NUR 104 Exam 1

An obese client has returned to the unit after receiving electroconvulsive therapy (ECT). A nurse requests assistance in moving the client from the stretcher to the bed. Which direction should the nurse give to a nurse who volunteers to help? A. "Obtain the sliding board or two other people to assist us." B. "Get the hydraulic lift; the client is still groggy." C. "Place the client in a semi-Fowler's position to make the move easier." D. "Place the client on the side then use a drawsheet to bring the client to the bed."

A. "Obtain the sliding board or two other people to assist us."

Which statement by a staff nurse on the orthopedic floor indicates the need for further staff education? A. "The client is receiving physical therapy twice per day, so they don't need a continuous passive motion device." B. "The continuous passive motion device can decrease the development of adhesions." C. "Bleeding is a complication associated with the continuous passive motion device." D. "Monitoring skin integrity is important while the continuous passive motion device is in place."

A. "The client is receiving physical therapy twice per day, so they don't need a continuous passive motion device."

The nurse is caring for a female client who underwent surgery 8 hours ago and is unable to void. When placing an indwelling urinary catheter in this client, the nurse should first advance the catheter how far into the urethra? A. 2" (5 cm) B. 6" (15 cm) C. 8" (20 cm) D. ½" (1 cm)

A. 2" (5 cm)

A client returns to the nursing division after a procedure. The client tells the nurse that the client was awake during the procedure and recalls certain events. What is the nurse's priority intervention? A. Ask for additional information from the client. B. Inform the nursing supervisor of the incident. C. Consider changing assignments with another nurse. D. Contact the hospital administrator.

A. Ask for additional information from the client.

The nurse is caring for an elderly patient who needs help with ADLs. Which is most important for the nurse to understand to avoid injury when implementing care? A. Bending and twisting while providing care may cause injury. B. The center of gravity is located at the waist. C. A client's level of consciousness and ability to cooperate are not important factors during transfer. D. Tightening the abdominal muscles and tucking the pelvis may strain the lower back.

A. Bending and twisting while providing care may cause injury.

A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution? A. I.V. tubing with a volume-control chamber B. I.V. tubing with a macrodrip chamber C. I.V. tubing with a special filter D. standard I.V. tubing used for adults

A. I.V. tubing with a volume-control chamber

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first? A. Institute isolation precautions. B. Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour. C. Obtain a nasopharyngeal specimen for reverse-transcription polymerase chain reaction testing. D. Obtain a sputum specimen for enzyme immunoassay testing.

A. Institute isolation precautions.

A 3-month-old admitted to the pediatric unit with meningococcal meningitis has just been assessed by the registered nurse. Which nursing intervention has the highest priority at this time? A. Instituting droplet precautions B. Administering acetaminophen C. Obtaining history information from the parents D. Orienting the parents to the pediatric unit

A. Instituting droplet precautions

A client arrives in the emergency department reporting dizziness and lightheadedness after taking sildenafil citrate prior to sexual activity. The nurse obtains a BP of 86/48 mm Hg. Taken in combination with sildenafil citrate (Viagra), which medication is the most likely cause of these symptoms? A. Nitroglycerin (Nitrostat) B. Albuterol (Ventolin HFA) C. Lisinopril (Prinivil) D. Ibuprofen (Motrin)

A. Nitroglycerin (Nitrostat)

When preparing a client, age 50, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation perforation, and surgery. Based on which evidence, why is the nurse selecting this nursing diagnosis? A. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture. B. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix. C. The appendix may develop gangrene and rupture, especially in a middle-aged client. D. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage.

A. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture.

A nurse is caring for a client with a history of falls. Which interventions take priority in this client's care? Select all that apply. A. Place the call light within the client's reach. B. Keep the bed in the lowest possible position. C. Implement neurological checks every 4 hours. D. Encourage the client change positions frequently while in bed. E. Provide immediate response to the client's toileting needs. F. Assign security personnel to sit outside of the client's door.

A. Place the call light within the client's reach. B. Keep the bed in the lowest possible position. E. Provide immediate response to the client's toileting needs.

A young male client with no history of health problems has difficulty achieving or maintaining an erection. The healthcare provider has ordered evaluations to diagnose the problem. Which activities would be appropriate actions for the nurse? Select all that apply. A. Prepare the client to have blood drawn for hormone levels. B. Prepare the client for surgery. C. Reinforce education for nocturnal rigidity measurements. D. Prepare for duplex Doppler ultrasonography. E. Inform the client to abstain from sexual contact prior to testing.

A. Prepare the client to have blood drawn for hormone levels. C. Reinforce education for nocturnal rigidity measurements. D. Prepare for duplex Doppler ultrasonography.

A client is on a stretcher and needs to be transported to another location. Which action should the nurse take to prevent a personal injury when transporting this client? A. Stand at the head of the stretcher and push the device. B. Stand at the foot of the stretcher and pull with the arms. C. Stand at the side of the stretcher and push with the arms. D. Stand at the foot of the stretcher and pull the client's feet.

A. Stand at the head of the stretcher and push the device.

A psychiatric treatment team is planning care for a client who was involuntarily admitted for treatment of depression and suicide ideation. When planning the client's care, what legal parameters of care should the nurse be aware of? A. The client is able to refuse medications. B. The client is able to obtain release against medical advice. C. The client is in need of a public guardian. D. The client is considered to be incompetent.

A. The client is able to refuse medications.

A 50-year-old client is scheduled for a test for prostate-specific antigen (PSA). What should the nurse tell the client with respect to the procedure? A. The test is often repeated each year even if this result is negative. B. The test is very reliable for predicting prostate cancer. C. Inform client that he may feel mild discomfort during the injection. D. Monitor bowel movements after the procedure for changes in stool pattern.

A. The test is often repeated each year even if this result is negative.

A client tells the nurse that they are having trouble with sexual intercourse since they have had atrophy of the bulbourethral glands. Which suggestions can the nurse make to alleviate the discomfort for them and their partner? A. Use additional lubrication such as water-soluble gel. B. Take warm baths prior to intercourse. C. Use medication to sustain erections. D. Use aids to intercourse.

