Readiness

The nurse plans care for a client admitted with fever, vomiting, and diarrhea. Which laboratory value demonstrates an improvement in the client's condition? 1. Specific gravity of urine 1.020 and hematocrit 42%. 2. Specific gravity of urine 1.039 and hematocrit 50%. 3. Specific gravity of urine 1.010 and hematocrit 52%. 4. Specific gravity of urine 1.030 and hematocrit 35%.

1. Specific gravity of urine 1.020 and hematocrit 42%.

A man diagnosed with a stroke develops dysphagia. Before allowing the client to eat, which action should the nurse take FIRST? 1. Place client in semi-Fowler's position. 2. Auscultate bowel sounds. 3. Check client's gag reflex. 4. Offer to cut client's food.

3. Check client's gag reflex.

The nurse cares for a client diagnosed with depression. Which statement by the client indicates improvement? 1. "I have been sleeping 6 hours at night." 2. "I have lost 2 lbs in the past week." 3. "Lately, I have trouble watching television." 4. "I have much less muscle tension now."

1. "I have been sleeping 6 hours at night."

A 12-year-old diagnosed boy with a fractured right femur is placed in balanced suspension traction with a Thomas splint and Pearson attachment. The nurse is MOST concerned by which client statement? 1. "I will experience more muscle spasms and pain while my leg is in traction." 2. "I can lift my body up while I grab the overhead trapeze and bend my left leg." 3. "The health care provider told me it is okay to move the head of my bed up and down by myself." 4. "I need to put the phone where I can reach for it without moving onto my side."

1. "I will experience more muscle spasms and pain while my leg is in traction."

The nurse teaches a client with a spinal cord injury how to perform self-catheterization at home. Which statement, if made by the client, indicates that teaching has been successful? 1. "I will keep the catheter in a plastic bag." 2. "I will catheterize myself every 2 hours." 3. "I will wear sterile gloves." 4. "I will wash the perineum with alcohol prior to catheterizing myself."

1. "I will keep the catheter in a plastic bag."

The husband of an elderly client who is incontinent asks the nurse whether his wife will have to wear diapers. Which response, if made by the nurse, is MOST appropriate? 1. "Let's discuss your specific concerns about your wife." 2. "Have you tried any type of incontinence pads in the past?" 3. "Let's wait and see if incontinence pads are necessary." 4. "There are many brands of adult diapers available for you to try."

1. "Let's discuss your specific concerns about your wife."

The husband of a woman at 39 weeks gestation calls the clinic nurse and states, "My wife's water just broke, and I think she's going to have the baby!" Which statement, if made by the nurse, is BEST? 1. "Look at your wife's vaginal area and tell me what you see." 2. "Time the contractions for 5 minutes." 3. "Tell your wife to pant between contractions." 4. "I will instruct you about how to deliver the baby."

1. "Look at your wife's vaginal area and tell me what you see."

The nurse prepares to assign a client requiring a capillary blood glucose test to a newly hired nursing assistive personnel. Which action should the nurse take FIRST? 1. "Show me how you check a capillary glucose level." 2. "How many of these glucose checks have you done in the past?" 3. "Would you like for me to go with you when you do the glucose test?" 4. "Was this procedure covered during your nursing assistive personnel class?"

1. "Show me how you check a capillary glucose level."

The nurse plans care for a 42-year-old man receiving disulfiram (Antabuse). Which of the following statements requires an IMMEDIATE intervention by the nurse? 1. "This medication will prevent me from drinking alcohol." 2. "I should not take cough syrup preparations while taking Antabuse." 3. "If I discontinue the Antabuse, I should not consume alcohol for 2 weeks." 4. "Even small amounts of alcohol may cause nausea, vomiting, and headache."

1. "This medication will prevent me from drinking alcohol."

The nurse makes a follow-up phone call to the family of an infant receiving treatment for watery diarrhea after 7 days of amoxicillin (Amoxil) therapy. The nurse knows teaching is successful if the family makes which statement? 1. "We wear a fresh pair of clean gloves with each diaper change." 2. "We are not allowing our other children to be in the same room with the baby." 3. The grandmother wears a mask when changing the baby's diaper. 4. The mother wears an apron when changing the baby's diaper.

1. "We wear a fresh pair of clean gloves with each diaper change."

The home care nurse makes an initial visit to an 80-year-old client. The client's daughter states that her mother has a history of colon cancer and has been restless and confused for about a week. It is MOST important for the nurse to obtain an answer to which question? 1. "What medication is your mother taking?" 2. "Is there a family history of diabetes?" 3. "Describe your mother's usual diet." 4. "Does your mother complain of difficulty urinating?"

1. "What medication is your mother taking?"

A 50-year-old woman with a history of alcohol abuse is treated in the emergency room for acute alcohol intoxication. It would be MOST important for the nurse to obtain the answer to which question? 1. "When did you have your last drink?" 2. "How much alcohol have you consumed?" 3. "Have you ever used drinking in the morning to get rid of a hangover?" 4. "How many drinks do you need before you feel high?"

1. "When did you have your last drink?"

Levodopa (L-Dopa) is prescribed for a 61-year-old woman. Which statement, if made by the client to the nurse, would indicate that the client needs further instruction? 1. "While I take this medication, I should eat a high-protein diet." 2. "I should change positions slowly at first so I don't get dizzy." 3. "If I have muscle twitching, I should report it to my health care provider." 4. "I should check with my health care provider before taking any over-the-counter medications."

1. "While I take this medication, I should eat a high-protein diet."

A man scheduled for a vasectomy tells the nurse that he and his wife are involved in a monogamous relationship. Which statement by the nurse is BEST? 1. "You will need to wear a condom when having sexual intercourse for 6 weeks following the vasectomy." 2. "No other form of birth control is necessary for you or your wife at this time." 3. "You do not need to wear a condom when having sexual intercourse for the next few weeks, but your wife should use spermicidal jelly." 4. "Always wear a condom when having sexual intercourse because not all vasectomies are successful."

1. "You will need to wear a condom when having sexual intercourse for 6 weeks following the vasectomy."

A client is prescribed prednisone and asks about possible adverse effects. The nurse teaches the client about which common adverse effects of prednisone? Select all that apply 1. (1.) Osteoporosis. 2. (2.) Decreased white count. 3. (3.) Low blood sugar. 4. (4.) Low serum potassium. 5. (5.) Retinal detachment. 6. (6.) Fluid retention

1. (1.) Osteoporosis. 4. (4.) Low serum potassium. 6. (6.) Fluid retention

The nurse presents a class on herbal medications at a community health care seminar. Which statement should be included in the class? Select all that apply 1. (1.) The potency of herbal preparations varies between manufacturers. 2. (2.) The FDA tests and regulates herbal preparations. 3. (3.) Herbal preparations are classified as dietary supplements. 4. (4.) Ma huang contains ephedra and can be dangerous for people with high blood pressure. 5. (5.) Herbal preparations are used in the treatment of immune system dysfunction.

1. (1.) The potency of herbal preparations varies between manufacturers. 3. (3.) Herbal preparations are classified as dietary supplements. 4. (4.) Ma huang contains ephedra and can be dangerous for people with high blood pressure.

The nurse on the maternity unit must accept a transfer client from a medical/surgical unit. The nurse considers which transfer client appropriate? 1. A 38-year-old client with a diagnosis of systemic lupus erythematosus. 2. A 45-year-old client receiving daily external radiation therapy treatments for breast cancer. 3. A 58-year-old client receiving antibiotic treatment for cellulitis of the left leg. 4. A 74-year-old client who has received intravenous antibiotics for 7 days.

1. A 38-year-old client with a diagnosis of systemic lupus erythematosus.

A nurse from the surgical floor is reassigned to the pediatric unit. Which of the following client assignment is MOST appropriate for this nurse? 1. A 5-month-old infant after a cast application on the left extremity due to club foot. 2. A 4-year-old boy with right abdominal swelling and a decreased appetite. 3. A 6-year-old boy admitted with cystic fibrosis and a temperature of 101.5 F (38.68 C). 4. A 10-year-old girl with newly diagnosed type 1 diabetes.

1. A 5-month-old infant after a cast application on the left extremity due to club foot.

The nurse identifies which client is at risk to develop metabolic acidosis? Select all that apply 1. (1.) A client diagnosed with type 1 diabetes mellitus. 2. (2.) A client diagnosed with salicylate toxicity. 3. (3.) A client diagnosed with bilateral bacterial pneumonia. 4. (4.) A client diagnosed with acute renal failure. 5. (5.) A client diagnosed with continuous nasogastric drainage. 6. (6.) A client diagnosed with severe diarrhea.

1. A client diagnosed with type 1 diabetes mellitus. 2. A client diagnosed with salicylate toxicity. 6. A client diagnosed with severe diarrhea.

A woman with a diagnosis of Alzheimer's disease is admitted to the hospital for treatment of an upper respiratory tract infection. On admission, she is incontinent of urine. When assigning the client to a room on the nursing unit, which location would be BEST? 1. A semi-private room near the nurse's station. 2. A private room near the nurse's station. 3. A private room away from the nurse's station. 4. A semi-private room away from the nurse's station.

1. A semi-private room near the nurse's station.

The nurse is caring for clients in the pediatric clinic. Which of the following clients should the nurse see FIRST? 1. An 8-month-old infant who had 6 watery stools in the past 8 hours. 2. A 13-month-old infant who received the MMR immunization 8 days ago and has a temperature of 101° F (38.3° C). 3. A 2-year-old child who has swelling, pain, and tenderness of the upper arm after falling off a chair. 4. An 8-year-old discharged from the hospital 2 days ago for asthma.

1. An 8-month-old infant who had 6 watery stools in the past 8 hours.

The nurse cares for a client 4 hours after admission to the neuroscience unit due to a closed-head injury. Which is the MOST important action for the nurse to take? 1. Assess pupil shape and reactivity. 2. Take the client's rectal temperature. 3. Assess blood pressure and apical heart rate. 4. Observe the client's oxygen saturation level.

