QT 1
The nurse cares for a client receiving docusate 100 mg through a gastric tube. The solution contains 150 mg/15 mL. The nurse should administer how many mLs of the solution to the client?
10 mL
The health care provider orders hydromorphone hydrochloride 15 mg IM for a client. The nurse observes for which adverse effects? A. Photosensitivity and constipation. B. Hypotension and respiratory depression. C. Tardive dyskinesia and diplopia. D. Dry mouth and tinnitus.
B
The health care provider orders mannitol for the client with a closed head injury. Which response does the nurse recognize as desired to this medication? A. The blood pressure increases to 150/90. B. Urinary output increases to 175 mL/hour. C. There is a decrease in the level of activity. D. There is an absence of fine tremors of the fingers.
B
Which observation suggests to the nurse the client has developed an Addisonian crisis? A. Muscular weakness and fatigue. B. Restlessness and rapid, weak pulse. C. Dark pigmentation of the skin. D. Gastrointestinal disturbances and anorexia.
B
Which type of foods does the nurse encourage for the client diagnosed with hypoparathyroidism? A. Foods high in phosphorus. B. Foods high in calcium. C. Foods low in sodium. D. Foods low in potassium.
B
The parents of a child with hemophilia ask the nurse to explain the cause of the disease. Which response by the nurse is best? A. "Affected male inherits gene from the mother and can only transmit it to daughters" B. "Both the mother and the father carry a recessive trait." C. "The mother transmits the disease to her son." D. "There is a 50% chance that the mother will pass the trait to each of the daughters."
C
Which information does the nurse recognize as being the most pertinent to the diagnosis of cholecystitis? A. Flatulence. B. Nausea and vomiting. C. Right upper abdominal pain. D. Dyspepsia.
C
The middle-aged client is admitted to an inpatient psychiatric unit. The client reports a family member is trying to steal the client's property. The client is diagnosed with paranoid disorder. The nurse suspects the client is demonstrating which symptom? A. Delusions of persecution. B. Command hallucinations. C. Delusions of reference. D. Persecution hallucinations.
A
The nurse cares for the client with ataxia. Which action is most important? A. Supervise ambulation. B. Measure the intake and output accurately. C. Consult the speech therapist. D. Elevate the foot of the bed.
A
Several days after the delivery of a stillborn, the parents say, "We wish we could talk with other couples who have gone through this trauma." Which response by the nurse is best? A. "SIDS will provide you with this opportunity." B. "SHARE will provide you with this opportunity." C. "RESOLVE will provide you with this opportunity." D. "CANDLELIGHTERS will provide you with this opportunity."
B
The adolescent is brought to the hospital for treatment of deep partial thickness and full thickness burns sustained in a house fire. An intravenous infusion is started in the client's left forearm. The nurse identifies which reason as the primary purpose for the IV? A. Provide a route for pain medications. B. Maintain fluid balance. C. Prevent gastrointestinal upset. D. Obtain blood specimens for analysis.
B
The health care provider inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that which outcome is the primary purpose of the pacemaker? A. Increases the force of myocardial contraction. B. Increases the cardiac output. C. Prevents premature ventricular contractions (PVCs). D. Prevents systemic overload.
B
The nurse administers oral verapamil to a client. Which assessment does the nurse make before administering the medication? A. The client's electrolytes. B. The client's urine output. C. The client's weight. D. The client's heart rate.
D
Which symptoms alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness? Select all that apply. A. Tremors. B. Elevated temperature. C. Depression. D. Nocturnal leg cramps. E. Night sweats. F. Decreased concentration.
A, B, D
The nurse recognizes which symptoms are EARLY signs of lithium toxicity? Select all that apply. A. Fine motor tremors. B. Involuntary muscle movements. C. Seizures. D. Nausea and vomiting. E. Orthostatic hypotension. F. Diarrhea
A,D,F
The nurse cares for the client diagnosed with a pneumothorax resulting from a motor vehicle accident three days ago. The client has a chest tube connected to a three-chamber water-seal drainage system with 20 cm suction. The nurse determines the lung has re-expanded if which observation is made? A. There is no drainage in the collection chamber for 3 hours. B. The fluid in the water-seal chamber does not fluctuate with respirations. C. There is continuous bubbling in the water-seal chamber. D. There is gentle bubbling in the suction-control chamber.
B
The nurse cares for the postoperative client diagnosed with type 2 diabetes controlled with oral antihyperglycemic agents. The client asks why the health care provider ordered subcutaneous insulin injections after surgery. The nurse's response is based on knowing which physiological process? A. Tissue injury after surgery decreases blood glucose. B. Anesthesia acts to increase glycogen stores. C. Being NPO inhibits normal blood glucose control. D. Surgery often leads to insulin dependency.