A. Use additional lubrication such as water-soluble gel.

The nurse is teaching a group of caregivers about high-risk choking hazards for preschoolers. Which foods and objects does the nurse include? Select all that apply. A. balloons B. popcorn C. coins D. bananas E. thin liquids

A. balloons B. popcorn C. coins

What outcome is associated with orchitis? A. inflammation of the testes. B. cancer of the testes C. fluid around the testes D. torsion of the testes

A. inflammation of the testes.

A client admitted with dehydration has urinary incontinence and excoriation in the perineal area. Which action would be a priority? A. keeping the perineal area clean and dry B. offering the urinal every 3 hours C. maintaining a fluid intake of 1 L/day D. applying moist, warm compresses to the client's perineal area

A. keeping the perineal area clean and dry

When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as what? A. nonmaleficence B. informed consent C. self-determination D. pro-choice

A. nonmaleficence

A nurse is assisting a healthcare provider performing a digital rectal examination of a client. This test, along with prostate-specific antigen (PSA) blood test, is used as an early detection of what disease? A. prostate cancer B. colorectal cancer C. erectile dysfunction D. orchitis

A. prostate cancer

The X-rays of a client who was brought to the emergency department after falling on ice reveal a leg fracture. After a cast is applied and allowed to dry, the nurse teaches the client how to use crutches. Which instruction should the nurse provide about climbing stairs? A. "Place both crutches on the first step and swing both legs upward to this step." B. "Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together." C. "Place the crutches and injured leg on the first step, followed by the unaffected leg." D. "Place the injured leg and the crutch on the unaffected side on the first step; the unaffected leg and crutch on the injured side follow."

B. "Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together."

Which child would be at increased risk for a respiratory syncytial virus (RSV) infection? A. 2-month-old child managed at home B. 2-month-old child with broncho pulmonary dysplasia C. 3-month-old child requiring low-flow oxygen D. 2-year-old child

B. 2-month-old child with broncho pulmonary dysplasia

A nurse on duty in the pediatric ward notices an unidentified person carrying a baby in her arms. The baby is dressed in hospital garb. What action should the nurse take immediately? A. Notify the facility's security personnel. B. Alert the supervisor and call "Code Pink". C. Shut all the doors to the unit. D. Notify the local police.

B. Alert the supervisor and call "Code Pink".

The nurse is assisting a healthcare provider in debriding a necrotic skin wound. The healthcare provider is using a plastic basin to collect the bloody supplies. When cleaning the area on completion of debridement, which nursing action is done after placing the supplies in a hazardous material bag? A. Wash the basin in hot, soapy water. B. Dispose of the plastic basin. C. Spray the basin with a disinfectant agent. D. Clean the basin with an antiseptic agent.

B. Dispose of the plastic basin.

While preparing to start a stat I.V. infusion, a nurse notices a broken ground wire on the infusion pump's plug. What would the nurse do first? A. Continue to use the infusion pump. B. Obtain another pump from central supply. C. Pull the pump out of service. D. Report the problem to central supply.

B. Obtain another pump from central supply.

A client living in a long-term care facility has become increasingly unsteady when out of bed. The nurse is worried that the client is going to climb out of bed and fall. The facility has a least restraint policy for the clients. Which action should the nurse take to best ensure the safety of the client while complying with policy? A. Instruct the client on use of the call bell. B. Provide a bed that is low to the floor. C. Have a family member stay with the client. D. Raise all side rails while the client is in bed.

B. Provide a bed that is low to the floor.

A client is undergoing transurethral resection of the prostate (TURP). What is the purpose of this procedure? A. To diagnose nocturnal erections. B. To remove a small tissue sample of the prostate. C. To remoove a cancerous prostate. D. To diagnose erectile dysfunction.

B. To remove a small tissue sample of the prostate.

A health care provider and nurse are discussing treatment options with a client diagnosed with severe ulcerative colitis symptoms. Which potential complication requires frequent assessment? A. gastritis B. bowel herniation C. bowel outpouching D. bowel perforation

B. bowel herniation

What type of isolation precautions would the nurse request for a child diagnosed with group-A beta-hemolytic streptococcus? A. universal precautions B. droplet precautions C. contact precautions D. airborne precautions

B. droplet precautions

A facility has a system for transcribing medication orders to a Kardex as well as a computerized medication administration record (MAR). A physician writes the following order for a client: "Prednisone 5 mg by mouth daily for 3 days." The order is correctly transcribed on the Kardex. However, the nurse who transcribes the order onto the MAR neglects to place the limitation of 3 days on the prescription. On the 4th day after the order was instituted, a nurse administers prednisone 5 mg by mouth. During an audit of the chart, the error is identified. The person most responsible for the error is the: A. nurse who transcribed the order incorrectly on the MAR. B. nurse who administered the erroneous dose. C. pharmacist who filled the order and provided the erroneous dose. D. facility because of its policy on transcription of medications.

B. nurse who administered the erroneous dose.

The nurse notices a bottle of Chlorosorb in a client's room. What type of danger does this substance pose for the client and nursing staff? A. fire B. poison C. skin or eye irritant carcinogen

B. poison

A visitor asks the nurse about entering the room of a client who has contact precautions for methicillin-resistant Staphylococcus aureus (MRSA). The nurse explains the necessary precautions needed to visit the client. What statement by the visitor reflects understanding of the contact precautions teaching? A. "The mask will decrease the risk of my friend spreading MRSA." B. "The use of these masks and gloves will decrease the risk of me getting MRSA." C. "By using gowns, gloves, and washing my hands, I will decrease the spread of MRSA." D. "I will wash my hands after I go in the room and if I touch anything in my friend's room."

C. "By using gowns, gloves, and washing my hands, I will decrease the spread of MRSA."

A young adult was told that he had a significant reaction to the Mantoux test. The client asks the nurse what is the meaning of this significant reaction. How does the nurse appropriately respond? A. "You have active tuberculosis." B. "You had active tuberculosis." C. "You have been exposed to tuberculosis." D. "You are immunocompromised."

C. "You have been exposed to tuberculosis."

A client is diagnosed with genital herpes simplex. Concerned about spread of the virus to others, the nurse questions the client about recent sexual activity. What is the average incubation period for localized genital herpes simplex infection? A. 6 to 18 hours B. 1 to 2 days C. 3 to 7 days D. 10 to 14 days

C. 3 to 7 days

A client with left hemiparesis is having difficulty swallowing a potassium chloride 20 mEq tablet. What should the nurse do? A. Crush the pill and administer with a small amount of liquid. B. Break the pill into small pieces and administer with apple sauce. C. Ask the health care provider for an order to administer a different consistency through a different route. D. Administer the medication with a large amount of liquid.