1. Assess pupil shape and reactivity.

A woman is admitted to the hospital complaining of diarrhea and vomiting for 3 days. The blood pressure is 90/60, apical heart rate 96, and respiratory rate 22 with shallow respirations. Laboratory results include Na+ 147 mEq/L, K+ 5.6 mEq/L, hematocrit 52%, hemoglobin 14 g/dL. The client is receiving 5% dextrose in 0.45% normal saline with K+ 20 mEq at 125 mL/hr. Prior to calling the healthcare provider, it is MOST important for the nurse to take which of these actions? 1. Change IV fluids to 5% dextrose in 0.45% normal saline. 2. Increase IV flow rate to 150 mL/hour. 3. Check the hourly urine output. 4. Observe the client for muscle weakness.

1. Change IV fluids to 5% dextrose in 0.45% normal saline.

On the third day after a thyroidectomy, the nurse notes that the client has developed tremors. Which of the following is the MOST appropriate action for the nurse to take? 1. Check the client's calcium level. 2. Check the client's glucose level. 3. Check the client's potassium level. 4. Check the client's sodium level.

1. Check the client's calcium level.

A man is returned to his room in stable condition after a transurethral prostatectomy (TURP). He has continuous bladder irrigation through a 3-way urinary drainage catheter with a 30-mL balloon tip. Tension has been applied to the catheter. The client reports that he feels pressure in his bladder and rectum, and feels as though he has to urinate. Which action should the nurse take FIRST? 1. Check the patency of the catheter. 2. Assess residual urine volume using bladder ultrasonography. 3. Assess the amount of drainage in the urinary drainage bag. 4. Decrease the tension on the catheter.

1. Check the patency of the catheter.

A 22-year-old woman at term comes to the hospital in labor. Two hours after admission, the client remains 4 centimeters dilated, and her contractions are weak. The healthcare provider orders oxytocin (Pitocin). Which finding would require an intervention by the nurse? 1. Contractions every 2 minutes, lasting 90 seconds. 2. Contractions every 3-4 minutes, lasting 60 seconds. 3. Fetal heart rate of 110 beats per minute at the peak of a contraction. 4. Fetal heart rate of 158 bpm at the end of a contraction.

1. Contractions every 2 minutes, lasting 90 seconds.

A client contaminated with an unidentified hazardous material arrives by ambulance at a local hospital. Which action should the nurse take FIRST? 1. Determine the decontamination that occurred in the field. 2. Reassure the client that he will receive excellent care. 3. Identify the type of hazardous material. 4. Remove all the client's clothing.

1. Determine the decontamination that occurred in the field.

The health care provider (HCP) provider orders hydralazine 25 mg IM on call for a client before surgery. The LPN/LVN administers hydroxyzine 25 mg IM to the client. Which of the following is the MOST appropriate action for the nurse to take? 1. Document "Hydralazine 25 mg ordered; hydroxyzine 25 mg given; HCP notified; blood pressure 130/84; pulse 86; respiration 12." 2. Document "Hydroxyzine 25 mg given; hydralazine 25 mg ordered; HCP notified; vital signs stable." 3. Document "Hydroxyzine 25 mg mistakenly given; hydralazine 25 mg ordered." 4. Document "Hydroxyzine 25 mg given; incident report completed."

1. Document "Hydralazine 25 mg ordered; hydroxyzine 25 mg given; HCP notified; blood pressure 130/84; pulse 86; respiration 12."

Heparin 5,000 units subcutaneously is ordered every 12 hours for a client. The result of the client's most recent PTT is 55 seconds. Which action by the nurse is MOST appropriate? 1. Document the result and administer the heparin. 2. Withhold the heparin. 3. Notify the healthcare provider. 4. Have the test repeated.

1. Document the result and administer the heparin.

The nurse cares for a client during a 24-hour urine specimen collection. Several hours later, the client tells the nurse that she has started to menstruate. Which action by the nurse is MOST appropriate? 1. Inform the health care provider that the client is menstruating. 2. Send the urine collected prior to the onset of the client's menstruation to the lab. 3. Insert an indwelling bladder catheter during the remainder of the collection period. 4. Request a separate urine collection container from the laboratory to be used during the remainder of the urine collection period.

1. Inform the health care provider that the client is menstruating.

The nurse cares for a client 72 hours after a right-below-knee amputation. Which is the MOST important action for the nurse to take? 1. Lay the client prone for 25 minutes every 3-4 hours. 2. Dangle the client's residual limb over the side of the bed. 3. Abduct the client's residual limb by placing pillows between the legs. 4. Elevate the client's residual limb on a pillow.

1. Lay the client prone for 25 minutes every 3-4 hours.

The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the following is the MOST appropriate action for the nurse to take? 1. Leave the cuff inflated and suction through the tracheostomy. 2. Deflate the cuff and suction through the tracheostomy tube. 3. Inflate the cuff pressure to 40 mm Hg before suctioning. 4. Adjust the wall suction pressure to 160 to 180 mm Hg before suctioning.

1. Leave the cuff inflated and suction through the tracheostomy.

The nurse teaches a client about foods and beverages that may be consumed on a low- sodium diet. Which beverage, if selected by the client, indicates an understanding of the instructions? 1. Lemonade. 2. Skim milk. 3. Ginger ale. 4. Tomato juice.

1. Lemonade.

The home care nurse visits a client who had a traditional cholecystectomy 10 days ago. The client returned to the healthcare provider to have the T-tube removed 2 days ago. It is MOST important for the nurse to take which action? 1. Observe the color of the client's urine and stool. 2. Ask the client to describe the quality and quantity of pain she is experiencing. 3. Instruct the client to avoid fatty foods for 6 weeks. 4. Listen to bowel sounds.

1. Observe the color of the client's urine and stool.

The nurse assesses the IV site before administering vancomycin. The nurse notes that the area around the IV infusion site is pale and feels cool. Which INITIAL action will the nurse perform? 1. Remove the intravenous catheter and elevate the arm on 1 or 2 pillows. 2. Begin the vancomycin infusion and reassess the infusion site in 15 minutes. 3. Withhold the vancomycin infusion and notify the healthcare provider. 4. Apply warm, moist compresses to the infusion site for 30 minutes and then administer the medication.

1. Remove the intravenous catheter and elevate the arm on 1 or 2 pillows.

The home care nurse is visiting an alert, oriented woman living with her daughter. The client is malnourished and has multiple bruises on her body, and the situation is reported to the appropriate authority. After counseling the client and daughter, the nurse notes the situation has not improved. The client decides to remain with her daughter. Which action, if taken by the nurse, is MOST appropriate? 1. Respect the client's decision to stay in her daughter's home. 2. Insist the client move in with her other child. 3. Begin guardianship procedures. 4. Place live-in help in the home.

1. Respect the client's decision to stay in her daughter's home.

A client returns to the unit following a thyroidectomy. Which assessment finding requires an intervention by the nurse? 1. The client makes noises when breathing. 2. The client reports pain at the surgical site. 3. The client asks for liquids to drink. 4. The client is sleepy from anesthesia.

1. The client makes noises when breathing.

In preparation for a total laryngectomy, the nurse teaches a client how to support his neck after surgery. Which of the following demonstrations by the client indicates to the nurse that teaching is successful? 1. The client raises the elbows and places the hands behind the neck. 2. The client places one hand on the forehead and the other hand on the back of the head. 3. The client covers the ears with both hands and presses firmly. 4. The client grasps the chin with one hand and places the other hand on the forehead.

1. The client raises the elbows and places the hands behind the neck.

A client with an 8-year history of ulcerative colitis is admitted to the hospital with severe abdominal cramping and diarrhea. The client has experienced 18 to 20 stools a day for the last 4 days. The nurse is MOST concerned by which finding? 1. The client's diastolic blood pressure decreases 20 mm when the client rises to a standing position. 2. The client's urinary specific gravity is 1.020. 3. The client has lost 3 pounds since her last admission. 4. The client appears pale and thin.

1. The client's diastolic blood pressure decreases 20 mm when the client rises to a standing position.

The nurse observes a student nurse examine a client's chest. Which action requires an intervention by the nurse? 1. The student nurse auscultates heart sounds and then palpates for tactile fremitus. 2. The student nurse uses the diaphragm of the stethoscope to listen to heart sounds. 3. The student nurse places the stethoscope firmly against the skin surface. 4. The student nurse inspects the chest before performing palpation.

1. The student nurse auscultates heart sounds and then palpates for tactile fremitus.

The nurse observes a student nurse caring for a client with a tracheostomy and humidified oxygen. Which of the following actions taken by the student nurse requires an intervention by the nurse? 1. The student nurse sets the wall suction to 160 mm Hg pressure prior to suctioning. 2. The student nurse increases the oxygen level to 100% prior to suctioning. 3. The student nurse uses a catheter half the size of the tracheostomy opening. 4. The student nurse tells the client to breathe normally as the catheter is inserted.

1. The student nurse sets the wall suction to 160 mm Hg pressure prior to suctioning.

The nurse teaches a client who is lactose-intolerant about some alternative ways to maintain an adequate diet. The nurse will suggest the client include which food items in the diet? 1. Tofu and green leafy vegetables. 2. Beef and tomato salad. 3. Cottage cheese and yogurt. 4. Custard and mashed potatoes.

1. Tofu and green leafy vegetables.

A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which finding BEST indicates improving fluid status? 1. Urinary output of 1,500 mL in 24 hours. 2. Serum hematocrit 52%. 3. Oral fluid intake of 900 mL in 24 hours. 4. Blood pressure of 100/82.

1. Urinary output of 1,500 mL in 24 hours.

An LPN/LVN informs the nurse that aspirin 325 mg was given to a client even though 80 mg aspirin had been ordered once daily. The LPN/LVN asks the nurse if it is necessary to complete a medication-error form since "no harm was done." Which statement, if made by the nurse, is BEST? 1. "What do you mean, "no harm was done"? 2. "A medication-error form must be completed whenever the wrong preparation of a medication is given." 3. "I will call the health care provider and ask what should be done to deal with this error." 4. "It is not necessary to complete an incident report with over-the-counter medications."

