is implementing cast care instructions for a client with a plaster cast applied 2 hours ago. Which cast care instruction would be included? Select all that apply. A.) Rest cast on a soft pillow B.) Keep the cast uncovered until air dried C.) Mark the cast if there is breakthrough bleeding D.) Place ice packs on side of the cast for the first 24 hours E.) Use the palms of hands when moving the cast for first 6 hours

A, B, C, D

The nurse is performing a neurological assessment on a client who reports frequent headaches. What question(s) should the nurse ask during this assessment? Select all that apply. A.) When did the headaches begin B.) What symptoms accompany the headaches C.) Does anything relieve the headaches D.) Does anything make the headaches worse E.) Are you experiencing depression

A, B, C, D

The nurse, caring for a client who has chronic renal failure, suspects that the client is experiencing anxiety. Which statements by the client would validate the nurse's suspicion? Select all that apply. A.) I do not think I can continue working B.) My husband has taken over the house cleaning and cooking C.) I fear I am dying D.) I have an "uneasy" feeling most of the time E.) Most of the time I feel very "down and blue"

A, B, C, D

Which assessment findings would indicate to the nurse that a client may have a fracture? Select all that apply. A.) Swelling B.) Deformity C.) Crepitus D.) Discoloration E.) Tenting of skin

A, B, C, D

Which nurse is providing cost effective care to a client? Select all that apply. A.) Providing palliative care to a terminally ill client B.) Beginning discharge planning on admit C.) Counseling clients on cigarette smoking cessation D.) Educating a group of parents on the importance of childhood immunizations E.) Performing a postop wound dressing change using clean gloves

A, B, C, D

A 70 year old female client reports an occasional choking sensation over the past 12 hours. What additional symptoms reported by the client would indicate to the nurse that the client may be having a myocardial infarction. Select all that apply. A.) Unusual fatigue B.) Indigestion C.) Aching jaw D.) Feeling faint E.) Pain between the shoulder blades F.) Left arm paresthesia

A, B, C, D, E

A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance? Select all that apply. A.) Provides "just in time" posters outlining the importance of pain assessment B.) Conducts brief in-services for each shift C.) Counsels nurses when pain level scale is not utilized D.) Ensures that a complete and clear performance standard exists E.) Assesses nurses' reasons for not using pain level scales F.) Disciplines offenses through unpaid time off

A, B, C, D, E

The case manager is arranging a planning meeting for the care of a client diagnosed with COPD. Who should be included in the meeting? Select all that apply. A.) Client B.) Nurse C.) Pulmonologist D.) Social worker E.) Pharmacist F.) Occupational therapist

A, B, C, D, E

Which clinical manifestations would a nurse expect to find in a client who has sustained a flail chest injury? Select all that apply. A.) Dyspnea B.) Crepitus C.) Paradoxical chest wall movement D.) Chest pain on inspiration E.) Shallow respirations F.) Bradycardia

A, B, C, D, E

A client sustains a high-voltage electrical injury while at work. Which interventions should the occupational nurse initiate? Select all that apply. A.) Assess entry and exit wound B.) Monitor vital signs C.) Place a spine board D.) Connect to cardiac monitor E.) Perform the rule of nines F.) Apply a cervical collar to neck

A, B, C, D, F

The nurse is caring for a client following a cholecystectomy. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms? Select all that apply. A.) Drink between meals B.) Reduce intake of carbohydrates C.) Eat small, frequent meals daily D.) Sit semi-recumbent for meals E.) Remain upright for one hour after eating F.) Lie down on left side after eating

A, B, C, D, F

The nurse is caring for a client with a perineal burn. The skin is not intact. What signs are suggestive of infection? Select all that apply. A.) Color changes B.) Drainage C.) Odor D.) Fever E.) Bleeding F.) Increased pain

A, B, C, D, F

A client has been instructed to not take Non-steroidal Anti-inflammatory drugs (NSAIDs) post lumbar laminectomy with spinal fusion. The nurse knows that education was successful when the client identifies which medications should be avoided? Select all that apply. A.) Celecoxib B.) Ibuprofen C.) Naproxen D.) Acetaminophen E.) Indomethacin

A, B, C, E

A nurse is teaching a client about post-procedure thoracentesis nursing care. Which statements should the nurse include? Select all that apply. A.) Checking your vital signs frequently B.) Examining the dressing for bleeding C.) Listening to and percussing your lungs D.) Positioning you with your affected lung down E.) Palpating around the incision site for air under the skin

A, B, C, E

The nurse is planning to teach a group of assisted living residents about tuberculosis (TB) infection. What should the nurse include? Select all that apply. A.) Cover mouth when coughing B.) Proper handwashing C.) Obtain a TB skin test D.) Obtain a yearly chest x-ray E.) Proper disposal of tissues

A, B, C, E

What interventions would the nurse implement for a client diagnosed with nephrotic syndrome? Select all that apply. A.) Weigh daily B.) Measure abdominal girth C.) Provide skin care D.) Position in semifowlers E.) Intake and output

A, B, C, E

What signs/symptoms should the nurse assess for when caring for a client at risk for thrombocytopenia? Select all that apply. A.) Conjunctival hemorrhage B.) Petechiae on inside of mouth C.) Purpura D.) Fever E.) Blood oozing for IV site

A, B, C, E

What signs/symptoms would indicate to the nurse that the client has had an inhalation injury? A.) Stridor B.) Swallowing difficulty C.) Singed nasal hair D.) Blisters to the upper arms E.) Wheezing

A, B, C, E

Which information obtained during a well-baby checkup of a 3 month old infant would the nurse need to report ot the primary healthcare provider? Select all that apply. A.) Parent states infant tastes salty B.) Frequent coughing with thick, blood-streaked sputum C.) Foul-smelling, greasy stools D.) Able to hold head upright without head wobbling E.) No weight gain since last check-up

A, B, C, E

Which tasks could the nurse working on a cardiac unit delegate to a UAP? Select all that apply. A.) Bathe the client who is on telemetry B.) Apply cardiac leads and connect a client to a cardiac monitor C.) Help position a client for a portable chest x-ray D.) Feed a client who is dysphagic E.) Collect a stool specimen

A, B, C, E

Which signs/symptoms would lead the clinic nurse to suspect that a client may have bacterial meningitis? Select all that apply. A.) Nuchal rigidity B.) Photophobia C.) Positive Kernig D.) Negative Burdzinski E.) Fever 102.8 F F.) Reports headache 9/10

A, B, C, E, F

In order to prevent injury or discomfort and maximize overall performance, what essential elements of ergonomic principles should the nurse utilize when caring for clients? Select all that apply. A.) Promote maximal stability by utilizing a wide base of support B.) Maintain a low center of gravity C.) Use both the arms and the legs when performing strenuous activity D.) Save effort by lifting rather than rolling, turning or pivoting E.) Utilize muscles of the back rather than muscles of the shoulders F.) Obtain assistance from other nurses or nurse assistants as needed

A, B, C, F

The nurse is planning care for a client admitted with a diagnosis of Alzheimer's Disease. What interventions should the nurse include? Select all that apply. A.) Encourage participation in light exercise B.) Identify doors with pictures C.) Monitor food intake D.) Assign UAP to bathe client daily E.) Reminisce about successful and unsuccessful life events F.) Weigh weekly

A, B, C, F

A client is admitted to the hospital with a platelet count of 132,000 and a white cell count of 8,495. What interventions should the nurse implement? Select all that apply. A.) Monitor stools for occult blood B.) Place on fall prevention C.) Place client in protective isolation D.) Restrict venipunctures E.) Limit visitors

A, B, D

A client returns to the unit after a liver biopsy. Which nursing interventions would the nurse implement? Select all that apply. A.) Put a pillow under the costal margin B.) Place in a right side lying position C.) Perform passive range of motion exercises to right shoulder D.) Take vital signs every 10-15 minutes for first hour E.) Instruct the client to avoid strenuous exercise for 1 month

A, B, D

The drug nadolol is prescribed for a client with stable angina. Which findings would indicate to the nurse that the drug is effective? Select all that apply. A.) Decreased anxiety B.) Relief of chest pain C.) Bounding pulses D.) Lowered blood pressure E.) Bradycardia

A, B, D

The nurse is teaching a group of clients who have reduces peripheral circulation how to care for their feet. What points should the nurse include? Select all that apply. A.) Check shoes for rough spots in the lining B.) File toenails straight accross C.) Cover feet and between toes with creams to moisten the skin D.) Break in new shoes gradually E.) Use pumice stones to treat calluses

A, B, D

A nurse working in the operating room (OR) as a circulator. Which actions should the nurse perform to help prevent surgical-site infections? Select all that apply. A.) Keep the OR doors closed during a surgical case B.) Minimize traffic in the OR C.) Ensure the room has negative air flow D.) Monitor the sterile field at all times E.) Immediately discard any object that becomes contaminated

A, B, D, E

The client has been working on weight loss for 8 months and has been successful in losing 35 lbs. The client is now entering the maintenance phase of the health promotion plan. Which strategies are important for the nurse to emphasize as the client enters this phase? Select all that apply. A.) On-going support from weight loss program personnel B.) Periodic weigh-ins with the nurse C.) Discontinue programmatic exercise plan D.) Relapse prevention plan E.) Continued peer support

A, B, D, E

The nurse is planning care for a client who has a fractured hip. Which nursing interventions should the nurse plan to use for impaired physical mobility. Select all that apply. A.) Turn every two hours B.) Place a pillow between legs when turning C.) Sit in a chair three times per day D.) Encourage fluid intake E.) Encourage ankle and foot exercises

A, B, D, E

The nurse on a medical unit is reviewing the data on a client admitted to a medical unit. Which data supports the diagnosis of glomerulonephritis? Select all that apply. A.) Malaise B.) Blood pressure 160/92 C.) 24 hour urinary output ~960 mL D.) Costovertebral angle tenderness E.) Urine specific gravity of 1.040

A, B, D, E

The nurse is planning care for a client admitted with a diagnosis of acute renal injury. What interventions should the nurse include in this plan? Select all that apply. A.) Provide meticulous skin care B.) Reposition every 2 hours C.) Maintain a high carbohydrate, high protein diet D.) Provide foods low in phosphate E.) Monitor intake and output F.) Give IV medications in smallest volume allowed

A, B, D, E, F

Which food items, if chosen by a UAP, would indicate to the nurse that the UAP understands a clear liquid diet? Select all that apply. A.) White grape juice B.) Gelatin C.) Vanilla pudding D.) Lemon popsicle E.) Fat free broth F.) Tea with honey

A, B, D, E, F

A client is being admitted with a diagnosis of cirrhosis of the liver. What assessment findings should the nurse anticipate in this client? Select all that apply. A.) Firm, nodular liver B.) Ascites C.) Increased serum albumin levels D.) Increased ALT and AST levels E.) Lowered ammonia levels F.) Bleeding from the GI tract

A, B, D, F

A client is placed on neutropenic precautions. What interventions should the nurse initiate? Select all that apply. A.) Use antimicrobial soap for handwashing B.) Post neutropenic precautions sign on door C.) Administer acetaminophen for fever greater than 101 degree F D.) Administer platelets as prescribed E.) Vital signs at least every 4 hours

A, B, E

The nurse is developing a teaching plan covering emergency responses to smallpox. This presentation will be used with newly hired employees. What information is essential for this presentation? Select all that apply. A.) People may be exposed to smallpox but not get the disease B.) People may contract the disease by handling contaminated clothing or bedding C.) Smallpox is fatal in about 50% of cases D.) Smallpox victims are contagious for two weeks E.) Smallpox victims are isolated from others

A, B, E

Three hours after delivery of a client's newborn, the nurse assesses for bladder distension. What signs would the nurse note if the client's bladder is distended? Select all that apply. A.) Fundus 3 cm above umbilicus B.) Excessive lochia C.) Voids 200 mL every 2 hours D.) Fundus in abdominal midline E.) Tenderness above symphysis pubis

A, B, E

The nurse has been assigned to a client with a Steinman pin insertion 48 hours ago. Which pin site care interventions would the nurse implement? Select all that apply. A.) Perform pin care daily B.) Rinse pins with water C.) Clean with chlorhexidine D.) Dry the area with clean gauze E.) Monitor pin site every 10 hours

