Xtra NCLEX

592. CPR levels normal range

1-3 mg/dl 1 and below is low risk for heart disease 3 and above is High risk for heart disease

66. The nurse prepares a client with right sided weakness to get out of bed to a chair. Number the actions in the options in order of PRIORITY.

1. Instructs client about the procedure 2. Place the chair at an angle on the side of the bed 3. Secure the chair position 4. Assist the client to stand and move the left arm to the armrest 5. Instructs the client to keep the body weight forward and then pivot 6. Assist the client in sitting when the back of the legs touch the chair

604. Which client is at greatest risk of developing osteoporosis?

65 y/o who is on long term anticonvulsants

616. The nurse is caring for a female client who has had a sealed radiation implant recently removed from the cervix. As prescribed, the nurse MOST APPROPRIATELY should inform the client that she can engage in sexual intercourse in how many days?

7-10 days

298. A pregnant client has received a subarachnoid (spinal) block for labor, and the nurse is reinforcing instructions to the client for the postpartum period. The nurse determines that the client understands the instructions If the client states that she must lie flat for how many hours?

8-12 hrs

Pa02 normal range

80-100 mmHg

Saturation Sa02

95-100

446. The mother of a child with CF asks the clinic nurse about the disease. The nurse informs the mother of which characteristics of CF? Select all that apply

A chronic multisystems disorder that affects the exocrine glands A disease that causes production of abnormally thick secretions

488. The nurse educator is conducting a teaching session on the lab test used to monitor the progression of HIV. The nurse explains the purpose of the CD4:CD8 ratio. The nurse educator determines that learning has been EFFECTIVE if a student makes which statement?

A normal CD4:CD8 ratio is 2:1

216. The nurse caring for a client taking amitriptyline hydrochloride receives a lab report indicating a serum medication level of 148 ng/ml. The nurse understands that the level is indicative of which result?

A therapeutic serum medication level

516. The nurse understands that which are risk factors for development of breast cancer? Select all that apply

Age Obesity Family history Early menarche

322. The nurse determines that a client in labor is beginning the second stage when which findings are noted? Select all that apply

An urge to bear down The cervix is completely dilated The client beings to expel clear vaginal fluids

143. When planning client assignment and delegated tasks, the LVN should take which action when communicating with the members of the health care team?

Communicate a feeling of confidence

453. The nurse would plan to monitor a client with heart failure for hypokalemia as a side effect of pharmacological therapy if the client was receiving which medication?

Furosemide (Lasix)

10. The nurse is caring for a client with a suspected DX of hypercalcemia. Which S/S would be an indication of this electrolyte imbalance?

Generalized muscle weakness

599. The nurse is caring for a 40 y/o client and notes the client is able to give to and care for others. Which stage of psychosocial development has the client progressed to?

Generativity versus stagnation

215. The client with kidney failure is receiving epoetin alfa (Epogen). The nurse should monitor this client for which adverse effects of this medication?

HTN

419. The child with a basilar skull fracture is at risk for ICP. Which sign indicates an EARLY sign of ICP?

Headache N/V Visual disturbances Seizures Slight changes of LOC

Chest tube drainage greater than 100 may indicate

Hemorrhage

303. The nurse is caring for a client with gestational diabetes. The nurse explains to the client that she is at risk for which complications as the fetus continues to develop?

Hypoglycemia- low blood sugars

267. Alprostadil injection (Caverject) for treatment of Erectile dysfunction. Which statement indicates an understanding about this medication?

I might experience insomnia while taking this medication

261. The nurse is reinforcing instructions to the client who has been prescribed a contraceptive patch. Which statement, if made by the client indicates further teaching?

I will change the patch weekly, using the same location every time I change the patch

388. The nursery room nurse is monitoring a newborn who was born to an alcoholic abusing mother. Which findings would the nurse expect to note? Select all that apply

Irritability Flat midface Low nasal bridge

393. The nurse is collecting data on a newborn who was born to a mother who is addicted to drugs. Which findings does the nurse expect to note while data collecting on this newborn? Select all that apply

Irritability Incressant crying Hyperextended position Difficulty in consoling the newborn

166. The nurse is caring for a client who reports taking St. John's wort for treatment of depression. The nurse determines that a potential medication interaction can occur if the client is also taking which medication?

Lisinopril (Zestril)

354. The nurse is caring for a client who is on postpartum day 2. The nurse checks the lochia and should expect to note which findings?

Lochia rubra

521. The hippocampus is responsible for the storage of

Memory

199. A client has been DX with Graves' disease. Which medication would most LIKELY be prescribed?

Methimazole (Taparzole)

18. The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse should tell the client to select which food item that is high in riboflavin?

Milk Rationale: food sources of riboflavin include milk, lean meats, fish and grains

606. The nurse should expect to note which findings for the client suspected of having diabetes insipidus? Select all that apply

Muscle pain Dehydration

219. The nurse reinforces instructions to a client taking divalproex sodium to treat absence seizures. Which problem represents the MOST frequent side effect of this medication?

N/V Indigestion

226. The nurse she is the lab results for a serum digoxin (Lanoxin) level that was drawn for a client earlier in the day and notes that the results is 2.4 ng/ml. The nurse should take which action?

Notify HCP Rationale: dig normal values are 0.5-2.0ng/ml

Modifiable risk factors to high blood pressure

Obesity Stress Diet Sodium intake

627. A client asks the nurse to explain what milieu therapy is

Or therapeutic community, provides a safe, therapeutic environment for clients

559. Which type of fracture is MOST LIKELY to occur in a client with cancer who has bone metastasis?

Pathologic

119. The nurse understands that use of advance directives is enforced by which authorities body or act?

Patient Self-Determination Act

429. The nurse is reinforcing discharge instructions to the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is the PRIORITY in the discharge instructions?

Performing wound care

5. A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3. The nurse should take which action after seeing the lab results?

Place the normal report in the client's medical record

566. The nurse obtaining a skin culture from a client who is suspected of having a viral skin condition. After obtaining the specimen, the nurse should take which action NEXT?

Place the specimen on ice

380. Which interventions are the PRIORITY for a 10y/o child DX with acute glomerulonephritis? Select all that apply

Promoting bed rest Providing for a quiet play according to the child's developmental stage

74. The nurse who is collecting data from a client notes that the client's left eyelid is drooping. The nurse documents that the client is exhibiting which condition?

Ptosis, (is a sagging of the upper lid of the eye)

565. The nurse knows that a reported value of zero is normal for which substance in CSF?

RBC

Family is causing anxiety in patient with asthma complications, first

Redirect the family to help patient with deep breathing

432. The nurse caring for an infant with a cleft palate who is breastfeeding. Which measure specifically related to this disease process is of HIGHEST PRIORITY?

Respiratory assessment

594. Following a liver biopsy, the nurse should assist the client into which position?

Right side lying with a small pillow or towel under the puncture site

306. The nurse caring for a client with placenta previa MOST APPROPRIATE places the client in which position, if prescribed?

Side lying

290. A pregnant client received a lumbar epidural block in preparations for delivery. The nurse should MOST APPROPRIATELY assist the client into which position?

Side lying Rationale: lumbar epidural block, should be side lying position, or on the back with a rolled blanket underneath the right hip because this displaces the uterus, lifting the uterus of the vena cava and preventing vena cava syndrome

65. The client who has undergone open reduction internal fixation (ORIF) of the right hip has been retaining urine, and the HCP prescribes straight catheterization. In which BEST position should the nurse place the client to perform this procedure?

Side-lying (sims)

379. The nurse plans to monitor a child with Reye's syndrome for which manifestation to the disorder?

Signs of increased ICP

231. A client has a prescription to receive enoxaparin (Lovenox). The nurse prepares to administer this medication by which route?

Subcutaneously

86. A client has been DX with gout. In reinforcing a dietary plan for this client, the nurse should include which items on the list of foods that are acceptable? Select all that apply

Tapioca Chocolate

335. The nurse should reinforce teaching related to the risk of abruptio placentae if what information is obtained on assessment of a pregnant client?

The client has a history of HTN

89. The client is being scheduled for a position emission tomography (PET) scan. The nurse should plan to provide which explanation to the client?

The test uses small amounts of radioactive material

409. The nurse is evaluating the development level of a 2y/o child. Which finding should the nurse expect to observe in this child?

Uses a spoon with some spilling

370. The nurse determines that which play activity is MOST APPROPRIATE for a hospitalized preschooler in traction?

Using crayons and a coloring book

576. The nurse understands that which cranial nerve controls both swallowing and phonation?

Vagus nerve

493. A client is DX with a disorder involving the inner ear. Which findings are common client complaints associated with a disorder involving this part of the ear? Select all that apply

Vertigo-spinning sensation Tinnitus- ringing or buzzing

378. The nurse understands that respiratory syncytial virus (RSV) occurs PRIMARILY in which season?

Winter and spring

623. Rivaroxaban (Xarelto)

an oral Anticoagulant

278. The nurse working on the labor and delivery unit is monitoring a pregnant client and determine her readiness for labor. The nurse notes the following: cervix is dilated 2 cm, cervix is effaced 50%, cervix is of medium consistency and is in midposition, and the station of the presenting part is at -2. The nurse assigns which Bishop score to this client?

1 Rationale: 1 = 1-2 cm, effaced 40-50%, is medium consistency, and is midposition, presentation -2 station

630. 12 step program for gamblers

1. Acknowledge that he is entirely ready to have his defects of character removed 2. Admitting he is powerless over gambling and that his life has become unmanageable 3. Admitting to oneself and another human being the exact nature of one's wrong 4. Making direct amends whenever possible to all people who have been hurt, except when to do so would further harm them or others 5. Making an effort to practice the 12 step principles in all affairs and to carry this message to other compulsive gamblers

55. A client is DX with myasthenia gravis and the nurse needs to administer a medication to this client. Number the actions in the options in order of PRIORITY with regard to how the nurse should perform the actions. (First to last)

1. Check the medication prescription 2. Elevate the head of the bed 3. Check swallowing ability 4. Administer precisely at prescribed time 5. Document administration of the medication 5. Nurse monitors response to medication as the day progresses

369. The nurse is reinforcing instructions to the parents of a newborn regarding the vitamin K injection. The nurse informs the parents that newborns are deficient in vitamin K in the first how many days of life?

5-8 days

168. A client with severe preeclampsia is receiving IV magnesium sulfate. The nurse reviewing the lab results and determines that which magnesium level is w/i the therapeutic range?

5mg/dl Rationale: TR 4-7mg/dl

396. A combination of isoniazid, rifampin (Rifadin), ethambutol (Myambutol), and pyrazinamide (PZA) is prescribed for a 2y/o child with a positive TB Mantoux skin test, and the mother asks the nurse how long the child will need to take the medication. The nurse should tell the mother that the medication will need to be taken for how long?