C. Ask the health care provider for an order to administer a different consistency through a different route.

The nurse observes small white nodules on the roof of an infant's mouth. Which term will the nurse use when describing this finding to the health care provider? A. melasma B. milia C. Epstein pearls D. erythema toxicum

C. Epstein pearls

A client in the emergency department is diagnosed with a communicable disease. When complications of the disease are discovered, the client is admitted to the hospital and placed in respiratory isolation. Which infection warrants respiratory isolation? A. Chickenpox B. Impetigo C. Measles D. Cholera

C. Measles

A client is postoperative after a laparoscopy. After the procedure, the client reports severe pain under the right clavicle. Which is the priority action by the nurse? A. Prepare the client to return to surgery. B. Turn the client on the right side. C. Notify the healthcare provider. D. Administer an analgesic.

C. Notify the healthcare provider.

An adolescent who's newly diagnosed with type 1 diabetes provides a return demonstration of self-insulin administration. Which action by the client demonstrates proper disposal of the insulin syringe? A. Recapping the needle and disposing of the syringe in a double-lined trash receptacle B. Recapping the needle and placing the syringe in a designated puncture-resistant container C. Placing the syringe with the uncapped needle in the designated puncture-resistant container D. Placing the syringe with the uncapped needle in a plastic bag

C. Placing the syringe with the uncapped needle in the designated puncture-resistant container

Which steps should the nurse follow to insert a straight urinary catheter? A. Create a sterile field, drape the client, clean the meatus, and insert the catheter only 6". B. Put on gloves, prepare the equipment, create a sterile field, expose the urinary meatus, and insert the catheter 6". C. Prepare the client and the equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows. D. Prepare the client and the equipment, create a sterile field, test the catheter balloon, clean the meatus, and insert the catheter until urine flows.

C. Prepare the client and the equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows.

Which hormones are responsible for stimulating the mammary glands to produce and release milk after childbirth? Select all that apply. A. Estrogen B. Progesterone C. Prolactin D. Oxytocin E. Cortisol

C. Prolactin D. Oxytocin

A nurse observes that an alternate personality (a child) of an adult client with dissociative identity disorder (DID) is in control. The client is sitting in the dayroom, interacting with others. Which action would be most appropriate? A. Forcibly remove the client to prevent interaction with clients in the dayroom. B. Ask to speak to one of the adult alter personalities of the host personality. C. Remove the client from the dayroom and allow the client to play with toys. D. Remove the client from the dayroom and reorient in a safe place.

C. Remove the client from the dayroom and allow the client to play with toys.

Which nursing diagnosis takes highest priority for a client with a compound fracture? A. Imbalanced nutrition: Less than body requirements related to immobility B. Impaired physical mobility related to trauma C. Risk for infection related to effects of trauma D. Which nursing diagnosis takes highest priority for a client with a compound fracture?

C. Risk for infection related to effects of trauma

A nurse is caring for a client who has been diagnosed with hypovolemic shock. Which diagnostic procedure should the nurse review to obtain additional information about the client's condition? A. pH level of urine B. hemoglobin level C. Serum electrolyte levels D. blood sugar levels

C. Serum electrolyte levels

The nurse is obtaining a menstrual history from a female client. The client states that at times, they experiences cramps about 2 weeks after their menstrual cycle ends. Which information would the nurse provide the client? A. The client will have to have a biopsy to determine cancerous ovaries. B. The cramps may occur due to ruptured ovarian cysts. C. The cramps usually indicate ovulation. D. No education is required since there is nothing wrong with the client.

C. The cramps usually indicate ovulation.

What is the primary responsibility of a healthcare facility's safety committee? A. To take action in hazardous situations. B. To be prepared for emergencies. C. To track injury and illness rates. D. To relieve facility staff during a disaster.

C. To track injury and illness rates.

The physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should: A. take the specimen to the laboratory immediately. B. apply a solution to the stool specimen. C. collect the specimen in a sterile container. D. store the specimen on ice.

C. collect the specimen in a sterile container.

The nurse is working as part of multidisciplinary team in developing the plan of care for a premature neonate. Breast milk is being encouraged as part of the plan. The nurse understands that the use of breast milk for this neonate would help prevent which condition? A. Down syndrome B. hyaline membrane disease C. necrotizing enterocolitis D. Turner syndrome

C. necrotizing enterocolitis

A client diagnosed with major depression states, "Everything is my fault, and I would be better off dead." Which priority intervention would the nurse implement? A. document the client's statement B. notify the psychiatrist of the client's statement C. place the client on suicide precautions D. engage the client in a no-suicide contract

C. place the client on suicide precautions

A nurse is reinforcing the teaching plan for a postpartum client diagnosed with mastitis. The nurse determines that the client has understood the information when she states which organism as most likely responsible? A. Escherichia coli B. group beta-hemolytic streptococci (GBS) C. staphylococcus aureus D. streptococcus pyogenes

C. staphylococcus aureus

A young client develops a fever and rash and is diagnosed with rubella. The client's mother has just given birth to another child. Which statement by the mother best indicates that she understands the implications of rubella? A. "I told my partner to give the client aspirin for the fever." B. "I'll ask the physician about giving the baby an immunization shot." C. "I don't have to worry because I've had the measles." D. "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my children."

D. "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my children."

The parents of a 14-year-old child who underwent an atrial septal repair 5 days ago have asked if a few family members can visit. Which response by the nurse is appropriate? A. "Your child is extremely fragile, and visitations are not recommended." B. "Let's have your child communicate by phone calls with friends and family members instead." C. "We should not have visitors for another few days to best protect your child from infection." D. "While controlling infection and promoting rest are important, a few visitors would not be a problem at this stage of recovery."

D. "While controlling infection and promoting rest are important, a few visitors would not be a problem at this stage of recovery."

During preoperative teaching for a client who will undergo a subtotal thyroidectomy, the nurse should include which statement? A. "The head of your bed must remain flat for 24 hours after surgery." B. "You should avoid deep breathing and coughing after surgery." C. "You won't be able to swallow for the first day or two." D. "You must avoid hyperextending your neck after surgery."