C
The nurse is discussing growth and development with the parents of a 4-year-old child. The nurse identifies which type of play as characteristic of this age group? A. Solitary play. B. Parallel play. C. Associative play. D. Aggressive play.
C
The nurse knows that cortisol is responsible for which action? A. Preparing the body for "flight or fight." B. Regulating the calcium metabolism. C. Converting proteins and fat into glucose. D. Enhancing musculoskeletal activity.
C
The nurse on a psychiatric unit of the hospital declines the client's request to organize a party on the unit for the client's friends. The client becomes angry and uses abusive language toward the nurse. Which statement indicates the nurse has an understanding of the client's behavior? A. Allowing the client to use abusive language will undermine the authority of the nurse. B. Responding in kind to a client who uses abusive language will perpetuate the behavior. C. Abusive language is one of the behaviors symptomatic of the client's illness. D. The nurse should model acceptable behavior and language for all clients.
C
Which statement is documented by the nurse to reflect a client's emotional adjustment to being hospitalized in the intensive care unit? A. "The client is unable to complete activities of daily living without assistance." B."The client appears to be depressed and anxious regarding impending surgery." C. "The client constantly calls for nurses and cries uncontrollably." D. "The family is unable to visit more often than once a week because they live far away."
C
The 18-month-old is admitted to the unit with a diagnosis of laryngotracheobronchitis (LTB). During the initial assessment, the nurse expects to find which early symptoms? A. Kussmaul respirations and bradycardia. B. Elevated temperature and slow respiratory rate. C. Expiratory wheezing and substernal retractions. D. Inspiratory stridor and restlessness.
D
A client comes to the outpatient psychiatric unit for treatment of a fear of heights. The nurse knows that phobias include which behaviors? A. Projection and displacement B. Sublimation and internalization D. Rationalization and intellectualization E. Reaction formation and symbolization
A
The child is in the early stages of nephrotic syndrome. The nurse discusses which dietary change with the parents? A. Adequate protein, low sodium intake. B. Low protein, low potassium intake. C. Low potassium, low calorie intake. D. Limited protein, high carbohydrate intake.
A
The nurse knows that according to Erikson's stages of psychosocial development, which developmental stage best represent a 50-year-old client? A.Integrity versus despair and disgust. B. Generativity versus stagnation. C. Intimacy versus isolation. D. Identity versus role diffusion.
B
The nurse cares for the client receiving a blood transfusion for approximately 30 minutes. Which symptom indicates a severe allergic reaction is occurring? A. Bounding peripheral pulses. B. Chills. C. Respiratory wheezing. D. Lower back discomfort.
C
The nurse knows which mood-altering drug is most often associated with an increased risk for HIV infection related to intravenous drug use? A. Benzodiazepines. B. Marijuana. C. Barbiturates. D. Narcotics.
D
The nurse leads a parenting class for a group of expectant clients. How many extra calories a day does the nurse advise the clients to consume to support breastfeeding? A. 200 B. 300 C. 400 D. 500
D
The nurse supervises an LPN/LVN administering an enema to a client. The nurse determines the LPN/LVN's actions are appropriate if which action is observed? A. The LPN/LVN places the solution 20 inches above the anus. B. The LPN/LVN adjusts the temperature of the solution. C. The LPN/LVN inserts the tube 6 inches. D. The LPN/LVN positions the client left Sims' position.
D
Which action is the best way for the nurse to assess the fluid balance of an elderly client? A. Assess the client's blood pressure. B. Check the client's tissue turgor. C. Determine if the client is thirsty. D. Maintain an accurate intake and output.
D
The toddler diagnosed with lead poisoning is admitted to the pediatric unit. The health care provider writes an order to encourage fluids. Which fluid is best for the nurse to offer to the toddler? A. Milk. B. Water. C. Orange juice. D. Fruit punch.
A
The nurse cares for a 3-month-old infant scheduled for a barium swallow in the morning. Prior to the procedure, it is most appropriate for the nurse to take which action? A. Offer the infant only clear liquids. B. Make the infant NPO for 3 hours. C. Feed the infant regular formula. D. Maintain the infant NPO for 6 hours.
B
The adult client is preparing for a plasma cholesterol screening. Which instruction does the nurse give to the client? A. Eat a vegetarian diet for 1 week before the test. B. Limit alcohol intake to two glasses of wine the day before the test. C. Abstain from dairy products for 48 hours before the test. D. Only take sips of water for 12 hours before the test.