6 months

329. The nurse midwife is conducting a teaching session on the process of implantation and tells the group that implantation of the zygote takes place how many days after ovulation?

6-8 days

416. The nurse is caring for an infant with heart failure (HF). The nurse is monitoring for respiratory distress and is counting respirations. The nurse MOST APPROPRIATE counts respirations for how long?

60 seconds

645. The ideal number of clients in a psychotherapy group ranges from

7-10 members

41. The nurse is caring for a client who is retaining CO2 due to respiratory disease. The nurse anticipates that as the client's CO2 level rises, the pH will MOST LIKELY be which value?

7.30 Rationale: CO2 acts as an acid in the body. Therefore, when a rise in CO2, there is a corresponding fall in pH

552. The nurse caring for a client in Buck's (extensions) traction understands that no more than how many pounds (lb) should be applied to the pulley system?

8-10 lbs

99. Which clients should the ED triage nurse classify as urgent? Select all that apply

A client with a swollen ankle after a fall A client with the " worst headache" of the clients life Rationale: urgent refers to a client requiring treatment but life, limb or vision is not threatening

441. A child is DX with neuroblastoma. The nurse reviews the medical record and understands that which finding is specifically related to this type of tumor?

A firm, nontender, irregular mass in the abdomen

297. The nurse receives report for four maternity clients. Which clients does the nurse identify as being MOST at risk for developing disseminated intravascular coagulation (DIC)? Select all that apply

A gravida 3 with abruptio placentae A primigravida who has just been DX with sepsis A gravida 2 who has just been DX with dead fetus syndrome

385. The nurse is taking the B/p of a 3y/o child admitted to the hospital for mild dehydration from vomiting and diarrhea and obtains a reading of 90/50 mm Hg. The nurse interprets this as indicating which finding?

A normal finding Rationale: normal readings 72/110 systolic 40/73 diastolic

11. The nurse is caring for a client with respiratory insufficiency. The ABG results indicate a Ph of 7.50 and a POC2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which additional lab values should the nurse expect to note?

A potassium level of 3.0 mEq/L Rationale: respiratory alkalosis S/S tachypnea, change in mental status, dizziness, pallor around the mouth, spasms of the muscles in the hands, and hypokalemia

314. A client with severe preeclampsia is admitted to the maternity department. Which room assignment is MOST APPROPRIATE for this client?

A private room two doors away from the nurses station

426. The nurse is reviewing the HCP's prescriptions for a child who was hospitalized with nephrotic syndrome. Which dietary prescriptions would the nurse expect to be prescribed? Select all that apply

A regular, no salt added diet A NORAML protein mild sodium restricted diet

533. The nurse understands that which are risk factors for HTN? Select all that apply

Aging Obesity African American

587. Hypoglycemic reactions can occur

Anytime of the day Consume 10-15 g of carbohydrates 6-8 oz 2% milk

364. The nurse is caring for an infant with heart failure who was admitted 24 hrs ago. Which finding, specifically associated with this condition, should be reported to the HCP?

Apical pulse of 160 bpm/ increased from baseline of 120 bpm on admission

382. The nurse is monitoring a child for signs of ICP. The nurse should monitor for which signs of increased ICP? Select all that apply

Apnea Seizures Posturing Change in LOC

Capsaicin cream application

Apply cream to hands and wait at least 30 minutes before washing them

458. The nurse is assisting in the care of a client who was experiencing hypermagnesiumia. The nurse determines that the client status is returning to normal if the client no longer exhibits which manifestation?

Areflexia- loss of deep tendon flexes

527. Neutrophils phagocytize foreign particles such as

Bacteria

452. The nurse is caring for a client who is newly DX with asthma. The nurse is reinforcing instructions to the client and tells the client to avoid which triggers of acute asthma attacks? Select all that apply

Beer Molds Perfumes Animal dander

35. The nurse is reviewing the plan of care for the client who has just undergone bilateral knee replacement. Which intervention, if noted in the plan of care, indicates the NEED FOR FOLLOW-UP?

Begin continuous passive ROM exercises immediately Rationale: ROM should begin 24-48 hours after surgery

571. The nurse should monitor the client with herpes zoster (Shingles) lesions on the face for which complications associated with this condition? Select all that apply

Bell's palsy Skin necrosis Eye infections

474. The nurse reading the operative record for a client who had cardiac surgery notes that the client's cardiac output after surgery was 3.6 L/min. The nurse plans care knowing that this measurement indicates which range?

Below normal Rationale: normal 4-8 L/min

181. A HCP has prescribed etanercept (Enbrel) for a client with a DX of RA. The nurse explains to the client in layperson terms that this medication is classified as which type of medication?

Biological response modifier

491. The nurse is caring for a client who is at risk for retinal detachment. The nurse understands that which factors increase the clients risk for this disorder? Select all that apply

Cataracts Eye trauma Retinopathy Increasing age Family history

434. The nurse who is caring for the client with recently DX Hodgkin's lymphoma understands that which lymph nodes are usually affected first?

Cervical

292. The transition phase of the first stage of labor can be identified by which findings?

Cervical dilation of 8-10cm

Inadequate tissue perfusion S/S

Change in mental status Tachycardia with threads pulse Cool clammy skin Oliguria Tachypnea Decreased urine output (less than 30 ml/hr)

123. The nurse who specializes in nursing informatics is providing a teaching session to staff nurses regarding electronic documentation. The nurse should include which instructions as important guidelines to follow with regard to maintaining confidentiality of health records? Select all that apply

Changing of personal passwords on a regular basis. Developing a password hint that is difficult to guess Ensuring that accounts have been logged out when away from the computer

What should the nurse do after performing amniotomy

Check temperature q2hrs Monitor FHR before and after Note color, odor, and consistency of fluid Perform perineal care and change absorbent pads as needed

79. A client is admitted to the surgical unit postoperatively with a wound drain in place. Which actions should the nurse take in the care of the drain? Select all that apply

Check the drain for patency Observe for bright red bloody drainage Maintain aseptic technique when emptying

355. A 4 day old infant is receiving phototherapy at home for a bilirubin level of 14 mg/dl. The nurse should plan of care during the home visit to the infant?

Check the integrity and fluid and electrolyte status

359. A child is brought to the ED for an injury to the lower right arm that occurred after falling off a bicycle. The radiograph reflects that the fracture is across the entire bone shaft with some possible displacement. What interventions should the nurse plan to take? Select all that apply

Check the skin at the injury site for color and pallor Check for pain and point of tenderness of the injury Elevate the injured extremity above the level of the heart

77. The ruse caring for a client with a NGT is preparing to administer the scheduled medications through the NGT. The nurse MOST accurately checks for placement by performing which action?

Checking the pH of the gastric contents

509. The nurse notes documentation that an older client has a number of bright, ruby colored round lesions scattered on the trunk and thighs. The nurse concludes that this description is referring to which alteration in blood vessels of the skin?

Cherry angioma

622. The nurse caring for a client with actinic keratoses understands that this condition is caused by which factor?

Chronic exposure to the sun

465. A client of chronic Pruritus. The nurse investigating this complaint would review the medical record for documentation of which disorder that would support this client's complaint?

Chronic kidney disease (CKD)

23. Which clients would the nurse determine is at risk for developing of metabolic alkalosis? Select all that apply

Client who has been vomiting for 2 days Client receiving oral furosemide 40 mg daily

96. The nurse acts as the client's advocate in which situations? Select all that apply

Contacting the HCP to request a meeting for the client Questioning the HCP regarding a discrepancy in reported medication dosages between home and hospital

325. The HCP has prescribed an IV infusion of oxytocin (Pitocin) for a client in labor. The nurse ensures that which intervention is I'mplemented before beginning the infusion?

Continuous electronic fetal monitoring

147. Which type of law is concerned with enforcement of agreements among private individuals?

Contract

128. The case manager is responsible for which aspects of client care? Select all that apply

Coordinating consultations and referrals Establishing a plan of care with the client Addressing client concerns and facilitating discharge

589. Asking a client to perform rapid alternating hand movements is to test for

Coordination

619. The nurse is caring for a postoperative client following creation of an ileostomy. The nurse expects that the output in the IMMEDIATE postoperative period will be what color?

Dark green

161. A client with allergic dermatitis has been given a prescription for a tube of diphenhydramine (Benadryl) to use a topical agent. The nurse evaluates on a follow up visit that the medication was effective if which effect was noted?

Decreased in urticaria

45. The nurse is reviewing the lab report for the client who had a urine specific gravity determination done. The report indicates a value of 1.030. The nurse understands that which condition may potentially be causing this result?

Decreased renal perfusion Rationale: normal urine specific gravity level is 1.016 to 1.022, increased levels point to decreased renal perfusion

549. A client is DX with metabolic alkalosis as a result of excessive antacid use. The nurse is monitoring this client, expecting to note which findings?

Decreased respiratory rate and depth

407. A 10y/o child with asthma is being treated for acute exacerbation in the ED. Which finding would indicate that the condition is worsening?

Decreased wheezing

573. The nurse educator is conducting a teaching session on renal function studies with a group of nursing students. The educator informs the students that which factors can elevate the BUN level? Select all that apply

Dehydration Corticosteroid use GI bleeding

233. The nurse is administering a prescribed dose of dexamethasone to a client following cranial surgery. The nurse should monitor for which adverse effect of this medication?

Delayed would healing

184. The nurse is performing a flow up teaching session with a client discharged 1 month ago who is taking fluoxetine (Prozac). What information would be important for the nurse to obtain during this client session about the side effects related to this medication?

GI dysfunction CNS

256. A client is being discharged to home with a prescription for a daily dose of amlodipine (Norvasc), and the nurse is reinforcing medication instructions. The nurse determines the client needs further teaching if the client states to take the medication with

Grapefruit juice

84. The client with HTN has been told that it is necessary to maintain a diet in low sodium. The nurse who is reinforcing teaching to this client about foods that are allowed should include which food items in a list provided to the client? Select all that apply

Grapes Summer squash

160. The nurse caring for the client who has been prescribed tamoxifen (Nolvadex) for off label use understands that which condition may be present?

Gynecomastia

Peripheral artery disease (PAD) factors

HTN DM Hyperlipidemia Smoking

431. The nurse caring for a newborn with hyperbilirubinemia understands that jaundice affects which part first?

Head

436. The nurse is reinforcing teaching to the parents of an infant with gastroesophageal reflux (GER) regarding proper positioning to manage reflux. The nurse tells the parents that the infant should be maintained in which position at night?

Head elevated prone position

265. The nurse is providing information about the side effects and adverse effects of chronic gonadotropin to the client who has been prescribed it. What should the nurse include? Select all that apply

Headache Bloating Risk of birth defects Orthostatic HTN

31. An older adult has been lying in bed for 2 hours. The nurse who is repositioning this client would be MOST concerned with examining which areas of the client's body? Select all that apply

Heals Sacrum Back of the head Greater trochanter

492. A client is DX with a disorder involving the middle ear. Which is the MOST common client complaint associated with a disorder involving this part of the ear?