A, C

The nurse is performing a neurological assessment on an adult client suspected of having a traumatic brain injury (TBI). Which signs/symptoms would indicate to the nurse that the client's ICP is increasing? Select all that apply. A.) Projectile vomiting B.) Narrowing pulse pressure C.) Delay in verbal response D.) DTR: Left 2+/4+ Right 2+/4+ E.) Negative Babinski F.) Glasgow Coma Scale Score 13

A, C

What actions would be appropriate for the nurse to take when performing peritoneal dialysis on a client diagnosed with renal injury? Select all that apply. A.) Dialysate is warmed to body temperature by allowing it to sit out for a short period of time B.) The dialysate is infused through the catheter into the stomach C.) Once infused, dialysate remains for prescribed dwell time D.) Withdraws dialysate using a large piston syringe E.) Assists client to stand if all the drainage is not removed

A, C

A client is admitted with hypocalcemia. Which treatment would the nurse anticipate for this client? Select all that apply. A.) PO Calcium B.) Rapid IV Push Calcium C.) Vitamin D D.) Sevelamer hydrochloride E.) Phosphate supplements

A, C, D

A client with deep partial thickness burns to arms and legs is admitted to the burn unit. The nurse knows elevated results are most likely to be noted initially in what laboratory tests? Select all that apply. A.) Hematocrit B.) Albumin C.) Potassium D.) Creatinine E.) Magnesium

A, C, D

A client's skeletal traction has been accidently released. What signs/symptoms does the nurse expect to see? Select all that apply. A.) Pain B.) Foot drop C.) Muscle spasm D.) Bone displacement E.) Itching under the straps

A, C, D

A nurse is teaching the client with asthma on proper use of an inhaler. Which statements by the client indicates that teaching has been effective? Select all that apply. A.) Exhale completely before using my inhaler B.) Use my steroid inhaler before the bronchodilator C.) Inhale slowly and push down firmly on the inhaler D.) Rinse my mouth with water before using my inhaler E.) Wait 5 minutes between puffs

A, C, D

The nurse is assessing a newborn to determine gestational age. What findings by the nurse would indicate the infant is premature? Select all that apply. A.) Folded ear pinna springs back slowly B.) Peripheral cyanosis on feet and hands C.) Shoulders and chest have moderate lanugo D.) Vernix covering axilla, back and buttocks E.) Feet soles entirely covered in creases

A, C, D

The nurse is developing the plan of care for a client admitted for the treatment of mania. What interventions should the nurse include? Select all that apply. A.) Give one cigarette to client at a time B.) Discuss delusional belief with client C.) Have finger foods available at mealtime D.) Give high calorie foods between meals E.) Provide soothing music in room during waking hours

A, C, D

The nurse is educating a client newly diagnosed with chronic stable angina about Nitroglycerine SL. What points should the nurse include? Select all that apply. A.) Nitroglycerine increased blood flow to the heart B.) Take one nitroglycerine every five minutes until the pain stops C.) Sit or lie down when taking nitroglycerin D.) The most common side effect is a headache E.) Keep nitroglycerin in a clear, plastic bottle

A, C, D

The nurse is preparing discharge teaching instructions for a client post right radical mastectomy with reconstruction. What instruction should the nurse include? Select all that apply. A.) Squeeze tennis ball with right hand every 2-4 hours while awake B.) No blood pressure readings in right arm for one year C.) Wear gloves when gardening D.) Wear your watch on your left wrist E.) Brush your hair with your left hand until pain free

A, C, D

What assessment finding by the nurse would support a client diagnosis of basilar skull fracture? Select all that apply. A.) Positive Halo test B.) Hyper-reflexia C.) Raccoon eyes D.) Battle's sign E.) Kernig sign

A, C, D

What should the nurse include when educating a client about the use of nitroglycerin sublingual? Select all that apply. A.) Do not swallow nitroglycerin B.) Keep the medication in a moist, warm place C.) The medication may burn when taken D.) Sit or lie down when taking this medication E) The most common side effect is vomiting

A, C, D

Which clinical manifestation does the nurse expect to see in a client diagnosed with Addison's disease? Select all that apply. A.) Confusion B.) Hypertension C.) Vitiligo D.) Hyperkalemia E.) Hypernatremia F.) Weight gain

A, C, D

A client has a history of deep vein thrombosis (DVT) and pulmonary embolism (PE). What should be included in the teaching by the nurse as preventative measures for the development of a DVT and PE? Select all that apply. A.) Drink plenty of fluids on a daily basis B.) Stop and move around every 4 hours when taking a long trip C.) Perform isometric and stretching exercises in the lower extremities D.) Need for weight management E.) Walk around 4-6 times per day

A, C, D, E

A client has returned to the room post stem cell transplantation. What early signs of rejection should the nurse monitor for in the client? Select all that apply. A.) Abdominal pain B.) Straw colored urine C.) Jaundice D.) Pruritus E.) Diarrhea

A, C, D, E

Which tasks would be appropriate for the charge nurse to assign to an LPN/VN? Select all that apply. A.) Collect data on a new client admit B.) Administer morphine IVP to a two day post-op client C.) Bolus feeding a client who has a gastronomy tube D.) Reinserting a nasogastric (NG) tube that a client accidentally pulled out E.) Monitoring patient control analgesic (PCA) pump pain medication being delivered to a client

A, C, D, E

What signs/symptoms does the nurse expect to see in a client who has ulcerative colitis? Select all that apply. A.) Abdominal cramping B.) Hematemesis C.) Diarrhea D.) Fever E.) Rebound tenderness F.) Rectal bleeding

A, C, D, E, F

A new nurse is documenting in a client's electronic health record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse? Select all that apply. A.) Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services B.) Appears to be having abdominal discomfort C.) Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon D.) Pre op Diazepam 10.0 mg given po E.) Transferred to surgical suite per stretcher with side rails up, in stable condition

A, C, E

An oncology client with a Hickman catheter is being discharged to receive chemotherapy via cassette pump at home. The nurse is aware that discharge instructions should include what information? Select all that apply. A.) Always use two pairs of gloves when preparing chemotherapy medications B.) Discarded chemotherapy cassettes and tubing can be placed in regular trash C.) Used needles or syringes must be placed into plastic chemotherapy receptacle D.) Linens soiled with chemotherapy drugs can be washed with regular laundry E.) Waste is placed into chemotherapy bags and picked up by medical supplier F.) Regular home cleaning products are appropriate for spilled chemotherapy medications

A, C, E

Following chemotherapy for acute lymphocytic leukemia (ALL), the client's lab results indicate a white blood count for 1000 cells mm3. What measures should the nurse institute immediately? Select all that apply. A.) Request to change IM antiemetic medication to oral pill B.) Have client increase fresh fruits and vegetables in diet C.) Obtain client's temperature at least every two hours D.) Move client into isolation with a negative flow room E.) Remove fresh flowers and limit visits from children

A, C, E

The nurse is caring for a client diagnosed with chronic renal failure has been taking Epoetin alfa for 2 months. What should the nurse monitor for pertaining to Epoetin alfa during the client's visit? Select all that apply. A.) Hypertension B.) Hallitosis C.) Hemoptysis D.) Oliguia E.) Dependent edema

A, C, E

What laboratory results would the nurse anticipate finding in a client receiving chemotherapy who is experiencing pancytopenia? Select all that apply. A.) White blood cell count 3,800 B.) White blood cell count 15,000 C.) Platelet count of 90,000 D.) Platelet count of 450,000 E.) Red blood cell count of 3.0 million F.) Red blood cell count of 7.3 million

A, C, E

When performing an admissions assessment, what should the nurse recognize as signs/symptoms of hyperthyroidism? Select all that apply. A.) Nervousness B.) Weight gain C.) Exopthalmos D.) Loss of appetite E.) Constipation F.) Hot and sweating

A, C, F

A client admitted to a psychiatric facility is refusing all medications. The nurse notes the client appears to be responding to auditory hallucinations. What actions by the nurse would be appropriate? Select all that apply. A.) Assign staff to stay with client B.) Place client into a seclusion room C.) Ask client to explain auditory sounds D.) Frequently reorient client to reality E.) Turn up radio to mask hallucinations

A, D

A client has just delivered a newborn. Based on the PCP's notation, what prescriptions does the nurse anticipate administering to the mother? Select all that apply. PCP Notation: Healthy male (21 inches long, 7 pounds) delivered to a 22 y/o female. Para 1 Gravida 1. Client is Rh negative and the newborn is Rh positive. Rubella titer less than 1:8.. Hepatitis B status negative. Tetanus toxoid 2 years ago. A.) Measles, mumps and rubella (MMR) vaccine B.) Hepatitis A vaccine C.) Hepatitis B immune globulin D.) RH0(D) immune globulin E.) Tetanus toxoid

A, D

The nurse is educating a group of college students about cancer prevention and screening. Which secondary prevention should the nurse include? Select all that apply. A.) Annual mammogram starting at age 40 B.) Maintain normal body weight C.) Cancer support group D.) Colonoscopy beginning at age 50 E.) Limit or eliminate alcohol intake

A, D

The nurse receives new primary healthcare provider prescriptions on a client diagnosed with Addison's disease. What prescription should the nurse question? Select all that apply. A.) Weigh QD B.) IV of Normal Saline at 125 mL/hr C.) MRI of pituitary gland D.) Fludrocortisone acetate 0.1 mg by mouth T.I.W E.) Dehydroepiandrosterone (DHEA) 5 mg by mouth every other day

A, D

Which client assignments are MOST appropriate for the charge nurse to delegate to an LPN/VN who works on the pediatric unit? Select all that apply. A.) 10 year old paraplegic in for bowel training B.) 2 year old with asthma newly admitted with dehydration C.) 3 month old admitted with septicemia D.) 7 year old in Buck's traction for a femur fracture E.) 10 year old transferred from ICU yesterday with a head injury

A, D

Which selection by the client indicates to the nurse that the client understands food allowed during a vanillylmandelic acid (VMA) test? Select all that apply. A.) Milk B.) Caffeine C.) Citrus fruit D.) Chicken E.) Vanilla ice cream

A, D

A medical secretary is transcribing hand written medical orders for several clients. When the charge nurse reviews the orders, several seem to have transcription errors. What orders should the nurse verify immediately with the PCP? A.) Adm. Diagnosis: Anterior MI cardiac enzymes x 3 & 12-lead ECT B.) S/P cataract removal to OD. Continue eye gtts twice daily to OU C.) H & P: Client indicates hx of cirrhosis with HDV, HTN and IDDM D.) Dx: renal insufficiency. Fluid restriction 1000 mL/24 hr with I & D q shift E.) Reports hx of COPD x 20 years, with occasional wet cough and SBO

A, D, E

A pregnant client who had been on a magnesium drip for severe pregnancy induced hypertension (PIH) has had an emergency cesarean section at 35 weeks. The newborn nursery nurse should anticipate what findings in the newborn related to the magnesium therapy? Select all that apply. A.) Hypotension B.) Hypoglycemia C.) Hyperreflexia D.) Flaccid muscle tone E.) Respiratory depression

A, D, E

What side effects would the nurse expect to find in a client who has received too much levothyroxine? Select all that apply. A.) Angina B.) Bradycardia C.) Hypotension D.) Heat intolerance E.) Tremors

A, D, E

When inspecting the equipment in a client's room, what would the nurse recognize as electrical safety hazards? Select all that apply. A.) Flickering overhead light B.) Ground-fault circuit interrupter electrical sockets C.) Hospital labeled UL power strip D.) Bent electrical bed cord E.) Cracked electrical socket

A, D, E

A client is admitted to the emergency department (ED) following blunt trauma to the chest from a motor vehicle accident. A hemothorax and pneumothorax are suspected. What signs and symptoms would the nurse anticipate recording to support this diagnosis? Select all that apply. A.) Shortness of breath B.) Decreased heart rate C.) Wheezing in the affected area D.) Chest pain E.) Cough F.) Subcutaneous emphysema

A, D, E, F

The nurse is instructing the mother of a toddler diagnosed with cystic fibrosis (CF) about specific dietary modifications the child will need. The nurse knows the teaching is successful when the mother selects what foods? Select all that apply. A.) Potato chips B.) Low-fat yogurt C.) Salt free bacon D.) Hot dog on a bun E.) Fresh avocados F.) Macaroni and cheese

A, D, E, F

How would the nurse interpret this client's Arterial Blood Gas results? - pH: 7.30 - PaCO2: 55 mmHg - Bicarb: 25 mEq/L - PaO2: 93 mmHg - SaO2: 95% Select all that apply. A.) Respiratory acidosis B.) Respiratory alkalosis C.) Metabolic acidosis D.) Metabolic alkalosis E.) Uncompensated F.) Partially compensated G.) Fully compensated

A, E

The community health nurse is presenting information about birth control measures to a group of young females. The nurse explains than an intrauterine device (IUD) is MOST appropriate for what individuals? Select all that apply. A.) A mother of a toddler who wants another child in three years B.) The client with a recent exacerbation of sickle cell anemia C.) A client with stage II breast cancer who has finished chemotherapy D.) An adolescent who has recently become sexually active E.) The client has a double mastectomy seven years ago

A, E

The nurse has informed a client diagnosed with heart failure about the treatment plan, including prescriptions for an ACE inhibitor and a 2 gm sodium diet. Which statement by the client would indicate to the nurse that the client understands the treatment plan? Select All That Apply A.) "I plan to elevate the head of my bed on concrete blocks so I can sleep better." B.) "Instead of using salt, I should use a salt substitute to season my food." C.) "It is important that I weigh myself weekly to monitor for weight gain." D.) "I need to eat foods high in potassium while taking an ACE inhibitor." E.) "A low sodium diet will help decrease swelling in my legs."