2. "A medication-error form must be completed whenever the wrong preparation of a medication is given."

A 25-year-old multigravida client, 22 weeks gestation, calls to inform the clinic nurse that she was exposed to rubella 2 days ago. Which statement, if made by the nurse, is MOST appropriate? 1. "You need to see the health care provider today, but come in after hours." 2. "Come in this afternoon for your regularly scheduled appointment." 3. "You will receive the rubella vaccine during your regularly scheduled appointment." 4. "Please cancel today's appointment and reschedule for next month."

2. "Come in this afternoon for your regularly scheduled appointment."

A 60-year-old client comes to the outclient clinic to receive the influenza vaccine. Which of the following questions, if asked by the nurse, is BEST? 1. "Have you had the flu in the past month?" 2. "Do you have any food allergies?" 3. "Has anyone in your family been sick?" 4. "Are you allergic to any medication?"

2. "Do you have any food allergies?"

The nurse plans care for a 4-year-old girl who has been sexually abused by her grandfather. Play therapy is scheduled as part of the treatment plan. Which statement, if made by the child's parents, indicates understanding of the primary purpose of play therapy? 1. "The main goal of play therapy is for our child to deal with any anger that she has." 2. "During these play sessions, our child will be encouraged to communicate at her own level." 3. "Our child's developmental level will be evaluated by a child development specialist during these sessions." 4. "The main purpose of play therapy is to determine exactly what type of abuse occurred."

2. "During these play sessions, our child will be encouraged to communicate at her own level."

The nurse cares for the client diagnosed with schizophrenia. Which question is MOST important for the nurse to ask the client's spouse? 1. "Have you noticed loud talking and excessive restlessness lately?" 2. "Has your spouse seemed withdrawn and less responsive to you during the last few weeks?" 3. "How would you describe your spouse's daily consumption of alcohol?" 4. "Does your spouse appear to have lost weight recently?"

2. "Has your spouse seemed withdrawn and less responsive to you during the last few weeks?"

The nurse cares for a client with Addison's disease who is taking 20 mg hydrocortisone (Cortef) daily. Which statement by the client requires an intervention by the nurse? 1. "I will need to have my blood sugar levels checked while on this medication." 2. "I may have episodes of low blood pressure while taking this medication." 3. "I need to weigh myself twice a week and keep a record of my weight." 4. "I should notify my health care provider if I am running a fever."

2. "I may have episodes of low blood pressure while taking this medication."

The nurse teaches a client who had an above-knee amputation (AKA) 2 days ago about how to care for the residual limb. Which statement, if made by the client, indicates to the nurse that the teaching is effective? 1. "I shall apply cream to the residual limb to soften the skin." 2. "I should rewrap my residual limb with elastic bandages 3 times a day." 3. "I will not be able to sleep on my stomach from now on." 4. "I will no longer be able to sit in straight back chairs at home."

2. "I should rewrap my residual limb with elastic bandages 3 times a day."

The nurse cares for a client scheduled for a femoral popliteal bypass procedure. When the nurse approaches the client with the informed consent form, the client says, "I don't need to talk to anybody about this procedure. I already know everything I need to know about it." Which response by the nurse is BEST? 1. "After I explain the operation to you, both of us will sign the form for legal purposes and it will be placed in your chart." 2. "Tell me what the healthcare provider told you about the risks and benefits of this operation." 3. "Can I answer any questions that you have about the procedure?" 4. "You should read all these materials to be sure that you understand everything about this procedure."

2. "Tell me what the healthcare provider told you about the risks and benefits of this operation."

The nurse observes a man standing with his adult children after the unexpected death of his wife. Which statement by the nurse is MOST appropriate? 1. "I'm sorry about your wife. I'm sure you will miss her." 2. "This must be a difficult time for you; I will stay with you." 3. "I know you're going to miss your wife; would you like to talk about some memories you both shared?" 4. "Is there anything I can get for you?"

2. "This must be a difficult time for you; I will stay with you."

The nurse cares for a client with chronic renal failure who has an arteriovenous fistula in the left arm. Which of the following should be included in the care of the client? Select all that apply 1. (1.) Assess and compare blood pressure in both arms. 2. (2.) Auscultate for "whooshing" sound over the fistula. 3. (3.) Palpate for warmth and tenderness over the area of the fistula. 4. (4.) Instruct the client to avoid getting the left arm wet. 5. (5.) Instruct the client to sleep with the left arm in the dependent position. 6. (6.) Instruct the client to avoid carrying heavy objects with the left arm.

2. (2.) Auscultate for "whooshing" sound over the fistula. 3. (3.) Palpate for warmth and tenderness over the area of the fistula. 6. (6.) Instruct the client to avoid carrying heavy objects with the left arm.

The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the morning. Which medication should the nurse question giving to the client? 1. 20 mg oral escitalopram (Celexa) in the morning. 2. 40 mg oral furosemide (Lasix) in the morning. 3. 300 mg of oral gabapentin (Neurontin) twice daily. 4. 10 mg zolpidem (Ambien) at bedtime.

2. 40 mg oral furosemide (Lasix) in the morning.

The nurse cares for clients in the antepartum clinic. Which client should the nurse see FIRST? 1. An 18-year-old multigravida client at 28 weeks gestation with a positive indirect Coombs' test. 2. A 24-year-old multigravida client at 32 weeks gestation with moderate facial edema. 3. A 30-year-old client at 26 weeks gestation with bilateral yellow breast exudate. 4. A 43-year-old primigravida client at 18 weeks of gestation reporting an absence of fetal movement.

2. A 24-year-old multigravida client at 32 weeks gestation with moderate facial edema.

The healthcare provider orders furosemide (Lasix) and spironolactone (Aldactone). Prior to administering Lasix and Aldactone, the nurse determines that the client's potassium level is 3.2 mEq/L. Which is the MOST important action for the nurse to take? 1. Hold the furosemide and spironolactone. 2. Administer only the spironolactone. 3. Administer only the furosemide. 4. Administer the furosemide and spironolactone.

2. Administer only the spironolactone.

The nurse cares for a client with a history of type 1 diabetes mellitus who has just returned to the surgical acute-care unit after a right below-knee amputation. The client's capillary blood glucose is 480 mg/dL. The postoperative orders indicate 6 units of regular insulin subcutaneously should be administered. Which of the following is the FIRST action the nurse should take? 1. Check the client records to see if insulin was given prior to surgery. 2. Administer the 6 units of regular insulin subcutaneously. 3. Administer the insulin when oral fluids are tolerated. 4. Contact the healthcare provider.

2. Administer the 6 units of regular insulin subcutaneously.

A client with a history of gastroesophageal reflux disease reports difficulty sleeping at night. Which of the following is a PRIORITY action for the nurse to take? 1. Instruct the client to drink 8 ounces of milk at bedtime. 2. Advise the client to use 2 pillows at night. 3. Instruct the client to limit fat intake during the day. 4. Advise the client to lie down after the evening meal.

2. Advise the client to use 2 pillows at night.

A client is brought to the clinic by the spouse. The client's lab results are Na+ 156 mEq/L, Cl- 100 mEq/L, K+ 4.0 mEq/L, BUN 86 mg/dL, glucose 100 mg/dL. Which is the MOST appropriate action for the nurse to take? 1. Assess for muscle weakness and dysrhythmias. 2. Assess for confusion and tachycardia. 3. Check for peripheral edema and lung crackles. 4. Determine if muscular twitching and muscle weakness are present.

2. Assess for confusion and tachycardia.

A young adult brings a friend to the emergency department and states that the friend has been using heroin. Which action by the nurse is the MOST appropriate? 1. Assess pupil size and reactivity. 2. Assess oxygen saturation levels. 3. Palpate dorsalis pedis pulses. 4. Ask the client if he knows today's date.

2. Assess oxygen saturation levels.

The nurse cares for a client in the cardiac care unit who had cardiopulmonary arrest 2 hours ago and was successfully resuscitated by emergency personnel. As the nurse enters the room, the client develops ventricular fibrillation and is unresponsive to loud spoken voice. Which of the following is the INITIAL action the nurse should take? 1. Ventilate the client with a manual resuscitator bag. 2. Defibrillate the client. 3. Administer sodium bicarbonate intravenously. 4. Begin chest compressions.

2. Defibrillate the client.

The healthcare provider has ordered a fenestrated tracheostomy tube to be capped. Which is the MOST important action for the nurse to take before the tracheostomy tube is plugged? 1. Administer 100% oxygen. 2. Deflate the cuff of the tracheostomy tube. 3. Suction the tracheostomy tube. 4. Administer humidified oxygen.

2. Deflate the cuff of the tracheostomy tube.

The nurse prioritizes the needs of a client who has been raped. Which nursing action is MOST important? 1. Observe the client for withdrawn, tearful behavior. 2. Determine if the client sustained any injuries. 3. Obtain information about events which preceded the rape. 4. Accurately document the client's comments about the rape.

2. Determine if the client sustained any injuries.

A woman delivers a 6-lb and 2-oz infant. The Apgar scores at 1 and 5 minutes are 8 and 9, respectively. Which action is MOST appropriate for the nurse to take? 1. Perform nasopharyngeal suctioning. 2. Document the Apgar score. 3. Administer O2 per mask. 4. Rub the infant's back.

2. Document the Apgar score.

The nurse cares for the client immediately after an ileostomy procedure. Which is the best INITIAL action for the nurse to take during client teaching? 1. Schedule the teaching demonstrations during family visits. 2. Encourage the client to discuss any concerns and to ask questions. 3. Show a video demonstrating ileostomy care. 4. Perform care for the ileostomy until the client is able to do it herself.