Hearing loss

Risk factors for renal disease

Heart failure Contact sports DM Chemical or environmental toxins exposures Family history Frequent UTI's High sodium diet HTN Medications Trauma Urolithasis Nephrolithiasis

614. The nurse is caring for a female client who recently had a sealed radiation implant removed from her cervix. The nurse should inform the client to notify the HCP if which symptoms are noted? Select all that apply

Hematuria Vaginal bleeding Frequent urination Abdominal distention

478. A client is admitted with a tentative DX of bladder cancer. The nurse expects the client history to reveal which EARLY manifestation of the disease?

Hematuria and absence of pain Hematuria- blood in the urine

584. Which lab finding indicates the NEED FOR FOLLOW UP for the client who has undergone renal biopsy?

Hemoglobin 8 g/dl Rationale: normal range males 14-16.5, women 12 to 15

266. Atazanavir (Reyataz) has been prescribed for a client with HIV. Which conditions, if noted in the client's past medical history, would indicate the need for increased monitoring of this client? Select all that apply

Hemophilia Hyperlipidemia DM

505. The nurse caring for a hospitalized client with laryngeal cancer is assisting the client with filling out a dietary menu. The nurse should encourage the client to select foods for which type of diet?

High calorie high protein

54. The nurse performing an eye assessment notes that the client can see objects clearly that are far away but cannot see objects clearly that are close up. The nurse documents this finding as which condition?

Hyperopia

601. A client reports to the nurse that he felt a lump when performing TSE. The nurse should make which response?

I am glad that you reported this, even though it might no be serious

362. The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicate their understanding of the plan? Select all that apply

I can still breastfeed my infant Circumcision has been delayed to save tissue for surgical repair

437. The nurse is reinforcing instructions to the mother of a child receiving radiation therapy. Which statement by the mother indicates a need for further INSTRUCTIONS

I do not need to limit the amount of sun my child gets

312. The nurse is reinforcing instructions to a mother with mastitis. Which statement by the mother indicates FURTHER instructions?

I need to avoid using the breast pump

238. Furosemide (Lasix) is prescribed for a client and the nurse is reinforcing teaching about the medication. Which statement by the client indicate an understanding of the instructions.? Select all that apply

I will sit up slowly before standing each morning I will take my medication every morning with breakfast

389. A 4y/o child is being transported to a trauma center for treatment of a partial and full thickness burn injury that is estimated to cover more than 40% of the body. The nurse anticipates that which treatment will be prescribed INITIALLY?

Insertion of Foley catheter

476. The nurse is caring for a client following a Billroth 2 resection. On review of the postoperative prescriptions, which treatment, if prescribed, should the nurse question and verify?

Irrigating the NGT

205. Allopurinol (Zyloprim) has been prescribed for a client. The nurse prepares to administer this medication, knowing that which information is accurate regarding it?

It decreases uric acid production and reduces uric acid concentrations in serum and urine

602. The nurse is helping with a teaching session regarding beta thalassemia major. The nurse reinforces instructions to the nursing students that this disorder occurs MOST often in persons of which ethnic origin? Select all that apply

Italian Syrian Greek

120. The nurse is caring for the assigned clients for the day. The nurse fulfills the wishes of 3/4 clients and because of time constraints is unable to fulfill the wishes of the 4th client. Which ethical principle has the nurse violated?

Justice Rationale: justice is defined as the equitable distribution of potential benefits and tasks determining the prescription in which the clients should be cared for.

502. A client has just undergone spinal fusion for a herniated lumbar disk. The nurse should implement which interventions to maintain client safety after this procedure? Select all that apply

Keep the HOB flat Place pillows under the length of the legs Use logrolling techniques for repositioning

133. The nurse manager is exercising a type of power on the nursing unit that is based on a position in the organization. Which type of power is the manager using?

Legitimate Rationale: legitimate power is based on a position in society, such as the organization

361. A child with croup is placed in a cool mist test. The mother becomes concerned because the child is frightened, constantly crying and trying to climb out of the tent. Which nursing actions are MOST APPROPRIATE? Select all that apply

Let the mother hold the child and direct a cool mist over the child's face Tell the mother that she can stay as long as she wants to alleviate the child's fear

30. The nurse is demonstrating adult CPR chest compression techniques to health care team members. Which action performed by a member on return demonstration indicates the NEED FOR FURTHER TEACHING in the performance of CPR?

Let's the fingers rest on the chest Rationale: to maximize the effectiveness and avoid organ injury

507. The nurse is reinforcing discharge instructions to a client following gastrectomy. Which measures should the nurse instruct the client to follow to assist in preventing dumping syndrome? Select all that apply

Lie down after a meal Limit fluid intake with meals

455. A client arrives at the ED and a sprained ankle is suspected. The nurse understands that which findings are consistent with a sprain? Select all that apply

Limited joint motion Tenderness on palpation Swelling of affected area Client description of feeling looseness in the joint

316. The nurse is caring for a client who has experienced intrauterine fetal demise (IUFD). The nurse expects to note which findings associated with this condition? Select all that apply

Loss of fetal movement Absence of FH tones Bleeding from puncture sites Prolonged bleeding and clotting times

Cranial nerve VIII (auditory nerve) may cause impairments like

Loss of hearing Dizziness Vertigo Client is at risk for falls

223. The client with a history of spinal cord injury is beginning medication therapy with baclofen (Lioresal). The nurse should caution the client about which occasional side effect of this medication?

Low blood pressure

285. The nurse is caring for a client who is at risk for preterm labor. Which findings indicate that preterm labor may be occurring? Select all that apply

Lower back pain Pelvic pressure Uterine contractions Change in the amount of discharge

470. A client is DX with left ventricular heart failure. The nurse should monitor the client for which manifestation characteristic of this disorder?

Lung congestion Rational: LEFT = LUNGS RIGHT = LIMBS

180. The nurse is caring for a client who has been prescribed amitripyline hydrochloride for the treatment of depression. The nurse should notify the HCP if which condition is noted in the client's recent medical history?

MI (Myocardial Infarction) heart attack

109. The nurse manager is performing an inservice session on disaster preparedness and is discussing the phase of disaster management. Which phase encompasses actions or measures that can prevent the occurrence of a disaster or reduce the damaging effects of a disaster?

Mitigation

279. The nurse is caring for a postpartum client with DM. The nurse should include which interventions in the plan of care for this client? Select all that apply

Monitor for a hypoglycemic reaction Regulate insulin needs as prescribed Monitor for signs of infection or hemorrhage Assess dietary needs based on insulin requirements

671. The nurse is reviewing a plan of care for a client with OCD. The nurse should include which interventions in the plan of care or this client? Select all that apply

Monitor for repetitive behavior Ensure that basic needs are met Educate the client about self care demands Establish a trusting nurse client relationship

575. The nurse is caring for a client who has just undergone cystoscopy with biopsy of the bladder. What nursing interventions should the nurse include in the plan of care for this client? Select all that apply

Monitor intake and output Administer sitz baths as prescribed Encourage deep breathing exercises

371. The nurse plans to implement which interventions for an infant with a DX of bladder exstrophy? Select all that apply

Monitor lab results and urinalysis Cover the bladder with a sterile, nonadhering dressing

276. The nurse is caring for a client in the postpartum period following c-section delivery. The nurse includes which interventions in the plan of care for this client? Select all that apply

Monitor urine output Monitor bowel sounds Encourage frequent voiding Assess incision and dressing frequently

331. Which intervention is a PRIORITY nursing action for a client experiencing dystocia?

Monitoring fetal status

321. Which is the PRIORITY to monitor in the care of a client with an ectopic pregnancy?

Monitoring the Apical pulse

659. The nurse understands that the client with which religious background will be prohibited from becoming an organ donor?

Muslim

68. A client, brought to the ED is DOA. The family of the client tells the nurse that the client cannot have an autopsy because of religious beliefs. The nurse understands that the client maybe a member of which religion? Select all that apply

Muslim Eastern Orthodox Orthodox Judaism

651. Which religions may prohibit autopsy? Select all that apply

Muslim Orthodox Jew Eastern Orthodox Christian

461. A client has been DX with paronychia. The nurse understands that this is a disorder of which structure?

Nails Rationale: paronychia usually occurs with a torn cuticle or ingrown toenail

536. The nurse notes that a client is having regular rapid and deep sustained respirations. The nurse should document these findings as which type of respirations?

Neurogenic hyperventilations

171. Calcitriol is administered to a client. Which findings should the nurse expect to note regarding this medication? Select all that apply

Normal serum calcium levels normal serum phosphorus levels

262. The nurse caring for a client who is taking valerian root for induction of sleep notes that the client has recently begun to have difficulty walking. Which action by the nurse is MOST APPROPRIATE at this time?

Notify HCP

Excessive drainage from a craniotomy incision saturated dressing greater than 50 per shift

Notify HCP of the color and amount of drainage

98. The nurse enters a client's room and the client is demanding release from the hospital. The nurse reviews the client's record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder and that the admission was voluntary. Which intervention should the nurse take FIRST?

Notify PHCP of the client's stated intent to leave the hospital

129. The new nursing graduate understands that nursing care plans enhance continuity of client care by serving as a written guideline and ensuring communication by identifying which item?

Nursing actions necessary to achieve the goals of care

563. The nurse is monitoring a client with myasthenia gravis for cholinergic crisis. Which findings indicate that this is occurring? Select all that apply

Pallor Blurred vision Abdominal cramps

485. Which nursing action indicates accurate knowledge of care of the client with an arteriovenous fistula (AV) for hemodialysis?

Palpate for a thrill at the fistula site Check pulse and circulation distal to the fistula Auscultate for the presence of a bruit at the fistula site Do not measure B/P on the extremity with the fistula

459. The nurse is reinforcing instructions to a client in how to perform a testicular self examination (TSE). Which instructions should the nurse reinforce? Select all that apply

Perform the examination after a shower Call the HCP if any lumps are felt

28. The nurse should take which action to accurately determine the length of a NGT for insertion in an adult client?

Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process

60. The nurse understands that the dietary preferences of an AfricanAmerican client may include which foods? Select all that apply

Pork Rice Greens Fried foods

58. The nurse has a prescription to administer the morning medications to a client through a NGT that is connected to wall suction. The nurse should implement which action to perform the procedure correctly?

Position the client in an upright position before medication administration Rationale: client should stay in upright position for 30-60 minutes after administration of medication

260. The nurse is caring for a client who has recently been prescribed melatonin to aid in sleep. Which PRIORITY finding should the nurse report to the HCP before administering the medication

Possibility of pregnancy

351. The nursing student is asked to identify quickening and what type of sign of pregnancy this process represents. The student accurately defines this process as which sign?