A, E

A client arrives at the clinic reporting a sharp pain, rated 10/10, radiating from the right flank around the lower right abdomen. The client reports nausea and vomiting. Based on this data, what problem does the nurse suspect? A.) Glomerulonephritis B.) Renal lithiasis C.) Nephrotic syndrome D.) Acute kidney injury

B

A client arrives at the emergency department with pneumothorax. A chest tube is inserted and placed to 20 cm of suction. Two hours later, the nurse notes tidaling in the water-seal chamber. Based on this data, which intervention should the nurse initiate? A.) Auscultate the lung sounds B.) Document the finding C.) Notify the PCP D.) Place the client on oxygen

B

A client comes into the clinic for a routine check-up during the second trimester of pregnancy. The client reports gastrointestinal (GI) upset and constipation. The nurse reviews the client's medications. Which client medications is most commonly associated with GI upset and constipation? A.) Calcium supplement B.) Ferrous sulfate C.) Folic acid D.) Cetirizine

B

A client had radiation seeds implanted to treat prostate cancer. When entering the room to initiate discharge teaching, the nurse observes the spouse emptying the client's urinal. What is the nurse's priority action? A.) Immediately escort spouse to ED to check radiation levels B.) Begin discharge teaching to the client and spouse C.) Have spouse wash hands thoroughly and apply sterile gloves D.) Explain that spouse must remain outside the room until urinal is emptied

B

A client is admitted to a chemical dependency unit for addiction treatment. Which of the client's belongings should the nurse remove from the client's room? A.) Shampoo and conditioner B.) Mouthwash and hand sanitizer C.) Toothpaste and dental floss D.) Lotion and foot powder

B

A client is admitted to the ICU after overdosing on meperidine. What is the nurse's FIRST priority? A.) Maintain continuous cardiac monitoring B.) Administer naloxone hydrochloride 0.4 mg IV every 2-3 minutes PRN C.) Provide alprazolam 0.25 mg PO PRN D.) Initiate IV fluid resuscitation with lactated ringers at 125 mL/hr

B

A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain. Vitals are Temp 99.8, Resps 34, Pulse 132 and BP 142/82. ABG results are pH 7.52, PaCO2 30 and HCO3 22. The nurse determines that the client is in what acid/base imbalance? A.) Respiratory acidosis B.) Respiratory alkalosis C.) Metabolic acidosis D.) Metabolic alkalosis

B

A client is taking an NSAID for the relief of joint pain. A gastrointestinal bleed is suspected. Which laboratory value alerts the nurse to possibility that the client is chronically losing small amounts of blood? A.) Prolonged bleeding time B.) Elevated reticulocyte count C.) Decreased platelet count D.) Elevated bands

B

A client presents to the emergency department (ED) reporting fever, cough and malaise. The nurse notes that the client has a rash appearing as vesicles, most prominently on the face, palms of the hands and soles of the feet. In addition to triaging the client as emergent, what should the nurse do? A.) Send the client to the waiting room B.) Place the client in a negative pressure room C.) Put a surgical mask on the client D.) Initiate contact precautions

B

A client presents to the emergency department with flu symptoms, fever and chills. The nurse notes that the vital signs are: T 102.8 F, P 128, RR 30, BP 154/88. ABG results are: pH 7.5, PaCO2 32, HCO2 23. What acid/base imbalance does the nurse determine that this client has developed? A.) Respiratory acidosis B.) Respiratory alkalosis C.) Metabolic acidosis D.) Metabolic alkalosis

B

A client returned to the unit following a total hip replacement. What statement by the client would indicate to the nurse that teaching has been successful? A.) I will try to keep my legs together as close as possible B.) I will not elevate the heat of the bed C.) I know that I cannot ever swim again D.) I can resume my exercises at the gym within one month

B

A client who has been given steroids for a prolonged period to treat asthma, reports dizziness, tingling of the fingers and muscle weakness. What action should the nurse take FIRST? A.) Determine current blood pressure B.) Connect client to a cardiac monitor C.) Administer oxygen D.) Obtain ABGs

B

A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital signs, laboratory studies and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing cause of the pain? A.) Surgical cannulation of the bile duct is causing spasm and pain B.) Carbon dioxide used intraperitoneally is irritating the phrenic nerve C.) Large abdominal retractors used in the procedure compressed a nerve D.) Side lying position in the operating room generated pressure damage

B

A client with severe depression and a previous history of attempted suicide has been receiving inpatient therapy for months. The nurse notes at breakfast the client is showered, in clean clothes with hair combed. What response by the nurse is MOST therapeutic at this time? A.) You look great today, so you must be feeling better B.) I see you are wearing a bright blue sweater today C.) Have something changed in your life this morning? D.) Today must be a very special occasion for you

B

A client, with a T5 injury, has not had a bowel movement in three days. Today, the client reports a headache rated 10/10. The nurse takes the client's vital signs: BP 180/110, HR 52, RR 20. What action by the nurse takes priority? A.) Administer hydralazine 20 mg IV B.) Elevate head of bed 45 degrees C.) Remove impaction with topical anesthetic D.) Close air vents in the room

B

A female client receiving chemotherapy for breast cancer reports vomiting, stomatitis and a 10 pound gain over the past month. The PCP orders an antiemetic and daily mouthwashes. When the home health nurse evaluates the client one week later, what change described by the client would BEST indicate improvement? A.) Eating three meals daily B.) Weight gain of two pounds C.) No further mouth pain D.) Improved skin turgor

B

A hospitalized client using a K-pad on an injured muscle reports the pad is not warming up. What should be the nurse's INITIAL action? A.) Unplug unit and plug into another wall outlet B.) Check temperature setting on the heating unit C.) Call maintenance to repair until immediately D.) Increase temperature on unit till pad heats up

B

A nurse has performed teaching with a client diagnosed with Cushing's disease. Which statement by the client would indicate understanding of the teaching? A.) The increased level of ADH will cause my potassium level to be too high B.) I will be retaining sodium and water due to the increased amount of aldosterone C.) I will be losing lots of fluid due to the hormonal imbalance I have D.) I will feel jittery and nervous due to the elevated thyroxine levels

B

A nurse is teaching a renal transplant client about self care after discharge. As part of the information about transplant rejection, the nurse cautions the client to notify the PCP of which occurrence? A.) Ecchymosis of incision B.) Tenderness over the kidney C.) Frequent polyuria D.) Subnormal temperature

B

An Asian client, who cannot speak or comprehend English, is brought to the emergency department by family. One family member is able to understand simple sentences of English. How would the nurse best explain how to obtain a clean catch urine to the client? A.) Have the family member repeat the nurse's explanation to the client B.) Contact Social Services to find an authorized interpreter C.) Use simple hand motions to explain the procedure to the client D.) Draw a diagram to demonstrate the use of the sterile cup when obtaining the specimen

B

At a monthly staff meeting in a long-term care facility, the charge nurse requests staff input to create new activities for the clients. An RN has been assigned to gather information for staff consideration. What method would provide the RN with the best data for this project? A.) Ask clients' families which activities they would like to have available B.) Research professional articles for guidelines to activities in long-term care C.) Have clients peruse a variety of games and select what interests them D.) Contact other facilities to inquire what types of programs they provide

B

Te emergency responders enter the emergency department with a client in cardiac arrest. One of the responders is performing chest compressions. What is the BEST assessment for the nurse to determine if the responder is compressing with enough depth and forth? A.) Dilated pupils after 1 minute of CPR B.) Presence of a carotid pulse with each compression C.) Cardiac rhythm on the monitor D.) Rise and fall of the client's chest with ventilations

B

The home health nurse is caring for a Mexican-American client who has been discharged from the hospital post myocardial infarction. While the nurse is at the house, a curandero is also at the home at the request of family members. What is the BEST action by the nurse? A.) Leave, and return once the curandero has left B.) Discuss the plan of care with the client, family and curandero C.) Ask the curandero to leave so that the client can be reassessed D.) Explain to the family that the curandero is not a reliable healthcare option

B

The new nurse is caring for a client receiving oxygen by nasal cannula. Which action would require the charge nurse to intervene? A.) Apply gauze padding beneath the tubing B.) Use petroleum jelly on the nares and cheeks C.) Provide mouth and nose care every 4 hours as needed D.) Place the oxygen tubing above the ears

B

The nurse administers chemotherapeutic drugs to a client with breast cancer. Where should the nurse dispose of the medication vials? A.) In a puncture-resistant biohazard container B.) In a chemotherapy sharps container C.) In a biohazard waste container D.) In a chemical container

B

The nurse completed discharge teaching on a client with two fractured ribs. Which statement by the client would indicate the need for FURTHER teaching? A.) I will take deep breaths using my incentive spirometer every 2 hours B.) I will wrap my chest in an elastic bandage to support and immobilize my ribs C.) I will talk to my PCP before taking the narcotic pain medicine that I currently have at home D.) I will notify my PCP if I develop any change in my respirations or secretions

B

The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the MOST logical rational for the client's action? A.) Confusion and disorientation B.) Scared and lonely and grabs the nurse's hand for comfort C.) Would like to talk to the nurse D.) Would like to reminisce with the nurse

B

The nurse is caring for a client being admitted to the ED after being stabbed in the chest. An occlusive dressing is covering the chest wound upon arrival. The client's condition begins to deteriorate. Assessment reveals tracheal deviation, diminished breath sounds bilaterally, and asymmetrical chest wall movement. What would be the priority nursing intervention? A.) Administer high flow O2 per face mask B.) Remove the occlusive dressing C.) Notify the PCP D.) Initiate rapid IV resuscitation

B

The nurse is caring for a client prescribed vancomycin for Methicillin-Resistance Staphylococcus Aureus (MRSA) infection. What nursing intervention is appropriate? A.) Provide the client food or snack to take with the medication B.) Verify that the client's BUN and creatinine are within normal range C.) Administer an antiemetic prior to vancomycin administration D.) Request the placement of a PICC line for IV administration

B

The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which statement by the client indicates an understanding of foot care? A.) I will soak my feet for 30 minutes a day B.) I will avoid using a heating pad on my feet C.) I can use scissors to remove the corns on my toes D.) I enjoy walking without my shoes around the house

B

The nurse is preparing to collect a capillary blood specimen for measuring blood glucose. Which action is MOST likely to result in an adequate stick for the client? A.) Place the finger at heart level when making the stick B.) Warm the finger prior to the stick C.) Keep the injector loose against the skin D.) Place the finger above heart level when making the stick