2. Encourage the client to discuss any concerns and to ask questions.

The nurse cares for a client who had a Roux-en-Y gastric bypass procedure 4 hours ago. The client's vital signs are blood pressure 92/68, apical heart rate 112 per minute, and respiratory rate 22 per minute. Which order should the nurse question? 1. 0.9% sodium chloride water infusion at 150 mL/hour. 2. Epinephrine (Adrenalin) 1 mg bolus intravenously. 3. Monitor urinary output hourly for 24 hours. 4. 50 mL 25% albumin (human) 50 mL intravenously.

2. Epinephrine (Adrenalin) 1 mg bolus intravenously.

The nurse enters a client's room and discovers the client is having difficulty breathing because the tracheostomy tube has become dislodged. Which is the INITIAL action the nurse should take? 1. Perform mouth-to-stoma breathing. 2. Extend the client's neck. 3. Place the client in high-Fowler's position. 4. Administer oxygen.

2. Extend the client's neck.

The nurse cares for an elderly man diagnosed with Alzheimer's disease. It is MOST important for the nurse to take which action? 1. Leave the television on all day in the client's room. 2. Frequently inform the client of the room and bathroom location. 3. Provide the client with newspapers and magazines. 4. Assign a staff member to check on the client every 15 minutes.

2. Frequently inform the client of the room and bathroom location.

At 7 A.M., the nurse administers 10 mg glipizide (Glucotrol XL) to a 75-year-old client. At 11 A.M., the nurse notes that the client is drowsy, pale, and has cold, clammy skin. Which is the INITIAL action the nurse will take? 1. Administer 1 mg glucagon subcutaneously. 2. Give the client 1 cup of fruit juice to drink. 3. Determine if the client ate breakfast. 4. Notify the healthcare provider.

2. Give the client 1 cup of fruit juice to drink.

A 26-year-old woman comes to the emergency room for a possible ruptured ectopic pregnancy. On admission, the client's vital signs are pulse 90, blood pressure 110/70, respirations 20. A half-hour later, her vital signs are pulse 120, blood pressure 86/50, respirations 26. Which of the following is the MOST appropriate initial action for the nurse to take? 1. Administer pain medication. 2. Increase the rate of the IV fluids. 3. Ask the client to identify where she is. 4. Check the client's white cell count.

2. Increase the rate of the IV fluids.

The nurse feeds the client in a chair when the client suddenly begins to choke on food. The client is conscious but unable to speak. Which action is MOST appropriate for the nurse to take? 1. Encourage the client to cough and breathe deeply. 2. Leave the client in the chair and apply vigorous abdominal or chest thrusts from behind. 3. Return the client to the bed and apply vigorous abdominal or chest thrusts while straddling the client's thighs. 4. Apply several vigorous back blows until the food dislodges.

2. Leave the client in the chair and apply vigorous abdominal or chest thrusts from behind.

A femoral angiogram is scheduled for a client. It is MOST important for the nurse to take which action prior to the angiogram? 1. Clean and shave the catheter insertion-site area. 2. Locate and note the presence of peripheral pulses. 3. Encourage the client to increase oral fluid intake. 4. Teach coughing and deep-breathing exercises.

2. Locate and note the presence of peripheral pulses.

A mother brings her 15-month-old infant to the pediatric clinic for immunizations. The mother tells the nurse that the infant has been diagnosed with cancer and is being treated with chemotherapy. The nurse should question the administration of immunization? 1. Hepatitis B (HB). 2. Measles/mumps/rubella (MMR). 3. Inactivated polio (IPV). 4. Diphtheria, tetanus toxoid, and acellular pertussis (DTaP).

2. Measles/mumps/rubella (MMR).

The nurse prepares to administer gentamicin (Garamycin) to the 65-year-old client. Which is the MOST important action for the nurse to take prior to administration of the medication? 1. Request a daily hemoglobin and hematocrit test. 2. Monitor the serum BUN and creatinine. 3. Request a highly-sensitive C-reactive protein (hs-CRP) test. 4. Monitor the erythrocyte sedimentation rate (ESR).

2. Monitor the serum BUN and creatinine.

A child in a new plaster walking cast has dusky, swollen toes. Which action by the nurse is MOST appropriate? 1. Get Doppler studies to check the pulse. 2. Notify the healthcare provider. 3. Determine if the cast is dry. 4. Check the client's vital signs.

2. Notify the healthcare provider.

Haloperidol (Haldol) 5 mg IM every 4 hours PRN is prescribed for a client. Which observation requires an IMMEDIATE intervention by the nurse? 1. Patient reports dizziness; heart rate 58 beats per minute. 2. Patient has tongue protrusion and muscle rigidity. 3. Patient has a facial rash and periorbital edema. 4. Patient reports sensitivity to light and blurred vision.

2. Patient has tongue protrusion and muscle rigidity.

A client with suspected active tuberculosis is scheduled for a chest x-ray. Which action, if taken by the nurse, is MOST appropriate? 1. Instruct the staff transporting the client to wear a gown and mask. 2. Place a face mask on the client. 3. Request that the x-ray be postponed. 4. Give the client an emesis basin and tissues.

2. Place a face mask on the client.

The nurse cares for a client after a lumbar laminectomy. Which action by the nurse is MOST important? 1. Elevate the head of the bed 30° and then turn the client. 2. Place a pillow between the client's legs and then turn the client. 3. Have the client grasp the side rail on the opposite side of the bed and then assist the client to turn. 4. Instruct the client to bend the knees and then assist the client to turn.

2. Place a pillow between the client's legs and then turn the client.

While playing on the floor in the hospital room, a 2-year-old has a tonic-clonic seizure. Which action should the nurse take FIRST? 1. Begin oxygen at 2 liters per minute through a nasal cannula. 2. Place a pillow under the client's head. 3. Administer diazepam (Diastat) 5 mg rectally. 4. Turn the client to the side.

2. Place a pillow under the client's head.

The nurse observes a peer self-administering fentanyl (Sublimaze) after removing it from the narcotic cabinet. Which is the MOST appropriate action for the nurse to take? 1. Tell the nurse what was observed. 2. Report the observation to the supervisor. 3. Complete an incident report. 4. Discuss the incident with another nurse.

2. Report the observation to the supervisor.

The nurse cares for a 24-year-old female client admitted to an inclient treatment unit with a diagnosis of purging-type bulimia. It is MOST important for the nurse to take which action? 1. Encourage the client to verbalize feelings about eating disorders. 2. Sit with the client in silence as she discusses her daily life and eating habits. 3. Ask the family to describe the client's eating habits prior to admission. 4. Ask the client about any emotional distress she may be experiencing.

2. Sit with the client in silence as she discusses her daily life and eating habits.

The nurse cares for the client diagnosed with lung cancer. The family states that the client has become confused and that urinary output has decreased during the previous 24 hours. Which finding MOST concerns the nurse? 1. 2+ pitting pretibial edema. 2. Sodium 128 mEq/L. 3. Weight gain of 2 kg in 24 hours. 4. Urine specific gravity 1.008.

2. Sodium 128 mEq/L.

A 52-year-old homeless woman is admitted to the psychiatric unit for treatment of chronic schizophrenia. The nursing assistive personnel reports to the nurse that when attempting to bathe the client, the client became uncooperative and demanded coffee and a snack. Which suggestion will the nurse give to the nursing assistive personnel? 1. Remind the client that too much caffeine is bad for her health. 2. Tell the client that she may have coffee and a snack when her bath is complete. 3. Remove the client from the bath and return her to bed. 4. Get help from other staff members to complete the bath.

2. Tell the client that she may have coffee and a snack when her bath is complete.

A client had a right kidney transplant 1 week ago. Which symptom, if experienced by the client, indicates to the nurse that the client is experiencing rejection? 1. The client complains of generalized muscle weakness. 2. The client complains of diffuse pain over the right abdomen. 3. The client gets up twice each night to void. 4. The client has lost 3 pounds.

2. The client complains of diffuse pain over the right abdomen.

The home care nurse visits a client diagnosed with Parkinson's disease. The nurse is MOST concerned if which of the following is observed? 1. The client has soft, monotonous speech. 2. The client is drooling. 3. The client rolls the left thumb against the fingers. 4. The client ambulates with a stooped posture.

2. The client is drooling.

The nurse cares for the client in the recovery room after a knee surgery procedure. The client has an oral airway in place. Which is the BEST indicator that the oral airway can be removed? 1. The client has a forceful cough during repositioning. 2. The client tries to chew on the oral airway. 3. The client tries to push the airway out with his tongue. 4. The client is able to swallow.

2. The client tries to chew on the oral airway.

The nurse is caring for an elderly client receiving total parenteral nutrition (TPN) due to malnutrition. Which observation, if made by the nurse, indicates that the client is improving? 1. The client gains 8 lbs in one week. 2. The client's edema decreases. 3. The client's hemoglobin increases. 4. The client's output is greater than the intake.

2. The client's edema decreases.

An adolescent is admitted to the hospital with a diagnosis of bacterial meningitis. Which of the following actions, if observed by the nurse, would require an intervention? 1. The LPN/LVN enters the client's room and leaves the door open. 2. The nursing assistive personnel leaves the client's room with the face mask hanging from the neck. 3. The student nurse washes hands and puts on gloves. 4. The client's mother stands away from the client while talking to the client.

2. The nursing assistive personnel leaves the client's room with the face mask hanging from the neck.

The nurse receives a phone call from the mother of a 10-year old child taking methylphenidate (Ritalin) daily. The mother reports the child has lost 2 pounds in the last 2 weeks. Which is the MOST appropriate response by the nurse? 1. "How much does your child exercise on a daily basis?" 2. "Stop giving the Ritalin for several days to see if the appetite improves." 3. "At what time do you give your child the Ritalin medication?" 4. "What is your child's bedtime and when does he usually awaken?"

3. "At what time do you give your child the Ritalin medication?"