Presumptive

14. A client with DM has a glycosylated hemoglobin A1 C level of 9%. On the basis of this test results, the nurse plans to reinforce teaching the client about the need for which measure?

Preventing and recognizing hyperglycemia

272. A client calls the HCP's office to schedule an appointment because a home pregnancy test was performed and the results were positive. The nurse determines that the home pregnancy test identified the presence of HCG in the urine. The nurse understands this indicates which findings?

Probable sign of pregnancy

71. The nurse enters the room of a client whose wastebasket is on fire. The nurse removes the client from the room, closes the door, and activates the fire alarm. After obtaining the fire extinguisher, which action should the nurse perform NEXT in preparing to extinguish the fire?

Pull the pin Rationale: PASS Pull Aim Squeeze Sweep

609. The nurse reinforcing teaching to a client with chronic airflow limitation about actions and actions that will help breathing during dyspneic episodes? Select all that apply

Pursed lip breathing Using a incentive spirometer Standing and leaning against the wall

333. TB is suspected in a pregnant woman, and a sputum culture is obtained and identifies Mycobacterium TB in the sputum. The nurse reinforces instructions to the mother regarding therapeutic management of the TB and provides the mother with what information? Select all that apply

Pyridoxine (VitaminB6) will be administered concurrently with isoniazid Isoniazid, pyrazinamide, and rifampin (Rifadin) will be needed for a total of approximately 9 months

188. A client has been given a prescription for gemfibozil (Lopid). The nurse reinforces instructions to the client to limit which food while taking this medication?

Red meat Rationale: gemfibozil reduces lipids

221. A client has begun medication therapy with pancrelipase (pancrease MT). The nurse concludes that the medication is having the optimal intended benefit if which effects are observed? Select all that apply

Reduction of fatty stools Improved nutritional status

102. The nurse manager is confronted by an angry HCP who states "You run the most inefficient unit in the hospital. I asked for my charts to be pulled and set up in a rack for rounds, and it is never ready when I arrive!" What is the MOST APPROPRIATE response by the nurse?

Remain silent, and then make a neutral response

Pubic lice

Remove with nit comb Sexual partner should also receive treatment Wash clothes and linens with hot water Wash pubic area with lice treatment shampoo

Storming stage means

Responding emotionally to task

555. A client who has sustained a fractures is to undergo reduction of the affected area. The nurse understands that this procedure achieves which outcome?

Restoration of the bone to proper alignment

307. The nurse is analyzing the results of a nonstress test that was performed on a pregnant client and notes that the results was "unsatisfactory." The nurse understands that this result indicates which findings?

Results cannot be interpreted

27. The nurse determines that the client understands the elements of follow-up care after a bone scan if the client states that he or she should perform which actions? Select all that apply

Resume the usual diet Drink plenty of water for a day or two following the procedure

342. The rubella titer is performed on a woman who has just been told that she is pregnant, and the results of the titer indicates that the mother is not immune to rubella. Which prescription should the nurse anticipate to be prescribed for this mother?

Retesting rubella titer during pregnancy

417. What type of skin traction reduces and realigns the fracture site

Russell traction

Hallucinations represent a serious

Safety risk to the client and others

72. The HCP prescribes the application of a heating pad to a client's back after discharge. The nurse should reinforce which instructions in the discharge teaching? Select all that apply

Set the heating pad on a low setting Cover the heating pad with a pillow case or towel Check the heating pad periodically for proper electrical function Check the skin integrity regularly for signs that the pad is too warm

139. The nurse is signing as a witness on an informed consent form for a client who is undergoing surgery. The nurse understands that in most states, signing as a witness indicates which condition?

Signing as a witness to the client's signature

517. The nurse is caring for a client who was recently DX with gastric cancer. The nurse understands that which are risk factors for this type of cancer? Select all that apply

Smoking Alcohol consumption Helicobacter pyloriinfection

648. A client who witnessed a terrorist attack exhibits the inability to talk. The nurse interprets this characteristic as indicative of which condition?

Somatization disorder

Ventricular repolarization

T wave represents

Signs of dehydration

Tachycardia Postural hypotension Dry mucosa membranes and poor skin turgor Flat neck and hand veins Decreased urine output Weight loss Confusion and lethargy

173. The nurse is caring for a client who has been prescribed salmeterol (Serevent Diskus) and is monitoring the client for adverse effects of this medication. Which findings would indicate potential development of an adverse effect?

Tachycardia= heart rate above 100, fast heart rate Diaphoresis= sweating Increase B/p

124. While riding the elevator to their assigned unit, two nurses are talking about a client who is hospitalized in the mental health unit. Which descriptions are accurate about confidentiality in this situation? Select all that apply

Talking about clients in public places is a violation of the clients confidentiality Talking about clients in public places can result in disciplinary action for the nurses

224. The nurse notes that a client receiving olanzapine (Zyprexa) is moving her mouth, protruding tongue, and grimacing. The nurse interprets that the client is experiencing which medication complication?

Tardive dyskinesia = involuntary, repetitive body movements

471. The nurse caring for an older client understands that which finding is abnormal related to the integumentary system?

Tearing of the skin

318. The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse accurately describes the process by making which statement?

The arteries carry waste products away from the fetus, (with two Arteries and one vein)

590. the primary care nurse is checking heart sounds on a client. The nurse understands that the second heart sound (S2) is heard BEST at which anatomic location

The base of the heart (S1 is best heard over the apex of the heart)

87. The nurse is caring for a client who is scheduled to have an EEG. The nurse determines that the client is ready for the procedure after noting which findings? Select all that apply

The client has shampooed their hair The clients antidepressant has been withheld for 48 hours as prescribed

16. The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for potassium deficit?

The client receiving NG suction Rationale: potassium-rich GI fluids are lost through GI suction

631. The nurse is caring for a Jewish client who was in a serious car accident and is on life support. With regard to the client's religious beliefs, the nurse understands which information?

The client should not be left alone at any time, and the presence of a rabbi is desirable.

148. Malpractice is determined if the nurse owed the client a duty and did not carry out the duty. What other aspect is required for malpractice to have occurred?

The client was injured

131. The nurse manager working in the ICU has adopted a bureaucratic leadership style. Which description is characteristic of this leadership style?

The manager relies on organizational policies and procedures for decision making

122. The nurse has filed an incident report after a client sustained a fall. The nurse should place the report in which location?

The nurse supervisor's locked mailbox

115. The nurse is collecting data on a newly admitted older client and suspects physical abuse. Which is MOST at risk for abuse?

The older client who is dependent on children to manage instrumental activities of daily living

146. The nurse understands that the central concept w/i the ethical principles of justice is identified by which description?

The order in which clients are cared for

327. The nurse is reviewing the record of a pregnant client and notes that the HCP has documented the presence of Goodell's sign. The nurse determines that the sign is indicative of which findings?

The softening of the cervix that normally occurs during pregnancy

295. A pregnant client in the prenatal clinic is scheduled for a biophysical profile and asks the nurse what test involves. What are the MOST APPROPRIATE nursing responses? Select all that apply

The test measures amniotic fluid volume and fetal tone This test measures FHR and breathing movements

Client with pneumonia who is receiving IV fluids and has a new S3 heart sound

This could be volume overflow or heart failure

442. The nurse is gathering supplies in preparation to administer a tepid bath to a child with a fever. Which items should the nurse gather? Select all that apply

Towels Washcloths Rubber toys Lightweight PJ's

572. The nurse is collecting data on the neurological system of a client and asks the client to clench the teeth and then attempts to open the jaw while telling the client to try to keep the jaw closed. Which cranial nerve is the nurse testing?

Trigeminal

189. The client who is HIV seropositive has been taking ritonavir (Norvir). The nurse tells the client that which follow up lab study will be necessary while taking this medication?

Triglyceride level Rationale: this medication can increase triglyceride levels

374. Erik Erikson's stages of psychosocial stages

Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority Identify versus role confusion

271. The nurse is monitoring the fetal pattern of a client in active labor and notes a late deceleration on the monitor strip. Which statement is MOST APPROPRIATE? Select all that apply

Turn the client on her side Administer oxygen via face mask

501. The nurse is assisting in collecting data on a neurologic assessment and is checking the spinal accessory nerve (CN XI). The nurse should ask the client to perform which action to test this nerve?

Turn the head to the side, and resist the examiners attempt to punch the face toward the middle

78. The nurse just checked a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to MOST carefully monitor which parameter during the next hour?

Urinary output of 20 ml in 1 hr Rationale: minimum urinary output should be 30 ml/hr

640. A client who is DX with dementia becomes increasingly disoriented and confused as night. Which interventions should the nurse implement for this client? Select all that apply

Use a nightlight Provide a consistent nighttime routine

444. The nurse is reviewing the lab values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 20,000 cell/mm3. On the basis of this lab result, which interventions should the nurse document in the plan of care? Select all that apply

Use a soft toothbrush for mouth care Check urine and stools for signs of bleeding

137. The nurse working in the long term care setting understands that special consents are required in which statements? Select all that apply

Use of restraints Photo of client Performing autopsy Donating organs after death

387. The clinic nurse is data collection on the communication patterns of a 4m/o infant. The nurse determines that the infant is demonstrating the highest level of development achievement expected if the infant performs which actions?

Uses monosyllabic babbling

302. The nurse caring for a client in the postpartum period suspects subinvolution if which findings are noted? Select all that apply

Uterine tenderness Uterine pain on palpation Change in vital signs from baseline

291. A nurse is assisting with the delivery of a newborn infant. Which findings indicate that the placenta has separated from the uterine wall and is ready for delivery? Select all that apply

Vaginal fullness Changes in the shape of the uterus A sudden gush of dark blood from the introitus

588. The nurse is reinforcing postoperative instructions to a client who is about to undergo open reduction internal flexion (ORIF) on the right hip. Which information should the nurse provide to the client regarding what to expect postoperatively?

You will need to flex and extend your feet regularly and wear sequential compression devices

Amniotomy

artificial rupture of membranes

Acute epiglottis

inflammation of larynx caused by bacterial/viral infection can be dangerous when it closes glottis and causes suffocation

Allens test

occlude both ulnar and radial artery until hand blanches then release ulnar. If the hand pinks up, ulnar artery is good and you can carry on with ABG/radial stick as planned. ABGS must be put on ice and whisked to the lab.

112. Which responsibilities for disaster preparedness is the US are functions of ARC (American Red Cross) as opposed to FEMA? Select all that apply

provide crisis counseling Identify and train personnel Handle inquires from families

296. A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse midwife prepares to perform the amniotomy. The nurse who is assisting the nurse midwife understands that the fetus has to be at which station in order for this procedure to be performed?