B

The nurse is preparing to discharge a client who has been placed on tranylcypromine. The nurse teaches the client about food to avoid while taking this medication. What food choice by the client confirms appropriate understanding of the teaching? A.) Cottage cheese B.) Salami C.) Baked chicken D.) Potatoes

B

The nurse is providing dietary instructions to a client newly diagnosed with type 2 diabetes. Which food examples should make up the highest percentage of this client's recommended diet? A.) Pecans, eggs, pork chop B.) Wheat bread, dried beans, brown rice C.) Lean hamburgers, fish, skinless chicken D.) Whole milk, cheese, dark chocolate

B

The nurse is taking care of a client that has been on TPN for 5 days. Upon entering the room, the nurse observes that the TPN has been turned off. What is the nurse's PRIORITY action? A.) Flush the IV line B.) Obtain blood glucose level C.) Check written prescription D.) Restart TPN infusion

B

The nurse is teaching the family of a newly diagnosed diabetic client about treatment of hypoglycemia at home. Which guidelines should be given to the family of the client? A.) It is not necessary to treat mild hypoglycemia indicated by irritability B.) Treat a mild episode with 10-15 grams of carbohydrate C.) The client should consume 12 ounces of regular cola D.) The client should consume 2 cups of orange juice without added sugar

B

The nurse manager is performing a chart audit for clients who were restrained. For which client would the side rails in the up position be considered a restraint? A.) The client who requests that the rails be placed in the up position B.) The client who is confused and wanders about the unit C.) The client who is ambulatory and places the side rails up without soft assistance D.) The client who asks the family to place all the rails up before leaving

B

The nurse performs an assessment on a client who reports abdominal pain. Based on the assessment findings, what problem does the nurse suspect? Nursing Assessment: Awake, alert and oriented reporting diffuse abdominal pain rated 9/10. Skin warm and dry. Cullen's sign noted. Abdomen rigid with guarding. Temperature 101 degrees F, BP 96/64, HR 102, RR 26. A.) Cirrhosis B.) Pancreatitis C.) Peptic ulcer D.) Ulcerative colitis

B

When the surgical transport team arrives to take the client to the OR, the client is sitting in a chair in the room. What is the BEST way for the nurse to get the client onto the transport litter? A.) Using a footstool, assist client to step up and crawl onto litter B.) Have client return to bed and utilize slide boards to transfer litter C.) With feet placed apart, grasp client around waist and lift onto litter D.) Put Hoyer pad under client, using lift to move client from chair to litter

B

Which client can a nurse manager safely transfer from the telemetry unit to the obstetrical unit in order to receive a new admit? A.) Client admitted with possible tuberculosis awaiting skin test results B.) Client diagnosed with a seizure disorder C.) Client with a new pacemaker scheduled to be discharged in the morning D.) Client with a history of mild heart failure prescribed one unit of PRBCs for anemia

B

Which comment made by a new nurse regarding sodium polystyrene sulfonate indicates to the charge nurse that the new nurse understands the effects of this medication? A.) Sodium is exchanged for potassium in the blood B.) Fluids will need to be encouraged after administration C.) This medication will increase potassium and decrease sodium D.) Sodium polystyrene sulfate is only given as an enema

B

Which statement by a client scheduled to be discharged home following treatment for alcoholism would indicate that FURTHER instruction is necessary? A.) I will read labels to be sure there is no hidden alcohol in food B.) I should go to an Alcoholics Anonymous meeting when I feel the need to drink C.) I can call the clinic or my sponsor whenever I feel tempted to drink alcohol D.) Even one glass of alcohol can cause me to start drinking regularly again

B

Which statement made by a 67 year old client who recently retired indicates to the nurse that client has developed ego integrity? A.) I want to make my mark on the world B.) I am satisfied with my life so far C.) I wish I could go back and fix the mistakes I have made D.) Life is too short. I have more living to do

B

Which suggestion should the nurse provide to a client reporting frequent episodes of constipation? A.) Take a stool softener B.) Increase intake of fruit in the diet C.) Monitor elimination habits for the need week D.) Rest after each mal

B

Assessment of a trauma client in the ED reveals paradoxical chest wall movement, respiratory distress, cyanosis and tachycardia. The family is asking why the client needs PEEP. What should the nurse inform them regarding the rationale for this treatment? Select all that apply. A.) Ventilation is improved as positive pressure is exerted into the airways as the client begins to take in a breath B.) Gas exchange is improved and the work of breathing is decreased C.) It expands and realigns the ribs to aid in the healing process D.) Allows for positive pressure to be applied continuously during inspiration and expiration E.) It is less invasive and does not require the client ot be on the ventilator

B, C

The nurse is planning care for a client admitted for chemotherapy. What interventions should the nurse initiate to prevent infection? Select all that apply. A.) Change IV tubing every 48 hours B.) Place supplies for client in room C.) Limit nursing personnel in room D.) Bathe perineum once daily E.) Place in protective isolation

B, C

The nurse is providing teaching to a group of clients newly diagnosed with chronic stable angina. What points should the nurse include? Select all that apply. A.) Wait 1/2 - 1 hour after eating to exercise B.) Attend classes such as guided imagery to reduce stress C.) Temperature extremes can precipitate an angina attack D.) Gradually increase weightlifting training to improve cardiac output E.) Eat a low fat, low fiber diet to lose weight F.) Medications prescribed to prevent angina work by increasing the workload of the heart

B, C

Where should a nurse place the stethoscope when auscultating heart sounds? Select all that apply. A.) First intercostal space right of the sternum to hear sounds from the pulmonic valve area B.) Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area C.) Second intercostal space to the right of the sternum to hear sounds from the aortic valve area D.) Third intercostal space in the midclavicular line to hear sounds from the mitral area E.) Apex of the heart to hear the loudest 2nd heart sound (S2)

B, C

Which assessment findings does the nurse expect to find when assessing a client admitted to the emergency department with left sided congestive heart failure? Select all that apply. A.) Ascites B.) Bibasilar crackles C.) Orthopnea D.) Hepatomegaly E.) Anorexia

B, C

A client diagnosed with new onset atrial fibrillation has been prescribed dabigatran. What should the nurse teach the client? Select all that apply. A.) Place medication in a weekly pill organizer so that medication is not forgotten B.) Do not take with clopidogrel C.) Dabigatran decreases the risk of stroke associated with atrial fibrillation D.) Take this medication with food E.) aPTT and INR levels will be drawl monthly

B, C, D

A soldier who returned from combat 2 months ago was admitted to a psychiatric unit with a diagnosis of Dissociative Fugue. The police found the client wandering down the street in a daze after fighting with a stranger. Which nursing interventions should the nurse implement? Select all that apply. A.) Directly observe the client at least every 4 hours B.) Maintain a low level of stimuli C.) Remove all dangerous objects from environment D.) Convey a calm attitude toward the client E.) Discourage client's expression of negative feelings

B, C, D

The nurse sees that the new medication notes in a recent prescription is on the client's list of allergies. In the role of client advocate, what actions should the nurse take to ensure client safety? Select all that apply. A.) Document the medication with times and doses to be given, then administer the medication as ordered B.) Notify the PCP immediately that the medication prescribed is on the client's list of medication allergies C.) Stop the medication on the client's medication administration record D.) Check the client's allergy band against the list of client allergies documented in the medical record E.) Call the pharmacy to see if the medication needs to be changes

B, C, D

What symptoms does the nurse expect to see in a client with bulimia nervosa? Select all that apply. A.) Amenorrhea B.) Feelings of self-worth unduly influenced by weight C.) Recurrent episodes of binge eating D.) Recurrent inappropriate compensatory behavior to prevent weight gain E.) Lack of exercise

B, C, D

A client is to begin external beam radiation for Ewing's sarcoma. What symptoms would the nurse teach the client to expect during radiation treatments? Select all that apply. A.) Nausea and vomiting B.) Skin shedding C.) Erythema with pain D.) Pancytopenia E.) Exhaustion

B, C, D, E

A client receiving chemotherapy reports nausea and vomiting after every treatment. What interventions should the nurse initiate to reduce this side effect? Select all that apply. A.) Administer antiemetic immediately after treatment B.) Provide music therapy C.) Provide ginger ale to drink D.) Apply acupressure bands to wrists E.) Place peppermint essential oil diffuser in room

B, C, D, E

A primary healthcare provider has prescribed restraints for a violent adult client. Which measures would the nurse provide as proper interventions for this client? Select all that apply. A.) Observe the client in restraints every hour B.) Ensure that circulation to extremeties is not compromised C.) Assist client with needs related to nutrition and elimination D.) Provide help with personal hygeine E.) Renew restrain prescription in 4 hours if needed

B, C, D, E

The client has suicidal ideations with a vague plan for suicide. The nurse who is teaching the family to care for the client at home should emphasize which points? Select all that apply. A.) Family members are responsible for preventing future suicidal attempts B.) When the client stops talking about suicide, the risk has increased C.) Warning signs, even if indirect, are generally present prior to a suicide attempt D.) One suicide attempt increases the chance of future suicide attempts E.) Report sudden behavioral changes

B, C, D, E

The nurse is initiating a client assessment. What signs and symptoms would validate the client's diagnosis of Cushing's disease? Select all that apply. A.) Hypoglycemia B.) Mood alterations C.) Lipolysis D.) Truncal obesity E.) Hirsutism F.) Hyperkalemia

B, C, D, E

The nurse reassesses the client's pain level after administering an oral analgesic. The client states that the pain is better but continues to report a backache. Which non-pharmacologic interventions may help the client's backache? Select all that apply. A.) Educating the client regarding pain and pain control B.) Assisting the client into a side lying position C.) Providing a back massage D.) Providing heat therapy E.) Using distraction techniques

B, C, D, E

Which dietary information should the nurse provide to a client diagnosed with Celiac disease? Select all that apply. A.) The most cost effective way to follow the lactose free diet is to eat more fruits and vegetables B.) Cream based canned soups are a source of hidden wheat C.) You can eat foods containing fat, corn or rice D.) Avoid foods and beverages that contain malt E.) Do not eat traditional wheat products such as pasta

B, C, D, E

A lethargic client was admitted with encephalopathy secondary to cirrhosis. The client displayed a grossly distended abdomen, fine bibasilar crackles and +4 pitting edema to lower extremities. Following three days of treatment, the client is improved enough for discharge. Vital signs are now within normal limits and lungs clear. The client's elevated ammonia level has returned to normal, though PT/PTT levels are still elevated. The nurse knows discharge should include what information? Select all that apply. A.) How to measure and record abdominal girth daily B.) Keep lower extremities elevated while out of bed C.) Emphasize the need to eliminate alcohol intake D.) Remind client to use an electrical razor to shave E.) Check weight daily and report gain over 10 lbs F.) Restrict protein intake to just 40 g daily

B, C, D, F

Which interventions should the nurse include for a client for a sickle cell crisis who is experiencing pain? Select all that apply. A.) Apply cold compresses to affected joints B.) Massage affected areas gently C.) Support and elevate swollen joints D.) Monitor pain level by looking for BP, respiratory and heart rate elevation E.) Place client on NPO status F.) Administer Normal Saline at 125 mL/hr

B, C, D, F

The nurse should wear gloves when administering which medication? Select all that apply A.) Lorazepam 1mg orally B.) Nitroglycerin ointment 2% 0.5 inch to chest C.) Ceftriaxone 250mg intramuscularly D.) Metronidazole 500mg intravenous piggyback E.) Humalog 8 units subcutaneously

B, C, E

The staff nurse is caring for a 3 month old client receiving potassium IV therapy. Which actions indicate to the charge nurse that the staff nurse understands IV management? Select all that apply. A.) Uses a 15 gtt factor drip chamber when changing the IV tubing B.) Applies elbow restraints to prevent dislodgement of the IV catheter C.) Checks the IV site for blood return hourly D.) Instructs the UAP to count drip rate hourly E.) Attaches a volume-controlled IV administration set to IV bag prior to beginning IV therapy