The nurse describes to a male client how to collect a clean-catch urine for culture and sensitivity. Which explanation, if made by the nurse, is MOST accurate? 1. "The urinary meatus is cleansed with an antiseptic solution, and then a urinary drainage catheter is inserted to obtain urine." 2. "You will be asked to empty your bladder one half-hour before the test; you will then be asked to void into a container." 3. "Before voiding, the urinary meatus is cleansed with an antiseptic solution; urine is then voided into a sterile container; the container must not touch the penis." 4. "You must void a few drops of urine, and then stop; then void the remaining urine into a clean container which should be immediately covered."

3. "Before voiding, the urinary meatus is cleansed with an antiseptic solution; urine is then voided into a sterile container; the container must not touch the penis."

The client tells the clinic nurse that the client is thinking about using nicotine polacrilex (Nicorette). Which question is MOST important for the nurse to ask? 1. "Have you tried other methods to stop smoking?" 2. "How long have you been smoking?" 3. "Have you ever had chest pain?" 4. "Do you have a partial dental bridge?"

3. "Have you ever had chest pain?"

A client is admitted to a medical unit with a diagnosis of pneunocystis jiroveci pneumonia. A nurse from another client care area asks the nurse caring for this client about the client's condition. Which is the MOST appropriate statement for the nurse to make? 1. "I will give a brief report on the client's condition in private." 2. "You can get an update by reading the client's chart." 3. "I cannot discuss this client's condition with you." 4. "Why do you want to know about this client's condition?"

3. "I cannot discuss this client's condition with you."

The home care nurse visits a client with a halo fixator traction device. Which client statement MOST concerns the nurse? 1. "My wife looks at the pin sites every day." 2. "I like to bathe in the tub." 3. "I drove to the library yesterday." 4. "I drink with a straw."

3. "I drove to the library yesterday."

The nurse teaches elderly residents of an assisted-living facility about wellness and health promotion. The nurse is MOST concerned about which statement by one of the residents? 1. "My health care provider tells me I may need the chickenpox vaccine." 2. "I get my flu shot every year in November at a local pharmacy." 3. "I got a pneumonia vaccine about 10 years ago." 4. "The last time I got an injection in my arm, it felt hot and swollen for a day."

3. "I got a pneumonia vaccine about 10 years ago."

The nurse instructs a client about include digoxin (Lanoxin), furosemide (Lasix), spironolactone (Aldactone), and a low-sodium diet. Which statement by the client indicates the need for further instruction? 1. "I should weigh myself every morning and call the health care provider if I gain more than a couple of pounds in a few days." 2. "I should call the health care provider immediately if I start to feel nauseated or have difficulty breathing with normal activities." 3. "I plan to use salt substitutes now that I have to limit my sodium intake." 4. "I should read food and nonprescription medication labels to check the ingredients."

3. "I plan to use salt substitutes now that I have to limit my sodium intake."

The nurse teaches a client about how to care for an ileostomy. Which comment, if made by the client to the nurse, indicates further teaching is needed? 1. "The skin around the stoma should be cleaned with warm water and thoroughly dried." 2. "The appliance should fit snugly around the ileostomy opening." 3. "I should take polyethylene glycol (MiraLax) with a large glass of water." 4. "I will continue to take a daily multi-vitamin."

3. "I should take polyethylene glycol (MiraLax) with a large glass of water."

A news reporter and camera person arrive on the nursing unit to videotape an interview of a client. When the nurse refuses their request, the reporter references his First Amendment rights. Which statement, if made by the nurse, is MOST appropriate? 1. "Why do you want to talk with the client?" 2. "I'll ask the client if he is ready to speak with you." 3. "I will need to call the nurse manager about your request." 4. "Does the client know that you are coming?"

3. "I will need to call the nurse manager about your request."

The parents of a newborn boy ask the nurse whether they should have their son circumcised. Which response by the nurse is MOST appropriate? 1. "The benefits of the procedure usually outweigh the risks of bleeding and infection." 2. "You should ask your obstetrician or pediatrician to advise you." 3. "It is not mandatory that your son have a circumcision. What are your concerns?" 4. "Some parents worry about the pain associated with circumcision, but there is actually very little discomfort."

3. "It is not mandatory that your son have a circumcision. What are your concerns?"

The nurse is called to the bathroom of a woman who delivered an 8 lb 4 oz male 12 hours ago. The nurse notes that there is blood running down the client's leg. Which statement, if made by the nurse, is BEST? 1. "Leave your perineal pad in the bathroom so I can evaluate the lochia." 2. "Why don't you go back to bed so you can rest?" 3. "Let me help you back to bed so I can check your fundus." 4. "Sit in this chair so I can check your blood pressure."

3. "Let me help you back to bed so I can check your fundus."

The home care nurse observes an elderly woman on a low-sodium diet eating a dill pickle that her son gave her with lunch. Which response by the nurse is MOST appropriate? 1. "Giving your mother salty food will only make her condition worse." 2. "Didn't your mother tell you she's on a low-sodium diet?" 3. "Tell me what you know about your mother's diet." 4. "Let's make an appointment for you to meet with a dietician."

3. "Tell me what you know about your mother's diet."

The school nurse teaches accident-prevention to the parents of school-aged children. Which statement, if made by a parent to the nurse, indicates teaching is effective? 1. "I'm going to make sure my child wears a helmet, shin guards, and gloves when he rides his bike." 2. "I keep my guns and ammunition in a locked cabinet in the basement." 3. "The next time we go to the park, I'm going to teach my child the correct way to climb on the monkey bars." 4. "I'm going to make sure my wife and I observe our child when he plays outside with friends."

3. "The next time we go to the park, I'm going to teach my child the correct way to climb on the monkey bars."

The nurse cares for clients in a mental health center. The nurse observes the client, formerly homeless and malnourished, diagnosed with chronic schizophrenia putting food from lunch into a plastic bag. Which statement by the nurse is MOST appropriate? 1. "We don't allow people to take food from the dining room." 2. "What are you going to do with the food?" 3. "We will be serving snacks and juice at 3 P.M." 4. "Let's go watch a movie with the others."

3. "We will be serving snacks and juice at 3 P.M."

The home care nurse cares for a client who is diagnosed with hypertension and mild depression. The client's daughter states that her mother has been falling frequently. WWhich response by the nurse is BEST? 1. "Let's get your mother a walker." 2. "Do you think it's time to put your mother in a nursing home?" 3. "When does your mother fall?" 4. "Does your mother seem to be more confused lately?"

3. "When does your mother fall?"

One afternoon in the hospital day room, the nurse overhears a woman with chronic schizophrenia say to another other client, "I hate you, get away from me or I'll kill you." Which of the following responses, if made by the nurse, is MOST appropriate? 1. "I will not let that client hurt you." 2. "There is no reason for you to be angry with that client." 3. "You seem to be frightened by that client." 4. "You don't really want to kill that client."

3. "You seem to be frightened by that client."

The nurse teaches the client how to perform a colostomy irrigation. During the teaching, the client states, "I can't do this." Which response, if made by the nurse, is BEST? 1. "Sure you can do this. You just need to have more practice." 2. "I'll do it for you this time, but you must perform the irrigation the next time." 3. "You seem to be frustrated. What are your specific concerns?" 4. "Most of the other clients learn this without any difficulty. Let's try it again."

3. "You seem to be frustrated. What are your specific concerns?"

The nurse reviews medications with a 35-year-old female. The client takes 200 mg carbamazepine (Tegretol) orally twice daily. The client asks the nurse about future pregnancies. Which statement by the nurse is MOST appropriate? 1. "If you take 5 mg folic acid daily while trying to conceive, you should be able to get pregnant." 2. "It is recommended that you take carbamazepine suspension instead of the tablets when trying to get pregnant." 3. "You should contact your health care provider and discuss your concerns about pregnancy." 4. "If you avoid drinking grapefruit juice, there should be no problem with conception."

3. "You should contact your health care provider and discuss your concerns about pregnancy."

The nurse is responsible for triage of injured residents of an apartment building that collapsed during a tornado. Which client should the emergency personnel see FIRST? 1. A 38-year-old client with potential fracture left femur. Blood pressure 110/78, pulse 92/minute, shallow respirations at 16/minute. 2. A 42-year-old client with ecchymotic areas on the left anterior and posterior chest. Blood pressure 142/90, pulse 88/minute, shallow respirations at 20/minute. 3. A 48-year-old client with severe head trauma. Blood pressure 168/52, pulse 58 per minute, irregular respirations at 12/minute. 4. A 64-year-old client complaining of left hand and wrist pain asking, "Where am I?" Blood pressure 128/72, pulse 88/minute, respirations unlabored at 16/minute.

3. A 48-year-old client with severe head trauma. Blood pressure 168/52, pulse 58 per minute, irregular respirations at 12/minute.

The home health nurse is planning client visits for the day. Which of the following clients should the nurse see FIRST? 1. A 70-year-old diabetic with fasting blood glucose readings of 240-260 mg/dL for 1 week. 2. A 65-year-old discharged from the hospital 2 days ago following coronary artery bypass graft surgery (CABG). 3. A 55-year-old with congestive heart failure who gained 3 lbs in the last 24 hours. 4. A 40-year-old with metastatic breast cancer complaining of pain unrelieved by pain medication.

3. A 55-year-old with congestive heart failure who gained 3 lbs in the last 24 hours.

The nursing team consists of one RN, one LPN/LVN and two nursing assistive personnel (NAPs). Which assignment is MOST appropriate for the LPN/LVN? 1. A 38-year-old client diagnosed with Guillain-Barré syndrome receiving plasmapheresis therapy. 2. A 72-year-old client admitted yesterday with a 10-day history of oral antibiotic therapy and a 24-hour history of watery diarrhea. 3. A 78-year-old client diagnosed with a thrombotic cerebrovascular accident 5 days ago. 4. A 86-year-old client just admitted with malaise, a productive cough, and WBC 17,000 mm3.

3. A 78-year-old client diagnosed with a thrombotic cerebrovascular accident 5 days ago.

A registered nurse from a surgical floor is reassigned to a medical unit. Which of the assignment is MOST appropriate for this nurse? 1. A client with type 1 diabetes mellitus scheduled for discharge at 2 P.M. 2. A client admitted 4 hours ago with a diagnosis of myocardial infarction. 3. A client with Alzheimer's disease who requires a tube feeding. 4. A client admitted yesterday with a diagnosis of left-sided cerebral vascular accident.