D. "You must avoid hyperextending your neck after surgery."

A client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. Which of the following approaches should the nurse initially utilize? A. Enter the room quietly and move beside her to assess her injuries. B. Call for staff back-up before entering the room and restraining her. C. Move as much glass away from her as possible and sit next to her quietly. D. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her.

D. Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her.

A client has been camping in the woods in cold temperatures and is brought to the Emergency Department with suspected hypothermia. What ordered action is important at this time? A. Warm the client rapidly to a body temperature of 98.6°F. B. Apply hot packs to the skin. C. Give the client hot coffee or tea. D. Gradually rewarm the client.

D. Gradually rewarm the client.

What us the purpose of the flagellum of the sperm? A. Contains 23 chromosomes. B. Contains enzymes that dissolve the tough cell wall of the ovum. C. Provides the energy necessary for locomotion. D. Propels the sperm with a lashing motion.

D. Propels the sperm with a lashing motion.

Which major hormone is responsible for the secondary male sex characteristics? A. Follice-stimulating hormone B. Interstitial cell-stimulating hormone C. Androgens D. Testosterone

D. Testosterone

The nurse is teaching a client how to rotate insulin injection sites. What is the purpose of rotating injection sites? A. To prevent bruising B. To prevent medication leakage from the tissue or muscle C. To prevent erratic drug distribution D. To prevent the formation of hard nodules

D. To prevent the formation of hard nodules

A home health nurse is evaluating a client's fall risk. Which observations would concern the nurse? A. holding a cane on the uninvolved side B. wearing slippers with a non-skid bottom C. using a bath seat when showering D. decreased strength in lower extremities

D. decreased strength in lower extremities

An 11-year-old child contracted severe acute respiratory syndrome (SARS) when traveling abroad with the parents. The nurse knows to put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective equipment should the nurse wear? A. gloves B. gown and gloves C. gown, gloves, and mask D. gown, gloves, mask, and eye goggles or eye shield

D. gown, gloves, mask, and eye goggles or eye shield

When planning care for a child with rheumatic fever, which is the greatest area of concern? A. nutrition B. anxiety management C. cognitive delays D. prevention of falls

D. prevention of falls

A client is having a breast biopsy with the entire lump to be removed and analyzed. Which type of breast biopsy would the nurse prepare the client for? A. Needle biopsy B. Excisional biopsy C. Incisional biopsy D. Aspiration biopsy

B. Excisional biopsy

A nurse is reviewing information about immunizations with a new mother. The nurse determines that the woman has an understanding of the information based on which client statement about active immunity? A. "Although it is only temporary, this immunity develops rapidly." B. "Antibodies in my blood are transmitted to my baby." C. "Direct exposure by a vaccine or disease leads to this type of immunity." D. "I can give it to my baby when I give him my breast milk."

C. "Direct exposure by a vaccine or disease leads to this type of immunity."

A client informs the nurse that their wife wants them to have a vasectomy, but they are afraid that they will lose their ability to have an erection. Which response by the nurse is best? A. "Maybe you better think about this before you consent to major surgery." B. "It may affect it only temporarily after the surgery." C. "The operation does not affect erection or ejaculation." D. "Maybe your wife should have a sterilization procedure."

C. "The operation does not affect erection or ejaculation."

The nurse is admitting a client with abdominal pain, bloody stools, weakness, and dizziness when the client reports feeling the urge to have a bowel movement. What is the priority action by the nurse? A. Have the client ambulate to the bathroom. B. Assist the client to the bedside commode. C. Assist the client onto the bedpan. D. Ask the client to wait for specimen collection.

C. Assist the client onto the bedpan.

The nurse is caring for a client involved in a house fire with burns to the chest and upper arms. What signs observed by the nurse indicate the client may have also sustained inhalation injuries? Select all that apply. A. Fever B. Neck pain C. Flecks of soot in the saliva D. Hoarse voice E. Singed nasal hairs

C. Flecks of soot in the saliva D. Hoarse voice E. Singed nasal hairs

When a client has sustained a serious burn, what is the immediate action by the nurse? A. Apply burn cream to the area. B. Apply ice to the burned area. C. Stop the burning process. D. Remove burning fabric or other material from the skin.

C. Stop the burning process.

A nurse is changing a client's dressing and providing wound care. Which activity should the nurse perform first? A. evaluate the drainage in the wound B. slowly remove the soiled dressing C. wash hands thoroughly D. put on latex gloves

C. wash hands thoroughly

The nurse is caring for a client with a nasogastric tube and in mitt restraints. Which nursing action is required every 1 to 2 hours? A. Assist the client to the bathroom. B. Assess cognitive status. C. Offer the client sips of clear liquids. D. Remove restraints and assess skin and circulation.

D. Remove restraints and assess skin and circulation.

A client is receiving continuous bladder irrigations after having a transurethral resection of the prostate (TURP). While the irrigation is in process, the client reports a feeling of fullness and right flank pain. Which is the first action by the nurse? A. Administer analgesics as prescribed. B. Turn the client on the left side to improve flow. C. Increase the amount of flow of the solution. D. Shut off the continuous irrigation and notify the team leader or surgeon.

D. Shut off the continuous irrigation and notify the team leader or surgeon.

A nurse is caring for a client with multiple myeloma. When assisting with the plan of care, which nursing intervention is most appropriate? A. monitoring respiratory status B. balancing rest and activity C. restricting fluid intake D. preventing bone injury

D. preventing bone injury

The school nurse is teaching teenage girls how to prevent vaginal infections. Which guidelines are recommended for feminine care? Select all that apply. A. Wipe from back to front when going to the bathroom. B. Pull panties, with perineal pad attached, straight down. C. Douche at least once a week. D. Use vaginal sprays or scented powders between bathing. E. Wear only cotton panties. F. Avoid tight pants or jeans.

GOT 0.67 potentially missing one more with correct answer options being E and F

A client is diagnosed with benign prostatic hyperplasia and prescribed the 5-alpha reductase inhibitor finasteride (Proscar). Which information would the nurse be sure to include when reinforcing education regarding this medication? A. The medication will eliminate bacteria in the prostate. B. The medication will take approximately 6 months to be effective. C. The medication will assist with achieving and maintaining an erection. D. The medication will prevent the formation of kidney stones.