B, C, E

A client was diagnosed with a fractured ulna 8 hours ago. Which assessment data may indicate a compartment syndrome? Select all that apply. A.) The pain is located at the elbow area B.) The prescribed opioid does not relieve the pain C.) When forearm is elevated, the swelling in the forearm is reduced D.) The pain in the forearm is described as a 9 on a 10 scale and throbbing E.) When placing a cold compress on the forearm, the pain level is reduced

B, D

A nurse is caring for a client with a possible diagnosis hyperparathyroidism. Which serum laboratory value would validate this diagnosis? Select all that apply. A.) BUN 12 mg/dL B.) Calcium 12 mg/dL C.) Sodium 140 mg/dL D.) Phosphate 2.8 mg/dL E.) Potassium 3.5 mEq/L

B, D

The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair? Select all that apply. A.) Shaving the hair with a razor B.) Removing the hair with clippers C.) Lathering the skin with soap and water prior to shaving with a razor D.) Using a depilatory cream E.) Always use a new, sharp razor

B, D

An elderly widower has been admitted to a psychiatric crisis unit with a diagnosis of major depression with agitation. What behaviors would the nurse expect to observe during an initial assessment? Select all that apply. A.) Memory loss B.) Difficulty focusing C.) Excessive sleepiness D.) Short-tempered E.) Hand-wringing

B, D, E

The nurse is preparing a teaching plan for a client newly diagnosed with fluid retention and heart failure. What should the nurse advise the client to avoid? Select all that apply. A.) Broiled, fresh fish B.) Effervescent soluble medications C.) Seasoning with lemon pepper D.) Chicken noodle soup E.) Deli-ham sandwiches

B, D, E

The nurse is preparing to administer magnesium sulfate IV to an alcoholic client with hypomagnesemia. Prior to the initiation of IV magnesium, which assessment data would be important for the nurse to document? Select all that apply. A.) Liver function B.) Respiratory rate C.) Calcium levels D.) Deep tendon reflexes (DTRs) E.) Urinary output

B, D, E

What information on burn prevention strategies should the nurse include when providing an education program at a community center? Select all that apply. A.) Have chimney professionally inspected every 5 years B.) Clean the lint trap on the clothes dryer after each use C.) Keep anything that can burn at least 1 foot away from space heaters D.) Do not hold a child while drinking a hot drink E.) Home hot water heater should be set at a maximum of 120 F

B, D, E

The nurse performs a rapid assessment on a client who states, "I feel really sick and my heart is beating so fast." What signs and symptoms would indicate to the nurse that the client's cardiac output is inadequate? Select all that apply. A.) CVP 5 mmHg B.) Moist skin C.) Urinary output 150 mL over 4 hours D.) Weak radial pulses E.) BP 90/50, HR 200, RR 22 F.) Mild chest discomfort

B, D, E, F

The nurse is preparing to discharge a client home from the hospital. Which statement made by the client indicates to the nurse that instructions about antibiotic administration has been successful? Select all that apply. A.) I will take the antibiotic until I feel better, but save some to take in case the infection returns B.) I should follow the instructions on the label C.) I need to double the dose for two days so I will get better D.) I should double the dose the next day the antibiotic is due after missing a dose E.) I will finish all of my antibiotic medication

B, E

The nurse is reviewing the PCP's initial prescriptions for a client diagnosed with diabetic ketoacidosis (DKA)? Which prescriptions from the PCP would the nurse question? Select all that apply. A.) Arterial blood gasses B.) 500 mL D5W at 100 mL per hour C.) Serum glucose levels every hour D.) Hourly adjustments of regular insulin IV according to serum glucose level protocol E.) 100 mL 0.45% NaCl with KCL 10 mEq/L IV

B, E

Which tasks can the nurse delegate to the UAP? Select all that apply. A.) Report lab results to the client B.) Measuring intake and output C.) Discontinuing an IV D.) Discussing client condition with the client's spouse E.) Performing oral hygiene for an older client

B, E

A client calls the prenatal clinic at 37 weeks gestation to report expelling large amounts of fluid. What instruction by the nurse is MOST appropriate at this time? A.) Lie on left side and take slow, deep breaths B.) Call an ambulance and go to emergency room C.) Come to the clinic for assessment and evaluation D.) Go directly to the hospital emergency room

C

A client diagnosed with lung cancer is told that the client only has about 6 months to live. The spouse tells the nurse, "I pray every night that God will give me more time with my loved one." Which Kübler-Ross stage of grief does the nurse recognize the spouse to be exhibiting? A.) Anger B.) Acceptance C.) Bargaining D.) Depression

C

A client diagnosed with major depression has been admitted to a psychiatric facility for medication management. During nighttime rounds, an LPN notes the client is not in bed. Which behavior by the client should the LPN report to the RN IMMEDIATELY? A.) Sitting in a chair crying B.) Reports inability to sleep C.) Rearranging furniture D.) Pacing around the room

C

A client in the ICU who is on a ventilator, suddenly exhibits signs of decreased cardiac output. A quick assessment reveals that the client has cyanosis, absence of breath sounds on the right side, neck vein distension and the trachea is deviating to the left. What initial emergency measure should the nurse expect to be performed? A.) Insertion of a chest tube in the 7th intercostal space B.) Immediate removal of client from the ventilator C.) Needle decompression of the right 2nd intercostal space D.) Emergency thoracentesis of the left lung

C

A client in the manic phase of bipolar disorder is constantly walking around the day room and refuses to sit down and eat the spaghetti and meatballs sent by the kitchen. Which food should the nurse request from dietary? A.) Carrots and apples B.) Donuts C.) Pepperoni pizza sticks D.) Strawberry pastry

C

A client is admitted with reports of prolonged diarrhea. The client's admission potassium level was 3.3 mEq/L and is receiving an IV of D5 1/2 NS with 20 mEq/L at 125 mL/hr. The UAP reports an 8 hour urinary output of 200 mL. The previous 8 hour urinary output was 250 mL. What should be the nurse's priority action? A.) Encourage the client to increase PO fluid intake B.) Administer a supplemental PO dose of potassium C.) Stop the IV potassium infusion D.) Administer polystyrene sulfonate PO

C

A client is given an intramuscular injection of morphine following a laparoscopic cholecystectomy four hours ago. What client data would BEST indicate to the nurse that the medication has been effective? A.) Rates pain as 6 on 1-10 scale B.) Heart rate is within normal limits C.) Ambulates with assistance of one D.) Voided 250 mL in 4 hours

C

A client of Jewish faith has requested a Kosher diet. Which food tray would the nurse provide to the client? A.) Medium rare steak, potato salad, peas and coffee B.) Ham sandwich, chips, fruit salad and juice C.) Broiled white fish, baked potato, mixed salad and tea D.) Baked chicken, vegetable medley, rice and milk

C

A client on the med-surg unit is being treated for dehydration and pneumonia. The UAP has entered the room to complete AM care, but the client refuses, reporting feeling too tired from a "poor night's sleep". The UAP reports the refusal to the nurse. What statement by the nurse provides the best explanation to the UAP? A.) "Explain to the client that we are short staffed, so AM care needs done at this time." B.) "Don't worry about it; just tell the next shift they will need to do this client care." C.) "Let's look over your shift assignments to see if we can rearrange some other tasks." D.) "It is crucial for this client to be able to rest, so clean sheets can wait till tomorrow."

C

A client returns to the room post appendectomy. In what position should the nurse place the client? A.) Sims' B.) Prone C.) Semi-Fowlers' D.) Right lateral

C

A client who has a history of major depression is in the emergency department. Which statement would demonstrate a risk of suicide or self-directed injury? A.) I can't do anything right anymore B.) I am not sure what to do anymore C.) I just cannot take this loneliness anymore D.) No one cares about me

C

A client with a history of paranoid personality disorder is admitted to the hospital with extreme weight loss. Family states client has been refusing medications and food due to fears of being poisoned. What initial response by the nurse is most important? A.) Tell me about your fears of being poisoned B.) No one is trying to poison your food or meds C.) You certainly are having scary thoughts D.) You need to stop this behavior and eat, this is very unhealthy

C

A confused elderly client is brought to the emergency department by a family member who states the client fell down a flight of stairs. In addition to multiple facial contusions, x-rays reveal a spiral fracture of the left forearm. After assisting the PCP in applying a short arm case, the nurse identifies which action as a PRIORITY in discharge planning? A.) Ask the family to restrict the client to the first floor B.) Instruct the client on home safety issues C.) Notify social services to arrange a home visit D.) Discuss cast care with client and family

C

A factory employee is brought to the emergency room on first shift with a severe hand laceration occurring at work. The employee is quite upset, indicating previous competency on the machine. When reviewing medications, the nurse notes the client has recently started alprazolam at bedtime. What vital information about this medication should the nurse provide to the client? A.) Consider getting new glasses B.) Stand up slowly when sitting C.) Do not operate dangerous machines D.) Instructions for taking medication appropriately

C

A female client considers using spermicidal agents because she wants both birth control and protection from sexually transmitted infections (STIs). What information should the nurse provides the client about spermicidal agents? A.) Effectively reduces vaginal fungal infections such as Candida albicans B.) Eliminated bacterial and viral sexuality transmitted infections C.) Most effective when used in conjunction with barrier methods, such as a diaphragm D.) Causes few side effects

C

A new mother calls the clinic and tells the nurse, "I don't have any help taking care of my 3 week old baby. I don't know what to do. I just feel like I can't take care of him anymore. I wish I never had him sometimes. Maybe then my husband would spend more time at home." What would be the nurse's BEST response? A.) You are experiencing maternity blues, which will go away on its own B.) You are just tired. Tell your husband that you need his help C.) Come to the clinic now so that we can help you D.) Have you thought about getting a family member to help with the baby

C

A newly admitted client tells the nurse, "I am hearing voices." Which response by the nurse is MOST appropriate? A.) Your head is turned to the side as if you are listening to voices B.) I don't hear anyone but you speaking C.) Tell me what the voices are saying to you D.) Let's talk about your anxiety right now

C

A nurse assesses the 5 minute APGAR on a term, newborn infant. Based on the APGAR score, what should be the nurse's PRIORITY intervention? Activity: 1 - Arms and legs flexed Pulse: 2 - > 100 bpm Grimace: 1 - Grimaces Appearance: 1 - Normal except extremities Respirations: 1 - Slow, irregular A.) Continue APGAR scoring every five minutes until 20 minutes of life B.) Transfer newborn to the NICU ASAP C.) Administer "blow-by" oxygen while suctioning D.) Perform cardiopulmonary resuscitation

C

A nurse has educated a client on crutch walking. Which statement by the client would indicate to the nurse that the client needs FURTHER instruction? A.) I will not alter the height of my crutches B.) My body weight should be supported at the hand grips with my elbows flexed at 30 degrees C.) When I rise from my chair, I should position my crutches on my unaffected side D.) I will not lean on my crutches while standing

C

A nurse is caring for a 65 year old client diagnosed with dehydration. The client has been receiving IV normal saline at 150 mL/hour for the past 4 hours. Which finding would the nurse need to notify the PCP? A.) Blood pressure 136/84 B.) Report of nausea C.) Anxiety D.) Urinary output at 50 mL/hour

C

A nurse on a surgical unit is assigned a client who had a total thyroidectomy 3 days ago. As the nurse enters the room which nursing assessment is the priority for this client? A.) Eating a soft diet B.) Positioned at 15 degrees in bed C.) States hands are tingling D.) Expresses frontal neck pain level of 5 out of 10

C

A nurse working in a locked psychiatric unit is caring for a client diagnosed with paranoia. The client becomes very agitated and shouts, "I'm not going to my session today!" What action by the nurse would be most appropriate? A.) Sit with the client and say a prayer B.) Send the client to the session after explaining that shouting is not allowed C.) Escort the client to an easel and canvas in order for the client to paint D.) Call for assistance and put the client in seclusion

C

A primary healthcare provider has prescribed sterile saline 1.5 mL IM every 4 hours as needed for pain for a client who reports frequent "severe" headaches. What action should the nurse take? A.) Administer the medication as prescribed B.) Obtain pre-filled syringes from the pharmacy C.) Discuss client rights with the primary care provider D.) Tell the client what has been prescribed