0 station Or + station

257. A hospitalized client with DM receives regular insulin at 0700. The MOST carefully monitors the client for a hypoglycemic reaction between which hrs?

0800-1200 hours Regular insulin 1-5 hrs peak

50. Applying and removing PPE

1. mask 2. Gown 3. Gloves 4. Gloves 5. Gown 6. Mask

178. A client receiving long term therapy with lithium carbonate (Lithobid) exhibits polyuria and prolonged vomiting and diarrhea. The nurse anticipates that the results of the most recent serum lithium level will be between which levels?

1.5 and 2 MEq/L Rationale: TR lithium carbonate 1-1.4 mEq/L

450. Cycloserine (Seromycin) is added to the medication regimen for a pediatric client with TB. The recommended dosage is 10 mg/kg/day. The child weights 66lbs. The medication is dispensed as 150 mg/5ml. How many ml should the child receive daily? Fill in the blank D/A x volume = ml

10 ml

324. The nurse understands that chorionic villus sampling (CVS) is performed ideally between which weeks of gestational age?

10-13 weeks

319. The nurse prepares to check a FHR using a Doppler Ultrasound knowing that the FH beat can first be heard with this device at which gestational week?

12 weeks

HC03

22-26 mEq/L

323. A woman is pregnant for the 4th time. She had one spontaneous abortion in the first trimester, a son who was born at 36 weeks, a daughter who was born at 30 weeks. What is her GTPAL score?

4,0,2,1,2

435. The nurse is administering neonatal resuscitation with a ventilation bag and mask because the newborn is apneic and gasping and the HR is below 100 bpm. The nurse should deliver how many breath/min?

40-60

2. The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions with regard to avoiding the use of herbal medications?

A 10 y/o female client with a UTI Rationale: children should not be given herbal therapies, especially in home without professional supervision

126. The nursing instructor is conducting a teaching session regarding the role of a case manager. Which statement, if made by a student, indicates a NEED FOR FURTHER INSTRUCTION?

A case manager's involvement ceases after discharge

454. The nurse plans to monitor which client for signs of hyperkalemia?

A client with severe burn injuries

127. The nursing instructor is conducting a teaching session on nursing care plans. Which statement, if made by the student, indicates for the NEED FOR FURTHER INSTRUCTIONS?

A nursing care plan involves members of the health care team ONLY

430. The nurse is assisting the HCP to perform the Ortolani maneuver on an infant with developmental dysplasia of the hip. The nurse determines that a positive response to this maneuver is which findings? Select all that apply

A palpable click upon entry of the femoral head over the acetabular ring A clunking sensation indicating the dislocated femoral head moving into the acetabulum

53. The nurse monitoring the lab results for a client receiving an antineoplastic medication by the IV route should be prepared to initiate bleeding precautions if which lab result is noted?

A platelet count of 50,00 cells/mm3

237. The nurse is listening to a 52y/o client's apical pulse before giving digoxin and notes that the heart rate is 58 bpm. How should the nurse interpret this?

Abnormal and requires further assessment NORAML range 60-100

367. The nurse monitors a child with increased ICP for signs of decerebrate posturing. The nurse observes for which characteristic of this type of posturing?

Abnormal extension of the upper extremities

293. The nurse is monitoring a client with a suspected DX of abruptio placentae. Which finding would the nurse expect to note?

Acute abdominal pain

207. A hospitalized client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client's blood pressure and administers nitroglycerin 0.04 mg sublingually. Five minutes later, the client is still experiencing chest pain. The B/p is still stable, the nurse should take which action NEXT?

Administer another nitroglycerin tablet

202. Which action by the nurse demonstrates safe administration of subcut enoxaparin (Lovenox)?

Administer the medication in the right anterolateral abdominal wall

653. A client has been admitted to the psychiatric unit for displaying violent behavior and is at risk for potentially harming others. The nurse should take which actions when caring for this client? Select all that apply

Admit the client to a room near the nurses station Face the client while speaking and providing nursing care Arrange for security officer to be available in the general area

512. The nurse is caring for a client with a latex allergy. The nurse understands that the common routes of exposure to this allergy include. Select all that apply

Aerosol Mucosal Parenteal Cutaneous

49. The nurse notes that the client's mechanical ventilator is set to control mode. The nurse understands that this setting well achieve which action?

Allows the lungs to rest

336. Which client is MOST at risk for developing postdelivery endometritis?

An adolescent who is experiencing an emergency c-section delivery for fetal distress

242. On review of a client's medication history, the nurse notes that the client is taking felodipine (Plendil). The nurse suspects that the client has which disorder?

Angina

246. A client has been prescribed scopolamine (Transderm Scopy). The nurse notifies the HCP if which condition is noted in the heath history?

Angle closure glaucoma

561. A client has been DX with cellulitis of the lower leg. The nurse anticipates that which interventions will be prescribed for this client? Select all that apply

Antibiotics Cleansing the skin with antibacterial soap Applying warm compresses to the affected area

657. Pharmacological therapy is prescribed for a client with Tourette's syndrome. The nurse expects that which type of medication will be prescribed?

Antidyskinetic

47. The nurse is conducting a respiratory assessment and is determining respirations per minute. The nurse understands that which factors generally affect the character of respirations? Select all that apply

Anxiety Exercise Smoking Acute pain Body position

258. The nurse gathers data from a client who has been taking buspirone hydrochloride for 1 month and determines that the medication is EFFECTIVE if the client reports an absence of which complication? Select all that apply

Anxiety Palpitations

522. The Broca's area is responsible for

Aphasia

638. A client with a DX of depression has experienced poor nutritional intake for the last 3 weeks. Which nursing interventions are MOST APPROPRIATE to address the client's poor nutritional intake? Select all that apply

Arranging to sit with the client during meals Offering several small meals and snacks Consulting with the nutritionist to provide a menu that is nutritionally sound

244. The nurse reinforcing dietary plans to teach the client to limit which foods while on Coumadin?

Arugula Romaine Brussels sprouts

642. The nurse understands that which cultural groups emphasize the family as the decision maker as opposed to the individual? Select all that apply

Asian American Native American African American Mexican American

489. The nurse is preparing to give a daily dose of digoxin (Lanoxin) to a client with a DX of A-fib and notes that the serum digoxin leve drawn earlier in the day measures 2.7 ng/ml. The nurse should take which action FIRST?

Assess the client for signs of toxicity Rationale: normal range 0.5-2.0

255. The nurse preparing to administer carboprost (Hemabate) for risk of postpartum bleeding should check the client for contraindications with other medications?

Asthma Cardiovascular disease

208. A client with T2DM is started on tolbutamide once daily. The nurse reinforces teaching to the client to take the medication at what time of the day?

At breakfast, to minimize gastric irritation and to enhance diabetic control

254. The nurse should provide the client with which information regarding the use of diphenhydramine (Benadryl)

Avoid activities requiring mental alertness

629. A client with schizophrenia is experiencing distressful thoughts secondary to paranoia. Which interventions should the nurse include in the plan of care? Select all that apply

Avoid laughing when near the client Maintain individualized socialization with peers

311. The nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which sign would indicate a LATE sign of excessive blood loss?

B/p changes from 130/88 to 89/60

248. The nurse is monitoring a child who is receiving EDTA for the treatment of lead poisoning. The nurse reviews the lab results during treatment and is particularly concerned with monitoring which lab result?

BUN

338. A pregnant client with vaginal bleeding is admitted to the labor unit. The labor room nurse is collecting admission data and would suspect a DX of abruptio placentae if which findings were noted? Select all that apply

Back pain Abdominal pain Increase fundal height Hard, board like abdomen

200. The nurse is caring for a client with MS who is receiving an IV dose of methocarbamol (Robaxin). While caring for this client, the nurse should carefully monitor for which findings?

Bradycardia = low heart rate, below 60 HTN

349. The nurse is reinforcing instructions to a client in the early stages of labor in breathing techniques. The nurse describes a pattern in which the woman blows repeatedly using short puffs when the urge to push is strong. Which BEST describes this breathing pattern?

Breathing to prevent pushing

508. The nurse caring for the client withHIV institutes neutropenic precautions if which lab value is noted?

CD4+ cell count of 200 cells/L Immune system problems occur when CD4+ T-cell count is between 200-499

81. The nurse is reinforcing a general teaching session about foods to eat that decrease the risk of developing cancer. The nurse should tell the client that which foods should be increased in the diet to help decrease the risk for cancer development? Select all that apply

Cabbage Broccoli Apricots Cauliflower Brussels sports Carrots Yellow and green leafy veggies

611. Reinforcement of discharge teaching for the client recovering from an attack of acute pancreatitis should include which intstruction?

Caffeine products should be eliminated as they may aggravate symptoms

142. The LVN working in the long term care facility is planning client assignments for the day. Which PRIORITY consideration should the nurse remain mindful of when preparing the assignments?

Client safety

132. The nurse manager is exercising a type of power on the nursing unit that is based on the ability to punish an employee. Which type of power is the manager using?

Coercive Rationale: coercive power is based on the ability to punish an employer

490. The nurse is discussing the condition of a client with acute respiratory distress syndrome (ARDS) with the HCP. The HCP states that due to fluid in the alveoli, surfactant production is decreasing. The nurse interprets that the natural consequence of insufficient surfactant is which complication?

Collapse of alveoli and decreased compliance

445. The nurse is preparing to implement diagnostic procedure that will confirm the DX for a child with suspected neuroblastoma. The nurse prepares to implement which action?

Collect a 24hr urine sample

539. The Ishihara chart consist of numbers composed of colored dots located within a circle of color dots. The client is asked to read the numbers on the chart to detect if

Color vision

613. The community health nurse is reinforcing a teaching session on lung cancer. S/S of lung cancer

Cough Wheezing Chest pain Hoarseness

241. The client who has an eye injury has been prescribed prednisone. The nurse should MOST carefully monitor for side effects of this medication, especially with what health condition?

DM Rationale: this medication causes blood glucose levels to spike

308. The nurse understands that an amniocentesis is indicated for which purpose? Select all that apply

DX of genetic disorders Assessment of pulmonary maturity DX of fetal hemolytic disease

537. The client who underwent which procedure is MOST LIKELY to have the greatest consistency in effluent from the stoma?

Descending colostomy

288. The postpartum nurse is caring for a client who just delivered a healthy newborn. The nurse would be concerned about the presence of subinvolution if which occurred? Select all that apply

Development of infection Retained placental fragments from delivery

170. The nurse is caring for a client who is taking acetylsalicylic acid (aspirin, ASA). The nurse determines that the client is experiencing metabolic effects of this medication if which findings are noted? Select all that apply

Diaphoresis= sweating Dehydration= loss of body fluids Hyponatremia= low sodium levels in the body

183. The nurse monitors a client with a history of opioid abuse for which S/S associated with opioid w/d? Select all that apply

Diaphoresis=sweating Tachycardia=fast heart rate (over 100) HTN=high blood pressure 140/90 and above Frequent sneezing Abdominal cramps Dysphoric mood= sadness, heaviness, numbness or sometimes irritability and mood swings Nausea Vomiting Diarrhea Muscle aches Piloerection= hair standing up Lacrimation= runny eyes Rhinorrhea= runny nose Yawning Fever Insomnia

164. The client with acromegaly has been started on medication therapy with octreotide acetate (Sandosatin). The nurse should monitor this client for which frequent side effect of this medication?