B. The medication will take approximately 6 months to be effective.

A physician enters a computer order for a nurse to irrigate a client's nephrostomy tube every 4 hours to maintain patency. The nurse irrigates the tube using sterile technique. After irrigating the tube, the nurse decides that she can safely use the same irrigation set for her 8-hour shift if she covers the set with a paper, sterile drape. This action by the nurse is A. appropriate because the irrigation just checks for patency. B. inappropriate because irrigation requires strict sterile technique. C. appropriate because the irrigation set will be used only during an 8-hour period. D. inappropriate because the sterile drape must be cloth, not paper.

B. inappropriate because irrigation requires strict sterile technique.

A licensed practical nurse (LPN) is assisting a registered nurse in caring for a primigravida client with acquired immunodeficiency syndrome (AIDS) who is at term and in early labor. When providing care to this client, which area would the LPN focus on as the priority? A. crisis intervention B. infection control measures C. fluid balance D. fetal oxygenation

B. infection control measures

A nurse is caring for a client with a history of falls. What is the first priority when caring for a client at risk for falls? A. place the call light within the client's reach B. keep the bed in the lowest possible position C. instruct the client not to get out of bed without assistance D. keep the bedpan available so the client doesn't have to get out of bed

B. keep the bed in the lowest possible position

The nurse needs to pick up a large object that is sitting on the floor in a client's room. Which action most increases the nurse's risk of a back injury? A. moving close to the object B. leaning forward toward the object C. using the arms and legs to lift the object D. bringing the body close to the level of the object

B. leaning forward toward the object

A client is scheduled for an electroencephalogram (EEG) after having a seizure for the first time. Which instruction does the nurse provide to the client as preparation for this test? A. "Do not eat anything for 12 hours before the test." B. "Do not shampoo your hair for 24 hours before the test." C. "Avoid stimulants and alcohol for 24 to 48 hours before the test." D. "Avoid thinking about personal matters for 12 hours before the test."

C. "Avoid stimulants and alcohol for 24 to 48 hours before the test."

The nurse is providing care for a pregnant 16-year-old client. The client says that she's concerned she may gain too much weight and wants to start dieting. The nurse should respond by saying: A. "Now isn't a good time to begin dieting because you are eating for two." B. "Let's explore your feelings further." C. "Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems." D. "The prenatal vitamins should ensure that the baby gets all the necessary nutrients."

C. "Nutrition is important because depriving your baby of nutrients can cause developmental and growth problems."

A nurse applies standard precautions when caring for a client with human immunodeficiency virus (HIV). The nurse takes what action when applying standard precautions? A. wearing gloves when helping client dress B. providing a dedicated commode at bedside C. wearing gloves for providing mouth care D. gowning and gloving for intravenous insertion

C. wearing gloves for providing mouth care

A client newly admitted to a psychiatric inpatient setting demands a soda from a staff member who tells him to wait until lunch arrives in 20 minutes. The client becomes angry, pushes over a sofa, throws an end table, and dumps a potted plant. Which goal should a nurse consider to be of primary importance? A. Talking with the client's family about his angry feelings B. Performing an assessment for tardive dyskinesia C. Learning to effectively express needs to staff and others D. Demonstrating control over aggressive behavior

D. Demonstrating control over aggressive behavior

As the nurse arrives to visit a family 2 days after release from the hospital, she hears shouting and swearing between the mother and father and several loud crashes, just as she is going to knock on the door. What action by the nurse is the most appropriate? A. Knock on the door and wait to see if someone comes to the door. B. Knock on the door and shout, "It is the nurse. Can I help you?" C. Return to the car and call the family on a cell phone. D. Return to the car and call the police.

D. Return to the car and call the police.

A client requests an office visit for a Pap test. When is the best time for the nurse to schedule the client? A. The timing of the test is not significant and the appointment can be scheduled at any time. B. The appointment should be scheduled while the client is on their menstrual period. C. The appointment should be scheduled the day after the client's menstrual period. D. The appointment should be scheduled between the client's menstrual periods.

D. The appointment should be scheduled between the client's menstrual periods.

The nurse is gathering data from several children in the clinic with reports of diarrhea. Which child would be at greatest risk for giardiasis? A. child that rides a school bus B. child that plays on a playground close to home C. child that attended a sporting event at a large arena D. child that attends group day care

D. child that attends group day care

A school-age child with fever and joint pain has just received a diagnosis of rheumatic fever. The child's parents ask a nurse if anything could have been done to prevent this disorder. Which intervention would have been most effective in preventing rheumatic fever? A. immunization with the hepatitis B vaccine B. isolation of individuals with rheumatic fever C. use of prophylactic antibiotics for invasive procedures D. early detection and treatment of streptococcal infections

D. early detection and treatment of streptococcal infections

A nurse inadvertently transcribes a client's medication order that was written as "Ampicillin 250 mg four times a day" as "Ampicillin 2500 mg four times a day." The nurse gives two doses as transcribed to the client. Another nurse gives one dose before the pharmacist questions the reorder of the medication. What should the two nurses do in this situation? A. Both nurses must acknowledge making the medication error. B. Tell the pharmacist that the wrong quantity of medication was sent to the unit. C. Adjust the medication administration record to reflect the correct dose only. D. Only the nurse who transcribed the order should be accountable for the error.

A. Both nurses must acknowledge making the medication error.

A nurse is repositioning a client in bed. What should the nurse do to maintain proper body mechanics? A. straighten the knees and back B. use a wide stance for support C. lift the client to the proper position D. stand several feet from the client

B. use a wide stance for support

The nurse is administering digoxin to a client diagnosed with congestive heart failure (CHF). The health care provider has ordered digoxin 0.125 mg PO daily. Calculate how many tablets will the nurse administer from a unit dose of 0.25 mg/tablet?

0.5 tablets

A client is scheduled to have a prostatectomy in 1 week. The client informs the nurse that they realize that their sexual life is over. Which information should the nurse provide to the client? Select all that apply. A. Alternative means of sexual expression B. Use of medications prescribed by the physician C. Strategies for how to accept the loss of a sexual life D. Aids to intercourse E. Prevention of infection

A. Alternative means of sexual expression B. Use of medications prescribed by the physician D. Aids to intercourse

A nurse is working on a labor and delivery unit that requires all visitors to pass a screening protocol prior to entry. What is the nurse's priority action when a person gains access to the unit after bypassing the screening protocol? A. Call security personnel to remove the visitor. B. Check to make sure each neonate is with its parent. C. Stop the visitor, and ask for identification. D. Note the time and a detailed description of the individual.