3. A client with Alzheimer's disease who requires a tube feeding.

A nurse is performing triage in the emergency department. Which of the following clients should the nurse see FIRST? 1. A client with an open fracture of the left femur. BP 110/60, P 86, R 20, T 99.2° F (37.3° C). 2. A client complaining of a "crushing" headache. BP 160/ 100, P 76, R 18, T 98.4° F (36.9° C). 3. A client with burns on the face, chest, and hands. BP 120/80, P 100, R 24, T 98.8° F (37° C). 4. A client with type 1 diabetes. Blood sugar 480 mg/dL. BP 100/60, P 100, R 26, T 99.4° F (37.4° C).

3. A client with burns on the face, chest, and hands. BP 120/80, P 100, R 24, T 98.8° F (37° C).

The nurse reviews room assignments for 4 clients admitted to the unit. The nurse should question which room assignment? 1. A child with chickenpox placed in a private room at the end of the hall. 2. A child with meningitis placed in a private room across from the nurses' station. 3. A client with cellulitis of the right leg placed in a semi-private room with a client diagnosed with type 1 diabetes. 4. A client with essential hypertension placed in a semi-private room with a client who has pancreatitis.

3. A client with cellulitis of the right leg placed in a semi-private room with a client diagnosed with type 1 diabetes.

The nurse assesses the fetal monitor of a client in labor. Which fetal heart rate pattern requires an intervention by the nurse? 1. A baseline rate of 140-150 between contractions with moderate variability. 2. Consistent heart rate accelerations that coincide with fetal movements. 3. A heart rate that slows following the peak of the contraction and returns to baseline after the contraction ends. 4. Gradual slowing of the heart rate that begins with the onset of the contraction and returns quickly to the baseline.

3. A heart rate that slows following the peak of the contraction and returns to baseline after the contraction ends.

A nurse is presented with a group of clients in the emergency room. The nurse knows that which of the following clients needs immediate attention? 1. A child who is bleeding from a facial injury. 2. A middle-aged client with midsternal chest pain. 3. A middle-aged client in respiratory distress. 4. An infant who has been vomiting for 8 hours.

3. A middle-aged client in respiratory distress.

The client with with a 5-year history of alcohol abuse is treated in the emergency room for acute alcohol intoxication. The client is agitated and verbally abusive. Admission orders include chlordiazepoxide (Librium) 50 mg IM or PO every 4-6 hours for agitation. Which action by the nurse is MOST appropriate? 1. Place the client in chest restraints. 2. Assist the client to the bathroom every 2 hours. 3. Assign a licensed practical nurse to stay with the client. 4. Administer disulfram (Antabuse) 500 mg every 12 hours.

3. Assign a licensed practical nurse to stay with the client.

The nurse cares for a client in active labor. The client's membranes rupture spontaneously at 6 centimeters of dilation. Which action actions should the nurse take FIRST? 1. Check the fetal monitor. 2. Place the client on her right side. 3. Auscultate fetal heart rate. 4. Check the client's heart rate and blood pressure.

3. Auscultate fetal heart rate.

The nurse cares for the client 3 days after a stroke. It is MOST important for the nurse to take which action? 1. Instruct the client to push with the feet while moving client up in bed. 2. Offer the client soft foods on request. 3. Auscultate the client's lungs every 4 hours. 4. Observe the client's legs for warm, reddened, and tender areas every 4 hours.

3. Auscultate the client's lungs every 4 hours.

The nurse cares for a client 4 hours after admission to the hospital for treatment of an anterior wall myocardial infarction. The client suddenly reports difficulty breathing and appears very anxious. Which action should the nurse take FIRST? 1. Evaluate the client's cardiac rhythm. 2. Check for cyanosis of the hands and the toes. 3. Auscultate the client's posterior lung fields. 4. Listen to the apical heart rate.

3. Auscultate the client's posterior lung fields.

The nurse cares for a client diagnosed with Crohn's disease. The nurse instructs the client about diet. Which menu selection indicates to the nurse that teaching is effective? 1. Cheeseburger on a whole-wheat bun, french fries, and an apple. 2. Tomato soup, saltines, and a slice of unfrosted angel food cake. 3. Baked cod, biscuit without butter, fruit roll-up. 4. Macaroni and cheese, coleslaw, 2 macaroon cookies.

3. Baked cod, biscuit without butter, fruit roll-up.

The nurse is caring for an elderly client admitted for type 1 diabetes mellitus. The nurse notes that the client appears to have difficulty understanding what is said. Which of the following actions, if taken by the nurse, is MOST appropriate? 1. Ask the client if cotton-tipped applicators are used for ear cleaning. 2. Perform the Weber hearing test. 3. Check the client's ear canals for cerumen. 4. Use facial expressions and speak in a high frequency tone of voice.

3. Check the client's ear canals for cerumen.

A 42-year-old woman has a right mastectomy for treatment of breast cancer. The client is returned to her room with a Hemovac drain. Which of the following is the MOST important action for the nurse to take? 1. Open the drain port to provide an air vent. 2. Tape the collection chamber to the client's bed. 3. Compress the evacuator completely after emptying it. 4. Empty the collection chamber every 2 hours.

3. Compress the evacuator completely after emptying it.

The nurse cares for a client diagnosed with chronic bronchitis and peripheral vascular disease. The nurse expects to assess which of these breath sounds? 1. Continuous, high-pitched musical sounds heard on expiration. 2. Soft, high-pitched interrupted sounds heard on inspiration. 3. Deep, low-pitched rumbling sounds are heard mainly on expiration. 4. Harsh, grating sounds heard best during inspiration.

3. Deep, low-pitched rumbling sounds are heard mainly on expiration.

A 56-year-old man is scheduled for an MRI (magnetic resonance imaging). His history indicates that he suffered an injury during the Vietnam War. Which question is MOST important for the nurse to ask the client? 1. Where was your injury? 2. When were you wounded? 3. Did your injury involve shrapnel? 4. Were you exposed to chemical warfare?

3. Did your injury involve shrapnel?

A 25-year-old woman is admitted to the labor unit for delivery of her first child. Her husband is coaching her during labor. During the transitional phase of labor, the client begins to scream and grab the side rails with each contraction. Which action, if taken by the nurse, is MOST effective? 1. Offer the client pain medication before her next contraction. 2. Assist the client to a side-lying position with her knees flexed and a pillow between her legs. 3. Establish eye contact with the client and breathe with her. 4. Suggest to the client that she watch television between contractions.

3. Establish eye contact with the client and breathe with her.

A child sustains a crushing chest injury in a car accident. In the emergency room, an endotracheal tube is inserted. Several hours later the nurse enters the client's room and finds the child in respiratory distress. It is MOST important for the nurse to take which action prior to the angiogram? 1. Observe the color of the client's fingernail beds. 2. Assess the client's blood pressure in both arms. 3. Listen to the client's breath sounds. 4. Assess for intercostal retractions.

3. Listen to the client's breath sounds.

The nurse cares for a client who returned 4 hours ago after a subtotal thyroidectomy procedure. The nurse notes that the client sounds more hoarse when speaking than he did 1 hour ago. Which of the following is the MOST appropriate action for the nurse to take? 1. Check the gag and swallow reflex. 2. Instruct the client to chew small amounts of ice chips. 3. Notify the healthcare provider. 4. Instruct the client to cough and breathe deeply every 15 minutes.

3. Notify the healthcare provider.

A mother brings her 2-month-old infant to the emergency room. The mother states that her daughter has an elevated temperature and "hasn't kept anything down since yesterday." Which nursing action is MOST appropriate? 1. Administer 0.9% NaCl at 30 mL/hour. 2. Inquire if the child was delivered prematurely. 3. Offer the infant 4 oz of oral rehydration solution (ORS). 4. Ask if the child's older siblings have been ill.

3. Offer the infant 4 oz of oral rehydration solution (ORS).

A client is admitted to the hospital with a diagnosis of chronic bronchitis. Which action should the nurse take FIRST? 1. Weigh the client. 2. Place cardiac telemetry leads. 3. Place pulse oximetry on finger. 4. Obtain a sputum specimen

3. Place pulse oximetry on finger.

The nurse cares for a client diagnosed with a complete spinal cord injury 12 weeks ago due to compression fractures of the 5th and 6th cervical vertebrae. The client reports a sudden onset of sweating and has a flushed face and chest. Which action should the nurse take FIRST? 1. Perform a digital rectal examination. 2. Check the color and temperature of the extremities. 3. Place the client in high-Fowler's position. 4. Administer hydralazine (Apresoline) 20 mg intravenously.

3. Place the client in high-Fowler's position.

A pregnant woman receives an epidural anesthetic. After administration of the epidural anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse is MOST appropriate? 1. Place the client flat on her back. 2. Elevate the head of the bed 30 degrees. 3. Place the client on her left side with her legs flexed. 4. Place the client supine with the foot of the bed elevated.

3. Place the client on her left side with her legs flexed

A client is brought to the mental health center reporting severe headaches, insomnia, and poor appetite. Each time a question is asked, the client provides a lengthy, detailed description of events. Which of the following is the MOST important action for the nurse to take? 1. Remind the client of the time. 2. Tell the client that people are there to take care of her. 3. Sit and listen to the client. 4. Ask the client to be brief.

3. Sit and listen to the client.

A unit of packed cells is ordered for a client who has an intravenous infusion of dextrose 5% in water in progress. Which of the following is the MOST important action for the nurse to take? 1. Connect the packed red blood cells to the dextrose infusion. 2. Remove the dextrose infusion and replace it with the packed red cells. 3. Start a separate infusion of normal saline and use a "Y" connector to infuse the blood. 4. Start an infusion of lactated Ringer's solution and use a "Y" connector to infuse the blood.