C

An elderly client receives instructions regarding the use of warfarin sodium. Which statement indicates to the nurse that the client understands the possible food interactions which may occur with this medication? A.) I'm going to miss having my evening glass of wine now B.) I told my daughter to buy spinach for me. I'll have to eat more servings now C.) I will have to watch my intake of salads, something I really love D.) I'm going to begin eating more fish and pork and leave beef alone now

C

An elderly client with partial and full-thickness burns has begun receiving fluids at 600 mL/hr as determined by the Parkland (Consensus) formula. Based on the assessment data for the first four hours, what should the nurse report to the PCP? - 2:00: T 94, P 135, BP 85/40, RR 36, CVP 2 - 3:00: T 95.1, P 124, BP 90/50, RR 32, CVP 3.8 - 4:00: T 95.9, P 118, BP 98/58, RR 28, CVP 4.4 - 5:00: T 96.1, P 110, BP 104/64, RR 24, CVP 5.8 - 6:00 T 96.4, P 100, BP 110/68, RR 22, CVP 6 A.) The cardiovascular system is becoming severely overloaded B.) The speed of the IV should be reduced since CVP is now normal C.) The changes in the vital signs indicate an expected response to fluids D.) The client is deteriorating because of age and extent of the burns

C

During a clinic visit 3 months following a diagnosis of type 2 diabetes, the patient reports following a reduced-calorie diet. The patient has not lost any weight and did not bring the glucose-monitoring record. The nurse will anticipate a prescription of which laboratory test? A.) Fasting blood glucose level B.) Urine dipstick for glucose C.) Glycosylated hemoglobin level (HbA1C) D.) Glucose tolerance test (GTT)

C

One week ago, a client was involved in a motor vehicle crash and was brought to the Emergency Department. The client received two sutures to the forehead and was sent home. Today, the client's spouse notes the client "acts drunk" and cannot control the right foot and arm. Based on the data, what should the nurse suspect? A.) Meningitis B.) Transient ischemic attack C.) Subdural hematoma D.) Meniere's disease

C

Prior to signing a consent form for surgery, the client states, "I am not sure that I understand the possible risks for this surgery and what the alternative treatments are." What should the nurse do first? A.) Clarify any questions that the client may have and then share the client's concern with the primary healthcare provider B.) Reinforce that it is not unusual for clients to have questions about surgery C.) Inform the primary healthcare provider that the client has concerns about the surgery D.) Use open ended questions to explore client's concerns

C

The PCP instructs the nurse to place body tissues obtained from a biopsy into the container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What would be the nurse's BEST action? A.) Call the pathology department for directions on formalin's use and precautions B.) Look formalin up in the drug handbook C.) Read about formalin on the Material Safety Data Sheet (MSDS) D.) Explain to the PCP that nurses are not allowed to use formalin

C

The client has been instructed on crutch safety. The nurse identifies that further teaching is needed when the client makes which statement? A.) The crutches are adjusted according to my height B.) I will support my weight on the hand grips when not walking C.) I plan to place my affected leg on the step first when ascending stairs D.) I will position the crutches 1-2 inches below the axilla when walking with crutches

C

The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. The nurse notes paradoxical chest wall movement. Which problem does the nurse suspect? A.) Mediastinal shift B.) Tension pneumothorax C.) Flail chest D.) Pulmonary contusion

C

The client with bleeding esophageal varices has a Blakemore tube in place. What piece of equipment should be present at the bedside? A.) Tracheostomy set B.) Clamps C.) Surgical scissors D.) Tourniquet

C

The labor and delivery charge nurse is making staff assignments, including assignments to a new nurse. What client is MOST appropriate for the new nurse? A.) A gravida 3 para 2 in active phase of stage one, expecting twins B.) A gravida 2 para 0 at 41 gestation, awaiting induction C.) A primigravida in active phase of stage one, waiting for epidural D.) A 12 hour post Cesarean section needing assistance to ambulate

C

The nurse caring for a client who had a transurethral resection of the prostate (TURP) would increase the flow of the continuous bladder irrigation for which assessment data? A.) The drainage is continuous but slow B.) The drainage is cloudy and dark yellow C.) The drainage is bright red D.) No drainage of urine or irrigation solution is noted

C

The nurse has initiated discharge instructions for a client diagnosed with glomerulonephritis. What statement by the client would indicate to the nurse that FURTHER teaching is needed? A.) I will have protein in my urine for several months B.) My urinary output will increase in 1 to 3 weeks C.) I should keep a record of the headaches I experience over 3 months D.) I should notify my PCP if my urinary output decreases

C

The nurse is admitting a client with a fifteen year history of poorly controlled diabetes mellitus. During the initial assessment the client reports experiencing "numb feet". What nursing action takes PRIORITY? A.) Check blood glucose level B.) Assess for proper shoe size C.) Examine the client's feet for signs of injury D.) Test sensory perception in the client's feet

C

The nurse is assessing a pregnant client returning for her first, one month check up. The client has normal vital signs, blood count and urinalysis but has gained 6 pounds. What is the MOST important assessment at this time? A.) Blood glucose level B.) Ankles for edema C.) Twenty four hour diet recall D.) Confirmation of last menstrual period

C

The nurse is caring for a client diagnosed with heart failure who has developed pulmonary edema. Which finding BEST indicates that bumetanide is having a therapeutic effect? A.) Apical pulse 108/irregular B.) Foamy sputum C.) Urine output 175 mL per one hour D.) Respiratory rate 28/min

C

The nurse is caring for a client undergoing electroconvulsive therapy (ECT) for major depression. What is the nurse's MOST important intervention during treatment? A.) Monitor vital signs and cardiac functioning B.) Provide support to the client's arms and legs C.) Provide suctioning as needed D.) Place electrodes on temples

C

The nurse is caring for a newly admitted client with diabetes mellitus. The initial assessment reveals that the client in unresponsive, BP is 94/64, Respirations 38, Temperature 97.2 and Heart Rate is 100. The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance? A.) Respiratory acidosis B.) Respiratory alkalosis C.) Metabolic acidosis D.) Metabolic alkalosis

C

The nurse is caring for a surgical client who has developed a pulmonary embolus (PE). Which diagnostic test would be the MOST sensitive for providing a definitive diagnosis for a PE? A.) D-dimer B.) Pulmonary function test C.) Pulmonary angiography D.) Chest x-ray

C

The nurse is caring for an elderly client who is approaching death and expressing intense despair and anxiety. Based on Erikson's theory, the nurse recognizes that this client's despair and anxiety would MOST likely be based on what? A.) An inappropriate desire for youthfulness and staying young B.) The decision will never marry C.) The lack of a sense of wholeness, purpose and a life well lived D.) A fear of experiencing a painful death

C

The nurse is educating a group of college students about early signs and symptoms of cancer. What explaining the mnemonic "C-A-U-T-I-O-N", the nurse explains the 'N' stands for what sign/symptom? A.) Nausea B.) Nipple drainage C.) Nagging cough D.) Nose bleeds

C

The nurse is providing stump care discharge instructions to the client with a right below-the-knee amputation (BKA). The client responds, "What is the purpose of the compression sock on my stump?" Which statement by the nurse is appropriate? A.) The compression sock on the stump will increase your balance when crutch walking B.) Phantom limb pain will decrease by applying the compression sock tightly around the stump C.) A compression sock is applied to shape the stump smaller and rounder on the bottom D.) The application of a compression sock will decrease the risk of the incidence of deep vein thrombosis (DVT)

C

The nurse is teaching a client who has been prescribed peritoneal dialysis. What statement by the client indicates to the nurse that teaching was successful? A.) I need to decrease protein in my diet since my kidneys no longer work B.) Heating the dialysate in the microwave for 30 seconds will prevent abdominal cramping C.) I will notify my PCP if the peritoneal drainage is cloudy D.) The automated peritoneal dialysis (APD) is used every few hours during the day

C

The nurse is teaching a group of female clients about how to perform a self-breast exam. One client reports no family history of breast cancer and indicates disinterest in learning the technique. What is the most appropriate response by the nurse? A.) You can ask your healthcare provider to do this with your yearly physical B.) If you have no family history of cancer, you won't need to worry about this C.) Self-breast exams may detect early enough to successful treatment D.) You have the right to refuse anything related to health because of client rights

C

The pediatric nurse is assessing a child receiving an IV infusion of bleomycin for Ewing's sarcoma. Concerned about a decrease in the child's voiding, the nurse knows that the PRIORITY action is what? A.) Administer a PRN diuretic B.) Stop the infusion immediately C.) Assess three shifts of intake and output D.) Encourage sips of fluid every hour

C

The primary care provider (PCP) has prescribed a saline IM injection for a client who requests pain medication every 2-3 hours. What would be the nurse's BEST FIRST action? A.) Administer the injection B.) Take vital signs C.) Question prescription with PCP D.) Notify the nursing supervisor

C

What action by the nurse, who is administering platelets to a client, would require the charge nurse to intervene? A.) Verifies prescription for platelet transfusion B.) Confirm client has provided informed consent C.) Hangs platelets immediately upon arrival from blood bank refrigerator D.) Infuse platelets with normal saline solution

C

What is the MOST important action for the nurse to take prior to the client having a liver biopsy? A.) Make certain the consent has been sign B.) Obtain vital sings C.) Check clotting study results D.) Position client supine with right arm above head

C

What should the nurse do after administering a chemotherapeutic drug intravenously (IV) to a client in the outpatient infusion unit? A.) Hang a 250 mL normal saline (NS) to flush the IV line B.) Wear shoe covers during disposal of the drug C.) Place the IV bag and tubing into a chemotherapy waste container D.) Disposal of personal protective equipment (PPE) in a biohazardous container

C

Which client should the nurse, working the Emergency Department (ED), see FIRST? A.) Client diagnosed with COPD who has a nonproductive cough B.) Client who is diabetic and has an infected sore on the foot C.) Client with adrenal insufficiency feels week D.) Client with a fracture of the forearm that has been placed in a splint

C

While completing the admission history on an elderly client diagnosed with advancing Alzheimer's disease, the client's spouse begins to sob and states, "After all these years, we won't be together anymore." What would be the BEST response by the nurse? A.) You can come to visit anytime you want to B.) Would you like to see the room and facilities C.) Let's find a quiet place to sit and talk awhile D.) You did the best you could in this situation

C

While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and a dark collection of blood. What is the nurse's NEXT action? A.) Leave the scabbing area alone and apply extra ointment B.) Notify the PCP C.) Gently remove the debris and re-dress the wound D.) Apply skin softening lotion for 3 hours and then re-dress

C

While preparing chemotherapy, the nurse accidentally punctures the bag, spilling the solution on the floor. After activating the emergency spill protocol, what action should the nurse take FIRST? A.) Place absorbent pads and absorbent powder over the spill B.) Apply chemotherapy approved personal protective gown and gloves C.) Obtain the proper spill kit for the specific chemotherapy drug used D.) Post the "Caution-Chemo spill" sign outside the room door

C

A nurse observes a fire has started in the trash can of a client's room. What steps should the nurse take? Place steps in priority from first to last. A.) Activate the fire alarm B.) Extinguish the fire C.) Remove the client from the room D.) Obtain the fire extinguisher E.) Close the door to the client's room

C, A, E, D, B

In what order should the nurse assess assigned clients following report? Place in priority order. A.) Client one day post splenectomy B.) Client diagnosed with aplastic anemia needing education regarding ways to decrease infection risk C.) Client admitted with chemotherapy-induced neutropenia with a temperature of 100.8 F D.) Client with non-Hodgkin's lymphoma who is refusing prescribed chemotherapy regimen E.) Client diagnosed with cancer who is crying and states, "I am not ready to die."