C. Stop the visitor, and ask for identification.

The school nurse learns that at least one of the children in the school has a new diagnosis of erythema infectiosum (human parvovirus) after developing a bright red facial rash. What interventions should be implemented to prevent a possible spread of the infection to other students in the school? A. Require the client to remain at home until the rash fades. B. Remove the pets from the classroom. C. Teach everyone to implement hand hygiene. D. Administer acetaminophen to the client.

C. Teach everyone to implement hand hygiene.

A 45-year-old client informs the nurse that they think the signs of menopause have started and would like to know if they can stop their birth control pills. Which response by the nurse is best? A. "It is possible for you to become pregnant during developing menopause." B. "That would be fine. You should not take the pills during menopause." C. "You cannot become pregnant during this time due to decreased ovarian function." D. "Your symptoms are probably related to some other disorder."

A. "It is possible for you to become pregnant during developing menopause."

A client is scheduled for amniocentesis. When preparing her for the procedure, the nurse should complete which of the following tasks? A. Ask her to void. B. Instruct her to drink 1 L of fluid. C. Prepare her for I.V. anesthesia. D. Ask her to lie on her left side.

A. Ask her to void.

The smoke alarm sounds on the unit at the long-term care facility. Which acronym will guide the nurse's actions in the situation? A. RACE B. PASS C. CARE D. ACRE

A. RACE

The nurse observes a child with autism banging his or her head against the floor repetitively. Which nursing action is the priority? A. apply a helmet on the child B. administer sedation C. restrain the child D. allow the child to continue the repetitive behavior

A. apply a helmet on the child

A nurse is teaching a client with a left fractured tibia how to walk with crutches. Which instruction is appropriate? A. "Use the axillae to help carry the weight." B. "All weight should be on the hands." C. "Keep feet 12 inches (30 cm) apart to provide stability and a wide base of support." D. "Take long strides to maintain maximum mobility."

B. "All weight should be on the hands."

The licensed practical nurse is teaching a client with right-sided weakness proper cane use. Which instruction should the nurse include in her teaching? A. "Hold the cane on the same side as the injury." B. "Hold the cane on the opposite side from the injury." C. "Don't use the cane when climbing stairs." D. "Use the cane when walking further than 50 feet."

B. "Hold the cane on the opposite side from the injury."

A client being released from restraints says, "I'll never get that angry and lose it again. Those restraints were the worst things that ever happened to me." Which response by the nurse is most appropriate? A. "Do you really mean what you just said?" B. "I'd like to talk with you about your experience." C. "That was the worst thing that ever happened to you?" D. "Someday this experience won't bother you like it does now."

B. "I'd like to talk with you about your experience."

Which nursing action would be provided to a client who has a decrease in estrogen production? A. Discuss the necessity for hormone replacement. B. Discuss the need for a low-fat, low-salt diet. C. Discuss the increase in hair growth on the scalp, axillae, and external genitalia. D. Discuss the likelihood of an increase in musculature of upper arms and legs.

B. Discuss the need for a low-fat, low-salt diet.

The nurse is caring for an infant in the newborn nursery and observes that the right testicle appears to be undescended. Which nursing action is appropriate at this time? A. No action is required; this is a normal finding. B. Document the finding and report it to the physician. C. Inform the parents that the baby may not be able to have children. D. Do not apply a diaper.

B. Document the finding and report it to the physician.

A nurse is reinforcing education with a client on how to use transcutaneous electrical nerve stimulation (TENS) to manage pain. Which client statement indicates an accurate understanding of its use? A. "I'll leave the TENS unit on while I take a shower." B. "It's okay to increase the unit's amplitude as rapidly as needed." C. "I should clean the unit every 24 hours by soaking it in water for 5 to 10 minutes." D. "If I have a headache, nausea, or unpleasant sensations, I'll use my troubleshooting techniques."

D. "If I have a headache, nausea, or unpleasant sensations, I'll use my troubleshooting techniques."

The nurse is providing teaching for a client with hepatitis A. Which statement by the client indicates the need to reinforce the teaching? A. "I should not share bath towels with my family." B. "I should not share utensils with my family." C. "Hand washing is very necessary after using the bathroom." D. "It is all right to French kiss my partner."

D. "It is all right to French kiss my partner."

A client is being discharged after an acute myocardial infarction (MI). The client asks why metoprolol was prescribed. What education does the nurse reinforce? A. "Metoprolol will increase the heart rate." B. "Metoprolol increases the blood supply to the heart by dilating your coronary arteries." C. "Metoprolol makes the heart beat stronger to supply more blood to the body." D. "Metoprolol slow the heart rate and decreases the amount of work it has, so it can heal."

D. "Metoprolol slow the heart rate and decreases the amount of work it has, so it can heal."

A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse? A. Report the incident to the nursing regulatory agency. B. Complete an adverse drug reaction (ADR) report. C. Anticipate suspension from the facility due to the error. D. Report the incident to risk management.

D. Report the incident to risk management.

A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority? A. Bathing or hygiene self-care deficit B. Ineffective tissue perfusion: cerebral C. Dysfunctional grieving D. Risk for injury

D. Risk for injury

Which of the following objects poses the most serious safety threat to a 2-year-old child in the hospital? A. Crayons and paper B. Stuffed teddy bear in the crib C. Mobile hanging over the crib D. Side rails in the halfway position

D. Side rails in the halfway position

What are external indicators of menopause? Select all that apply. A. Tendency to gain weight B. Thinning of hair C. Loss of eyebrows D. Dry itchy skin E. Hair growth on chin

GOT 0.75 WITH A,B,D potentially missing one more

A nurse is caring for an adolescent girl experiencing menstruation for the first time. What changes occur in the body at this stage that the nurse should share with the adolescent girl? A. Irritability and insomnia B. Hot flashes C. Breast development D. Urinary incontinence

NOT A

What is the implication of decreased ovarian function? A. Susceptibility to fractures B. Increases the risk of heart disease C. Changes in sexual response D. Inability to become pregnant

NOT B

A client admitted to the health care facility with acute bronchitis is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the likely cause of this sound? A. The water level in the humidifier reservoir is too low. B. The oxygen tubing is pinched. C. The client has a nasal obstruction. D. The oxygen concentration is above 40%.