Diarrhea Nausea Gallstone formation Abdominal discomfort

157. The nurse is caring for a client who shows signs of benzodiazepine w/d. The nurse should ask the client about abruptly discontinuing which medication

Diazepam (Valium)

158. The nurse is caring for a client who has been prescribed suctalfate (carafate). The nurse notifies the HCP if which other medication is noted is noted in the medical record?

Digoxin (Lanoxin)

220. A client taking a MAOI is being monitored by the nurse for hypertensive crisis. Which findings would indicate the presence of this adverse effect? Select all that apply

Dilated pupils N/V Neck stiffness and soreness Occipital headache radiating frontally

670. The behaviors expected of a client with antisocial personality would include which characteristic?

Disregard for the rights of others

259. The client with chronic glaucoma is being started on medication therapy with acetazolamide. The nurse reinforces teaching to the client that which EARLY effect can occur following administration of the medication but subsides in time?

Diuresis - kidneys filter too much bodily fluids

612. S/S of transplant heart rejection

Dizziness Weakness Fatigue HTN Dysrhythmias

448. The nurse is collecting data on a 9y/o child who is suspected of having a brain tumor. Which question should the nurse ask to elicit data related to a hallmark symptom of a brain tumor?

Do you throw up in the morning ?

358. The nurse in the newborn nursery is obtaining admission vital sign on a newborn. The nurse notes that the newborns respiratory rate is 50 BPM and should take which action?

Document the findings

422. The nurse is monitoring a 3m/o infant for signs of ICP. On palpation of the fontanelles, the nurse notes that the anterior fontanelle is soft and flat. On the basis of this finding, which action should the nurse take?

Document the findings

386. The nurse is taking vital signs of a 3 y/o child who is hospitalized with a DX of croup and notes that the respiratory rate is 30 bpm. Which nursing action would be MOST APPROPRIATE?

Document the findings Rationale: normal 20-30

424. A child who has just undergone tonsillectomy is complaining of slight ear pain and is noted to have a low grade fever. Which nursing intervention is MOST APPROPRIATE at this time ?

Document the findings, and continue to monitor

583. The nurse is postoperatively caring for a client following arterial revascularization. The nurse notes redness, warmth, and edema in the affected area distal to the surgical site. What is the BEST nursing action at this time?

Documentation of this finding

104. The graduate nurse is told that the nurse managers leadership style is one of letting the staff nurses make decisions about the unit's operations. When the graduate nurse meets with the nursing staff, which question should the graduate nurse ask to confirm that the nurse manger's leadership style is "laissez-faire."

Does the manager assume a passive non directive approach

100. When a manager is interviewing a newly graduate nurse for an evening position on an orthopedic unit, the manager states that she makes client assignments for the evening and night staff so that the staff can concentrate on immediate client care. The graduate meets with the evening staff and asks what question to validate the graduates impression that the manager is autocratic?

Does the manager foster dependency?

4 year old

Drawing a circle Using spoon and fork Walking up and down stairs

33. The clinic nurse is discussing nutrition with a client who is lactose intolerant. The nurse should reinforce instructions to the client to supplement the dietary source of calcium by eating which foods?

Dried foods

227. The nurse is assisting in monitoring a client with leukemia who is receiving doxorubicin (Adriamycin) by IV infusion. The nurse should monitor for which findings that indicate medication toxicity?

ECG changes Rationale: this medication can cause severe toxicity to the heart

201. The nurse is caring for a client who has been prescribed bupropion (Wellbutrin) for the treatment of depression. The nurse MOST APPROPRIATE reinforces instructions to the client to take this medication at which time?

Early in the day to prevent interference with sleep

6. A hospital client is a lacto-vegetarian. Which food item should the nurse remove from the meal tray?

Eggs Rationale: lacto-vegetarians eat milk, cheese and dairy foods but avoid meat, fish poultry and eggs

392. The nursing instructor is conducting a teaching session on Lawrence Kohlberg's theory of moral development. The nursing instructor describes stage 0 as the infant having no awareness of what is right or wrong. Which stage is being described?

Egocentric judgment

42. The nurse collecting data on the home environment of an older client would be concerned about which unsafe findings? Select all that apply

Electrical cords taped to the floor Electrical appliances and cords near the sink

Polycythemia Vera teachings

Elevate legs and feet when sitting Increase fluid intake during exercise and hot weather Report swelling or tenderness in the legs

591. The nurse is receiving a client in transfer from the post anesthesia care unit following left above the knee amputation. The nurse should take which action when positioning the client at this time?

Elevate the FOB

598. The nurse is caring for a client with severe peripheral arterial disease (PAD) and is reinforcing instructions to the client about proper positioning. The nurse instructs the client that which positions are MOST APPROPRIATE for this disease? Select all that apply

Elevating the feet slightly at rest Sitting upright in a chair without leg elevation Sleeping with the affected limb hanging from the bed

94. The nurse has responded to the scene of a disaster, and the first victim the nurse encounters is one who has a large wound on the leg that is actively bleeding. The nurse should identify this victim as belonging to which classification?

Emergent

62. The nurse has developed a close relationship with a family of a client who is dying. Which nursing interventions are MOST APPROPRIATE in dealing with the family? Select all that apply

Encourage family discussion of feelings Accepting the family's expressions of anger Facilitating the use of spiritual practices identified by the family Keeping the family informed of changes in the client's condition

377. The nurse is reviewing a plan of care for a 7y/o child DX with acute glomerulonephritis. The nurse should follow which PRIORITY intervention in the plan of care?

Encourage limited activity and provide safety measures

644. Which intervention should the nurse include in the plan of care for a client with OCD? Select all that apply

Ensure that basic needs are met ID situations that precipitate compulsive behavior Set limits on behaviors that may interfere with the clients physical well being Implement a schedule for the client that distracts from the compulsive behaviors

569. The nurse is reinforcing instructions to a client who recently obtained a hearing aid. Which action, if performed by the client, indicates a NEED for further instructions?

Ensures the hearing aid is on before removing it from the ear.

562. The client nurse is collecting data on a client who has recently had MI and was discharged from the hospital. Which type of assessment is MOST APPROPRIATE at this time?

Episodic

658. The nurse planning care for a client who is at risk for suicide should include which intervention in the plan?

Establish a therapeutic relationship

144. The nurse who is using concepts of time management understands the importance of which action to ensure EFFECTIVENESS of this strategy?

Evaluate each strategy used at the end of the day

141. The LVN delegates the task of midstream clean catch urine specimen collection to the UAP. The nurse determines that the UAP has completed the task by the agreed upon deadline. What should the LVN do next?

Evaluate the outcome of the task

105. Which statement by the nurse manager reflects the manager's use of legitimate power regarding new policies and procedures?

Every manager has a responsibility to see that this new policy and procedure is followed 100% of the time. Please join me in this organization's efforts to continue to improve quality care

140. The LVN is delegating the task of specimen collection to the UAP. The LVN must be familiar with which requirements before delegation? Select all that apply

Experience of UAP State Nurse Practice Act Job description of the UAP Scope of practice of UAP

398. An adolescent with Ewing's sarcoma requires leg amputation. After the amputation, the child becomes very frightened because of aching and cramping felt in the missing leg. The nurse should perform which action to assist in alleviating the child's fear?

Explain that this is a temporary condition

514. What are the risk factors to laryngeal cancer? Select all that apply

Exposure to mold Frequent respiratory infections

383. According to Lawrence Kohlberg's theory of moral development, the law and order orientation stage is characterized by which finding?

Expressing concern with society as a whole

673. The nurse is providing end of life care of an Islamic client. The nurse understands that which factor is included in this religious group's end of life?

Expressing grief through hitting the body

365. The nurse caring for a newborn suspects the presence of an imperforate anus if which findings are noted? Select all that apply

External fistula of the perineum Stenosis of the anal rectal canal Absence of the anal rectal canal

456. The nurse asks the client to move the eyes into different positions is checking for

Extraocular muscle function

341. The nurse is preparing for the induction of labor for an assigned pregnant client. Which PRIORITY baseline assessment should be obtained prior to induction?

FHR

75. A client is told that she is enemic, and an iron supplement is prescribed. The nurse reinforces dietary teaching and should tell the client that which foods are rich in iron? Select all that apply

Fish Fowl Liver Beans Cereal grains Egg yolk Brewer's yeast Green leafy veggies

113. The community health nurse is preparing to reinforce teaching about "personal and family preparedness for disasters" to parents of school aged children. When MOST APPROPRIATE items needed in the event of a disaster should be included in the teaching? Select all that apply

Flashlight Batteries Battery op/ radio Extra pair eyeglassess

91. The nurse understands that which are examples of medical asepsis? Select all that apply

Hand hygiene Cleaning the over the bed hospital table with agency-approved solution

530. what are the risk factors of colorectal cancer

History of breast cancer 50 y/o and older History of ovarian cancer History of chronic inflammatory bowel disease

547. The primary care nurse is checking a clients risk for testicular cancer. Which factors, if noted in the clients history, are risk factors associated with this type of cancer? Select all that apply

History of undescended testicle Family history of testicular cancer

32. As prescribed, the nurse is applying a dressing to a client's wound that allows wound visualization, is waterproof, and is painless on removal. Which type of dressing material is being used?

Hydrocolloidal

526. Basophils mediate immediate

Hypersensitive reactions

564. A client is scheduled to undergo a thyroid scan with the use of technetium. The nurse describes the test to the client and explains that this substance will be administered by which route?

IV

467. The nurse is reinforcing teaching to a client about breast self awareness. The client asks the nurse where masses are most often found. Which response by the nurse is MOST APPROPRIATE? Select all that apply

In the axilla Beneath the nipple Upper outer quadrant

Hypovolemic shock is associated with

Inadequate tissue perfusion

179. The client who is currently taking levothyroxine sodium (synthroid) complains of cold intolerance, constipation, dry skin, weight gain, and puffy eyes. On the basis of these findings, the nurse anticipates which prescription?

Increase levothyroxine sodium dosage after checking the T4 levels

650. A client who sustained severe injuries in a motorcycle crash was DX with intensive care unit psychosis. The nurse would conclude that the client's status is improving if which client observation is made?