D
The nurse cares for the client receiving D5 0.45% NS 1,000 mL to run from 0900 to 1700. The drip factor on the delivery tubing is 20 gtt/mL. At what rate does the nurse set the IV to drip?
42 gtts/min 100 mL/8 hours = 125 mL/hr (125 mL/hr x 20 gtts/min)/60 min = 41.66 --> rounded bc not a pump!
At 32 weeks gestation, the client has an order for an ultrasound. The nurse determines that the client understands the procedure if the client makes which statement? A. The results will inform us of the baby's size. B. This test will evaluate the baby's lungs. C. The test will show us if there is any problem in the baby's genes. D. Early problems with the baby's blood can be identified with this test.
A
Prior to sending a client for a cardiac catheterization, it is most important for the nurse to report which information? A. The client has an allergy to shellfish. B. The client has diminished palpable peripheral pulses. C. The client has cool lower extremities bilaterally. D. The client is anxious about the pending procedure.
A
The client develops a postoperative infection and receives ceftriaxone sodium IV every day. It is most important for the nurse to monitor for which changes? A. The surface of the tongue. B. Hemoglobin and hematocrit. C. Skin surfaces in skin folds. D. Changes in urine characteristics.
A
The client is evaluated for infertility, and the health care provider prescribes clomiphene citrate 50 mg daily for 5 days. The client asks the nurse how the medication works. Which response by the nurse is best? A. Clomiphene citrate induces ovulation by changing hormonal effects on the ovary. B. Clomiphene citrate changes the uterine lining to be more conducive to implantation. C. Clomiphene citrate alters the vaginal pH to increase sperm motility. D. Clomiphene citrate produces multiple pregnancy for those who desire twins.
A
The home care nurse visits a new parent and a 2-week-old infant. The client asks the nurse which solid foods to give the child first. Which response does the nurse give? A. Rice cereal is usually the first solid food and is started around 4 to 5 months. B. Strained fruits are well tolerated as the first solid food, and infants like them. C. Introduction of solid foods is not important at this time. D. Solid foods are usually not started until the infant is around 6 months old.
A
The nurse cares for a client diagnosed with gastric reflux due to a hiatal hernia. The client asks the nurse why food and fluids should be withheld just before going to bed. Which response by the nurse is most appropriate? A."You are less likely to awaken during the night with heartburn if the stomach is empty." B. "Early-morning vomiting will be less of a problem if the stomach is empty." C. "Drinking or eating before lying down causes decreased respirations due to increased pressure on the lungs." D. "You may develop fluid overload if fluids are taken just before going to bed."
A
The nurse cares for the elderly client admitted with a possible fractured right hip. During the initial nursing assessment, which observation of the right leg validates this diagnosis? A. The leg appears to be shortened and is adducted and externally rotated. B. Plantar flexion is observed with sciatic pain radiating down the leg. C. From the hip, the leg appears to be longer and is externally rotated. D. There is evidence of paresis with decreased sensation and limited mobility.
A
The nurse prepares a teaching plan regarding colostomy irrigation. The nurse includes which information? A. The colostomy needs to be irrigated at the same time every day. B. Irrigate the colostomy after meals to increase peristalsis. C. Insert the catheter about 10 inches into the stoma. D. The solution should be very warm to increase dilation and flow.
A
The outpatient clinic nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for glucose and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which reason? A. The renal threshold for glucose is elevated in the elderly. B. Blood glucose monitoring is easier and less costly for clients to perform. C. Urine testing for glucose provides false-positive readings. D. Determination of the color on a reagent strip varies from person to person.
A
The nurse cares for an older client scheduled for a colon resection this morning. The nurse notes the client had polyethylene glycol-electrolyte solution and a soapsuds enema the previous evening. This morning the client passes a medium amount of soft brown stool. Which conclusion by the nurse is most accurate? A. The bowel preparation is incomplete. B. The client ate something after midnight. C. This is an expected finding before this type of surgery. D. The client passed the last stool left in the colon.
A *the patient should not have remaining soft stool
The health care provider writes an order for a stat dose of morphine 4 mg IV for pain. Three hours later the client again reports pain, and the nurse administers a second injection of morphine. Which best describes the nurse's liability? A. The nurse administered the medication appropriately; there is no liability. B. There is no order for a second dose of medication; the nurse is liable. C. The client was not injured; if injury did not occur, then the nurse is not liable. D. The nurse should have waited at least 4 hours; then there would be no liability.
B
The nurse cares for the newborn infant diagnosed with fetal alcohol syndrome. The nurse expects to see which characteristics? A. An infant large for gestational age (LGA), craniofacial abnormalities, and hydrocephalus. B. An infant with a small head circumference, low birth weight, and undeveloped cheekbones. C. An infant with a large head circumference, low birth weight, and excessive rooting and sucking behaviors. D. An infant with a normal head circumference, low birth weight, and respiratory distress syndrome.