B. The oxygen tubing is pinched.

A client reports frequent vaginal infections. Which suggestions can the nurse make to decrease the risk of infection in this client? Select all that apply. A. Douche daily. B. Wipe from front to back after voiding. C. Avoid the use of bubble bath. D. Thoroughly wash hands, especially during menses after voiding. E. Wear nylon panties.

B. Wipe from front to back after voiding. C. Avoid the use of bubble bath. D. Thoroughly wash hands, especially during menses after voiding.

A pediatric nurse is providing discharge instructions for the family of a school-age child with idiopathic thrombocytopenia. Which activity should be restricted until further notice? A. swimming B. bicycle riding C. computer games D. exposure to large crowds

B. bicycle riding

The licensed practical nurse (LPN) is assigned to care for a 4-year-old child who had a Harrington rod inserted the day before and notices the client is receiving antibiotics by a syringe pump. The nurse is IV certified, but uncomfortable because they are unfamiliar with the equipment. What would be the best course of action? A. Request another assignment. B. Refuse the assignment for safety reasons. C. Request in-service education for use of the syringe pump. D. Read through the unit policy and procedure manual.

C. Request in-service education for use of the syringe pump.

The nurse splashes a chemical used for disinfecting surgical instruments on both hands. Which resource will provide information regarding the contents of the chemical? A. Disaster plan B. Physician's Desk Reference C. Safety Data Sheet D. Poison control

C. Safety Data Sheet

The nurse is making an initial visit to the home of a client who ambulates with a walker. Which finding should the nurse identify as a safety hazard when completing an assessment of the client's home? A. A fire extinguisher is stored in the hall closet. B. Nightlights are in the hallway between the bedroom and bathroom. C. The banister along the stairway is made of iron. D. Electrical cords are covered with a carpet.

D. Electrical cords are covered with a carpet.

The home health nurse visits an older adult client and their spouse to discuss home safety prior to discharge from the hospital. What information should the nurse focus on to optimize safety? A. "It's important to have good lighting and clear, even flooring surfaces." B. "Your spouse should avoid unsteady ladders and electrical appliances." C. "Be sure to properly store all plastic bags and install handrails on steps." D. "Test your smoke alarms, and avoid handling flammable liquids."

A. "It's important to have good lighting and clear, even flooring surfaces."

A client is scheduled for a pelvic examination. In preparation for the procedure, which intervention by the nurse is appropriate? A. Ask the client to empty their bladder. B. Instruct the client to hold their breath when the speculum is inserted. C. Place the client in the prone position. D. Have a Vaseline-based gel available to lubricate the speculum.

A. Ask the client to empty their bladder.

A client is brought to the urgent care center with an injury to the left ankle sustained from a fall. X-ray interpretation determined that there is no fracture present, but the client does have a sprain. What education will the nurse reinforce to the client? A. PASS B. RICE C. RACE D. CPR

B. RICE

A nurse needs to administer prescribed medications to a client with heart failure. Prior to administering the medications, what actions should the nurse take? Select all that apply. A. Perform handwashing. B. Hold all the medications until the primary health care provider has examined the client. C. Check the client's medical record number and name on the identification bracelet. D. Check the client's allergies in the medical record, and verify them with the client. E. Ask the client if there are any medications that will be refused.

A. Perform handwashing. C. Check the client's medical record number and name on the identification bracelet. D. Check the client's allergies in the medical record, and verify them with the client.

The nurse is reviewing the proper technique for obtaining a urine specimen from an indwelling urinary catheter. When collecting the urine, what is the most appropriate technique to use? A. Collect urine from the drainage collection bag. B. Disconnect the catheter from the drainage tubing to collect urine. C. Remove the indwelling catheter and insert a sterile straight catheter to collect urine. D. Clean the tubing's drainage port with alcohol and then insert a sterile needle with syringe to collect the specimen.

D. Clean the tubing's drainage port with alcohol and then insert a sterile needle with syringe to collect the specimen.

The nursing team is caring for clients on a clinical unit when the fire alarm sounds. Which nurse on the team acts most appropriately to contain a fire? A. the nurse who closes all the inside doors B. the nurse who returns to the nurses' station C. the nurse who searches for signs of smoke D. the nurse who stays with an immobile client

A. the nurse who closes all the inside doors

A train accident sends a large number of injured passengers to the hospital. The hospital's disaster plan is put into effect. Which nursing action would best serve the hospital in this disaster situation? A. perform duties as outlined in the disaster plan B. volunteer to help where assistance is most needed C. offer advice about how to run the facility smoothly D. implement tasks that are beyond the scope of practice

A. perform duties as outlined in the disaster plan

A client comes to the clinic and is diagnosed with shingles. Which findings confirm this diagnosis? Select all that apply. A. severe, deep pain around the thorax B. red, nodular skin lesions around the thorax C. fever D. malaise E. diarrhea

A. severe, deep pain around the thorax B. red, nodular skin lesions around the thorax C. fever D. malaise

What physical changes should be discussed when educating a client on secondary sexual characteristics? Select all that apply. A. Pubic hair B. Decreased percentage of body fat tissue C. Wider hip structure D. Axillary hair E. Breast development

A. Pubic hair C. Wider hip structure D. Axillary hair E. Breast development

A nurse is investigating the smell of smoke in the hallway of a long-term care unit. On entering a client's room, the nurse finds the wastebasket on fire. The nurse takes immediate action. Place the nurse's actions in proper order from first to last. All options must be used. A. Rescue the client. B. Trigger the alarm. C. Confine the fire. D. Extinguish the fire.

A. Rescue the client. B. Trigger the alarm. C. Confine the fire. D. Extinguish the fire.

Several children in a kindergarten class have been treated for pinworm. To prevent the spread of pinworm, the school nurse meets with the parents and explains that they should: A. tell the children not to bite their fingernails. B. not let children share hairbrushes. C. tell the children to cover their mouths and noses when they cough or sneeze. D. have their children immunized.

A. tell the children not to bite their fingernails.

A client with erectile dysfunction (ED) is prescribed the drug sildenafil citrate (Viagra). Which information would the nurse be sure to include when reinforcing education of this medication? A. Seek medical intervention for erections lasting 3-4 hr. B. Take the medication with nitroglycerin (Nitrostat) to further dilate the arteries. C. If one pill does not work, double the prescribed dose. D. Prior to sexual activity, apply cool compresses to the penis.