C, A, E, D, B

An alert client presents to the emergency department with vomiting for 3 days and has been unable to keep food or fluids down for the last 24 hours. Which imbalances does the nurse suspect this client has? Select all that apply. A.) Hypocalcemia B.) Hypermagnesemia C.) Hypokalemia D.) Metabolic alkalosis E.) Respiratory acidosis

C, D

The nurse is teaching a group of clients in cardiac rehabilitation how blood flows through the heart. What information should the nurse include? Select all that apply. A.) Deoxygenated blood enters the heart through the pulmonary vein B.) Blood flows from the right atrium through the mitral valve to the right ventricle C.) The right ventricle pumps the blood to the lungs via the pulmonary artery where the blood becomes oxygenated D.) From the lungs, oxygenated blood goes to the left atrium via the pulmonary vein, then to the left ventricle E.) The right ventricle pumps the blood out through the aorta to the body

C, D

What impaired functions does the nurse expect to observe in the client admitted with an injury to the frontal lobe of the brain? Select all that apply. A.) Decreased sensation to touch B.) Impaired vision C.) Impaired speech D.) Decreased concentration E.) Decreased hearing

C, D

When caring for young adult clients, which developmental tasks would the nurse expect to see? Select all that apply. A.) Satisfying and supporting the next generation B.) Reflecting on life accomplishments C.) Developing meaningful and intimate relationships D.) Giving and sharing with an individual without asking what will be given or shared in return E.) Developing sense of fulfillment by volunteering in the community

C, D

A client is scheduled to be admitted to the surgical unit post total laryngectomy. What nursing intervention should the nurse include in the plan of care? Select all that apply. A.) Position left-side lying, supine B.) Place on clear liquid diet after peristalsis returns C.) Monitor tracheostomy for pulsations with heartbeat D.) Provide mouth care every 2 hours E.) Maintain a humidified environment

C, D, E

The nurse is discharging a client post right radial percutaneous transluminal coronary angioplasty (PTCA) with stent insertion. What instructions should the nurse give the client to reduce the risk of complications? Select all that apply. A.) Do not use the wrist to life more than 5 pounds for 24 hours B.) Stop taking aspirin in one week C.) Drink at least 8 glasses of water a day D.) Wear loose fitting sleeves E.) Do not shower or soak in the tub for one week F.) Take short walks around your house

C, D, F

What should the nurse include when teaching a client in renal failure about peritoneal dialysis? Select all that apply. A.) Instill 250 mL of fluid into the peritoneal cavity over 30 minutes B.) Use cold effluent when instilling into the peritoneal cavity C.) Following the prescribed dwell time, lower the bag to allow the fluid to drain out D.) The fluid that is returned should be clear in appearance E.) If all the fluid does not drain out, place the bed in the Trendelenburg position F.) A sweet taste may be experienced when peritoneal dialysis is used

C, D, F

A client is diagnosed with a duodenal ulcer due to H. Pylori. In addition to antibiotic therapy, the nurse anticipates that the client will also receive what class of pharmacologic agents? Select all that apply. A.) Miotic inhibitor B.) Serotonin antagonist C.) H2 antagonist D.) Acetylsalicylic acid E.) Proton pump inhibitor

C, E

A client, who received blunt chest trauma from an ATV accident, is admitted to the unit at 7 PM following insertion of a chest tube at 5 PM. The drainage collection chamber has 80 mL of drainage present upon arrival to the unit. Which assessment finding would be of concern to the nurse? Select all that apply. A.) Continuous bubbling is occurring in the suction control chamber B.) Intermittent bubbling is noted in the water seal chamber C.) CDU is sitting upright on the bedside table with fluid levels as prescribed D.) Slight fluctuations of water level in water seal chamber with respirations E.) 190 mL of drainage noted in drainage collection chamber at 8 PM

C, E

The nurse is discussing frostbite prevention with a group of teenagers who participate in cold weather activities. What information should the nurse provide? Select all that apply. A.) Limit alcohol intake when out in cold weather B.) Dress in several layers of tight fitting clothing C.) Eat well-balanced meals D.) Synthetic clothes absorb moisture and become wet quickly E.) Wear a wool headband over the ears F.) Wear several pairs of socks

C, E

What interventions should the nurse include when caring for a client who is receiving total parenteral nutrition (TPN)? Select all that apply. A.) Change tubing and filter every 48 hours B.) Monitor IV drip rate hourly C.) Compare new bag with prescription prior to infusing D.) Weigh weekly E.) Cover TPN with dark bag F.) Check urine for protein

C, E

Which intervention would the nurse include when planning care for a client who has increased Intracranial Pressure (ICP)? Select all that apply. A.) Place client supine B.) Hyperextend head to maintain airway C.) Maintain body temperature below 100.4 F D.) Cluster nursing care E.) Monitor vital signs for Cushing's Triad F.) Limit suctioning

C, E, F

How would the nurse interpret this client's Arterial Blood Gas (ABG) results? - pH: 7.35 - PaCO2: 30 mmHg - Bicarb: 19 mEq/L - PaO2: 89 mmHg - SaO2: 90% Select all that apply. A.) Respiratory acidosis B.) Respiratory alkalosis C.) Metabolic acidosis D.) Metabolic alkalosis E.) Uncompensated F.) Partially compensated G.) Fully compensated

C, G

A UAP has explained how to prevent the spread of infection to the charge nurse. Which statement by the UAP indicates further teaching is needed? A.) Soap and water should be used for handwashing when our hands are visibly soiled B.) Gloves do not have to be worn when taking a client's vital signs or passing out meal trays C.) Standard precautions should be used on all clients D.) When caring for a client who has a suppressed immune response, a N95 mask should be worn

D

A client arrives at the clinic with reports of persistent vomiting, weakness and leg cramps. The nurse notes that the client is irritable. BP 102/58, HR 108, RR 14. Based on this data, what acid/base imbalance does the nurse expect? A.) Respiratory acidosis B.) Respiratory alkalosis C.) Metabolic acidosis D.) Metabolic alkalosis

D

A client at 32 weeks gestation is admitted to the obstetric unit with a BP of 142/90 and 1+ proteinuria. Since no private rooms are available, the charge nurse must assign the client to a semi-private room. Which client should the charge nurse assign the client to room with? A.) Postpartum woman who delivered at term B.) Woman in preterm labor at 35 gestations C.) Woman with placenta previa at 37 weeks gestation D.) Pre-term labor client with twins at 28 weeks gestation

D

A client has responded positively to a series of electroconvulsive treatments (ECT), but reports concerns about on-going memory loss. What is the most appropriate response by the nurse? A.) It's only been a couple weeks so don't worry B.) Are you afraid your memory will not return C.) I will ask the psychiatrist to come talk with you D.) You seem very concerned about your memory

D

A client is admitted for observations following an unrestrained motor vehicle accident. A bystander stated that the client lost consciousness for 1-2 minutes. On admission, the client reports a headache and had a Glasgow coma scale (GCS) of 12. The GCS is now 12. What is the PRIORITY nursing intervention for this client? A.) Continue to assess every 15 minutes B.) Stimulate the client with a sternal rub C.) Administer acetaminophen with codeine for headache D.) Notify the primary healthcare provider

D

A client is admitted to the ICU with diabetes insipidus following a head injury. Which finding would the nurse anticipate in this client? A.) Low serum hematocrit B.) High serum glucose C.) High urine protein D.) Low urine specific gravity

D

A client is admitted to the emergency room with an open fracture of the left tibia which has been temporarily splinted. Which nursing intervention would the nurse implement? A.) Physically reduce the fracture B.) Externally rotate the left leg C.) Position the bed into a high Fowler's position D.) Cover the fractured site with a sterile dressing

D

A client is admitted with irritable bowel syndrome (IBS) and shingles. The nurse is discussing the client assignments with the charge nurse. Which staff member should not be assigned to this client? A.) The nurse with a history of roseola B.) The UAP with no history of roseola C.) The UAP with a history of chicken pox D.) The LPN with no history of chicken pox

D

A client newly diagnosed with Celiac disease is being instructed on a gluten-free diet. What statement by the client would indicate to the nurse that further teaching is needed? A.) I will still have occasional abdominal discomfort B.) I may need to take iron or vitamin supplements C.) I can have eggs but no wheat toast for breakfast D.) I should avoid fresh apples and strawberries

D

A client presenting at the clinic has a history of systemic lupus erythematosus (SLE). Which finding would indicate to the nurse that the client is having a flare-up of the disease? A.) Alopecia B.) Arthritis of hands C.) Weight gain D.) Fever

D

A client was admitted to the medical unit after an acute stroke. Which nursing activity can the registered nurse delegate to the LPN/VN? A.) Screen client for contraindications for tPA therapy B.) Place seizure precaution equipment in client's room C.) Perform passive range of motion (PROM) exercises D.) Administer enoxaparin 1 mg/kg subcutaneously every 12 hours

D

A client who is in the manic phase of bipolar disorder was admitted to the psychiatric unit two days ago. Since admission, the client has been overly active, dressing bizarrely and sleeping very little. What type of activity would be planned for this client for the period following the evening meal? A.) Encourage the client to watch TV with the other clients on the unit B.) Engage the client in a game of ping pong C.) Suggest that the client play monopoly with other clients D.) Provide soft lighting in the client's room for reading

D

A client with Graves' disease and exophthalmos returns to the clinic for evaluation. Which assessment indicates to the nurse that the client is adhering to the teaching plan? A.) Moist, shiny, soft hair B.) Resting heart rate of 120 C.) Adheres to the prescribed low-sodium diet D.) An absence of corneal irritation

D

A client with a history of syncope and transient arrhythmias has been ordered a Holter monitor for 48 hours. The nurse knows that teaching has been effective when the client makes what statement? A.) No follow up care will be needed after the monitor is removed B.) It's okay to shower or bathe while wearing this equipment C.) I have to take it easy and not exercise for the next two days D.) It is important to write down all my activities during this time

D

A client with cervical cancer received an internal cervical radiation implant. What should be the INITIAL nursing action if the radiation implant becomes dislodged and is found lying in the bed? A.) Call the client's PCP B.) Pick up the implant immediately with gloved hands and place it in a double biohazard bag C.) Notify the radiology department D.) Utilize long-handled forceps to pick up the implant and dispose of it in a lead container

D

A client with diabetes is hospitalized for debridement for a non-healing foot ulcer. Following the procedure, the nurse notes that the client has become confused and combative. The family expresses concern with the behavioral changes and requests that the client be restrained in bed. What is the nurse's PRIORITY action? A.) Notify the PCP B.) Apply a vest restraint as requested by family C.) Move clients to a room near the nurse's desk D.) Obtain a finger-stick blood glucose level

D

A client, who receives hemodialysis three times a week, has been placed on a fluid restriction of 1000 mL/day. What is the nurse's best action when the client is seen drinking a 12 oz (360 mL) soft drink? A.) Take the soft drink away from the client B.) Document the client is noncompliant C.) Notify dietary to no longer send beverages with food trays D.) Reinforce the importance of the fluid restriction with the client

D

A home health nurse visits a recently discharged client with right-sided paresis due to a stroke. The nurse discovers that the spouse has been feeding the client. What action should the nurse take? A.) Instruct the spouse to require the client to feed independently B.) Suggest the spouse hire an aide to feed and bathe the client C.) Advise the spouse to consider an extended care facility for the client D.) Determine why the spouse is not encouraging self-care by the client

D

A nurse enters a client's room to find the client on the floor having a seizure. What nursing action is APPROPRIATE for this client? A.) Hold the client's arms and legs B.) Insert a padded tongue blade into the client's mouth C.) Assist the client back into the bed D.) Place a rolled towel under the client's head

D

A nurse is caring for a client with fat embolus syndrome (FES). Which data would support the nurse's assessment that the FES has resolved? A.) Respirations - 24 B.) Oxygen saturation - 94% C.) Arterial blood gas - pH 7.34 D.) No infiltrates noted on chest x-ray

D

A nursing instructor is presenting a discussion on nephrotoxic medications? Which class of medications would the instructor discuss? A.) Opioids B.) Antidiabetic C.) Corticosteroids D.) Aminoglycosides

D

A renal transplant client has received discharge education. Which statement by the client indicates that further teaching is necessary? A.) I will need to notify my PCP if I developed a fever B.) I need to check my BP daily and report an increased BP C.) I will tell my PCP if I become easily fatigued D.) I will be on steroids for 3 months, then I will not have to take them

D

After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse assess FIRST? A.) Admitted 3 hours ago post appendectomy with small amount of drainage on dressing B.) Diagnosed with early onset Alzheimer's disease with confusion C.) Post operative internal fixation of the femur with crust forming on the Steinman pins D.) Receiving treatment for dehydration and is now picking at bedding and IV tubing

D

After the nurse administers ear drops to an adult client, it is important for the nurse to implement which action? A.) Leave the client lying with the unaffected ear facing up B.) Place a cotton ball firmly into the affected ear for 15 minutes C.) Pull the pinna of the ear down and back D.) Gently massage the tragus of the ear

D

An adolescent is admitted to the psychiatric unit following a repeat suicide attempt What is the nurse's priority action? A.) Have staff check on client once every hour B.) Ask client to explain why suicide was a choice C.) Place client in quiet seclusion with lights off D.) Assign a staff member to stay with the client

D

An elderly client arrives at the emergency room reporting a severe headache and blurred vision. The client indicates having awakened this morning with flu-like symptoms including nausea, vomiting and dizziness. The nurse notes the client appears very weak with shortness of breath and dark cherry red lips. Based on assessment findings, what life-threatening problem does the nurse expect? A.) Guillain Barre B.) Severe dehydration C.) Advanced influenza D.) Carbon monoxide poisoning

D

An expectant HIV positive client asks why zidovudine (ZDV) must be continued throughout the pregnancy. What is the best explanation by the nurse? A.) "The medication permits safe breastfeeding after delivery." B.) "It protects you against other infections during pregnancy." C.) "This drug prevents transmission of HIV to your partner." D.) "ZDV decreases the chance the baby will contract HIV."