3. Start a separate infusion of normal saline and use a "Y" connector to infuse the blood.

The nurse supervises care of clients on a postoperative surgical unit. Which of the following requires an immediate intervention by the nurse? 1. The nursing assistive personnel (NAP) obtains vital signs on a client who had a bowel resection 24 hours ago. 2. The NAP assists a client who had an above-the-knee amputation apply an elastic bandage to the residual limb. 3. The NAP assists a client who had a stroke 3 days ago with feeding. 4. The NAP assists a client who had a laparoscopic cholecystectomy 6 hours ago ambulate.

3. The NAP assists a client who had a stroke 3 days ago with feeding.

Based on the nurse's knowledge of the goal of diuretic therapy for a client with heart failure, which assessment BEST indicates that the client's condition is improving? 1. The client's weight has decreased 2 pounds. 2. The client's systolic blood pressure has decreased. 3. The client has fewer crackles heard during auscultation. 4. The client's urinary output has increased.

3. The client has fewer crackles heard during auscultation.

The nurse cares for clients on an acute-care surgical area. Which client should the nurse see FIRST? 1. The LPN/LVN reports that a client who had a thoracotomy 2 days ago has clots in the chest drainage system. 2. The nursing assistive personnel reports that a client who had a thyroidectomy 24 hours ago refuses to ambulate 30 minutes after receiving hydrocodone (Vicoden). 3. The family of a client who had a small bowel resection 48 hours ago reports the client is more confused than yesterday. 4. A client who had an ileostomy 3 days ago complains of "aching legs."

3. The family of a client who had a small bowel resection 48 hours ago reports the client is more confused than yesterday.

The nurse cares for a client with suspected subarachnoid hemorrhage who had a bilateral carotid angiogram 2 hours ago. Which finding requires an intervention by the nurse? 1. The client requests a large glass of water. 2. The client lies quietly in bed with a cloth placed over the forehead and eyes. 3. The head of the bed is elevated 30° and the client's legs are bent at the knee. 4. The urine specific gravity is 1.025.

3. The head of the bed is elevated 30° and the client's legs are bent at the knee.

The nurse cares for a client with suspected Neisseria meningitidis infection. Which action is MOST important for the nurse to take? 1. Wear a gown when entering the room. 2. Place the client in a negative-pressure isolation room. 3. Wear a face mask while assisting the client with activities of daily living. 4. Wash hands with soap and water for 3 to 4 minutes when exiting the room.

3. Wear a face mask while assisting the client with activities of daily living.

A 7-year-old boy is brought to the emergency room by his mother following a fall from his bicycle. X-ray reveals healed fractures of the ribs. The child's mother states, "My son is such a careless child; he's always having accidents or fights with his brother." Which response by the nurse would be MOST appropriate? 1. "When I document information about these injuries, it will be on your son's hospital record forever." 2. "How would you describe your son's relationship with his brothers and sisters?" 3. "What I see suggests that someone has been abusing your son." 2. "Come in this afternoon for your regularly scheduled appointment."

4. "Come in this afternoon for your regularly scheduled appointment."

A client calls the healthcare provider's office reporting a rash, intermittent fever, headache, fatigue, muscle pain, and stiff neck. It is MOST important for the nurse to ask which question? 1. "Have you ever felt this way before?" 2. "Have you noticed any swollen areas on your neck?" 3. "Have you recently noticed any flea bites?" 4. "Have you noticed any tick bites recently?"

4. "Have you noticed any tick bites recently?"

An elderly woman is being seen by the home care nurse following a partial gastrectomy for cancer. Which statement, if made by the client, requires further teaching? 1. "The healthcare provider told me to come in once a month for vitamin B12 injections." 2. "I eat frequently throughout the day." 3. "I do not eat concentrated sweets." 4. "I drink several glasses of iced tea with my meals."

4. "I drink several glasses of iced tea with my meals."

A man comes into the outclient rheumatology clinic for follow-up care after an episode of acute gouty arthritis. The nurse would be MOST concerned if the client made which of the following statements? 1. "I don't eat shrimp and scallops anymore." 2. "I play softball twice a week without any problem." 3. "I don't go to bars on Friday nights anymore." 4. "I have been drinking SlimFast for breakfast and lunch each day."

4. "I have been drinking SlimFast for breakfast and lunch each day."

The nurse cares for a client who is to receive thrombolytic therapy with tissue plasminogen activator (rtPA). The nurse is MOST concerned if the client makes which of the following statements? 1. "I take a multivitamin tablet daily for cold and flu prevention." 2. "I had major abdominal surgery a year ago." 3. "I get some stomach pain when I eat spicy foods." 4. "I hit my head and lost consciousness during a car accident 2 months ago."

4. "I hit my head and lost consciousness during a car accident 2 months ago."

The home care nurse instructs the daughter of a client diagnosed with congestive heart failure. The daughter states her father is taking digoxin (Lanoxin) 0.25 mg and the healthcare provider just prescribed furosemide (Lasix) 40 mg. Which statement, if made by the daughter to the nurse, indicates teaching is successful? 1. "I'm glad that Dad doesn't have to change his diet." 2. "Dad is going to have to eat more cottage cheese and add some more salt to his diet." 3. "Dad must increase his intake of cheese and yogurt." 4. "I should encourage Dad to eat more fresh fruits and vegetables."

4. "I should encourage Dad to eat more fresh fruits and vegetables."

The nurse teaches reality orientation to the husband of a woman with Alzheimer's disease and a moderate hearing loss. Which statement, if made by the client's husband, indicates that he understands this technique? 1. "I should ask my wife about current events we have discussed." 2. "I should reminisce with my wife about past events." 3. "I should frequently ask my wife for the date and time." 4. "I should place a calendar and clock in an obvious place."

4. "I should place a calendar and clock in an obvious place."

The nurse cares for the client diagnosed with type 2 diabetes. The client is scheduled for a renal computed tomography scan with contrast media at 10 a.m. The nurse is MOST concerned if the client makes which statement? 1. "My blood sugar was 124 mg/dL this morning." 2. "I drank a glass of water at midnight." 3. "Sometimes I get dizzy when I first get out of bed." 4. "I took my metformin (Glucophage ER) at 6 A.M. this morning."

4. "I took my metformin (Glucophage ER) at 6 A.M. this morning."

The nurse instructs a client on 100 mg losartan (Cozaar) and 25 mg hydrochlorothiazide (Hyzaar 100-25) tablets to be taken once daily. Which statement requires an intervention by the nurse? 1. "I will eat more fresh fruits while taking this medication." 2. "I should call my health care provider if I develop swelling of my lips." 3. "I can take this medication with or without food." 4. "I understand that I may develop a dry cough while taking this medication."

4. "I understand that I may develop a dry cough while taking this medication."

The nurse receives a phone call from a mother who was informed that her 10-month-old child was exposed to chickenpox at the day care center. Which statement, if made by the mother, MOST concerns the nurse? 1. "I will give my child Tylenol if a fever develops." 2. "I plan to wash the crib sheets often with a mild soap and water." 3. "I will keep the baby away from the other children right now." 4. "My 85-year-old grandmother is going to help take care of the baby while I am at work."

4. "My 85-year-old grandmother is going to help take care of the baby while I am at work."

A 39-year-old man is admitted with a diagnosis of Acquired Immune Deficiency Syndrome (AIDS). His lab results are hemoglobin 9.3 g/dL, hematocrit 25%, platelets 50,000/mm3, white cell count 1,500/mm3. Which order will should the nurse implement FIRST? 1. "Infuse 2 units of packed red cells." 2. "High-protein, high-carbohydrate diet as tolerated." 3. "Administer 2 units platelets." 4. "Place the client on neutropenic precautions."

4. "Place the client on neutropenic precautions."

The nurse in the outclient surgery unit prepares a 4-year-old child for surgery. It is MOST important for the nurse to make which of these statements? 1. "Your parents are going to leave a half hour before the surgery." 2. "You're going to talk with some other children who had this surgery." 3. "If you have this surgery, your parents will buy you a new toy." 4. "Take this doll and show me where the operation will be done."

4. "Take this doll and show me where the operation will be done."

The nurse counsels a woman at 36 weeks gestation who has attended childbirth class in preparation for labor and delivery. Which statement by the client requires an intervention by the nurse? 1. "I now know when to expect discomfort during labor and delivery and the things I can do to decrease the discomfort." 2. "My husband is still concerned that he is not sure what to do during the labor process." 3. "Even though I learned pain control techniques, I still may need some pain medication during labor and delivery." 4. "The breathing patterns I learned in class will decrease the amount of time I spend in labor."

4. "The breathing patterns I learned in class will decrease the amount of time I spend in labor."

A 50-year-old man scheduled for a vasectomy asks the nurse if he will be able to have sexual intercourse when he recovers from the surgery. Which statement, if made by the nurse, would be MOST accurate? 1. "My understanding is that each case is different after this procedure." 2. "There will be a short period of time during which you will be unable to sustain an erection." 3. "Most couples find that their sexual activity is more spontaneous after a vasectomy." 4. "This surgery should have no permanent effect on your sexual functioning."

4. "This surgery should have no permanent effect on your sexual functioning."

A woman is admitted to the hospital with a diagnosis of ovarian cancer. She has been treated with surgery and chemotherapy. The client states that she has no appetite and has lost 10 lbs in the last 4 weeks. Which statement, if made by the nurse, is MOST important? 1. "Have you noticed a decrease in your energy levels lately?" 2. "Do you notice any swelling of your hands and feet?" 3. "Describe your normal daily food intake." 4. "What are your favorite foods?"

4. "What are your favorite foods?"

The home care nurse is visiting a client terminally ill with pancreatic cancer who wishes to die at home. Which question, if asked by the nurse, is MOST appropriate? 1. "Are you sure you want to die at home?" 2. "Where will you put the hospital bed?" 3. "Would you like your minister to visit you?" 4. "Who will take care of you?"

4. "Who will take care of you?"