B
The nurse cautions the client with hypothyroidism to avoid which implementation? A. Warm environmental temperatures. B. Narcotic sedatives. C. Increased physical exercise. D. A diet high in fiber.
B
The nurse identifies the primary reason for elderly adults to have problems with constipation is because of which process? A. Elderly adults eat a small volume of food with decreased bulk. B. Elderly adults engage in less activity and have decreased GI muscle tone. C. Elderly adults have neurological changes in the gastrointestinal tract. D. Elderly adults have decreased sensation in the gastrointestinal tract.
B
The nurse performs the Rinne test on a client. Which is an accurate statement of how the first part of this test is performed? A. The stem of a vibrating tuning fork is held against the auditory canal until the client indicates sound can no longer be heard. B. The stem of a vibrating tuning fork is held against the mastoid bone until the client indicates sound can no longer be heard. C. The stem of a vibrating tuning fork is held in the middle of the forehead, and the client's hearing is assessed in both ears. D. The stem of a vibrating tuning fork is positioned 2 inches behind the client's head, and the length of time sound is heard is documented.
B
The nurse prepares the adult client diagnosed with intellectual delay for discharge. The health care provider ordered warfarin sodium, 5 mg each day. To maintain client safety, which action does the nurse take first? A. Instructs the significant other about the medication regimen. B. Determines the client's comprehension of the medication administration. C. Prepackages the medication to encourage correct administration. D. Encourages a return demonstration of medication self-administration.
B
The nurse provides care for a client with a tracheostomy. Which is the priority nursing diagnosis for this client? A. Problem with verbal communication. B. Inadequate airway clearance. C. Possible skin integrity impairment. D. Acute pain.
B
The nurse cares for the prenatal client at 8 weeks gestation with a positive VDRL. When the nurse prepares the teaching plan, it is MOST important for the nurse to include which information? A. Advise the client not to take any over-the-counter medication B. Instruct the client on the importance of taking all the medications C. Inform the client to refrain from sexual activity D. Maintain the confidentiality of sexual partners or contacts
B (this is a test for syphilis)
The 6-month old is brought to the clinic for a well-baby check up. During the exam, the nurse expects to observe which assessment findings? **Select all that apply A. A pincer grasp B. Sitting with support C. Tripling of birth weight D. Presence of the posterior fontanelle E. Playing peek-a-boo F. Rolling from back to abdomen
B, E, F
A postoperative cataract client is cautioned about not making sudden movements or bending over. The nurse understands that the rationale for this recommendation is to prevent which complication? A. Impairment of cerebral blood flow and headaches. B. Increased intracranial pressure. C. Pressure on the ocular suture line. D. Displacement of the lens implant.
C
In the process of a normal adjustment to a terminal illness, the nurse knows that the client's initial denial and isolation will give way to the second stage. The second stage is characterized by which behavior? A. Acceptance. B. Bargaining. C. Anger. D. Depression.
C
The 7-year-old child is seen in the clinic with a diagnosis of pituitary dwarfism. Which clinical manifestation is the nurse MOST likely to observe? A. Abnormal body proportions. B. Early sexual maturation. C.Delicate features. D. Coarse, dry skin.
C
The client had a kidney transplant yesterday, and the client's adult child has come to visit. The nurse instructs the adult child to take which action? A. No special actions are necessary. B. Wear a double mask and gloves. C. Perform good hand washing. D. Wear a gown and a mask.
C
The client in labor is monitored with an internal fetal monitor. The nurse knows which is the most important reason for the fetal monitor? A. To evaluate the progress of the client's labor. B. To assess the strength and duration of the client's contractions. C. To monitor the oxygen status of the fetus during labor. D. To determine if an oxytocin drip is necessary.
C
The client, gravida 2 para 1, is admitted with hypertension. The client reports her wedding band is tight. The nurse assesses for which indications of mild pre-eclampsia? A. Blurred vision and proteinuria. B. Epigastric pain and headache. C. Facial swelling and proteinuria. D. Polyuria and hypertonic reflexes.
C
The health care provider orders naproxen sodium for the elderly client. The nurse assesses the client for which symptoms? A. Stomatitis and photosensitivity. B. Bradycardia and dry mouth. C. Fluid retention and dizziness. D. Gynecomastia and impotence.