A. Seek medical intervention for erections lasting 3-4 hr.

What are the main effects of the gonadotropic hormones? Select all that apply. A. Stimulation of the formation of ova B. Stimulation of the secretion of hormones from sex organs C. Stimulation of the development of secondary female sexual characteristics D. Stimulation sustains pregnancy E. Stimulation of the hormone progesterone

A. Stimulation of the formation of ova B. Stimulation of the secretion of hormones from sex organs C. Stimulation of the development of secondary female sexual characteristics

A parent brings their 13-year-old son into the clinic and informs the nurse that they think something is wrong with their son. The parent states, "Every morning when I make his bed, there is a large wet spot on the sheet." What should the nurse discuss with the parent? A. The child is having normal nocturnal emissions caused most likely by hormone changes. B. The child may have regressed to a previous stage of development and started wetting the bed again. C. The child may have a urinary tract infection and should be checked. D. There may be some type of penile dysfunction that the physician will check.

A. The child is having normal nocturnal emissions caused most likely by hormone changes.

The nurse is caring for a geriatric client with a history of falls. While evaluating the client's risk of fall, the nurse should collect: A. gait and balance information. B. the agency's restraint policy. C. the family's psychosocial history. D. the client's dietary preferences.

A. gait and balance information.

The nurse observes a large amount of smoke and some flames coming from an unoccupied room in the hospital. After calling in the alarm, which action does the nurse take? A. Lock all of the doors so people cannot enter rooms. B. Open windows to let the smoke out of the room. C. Close all doors to confine smoke and fire. D. Take the elevator to the lowest floor in the hospital.

C. Close all doors to confine smoke and fire.

A client and their partner have been trying to conceive without results over the past 3 months. Which suggestion can the nurse make that is noninvasive and may increase the probability of success? A. Medications can be taken. B. It has only been 3 months, let nature take its course. C. Determine time of ovulation by checking basal body temperature. D. It is time to seek the advice of a fertility specialist.

C. Determine time of ovulation by checking basal body temperature.

A client is being treated for frostbite of the toes of both feet after exposure to severe cold. The provider has issued orders. What are the likely actions that the nurse will take in caring for this client? Select all that apply. A. Rubbing the client's toes to rewarm B. Loosening tight clothing from the client C. Separating the toes with cotton wedges D. Rewarming the toes with tepid water E. Covering the feet with hot towels

B. Loosening tight clothing from the client C. Separating the toes with cotton wedges D. Rewarming the toes with tepid water

A 13-year-old girl arrives in the clinic and informs the nurse that they just had their first menstrual period on April 23. Which documentation for this event is accurate? A. Onset of menstruation on April 23 B. Onset of menarche on April 23 C. Onset of menopause on April 23 D. Onset of puberty on April 23

B. Onset of menarche on April 23

A client is brought to the emergency department after ingesting a handful of unknown pills. Which action is the priority when collecting data on a suicidal client? A. Determining whether the client was trying to harm himself B. Determining whether the client had a support system C. Determining whether the client's physical condition is life-threatening D. Determining whether the client has a history of suicide attempts

C. Determining whether the client's physical condition is life-threatening

A nurse is preparing to administer an intramuscular (IM) injection. Immediately after administering the injection, what is the nurse's first action? A. Recap the needle and discard it in any medical waste container. B. Recap the needle and discard it in a puncture-proof container. C. Discard the uncapped needle in a puncture-proof container. D. Break the needle and discard the needle and syringe in any medical waste container.

C. Discard the uncapped needle in a puncture-proof container.

A client admitted to the psychiatric unit for treatment of repeated panic attacks comes to the nurses' station in obvious distress. After observing that the client is short of breath, dizzy, trembling, and nauseated, which action should the nurse first implement? A. Ask what the client is upset about B. Administer an antianxiety medication, as prescribed, and instruct the client to lie down in his room. C. Escort the client to a quiet area and suggest using a relaxation exercise that he or she has been taught. D. Reassure the client that the symptoms will disappear after he or she lies down and relaxes.

C. Escort the client to a quiet area and suggest using a relaxation exercise that he or she has been taught.

The nursing student is having difficulty obtaining a mobile computer for the purpose of administering medications using the electronic medical record. The student has been reprimanded for delivering medications late in the past and wants to ensure timely administration. What action should the student take? A. Print a copy of the medication record at the nurse's station to use at the bedside in order to administer the medications on time. B. Use the medication dispensing terminal to prepare the medications, and print a dispensing receipt to use for patient identification at the beside. C. Speak to the instructor about the unavailability of mobile computers for medication administration, and request assistance in obtaining one. D. Wait for a mobile computer to become available, and explain to the instructor that the reason for late administration was related to adhering to safety policy.

C. Speak to the instructor about the unavailability of mobile computers for medication administration, and request assistance in obtaining one.

While out of bed walking, a client reports dizziness and requests to go back to the room. The nurse obtains the blood pressure machine and obtains vital signs on the client. The client's pulse is 50 and the blood pressure machine reads 80/40 mmHg. The nurse notes the client is scheduled to receive verapamil and atenolol. Which actions by the nurse are best? Select all that apply. A. Give the medications and check vital signs later. B. Call the supervisor and ask what to do. C. Give the scheduled medications. D. Hold the medications. E. Call the healthcare provider and provide a report of the events and vital signs.

D. Hold the medications. E. Call the healthcare provider and provide a report of the events and vital signs.

A client experiences orthostatic hypotension while receiving furosemide to treat hypertension. How should the nurse intervene? A. Administer I.V. fluids as ordered. B. Administer a vasodilator as prescribed. C. Insert an indwelling urinary catheter as ordered. D. Instruct the client to flex the calf muscles and then sit up for several minutes before standing.

D. Instruct the client to flex the calf muscles and then sit up for several minutes before standing.

What should the nurse do to ensure a safe hospital environment for a toddler? A. Place the child in a youth bed. B. Move stacking toys out of reach. C. Pad the crib rails. D. Move the equipment out of reach.

D. Move the equipment out of reach.

The nurse reports a small fire in a trash can located in the break room. After obtaining a fire extinguisher, what is the initial action in using the extinguisher? A. Sweep across the base of the fire. B. Squeeze the handles together. C. Aim at the base of the fire, near the edge. D. Pull the pin of the fire extinguisher.

D. Pull the pin of the fire extinguisher.