The nurse performs dietary teaching for a client taking lithium carbonate (Lithonate). Which snack, if selected by the client, indicates that teaching is effective? 1. Four carrot sticks. 2. 8 oz of ice tea. 3. A whole banana. 4. 12 oz of lemonade.

4. 12 oz of lemonade.

The nurse reviews health assessments completed by student nurses. Which assessment warrants further investigation? 1. An 11-year-old female who states that she has had 3 periods in the past 6 months. 2. A 13-year-old male with intermittent voice changes. 3. A 14-year-old male with bilateral breast enlargement. 4. A 15-year-old female with bilateral breast buds.

4. A 15-year-old female with bilateral breast buds.

The home care nurse performs a health screening at the local mall. The nurse knows that which of the following clients is at HIGHEST risk for developing a stroke? 1. A 32-year-old Caucasian female who has a history of type 1 diabetes mellitus and has used oral contraceptive for 8 years. 2. A 49-year-old Caucasian male who works as an account executive at an ad agency and has a cholesterol level of 250 mg/dL. 3. A 56-year-old African-American female who consumes 1 to 2 alcoholic beverages weekly and has smoked cigarettes for 30 years. 4. A 69-year-old African-American male who has a history of hypertension and is 30 pounds overweight.

4. A 69-year-old African-American male who has a history of hypertension and is 30 pounds overweight.

The nurse teaches a wellness class to a group of women. The nurse knows that which of the following clients is MOST at risk for developing cervical cancer? 1. A woman who began menstruating at age 9. 2. A woman who used oral contraceptives for 8 years. 3. A woman diagnosed with endometriosis at age 20. 4. A woman who has had approximately 10 sexual partners.

4. A woman who has had approximately 10 sexual partners.

The client is admitted to the hospital with chest pain when taking deep breaths and peripheral edema. The health care provider's order for the client reads; "Digoxin 0.25 mg orally now. Repeat digoxin 0.25 mg orally in 12 hours." Which action, if taken by the nurse, is MOST appropriate? 1. Do not administer the second dose of digoxin. 2. Call the health care provider to clarify the order. 3. Administer half the prescribed second dose of digoxin. 4. Administer the first and second dose of digoxin as ordered.

4. Administer the first and second dose of digoxin as ordered.

A child is admitted to the hospital with a diagnosis of status asthmaticus. The nurse is MOST concerned if which of the following is observed? 1. SaO2 91%. 2. Expiratory wheezing. 3. Intercostal retractions. 4. Arterial pH 7.25.

4. Arterial pH 7.25.

The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse determines that the client has pressed the button 11 times and received 6 doses of morphine during the last hour. Which is the MOST appropriate action for the nurse to take? 1. Assess the patency of the PCA IV tubing. 2. Determine the client's understanding of the PCA pump function. 3. Obtain an order to begin a PCA infusion of fentanyl. 4. Ask the client to describe the pain.

4. Ask the client to describe the pain.

The nurse cares for a client being maintained on a ventilator. The client suddenly becomes distressed and agitated. Which of the following is the MOST appropriate action for the nurse to take? 1. Obtain an order for a tranquilizer. 2. Restrain the client. 3. Check the last arterial blood gas result. 4. Assess the client's breathing pattern in relation to the ventilator.

4. Assess the client's breathing pattern in relation to the ventilator.

The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused and incontinent of urine. What is the MOST important action for the nurse to take? 1. Insert an indwelling urinary drainage catheter. 2. Perform intermittent catheterization every 4 hours. 3. Offer the bedpan to the client every 2 hours. 4. Assist the client to a bedside commode every 2 hours.

4. Assist the client to a bedside commode every 2 hours.

A 60-year-old male client awakens frightened and agitated. He climbs out of bed, removes his indwelling urinary drainage catheter, and runs down the hall screaming. Which of the following is the FIRST action the nurse should take? 1. Notify the healthcare provider. 2. Restrain the client. 3. Replace the urinary catheter. 4. Check for injuries.

4. Check for injuries.

During a paracentesis, 1500 mL of fluid is removed from a client. Which action should the nurse take IMMEDIATELY following the procedure? 1. Measure the client's abdominal girth. 2. Weigh the client. 3. Assess the client's level of pain. 4. Check the client's blood pressure.

4. Check the client's blood pressure.

During the admission interview, the client reports a red, itchy raised rash on the chest and lip swelling after use of aspirin and penicillin. The admission orders include bed rest, soft diet as tolerated, naproxen (Naprosyn), and cefaclor (Ceclor). Which is the BEST description of expected breath sounds heard during auscultation? 1. Administer the Ceclor as ordered; do not administer the naproxen. 2. Administer the naproxen as ordered; do not administer the Ceclor. 3. Administer both the Ceclor and naproxen as ordered; document the client's response. 4. Do not administer the Ceclor or naproxen; notify the healthcare provider.

4. Do not administer the Ceclor or naproxen; notify the healthcare provider.

The nurse supervises the distribution of meal trays on a medical unit. Which tray will should be given to a client who has requested a kosher diet? 1. Cheeseburger, sliced tomato, french fries, and a milkshake. 2. Pork chops, applesauce, baked potato, and ginger ale. 3. Shrimp salad, sliced avocado, bread, and coffee. 4. Fruit salad, cottage cheese, crackers, and tea.

4. Fruit salad, cottage cheese, crackers, and tea.

Two days after admission to an alcoholic treatment unit, a 40-year-old man brags about his binges and boasts that he has not had a steady job in 3 years. Which activity, if selected by the nurse, would be MOST appropriate for this client? 1. Ask the client to lead a group discussion on alcoholism. 2. Ask the client to orient a client to the unit. 3. Encourage the client to play table tennis with other clients. 4. Have the client assume responsibility for the cleanliness of the dining

4. Have the client assume responsibility for the cleanliness of the dining

The nurse cares for an 80-year-old client taking medication for the treatment of hypertension and heart failure. Which action is MOST important for the nurse to take? 1. Check the client's blood pressure and heart rate immediately after ambulation. 2. Instruct the client to use a walker at all times during ambulation. 3. Encourage the client to walk with the feet as close together as possible. 4. Instruct the client to sit on the edge of the bed for 3 to 5 minutes before arising.

4. Instruct the client to sit on the edge of the bed for 3 to 5 minutes before arising.

The nurse discusses an appropriate diet with a client diagnosed with iron-deficiency anemia. Which meal, if selected by the client, indicates to the nurse, that teaching is effective? 1. Spaghetti with a sauce of ground beef, cheese, and garlic bread. 2. Baked sausage casserole with rice and sliced tomato. 3. Frankfurter, baked beans, and chopped cabbage salad. 4. Lamb chop, baked potato, and tossed green salad.

4. Lamb chop, baked potato, and tossed green salad.

The nurse cares for an 84-year-old man who appears disheveled, restless and confused. The nurse prepares to administer medication and observes that the client's armband is missing. Which is the MOST appropriate action for the nurse to take? 1. Ask the client's roommate to identify the client. 2. Ask the client to state his name. 3. Ask another nurse to identify the client. 4. Look in the chart at the picture of the client.

4. Look in the chart at the picture of the client.

The nursing team consists of two RNs, one LPN/LVN, and one nursing assistive personnel. The nurse should consider the assignment appropriate if the LPN/LVN is required to complete which task? 1. Ambulate a client 8 hours after a thoracotomy. 2. Give an enema to a client prior to a colonoscopy. 3. Complete a bed bath for a client with burns on the arms and legs. 4. Perform a dressing change on a client 3 days after a cholecystectomy.

4. Perform a dressing change on a client 3 days after a cholecystectomy.

The nurse cares for the client in the labor unit. During the transitional phase of labor, the umbilical cord becomes prolapsed. It is MOST important for the nurse to take which action? 1. Place the client on her back with thighs flexed on her abdomen. 2. Place the client on her left side with legs flexed. 3. Place the client supine with the head of the bed elevated 30°. 4. Place the client supine with the foot of the bed elevated.

4. Place the client supine with the foot of the bed elevated.

The nurse performs an assessment of a newborn boy. The nurse is MOST concerned if which of the by which observation? 1. The respiratory rate is 40 per minute with short periods of apnea. 2. The heart rate is 140 beats per minute with variation during sleeping and waking states. 3. A sudden loud noise causes abduction of the infant's arms and flexion of his elbows. 4. Stroking the outer sole of the infant's foot upward causes his toes to curl downward.

4. Stroking the outer sole of the infant's foot upward causes his toes to curl downward.

The nurse cares for the client diagnosed with Parkinson's. The nurse notes that the client is ambulating with short, accelerating steps. Which action is the MOST appropriate for the nurse to take? 1. Offer the client a wheelchair. 2. Provide the client a walker. 3. Suggest that the client wear comfortably fitting shoes. 4. Teach the client to walk with a broad-based gait.

4. Teach the client to walk with a broad-based gait.

A client is scheduled for transfer to another hospital. Which observation, if made by the nurse, would require an IMMEDIATE intervention? 1. Lactated Ringer's infusing IV into the client's left forearm is 400 mL behind schedule. 2. The client's nasogastric tube is draining a moderate amount of green liquid. 3. The client's blood pressure has changed from 140/80 to 150/88 in the last hour. 4. The client's SaO2 is 88%.

4. The client's SaO2 is 88%.

The nurse monitors the activities of a 9-year-old girl with juvenile rheumatoid arthritis (JA). Which activity is MOST appropriate? 1. The girl is jumping rope. 2. The girl is skipping. 3. The girl jumps off the end of a slide. 4. The girl participates on a swim team.

4. The girl participates on a swim team.

The nurse cares for clients in the pediatric clinic. The nurse would be MOST concerned if which of the following was observed? 1. A 3-month-old infant's back is rounded. 2. A 4-year-old has a blood pressure of 90/60. 3. A 5-year-old has a pulse of 88. 4. The hem of the skirt on a 10-year-old is longer on one side than the other.

4. The hem of the skirt on a 10-year-old is longer on one side than the other.