D

An infant has been prescribed Bryant's traction for a diagnosis for developmental dislocated hips (DDH). At what degree of hip flexion should the nurse maintain the infant's hip for proper traction alignment? A.) 15 B.) 30 C.) 45 D.) 90

D

Dietary teaching has been initiated for a client newly diagnosed with acute diverticulitis. The nurse knows that further instruction is necessary when the client makes what statement? A.) I must include a lot of fluid in my daily routines B.) I need to take my antibiotics at the same time daily C.) Rest and mild exercises are important for my recovery D.) Decreasing fiber in my diet can help prevent recurrences

D

During shift change the night charge nurse reports to the day charge nurse that a client admitted with an ingestion of unknown drugs, received a prescription for physical restraint at 3:00 am because the client was incoherent, combative and attempting to leave the facility. On last assessment at 7:00 am, the client was still combative. What is the BEST action by the day shift charge nurse? A.) Since the client is still combative, continue the restraints B.) Remove restraints until the PCP writes the prescription C.) Assign a UAP to check on the client periodically D) Obtain a prescription from the PCP

D

How would a case manager best describe a clinical pathway to nursing students? A.) A decision-making flowchart that uses the if/then method to address client responses to treatment. B.) A set of practice guidelines developed by a professional medical organization such as the American College of Surgeons. C.) A standardized set of preprinted primary healthcare provider prescriptions for client care, which expedite the prescription process and can be customized to individual clients. D.) A set of client care guidelines based on a specific client diagnosis, which provides an overview of the multidisciplinary plan of care.

D

Immediately following the birth of an infant, what is the nurse's PRIORITY action when caring for the newborn? A.) Examine the infant and take a set of vitals B.) Confirm identification and apply arm band C.) Instill silver nitrate solution into both eyes D.) Dry infant and place in warm environment

D

The UAP reports to the nurse that a client with Alzheimer's has been walking into rooms on the unit and stating. "This is my room, so get out!" What is the best instruction the nurse can give to the UAP? A.) Calmly sit with the client and have the client repeat the room number at frequent intervals B.) Have the client remain in the room so the client has become familiar with it C.) Place a sign on the client's door that clearly has the client's name so the client can identify it D.) Hang a familiar object on the door to enhance room recognition

D

The client is admitted with a diagnosis of bacterial meningitis. Which action should the nurse initiate first? A.) Darken room B.) Provide sponge bath for fever of 102 F C.) Pad side rails D.) Place on Droplet precautions

D

The client needs assistance to apply anti-embolism stockings each day in the long-term care facility. Today, as the nurse enters the room to apply the stockings, she finds that the client has been walking about the unit for 30 minutes. What should the nurse do first to lessen the risk of swelling of the lower extremities? A.) Ask the client to lie down and place the stockings on the legs B.) Ask the client to sit on the bedside and place the stockings on the legs C.) Tell the client that the nurse will return later to assist with the application D.) Elevate the extremities in bed for 30 minutes before application.

D

The family of a client being treated for bleeding esophageal varices asks the nurse why the client is receiving octreotide. How should the nurse respond? A.) Octreotide is an antibiotic given to decrease the risk of developing an infection B.) Taking this medication forms a protective barrier over the varices to prevent bleeding recurrence C.) Octreotide helps eliminate ammonia from the body D.) This medication lowers the pressure in the liver, so the bleeding stops

D

The night nurse on a step down unit suspects another nurse may be intoxicated. What initial action should the nurse take? A.) Ask another nurse to confirm suspicions B.) Call supervisor to report the intoxication C.) Confront the nurse privately in person D.) Discuss suspicions with unit nurse manager

D

The nurse approaches a client who entered the emergency department following a fall down a flight of stairs. The client is unresponsive with snoring and wheezes with respirations. How would the nurse BEST open the client's airway? A.) Endotracheal tube B.) Head-tilt-chin-lift maneuver C.) Oropharyngeal airway D.) Jaw thrust maneuver

D

The nurse is admitting an 8 month old infant to the pediatric unit. For what major development stressor in this infant should the nurse plan interventions? A.) Fear of unknown B.) Loss of daily routine C.) Body image disturbance D.) Separation anxiety

D

The nurse is assessing a client one hour post CABG surgery. Based on the assessment data, what action should the nurse take? Nursing Assessment: Client increasingly more difficult to arouse. Skin cool/damp. Distended neck veins. Lungs clear bilaterally. Heart sounds distant. CVP 8 mmHg. BP 90/60. A.) Administer stat dose of clopidogrel B.) Notify cath lab to prepare for angioplasty C.) Set up for a central catheter line D.) Prepare for immediate pericardiocentesis

D

The nurse is caring for a client 28 weeks pregnant who reports swollen hands and feet. Which sign or symptom would cause the GREATEST concern? A.) Nasal congestion B.) Hiccups C.) Blood glucose of 150 D.) Muscle spasms

D

The nurse is caring for a client post cardiac catheterization that was performed via the right femoral artery. What assessment finding in the right lower extremity would be of concern to the nurse? A.) Right pedal pulse 2+/4+ B.) Capillary refill 2 seconds C.) Erythema D.) Slight oozing of blood

D

The nurse is caring for a client receiving total parenteral nutrition (TPN). Which assessment would require the nurse to intervene? A.) TPN has been hanging for 12 hours B.) Central venous catheter's dressing is clean and dry C.) TPN fluid is room temperature when beginning administration D.) TPN appears oily in consistency

D

The nurse is caring for a client with tuberculosis receiving isoniazid therapy. Because of the possible peripheral neuropathy that can occur, which supplementary nutritional agents would the nurse expect to administer? A.) Cyancobalamin B.) Vitamin D C.) Ascorbic acid D.) Pyridoxine

D

The nurse is planning care for a newly admitted client who has an Arabic surname and whose spouse is wearing a traditional head covering. After verifying that the client prescriptions include a regular diet as tolerated, how would the nurse BEST meet the religious dietary needs for the client? A.) Allow the client to select whatever is acceptable from a regular meal tray B.) Review the client's admission data to determine any dietary restrictions C.) Call the dietitian to discuss special dietary needs with the client's spouse D.) Ask the client about dietary preferences needed to meet religious guidelines

D

The nurse is preparing to initiate postmortem care. Which postmortem care interventions would the nurse implement? A.) Identify the client by the name on the client's armband B.) Remove tubes and indwelling lines after cleansing the body C.) Insert the dentures after the family has viewed the body D.) Maintain body preparation according to the client's religious beliefs

D

The nurse is reviewing morning laboratory results on four clients. Which lab finding should the nurse report to the primary healthcare provider immediately? - Client diagnosed with DVT who is receiving a heparin infusion: aPTT - 85 sec - Client diagnosed with possible appendicitis: WBC - 18,000 per mm3 - Client diagnosed with rheumatoid arthritis: Sed rate - 100 mm/hr - Client diagnosed with congestive heart failure receiving furosemide: K+ - 2.9 mEq/L A.) aPTT B.) WBC C.) Sed rate D.) K+

D

The nurse is talking to the parent of a 3 year old child who was constipated 1 week earlier. The child is on a regular diet. What statement by the parent indicated to the nurse that the prescribed treatment for constipation has been effective? A.) My child drinks 1000 mL of fluid daily B.) My child is eating more fruit every day C.) I administered the prescribed oil-retention enema 6 days ago to my child D.) My child has had a soft, formed brown stool every day for 6 days without straining

D

The nurse notes a continuous bubbling in the water seal chamber of the chest drainage system. What should be the nurse's INITIAL action? A.) Clamp the chest tube closest to the chest wall B.) Increase the water level in the water seal chamber C.) Have the client take a deep breath and do valvalva maneuver D.) Notify the healthcare provider

D

The pediatric nurse is assessing a child following an appendectomy. What is the nurse's main PRIORITY following surgery? A.) Obtain vital signs every four hours B.) Assess the need for pain medication C.) Tally intake and output every eight hours D.) Auscultate lung sounds every four horus

D

These clients have arrived at the emergency department (ED) following an explosion at a local industrial plant. The ED is operating under disaster protocol. Which client should be treated FIRST? A.) The client whose blood pressure is 40 palpable, heart rate 30 and respirations 6 B.) The comatose client with fixed and dilated pupils C.) The unresponsive client with an open head fracture and visible white matter D.) The client with a sucking chest wound and tension pneumothorax

D

What IMMEDIATE action should the occupational health nurse taken once flames have been extinguished from a burned victim? A.) Remove jewelry B.) Wrap in a clean blanket C.) Cover burns with clean, dry cloth D.) Briefly soak burned area in cold water

D

What INITIAL arterial blood gas (ABG) results would the nurse likely see in a client who has overdosed on acetylsalicylic acid (ASA)? A.) pH 7.50, PaCO2 42, PaO2 63, SaO2 91, HCO3 28 B.) pH 7.32, PaCO2 36, PaO2 83, SaO2 95, HCO3 19 C.) pH 7.28, PaCO2 28, PaO2 72, SaO2 90, HCO3 16 D.) pH 7.48, PaCO2 30, PaO2 88, SaO2 92, HCO3 24

D

What instruction is MOST important to include when teaching a child how to self administer a combined dose of isophane suspension and regular insulin subcutaneously? A.) Alternate the injection sites from one body to another with each dose B.) Draw up the isophane suspension insulin first and then regular insulin into the same insulin syringe C.) Massage the injection site after the medication is injected D.) Insulin syringes should be stored at room temperature

D

What task by the RN should be performed FIRST? A.) Changing a burn dressing that is scheduled every four hours B.) Administering a scheduled IV antibiotic C.) Teaching a new diagnosed diabetic about diet and exercise D.) Assessing a newly admitted client

D

Which type of comment should the nurse expect from a client exhibiting clang associations? A.) Concrete explanations for abstract ideas B.) Reporting very small details when explaining something C.) Comments that are illogically associated D.) Use of rhyming words when talking

D

What activities should a nurse recommend to a group of adolescents who have been diagnosed with rheumatoid arthritis? Select all that apply. A.) Jogging B.) Volleyball C.) Tennis D.) Bicycle riding E.) Swimming

D, E

The nurse manager is teaching the principles of least restrictive intervention on a psychiatric unit with a new nurse. In order to demonstrate understanding of this principle, in what order would the new nurse correctly place interventions from LEAST restrictive to MOST restrictive? Place in the correct order. A.) Place client in the isolation room with staff observation B.) Walk the client out to the courtyard C.) Use four point soft cloth restraints D.) Take the client to the quiet room for a timeout E.) Verbally tell the client to stop the unaccepting behavior and escort client to another part of the day room F.) Restrain clients arms with wrist restraints

E, B, D, A, F, C