Increases the number of hours slept at one time and is increasingly alert

487. The nurse is reinforcing teaching on early detection of gastric cancer. Which S/S should the nurse include in the teaching session as EARLY S/S of this disease? Select all that apply

Indigestion Full feeling Epigastric pain Abdominal discomfort

626. The nurse should include which information in the nursing plan of care for a client with OCD? Select all that apply

Individualized goals and objectives Attendance at group therapy sessions Self care measures to improve hygiene

438. The nurse is caring for an 8y/o child and notes that the child has developed social, physical, and learning skills. To which stage of psychosocial development has the child progressed?

Industry versus inferiority

130. The charge nurse of a medical surgical unit is using the concepts of leadership and management to ensure functionality of the unit. The nurse understands that, as a leader or manager (as opposed to a follower), it is necessary to have which PRIORITY ability?

Influence others

13. The nurse is caring for a client with a DX of hyperparathyroidism. Lab studies are performed and the serum calcium level is 12.0 mg/dl. Based on this lab value, the nurse should take which action?

Inform the RN of the lab values

578. The nurse educator is observing a nursing student care for a client who is legally blind. The educator intervenes if the student performs which action?

Instructs the client to remain one step ahead of the student when ambulating

Suspension skeletal traction teaching

Intake at least 2L of clear fluids to prevent constipation Ensure weights hang freely and did not touch the ground Monitor for erythema, drainage, swelling, and malodor at pin insertion sites Perform frequent neurovascular checks for 24 hrs

608. The nurse is caring for a 67 y/o client and notes that the client has a sense of fulfillment. To which stage of psychosocial development has the client progressed?

Integrity versus despair

252. Tropicamide (mydriacyl) is prescribed to the client before cataract surgery, because

It dilates the pupil of the affected eye

330. The nursing instructor asks a student to describe uterine soufflé. Which statement by the student indicates an understanding of this term?

It is the soft blowing sound that can be heard when the uterus is auscultated

36. The nurses witnesses a construction worker fall from a ladder. The nurse rushes to the victim, who is unresponsive, and uses which method to open the victims airway?

Jaw thrust maneuver

403. The nurse is assigned to care for an infant with a DX of tricuspid atresia. The nurse plans care, knowing that this disorder has which characteristic?

Lack of communication from the right atrium to the right ventricle

663. A client with a DX of dependent personality disorder is MOST LIKELY to exhibit which problem? Select all that apply

Lacking self confidence Inability to make decisions

528. Dendritic cells perform the same antigen-presenting task as

Macrophages

284. The nurse is caring for a client with dystocia. The nurse understands that which factors are causes of this disorder? Select all that apply

Malpositioned fetus Excessively large fetus Abnormal presentation of the fetus

25. A nursing student is asked to ID the practices and beliefs of the Amish society. Which should the student ID? Select all that apply

Many choose not to have health insurance The believe that health is a gift from God They use both traditional and alternative health care, such as healers, herbs and massage' Funerals are conducted in the home w/o a eulogy, flower decorations, or any other display. Caskets are plain and simple, w/o adornment.

305. The nurse reviews the history in the medical record of a pregnant client with cardiac disease. The nurse understands that which disorders are included inGroup 3 of cardiac disease, having a mortality rate of 25-50%? Select all that apply

Marfan syndrome- genetic disorder that effects connective tissue Aortic coarctation- narrowing of the large blood vessels (aorta) that leads from the heart MI- heart attack

149. Which are examples of negligent act? Select all that apply

Medication errors resulting in injury Failure to monitor an IV flow rate resulting injury A fall that occurs as a results of failure to provide safety measures to a client Failure to report a charge in a client's condition to the HCP

463. The nurse is reinforcing teaching to a client who has DM and diabetic ketoacidosis (DKA) to develop a plan to prevent reoccurrence. Which instructions should be in the plan? Select all that apply

Monitor blood sugar levels 2-4 times daily Notify the HCP when illness occurs

249. Prednisone is prescribed for a client with adrenal insufficiency. When reinforcing teaching to the client about this medication, the nurse should include which points? Selecta all that apply

Monitor edema Report rapid weight gain Stay away from people with infections Take the medication with a meal or snack

498. The nurse is assisting the HCP in performing an edrophonium (Enron) test to DX myasthenia gravis. After administration of the medication, the client's strength deteriorates. The nurse determines that which is the result of the test?

Negative

503. Which description identifies the role of the neutrophil as it relates to the inflammatory process?

Neutrophils phagocytize any potentially harmful agents

Gained 10 lbs on levothyroxine, despite poor appetite, sleepy all the time, lab results show high levels of TSH, nurse should expect

New prescription to increase dose of levothyroxine

484. The nurse notes that a client is exhibiting flexor (decorticate) posturing. The nurse interprets that this is indicative of which problem?

Nonfunctioning cerebral cortex Flexor (decorticate) posturing is characterized by the client flexing one or both arms on the chest and extension of the legs stiffy.

108. After a group therapy session, a client approaches the nurse and verbalizes a need for seclusion because of uncontrollable feelings. Which is the MOST APPROPRIATE nursing action?

Obtain an informed, written consent from the client Rationale: by law for a client to be secluded or restrained, federal law requires written consent by the client

373. The nurse is collecting data on a child with a suspected DX of epiglottis and should take which actions during the data collections? Select all that apply

Obtain axillary temperature Monitor for respiratory distress Ask about the precipitating events Maintain NPO status

175. The nurse is caring for a client who has been prescribed tacrolimus (Prograf)to prevent organ rejection. The nurse MOST APPROPRIATE administers this medication by which method?

On an empty stomach

214. The HCP prescribes entanercept (Enbrel) for a client with RA. Which findings indicate to the nurse that the client is experiencing an injection site reaction to the medication? Select all that apply

Pain Itching Swelling Erythema= redness of the skin

51. The nurse should implement droplet precautions for a client with which communicable disease? Select all that apply

Pertussis Respiratory syncytial virus Scarlet fever

3. The RN reviews the results of the AGB values with the LVN and tells the LVN that the client is experiencing respiratory acidosis. The LVN should expect to note which on the Lab result report?

Ph 7.25, PCO2 50 mmHg

593. The nurse notes during data collection and history taking that an older client is exhibiting vision changes. The nurse determines that which finding requires the NEED FOR FOLLOW UP?

Photophobia

634. The nurse educator is conducting a teaching session regarding bullying. The nurse educator informs the students that the bully's power arises from which sources? Select all that apply

Physical strength and maturity Higher status within a peer group Knowing another child's weakness Recruiting other children as support

372. According to Freud's psychosexual stages of development, which description is associated with the phallic stage of development?

Pleasurable and conflicting feelings about the genital organs

187. A preoperative client has HCP prescriptions that state the client must be NPO after midnight. In reviewing the client's medications, the nurse should question the prescription to withhold which medication and determine whether it should be administered parenterally?

Prednisone (corticosteroids)

510. A client has experienced an anterior wall MI complains of dizziness and has a B/P 80/40 mm Hg. The cardiac monitor shows the following (no P waves )

Prepare for noninvasive temporary pacing

216. Desmopressin acetate (DDAVP) promotes which in DI

Promotes renal conservation of water

624. The nurse should use which approach when caring for a client with a DX of acute schizophrenia?

Provide assistance with grooming and nutrition until the client's thinking is cleared

411. The nurse understands that a PRIORITY consideration in caring for the child with autism is to ensure which intervention?

Provide consistency with routines

494. An anxious client is experiencing respiratory alkalosis from hyperventilation. The nurse should perform which action to assist the client?

Provide emotional support and reassurance

83. The client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Which interventions are focused on these abnormal lab values to promote client safety? Select all that aplly

Provide the client with a soft toothbrush Instruct the client to use an electric razor Monitor all secretions for frank or occult blood

281. The nurse is caring for a postpartum client who has had an episiotomy. Which prescription should the nurse question if noted in the medical record?

Provide warm packs during the first 24 hrs Rationale: never warm but use cold packs for swelling

514. The nurse is caring for a client who has lost a lot of blood due to complications during surgery. The nurse understands that which procedure will give the EARLIEST indications of fluid volume deficit?

Pulse rate

Ventricular depolarization

QRS wave

Ventricular refractory time

QT interval represents

317. The nurse monitors for which associated risk in a client who has just deliver a newborn following a pregnancy with a placenta previa? Select all that apply

Shock Hemorrhage

647. Which description is accurate with regard to Native American beliefs on end of life care?

Some avoid contact with the dying

427. The nurse is reinforcing discharge instructions to the parents of a child who has undergone tonsillectomy. The nurse should plan to reinforce which direction in the instructions?

The child should avoid crowds at this time

394. The nurse is reinforcing instructions to the mother of a child with cystic fibrosis. (CF) regarding the child's immunization schedule. Which statement should the nurse make to the mother?

The child will receive the recommended basic series of immunizations along with a yearly pneumonia and influenza vacccinations

652. The nurse is collecting data on a client with dissociative amnesia. Which description characterizes localized amnesia?

The client blocks out all memories about a specified period

499. The nurse notes that the HCP has documented a DX of sensorineural hearing loss on a client's chart. Which finding would the nurse expect to note for this client?

The client complains of ringing in the ear

641. The nurses is reviewing the record of the client who was admitted to the mental health unit by voluntary status. The nurse interprets this status as indicating which client information?

The client has the right to demand and obtain release from the hospital

597. While performing a neurologic data collection, the nurse notes that the client exhibits in coordination and unsteady gait. How would the nurse correctly document this finding in the medical record?

The client is demonstrating ataxia Ataxia is a failure of muscular coordination resulting in incoordination and an unsteady gait

596. The nurse enters the room of a client who had a craniotomy to check the client and intervenes if which finding is noted?

The client is in an upright position with the hips at a 90 degree angle

97. The night nurse received reports from the evening nurse on assigned clients. Which client should the nurse determine as HIGHEST PRIORITY?

The client who has DM, had a FBS of 56 mg/dl @6am, and Denise S/S of hypoglycemia; the last 15 min blood glucose check after intervention was 65 mg/dl

117. the following four clients arrive at a nursing unit w/i 5 minutes of each other. Which client can the LVN take?

The client who needs admission to the unit after being released from the PACU following appendectomy and whose condition is STABLE

150. The nurse working on medical surgical unit has received the assignment and report on the assigned clients. Which client should the nurse care for FIRST?

The client with COPD who required two respiratory treatments during the previous shift

8. The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse expects that this sodium level would be noted in a client with which condition?

The client with the syndrome of inappropriate secretion of antidiuretic hormone

519. The nurse is checking a client who has a T tube that was placed following open cholescytectomy. The nurse intervenes if which finding is noted?

The drainage system is above the level of the location of the gallbladder

125. Which accurately describes the principles of respondent superior?

The employer is ultimately responsible for any negligent act of an employee that is w/i the employee's scope of responsibility

250. Butorphanol tartate is prescribed for a women in labor. The nurse should make which statement to the client about the medication?