C
The nurse cares for a client receiving chlorpromazine. The nurse notes the client is restless, unable to sit still, and reports insomnia and fine tremors of the hands. Which does the nurse identify as the best explanation for these symptoms occurring? A. An adverse effect of the medication that will disappear as time passes. B. The reason the client is receiving this medication. C. Extrapyramidal adverse effects resulting from this medication. D. An indication the dosage of the medication needs to be increased.
C
The nurse cares for the child diagnosed with pediculosis capitis (head lice) who is being treated with permethrin 1% cream rinse. The nurse includes which information when instructing the child's parents? A. Apply the cream rinse every other day for 1 week. B. Wash the child's clothing and personal belongings in soap and cool water. C. Repeat the application of the cream rinse in 7 days if nits are still present. D. Comb the child's hair weekly with a nit comb.
C
The nurse prepares the older client for an intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response is based on which explanation? A. The health care provider is able to directly observe the kidney pelvis. B. An IVP assesses the glomerular filtration rate. C. The health care provider is able to examine the urinary tract by x-ray. D. Medication is injected into the urinary system.
C
The nursing team consists of an RN who has been practicing for 6 months, an LPN/LVN who has been practicing for 15 years, and a nursing assistive personnel who has been caring for clients for 3 years. The RN cares for which client? A. The client 1 day postop after an internal fixation of a fractured left femur. B. The client receiving diltiazem and phenytoin. C. The client ordered to receive two units of packed cells. D. The client admitted yesterday with exhaustion and a diagnosis of acute bipolar disorder.
C
The parent of a child with chickenpox asks the clinic nurse why the child will not come down with chickenpox again if exposed to the virus at school at a later date. Which explanation does the nurse give? A. Natural passive immunity occurs because the child receives antibodies from outside the body. B. Artificial active immunity occurs because the child receives specific antigens against the chickenpox virus. C. Natural active immunity occurs because the child's body actively makes antibodies against the chickenpox virus. D. Artificial passive immunity occurs because of the inflammatory process of chickenpox.
C
Which is most important for the rehabilitation nurse to assess during a new client's admission? A. The client's expectations of family members. B. The client's understanding of available supportive services. C. The client's personal goals for rehabilitation. D. The client's past experiences in the hospital.
C
A client with an endotracheal tube requires suctioning. Which is an accurate description of how the nurse performs this procedure? A. Inserts the suction catheter 4 in into the tube. Applies suction for 30 seconds, using a twirling motion as the catheter is withdrawn. B. Hyperoxygenate the client. Inserts the suction catheter into the tube, and suctions while removing the catheter in a back and forth motion. C. Explains the procedure to the client. Inserts the catheter gently while applying suction, and withdraws using a twisting motion. D. Inserts the suction catheter until resistance is met, and then withdraws it slightly. Applies suction intermittently as the catheter is withdrawn.
D
The nurse cares for clients in a drug rehabilitation facility. Which complication of IV drug abuse is the nurse most likely to observe? A. Jaundice. B. Rash. C. Bruising. D. Cellulitis.
D
The nurse cares for the client diagnosed with type 1 diabetes reporting decreased vision. The client asks the nurse what caused the visual changes. The nurse's response is based on which statement? A. The client's decreased vision is caused by bleeding into the inner ocular chamber of the eye. B. The client's decreased vision is caused by gradual separation of the retina from the base of the eye. C. The client's decreased vision is caused by an increase in the size of the vessels in the back of the eye. D. The client's decreased vision is caused by gradual destruction and degeneration of the retina.
D
The nurse collects the following data: anger directed by client toward staff in the form of frequent sarcastic or crude comments, increased wringing of hands, and purposeless pacing, particularly after the client has used the telephone. On the basis of the data, the nurse makes which nursing diagnosis? A. Social interaction impairment. B. Potential activity intolerance. C. Powerlessness. D. Difficulty with coping.
D
The nurse identifies which finding has the greatest impact on the elderly client's ability to complete activities of daily living (ADLs)? A. Perseveration. B. Aphasia. C. Mnemonic disturbance. D. Apraxia.
D
The nurse performs range-of-motion (ROM) exercises for an elderly client recently immobilized. The nurse identifies which statement as correct about range-of-motion? A. Passive ROM exercises increase muscle strength B. A full ROM must be completed for the elderly client. C. Exercises should be completed to the point of discomfort. D. ROM assists the elderly to carry out activities of daily living (ADLs).
D
The nurse cares for the client admitted with a diagnosis of a stroke and facial paralysis. Nursing care is planned to prevent which complication? A. Inability to talk. B. Loss of the gag reflex. C. Inability to open the affected eye. D. Corneal abrasion.
D *client will be unable to close eye voluntarily; when facial nerve (cranial nerve VII) is affected, the lacrimal gland will no longer supply secretions that protect the eye