The medication provides pain relief during labor

280. Which statement BEST describes the takinghold phase in a postpartum client according to Rubins phases of regeneration?

The mother is independent

350. The nurse is reinforcing instructions to the mother of a newborn in the proper procedure for cord care. Which action, if performed by the mother, indicates a need for further TEACHING?

The mother keeps the diaper over the cord for protection

405. The nurse is checking the status of jaundice in a child with hepatitis. Which anatomic area provides the BEST data regarding the presence of jaundice?

The nail beds Sclera Oral mucosa

116. A client is involuntarily admitted to the mental health unit because of episodes of extremely violent behavior toward himself and others. The client is now demanding to be discharged from the hospital immediately and threatens to "break every window in my room" if stopped. The nurse tells the client he will not be allowed to leave and calls security to the unit. The client states " I will sue!" Which represents the legal ramifications associated with the nurses interventions?

The nurse is reacting responsibly, so there are no legal consequences

580. Stereognosis is tested by determining the clients ability

To recognize familiar objects placed in the clients hands

138. The nurse understands that clients who are mentally or emotionally incompetent are unable to sign informed consent for themselves. Which conditions indicate that a client is mentally or emotionally incompetent? Select all that apply

Unconscious Chronic dementia Declared incompetent Under the influence of chemical agents/alcohol

523. Wernick's area consist of a small group of cells in the temporal lobe whose function is

Understanding language

196. The nurse is caring for a client who has been prescribed silver sulfadiazine (silvadene) for the treatment of burn injuries. Which baseline studies should be completed before initiation of medication therapy? Select all that apply

Urinalysis Renal function studies Hepatic function studies CBC (complete blood count)

111. From the following list of nursing activities, which can be performed by the LVN? Select all that apply

Urinary catheter Endotracheal suctioning IM medication admin Subcut medication admin

425. The nurse is reinforcing instructions regarding the administration of insulin to an adolescent who is newly DX with T1DM. The nurse tells the adolescent to follow which procedure for injection sites?

Use one major site for the morning injection and another site for the evening injection for 2-3 weeks before changing major sites

464. Which findings is the MOST characteristic manifestation of a right colon tumor?

Vague abdominal discomfort

418. The nurse is reinforcing discharge instructions to the mother of a child who has heart surgery. Which statement by the mother indicates a need for further INSTRUCTIONS

Visitors are not allowed until total healing occurs

4. The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is MOST IMPORTANT for the nurse to check which item?

Vital signs Rationale: change in vitals can indicate transfusion reaction

240. When on Coumadin the nurse reinforces the client to limit foods high in what substance

Vitamin K

524. The motor cortex in the precentral gyrus controls

Voluntary motor activity

668. The nurse understands that exploring and evaluating client problems occur during which phase of the therapeutic nurse client relationship?

Working

390. The nurse is reinforcing instructions to the mother of an infant who had a cleft palate repair. Which statement should the nurse make to the mother?

You may resume breastfeeding in the postoperative period

334. What instructions is MOST APPROPRIATE for the nurse to reinforce to the pregnant client with cardiac disease in order to prevent complications during pregnancy?

You should limit physical activity and be sure to get enough rest

Hemoglobin normal range

female: 12-16 male: 14-18

Polycythemia Vera

general increase in red blood cells

ventricular diastole

relaxation of the ventricles

Albuterol use

use during acute exacerbation Then use beclomethasone inhaler 5 min after albuterol Rinse your mouth after using beclomethasone inhaler

40. The nurse is caring for a client whose religious background is seventh day Adventist ( church of God). Which nursing actions are MOST APPROPRIATE in terms of providing for the dietary needs for this client? Select all that apply

Remove coffee from the breakfast tray Ensuring that there is no pork on the dinner tray Ensuring that meals are delivered in a timely fashion

44. The nurse is caring for a client whose religious background is Orthodox Judaism. The nurse is delivering the dinner tray to the client. Which nursing actions are MOST APPROPRIATE in order to provide for the dietary needs of this client? Select all that apply

Removing the milk if there is meat on the tray Determining that any fish being served have scales or fins Checking to be sure that any meat being served is from an herbivore Asking the client about any specific dietary preferences that need to be followed

282. A pregnant client just underwent a lumbar epidural block. The nurse should PRIORITIZE monitoring of which parameter frequently?

Respirations

433. The nurse is checking the respirations of a newborn who was just admitted to the nursery and should notify the HCP if which finding is noted?

Respiratory rate of 70 bpm Rationale: normal is 40-60 bpm

46. The nurse should institute contact precautions for which disease?

Respiratory syncytial virus Rationale: respiratory syncytial virus spreads thru direct client contact or environmental contact

52. The nurse is gathering data by inspecting the lacrimal apparatus of a client's eye. Due to its anatomical location, the nurse should perform which action?

Retract the upper eyelid and ask the client to look down

136. The quality improvement nurse working in the long term care setting is performing an evaluation and is using past medical records after the client's discharge for documentation of compliance with standards. Which type of evaluation is being performed by the nurse?

Retrospective review

299. 20 weeks gestation of pregnancy should be located where on the abdomen?

Right below the umbilicus

174. A client is receiving a phenothiazine antipsychotic medication on a daily basis. The nurse should reinforce teaching the client to implement which measure to minimize common side effects of this medication?

Rinse mouth with water frequently Sucking on hard candy Chewing sugarless gum

154. The nurse is caring for a client with metastatic breast cancer who is taking tamoxifen citrate (Nolvadex). The nurse plans to monitor for which trend in lab values for this client

Rising serum calcium levels Before initiation of therapy, get complete blood count, platelet count and serum calcium level

567. The nurse caring for a client with psoriasis understands that this condition typically affects which body parts?

Scalp Knees Elbows Sacral region

391. The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS) which finding would alert the nurse to the possibility of RDS?

Seesaw respirations

76. The nurse interprets from a client's behavior that the client maybe experiencing dysfunction in the area of the cochlea of the ear. The nurse should base this assumption on which symptom displayed by the client?

Sensorineural hearing loss

402. The nurse understands that which are characteristics of separation anxiety that can occur in a 2y/o child? Select all that apply

Separation anxiety can manifest as detachment The child may ignore the parents when they visit The child forms shallow relationships and is self centered

37. The nurse understands that which are examples of a nosocomial infection occurring in a health care facility? Select all that apply

Sepsis that results from contaminated IV fluid A UTI that develops after catheter insertion A streptococci wound infection that develops in a postoperative client The development of C-diff in an immunocompromised client A respiratory tract infection that develops in a client receiving frequent respiratory treatments and requiring frequent suctioning

182. The nurse is caring for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet (Foscavir). The nurse reviews the lab test results and determines the presence of adverse effect if which finding is noted?

Serum creatine 2.0mg/dl

665. A client with a DX of catatonic stupor is lying on the bed, hidden under the sheets, with their body pulled into the fetal position. The nurse should take which appropriate actions? Select all that apply

Set beside the client in silence and ask occasionally, open ended questions Leave the client alone, but check on her every 20-30 minutes

273. Data are collected on a pregnant client in labor, and the nurse notes that the client's hemoglobin;ob in and hematocrit levels are low, indicating anemia. The nurse should be MOST concerned about which findings?

Signs of infection Rationale: anemia clients are at higher risk of cardiac failure during labor, postpartum infections and poor wound healing

352. The home care nurse is visiting a prenatal client who has a history of heart disease. The nurse reinforces instructions to the client about home care measures to promote a healthy pregnancy and instructs the client to perform which actions? Select all that apply

Sleep on the left side Restrict visitors who may have an active infection Avoid the Valsalva maneuver because this causes strain on the heart

672. The nurse understands that which description are accurate with regard to the beliefs of the Amish? Select all that apply

Some prefer not to be photographed Funerals are conducted in the hone without a eulogy At death, a women is usually buried in her bridal dress Members highly value responsibility generosity, and helping others

637. The nurse is caring for a chemically dependent client who has the potential for violence. The nurse should implement which interventions? Select all that apply

Speaking slowly to the client Moving slowly when approaching the client Projecting an attitude of calm when caring for the client Encouraging the client to talk out feelings rather than act on them

581. The nurse has obtained a urine specimen from a client for UA. The nurse understands that placing the specimen in the refrigerator may cause an alteration in which lab finding?

Specific gravity

457. The nurse is reinforcing dietary instructions to a client who needs to eat an alkaline ash diet. The nurse determines that the client understands the information resented if the client chooses which selection from a diet menu?

Spinach salad, milk and a banana

283. A pregnant client is DX with syphilis. The nurse is aware that the client is MOST at risk for which complication of pregnancy?

Spontaneous abortion Rationale: maternal infections such as syphilis, toxoplasmosis, and rubella can cause spontaneous abortions

540. The nurse is reinforcing instructions to a hospitalized client with a DX of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? Select all that apply

Standing and leaning against a wall Sitting up and resting the elbows on the knees Sitting on the side of the bed and leaning on an over bed table

551. The nurse is caring for a client who has had a MI. The client asks about the risk factors for MI to minimize the possibility of reoccurrence. The nurse informs the client that which are risk factors? Select all that apply

Stress HTN Atherosclerosis- narrowing of the blood vessels due to plaque Coronary artery disease

618. A client is DX with hypopituitarism. The nurse reviews the client's medical record expecting to note a history of which conditions that can be a cause of this disease? Select all that apply

Stroke Tumors Trauma Encephalitis Autoimmunity

234. A client is scheduled to receive acetylcysteine (Mucomyst) 20% solution diluted in 0.9% NS by nebulizer. The nurse checks the clients room to ensure that which equipment is available for use as needed following the administration of this medication?

Suction equipment

421. After a tonsillectomy, the nurse reviews the HCP's postoperative prescriptions. Which prescriptions should the nurse question? Select all that apply

Suction every 2 hours Offer ice cream for sore throat

198. A client with MI is a candiate for alteplase (Activase) therapy. The nurse caring for the client is aware that it will be necessary to monitor for which adverse effect if the client receives this treatment?

Superficial bleeding

544. the nurse is reinforcing preprocedure instructions for a client who is undergo tomography of the ear. The nurse MOST APPROPRIATELY informs the client that he will need to be in which position during this test?

Supine

85. The nurse is preparing a client who will be undergoing a bone scan. The nurse MOST APPROPRIATE explains to the client that which position will be necessary for this procedure?

Supine

462. A client who underwent cardiac catheterization in the left femoral artery returns to the nursing unit. The nurse should plan to place the client in which position?

Supine, with the HOB elevated no more than 15 degrees

356. APGAR scoring

0= HR absent, respiratory absent, muscle tone limp or hypotonic, bulb response, no response, acrocyanotic cyanosis of extremities 1= less than 100, slow or irregular cry, some extremity flexion, grimaces, pink 2= greater than 100, good, crying lustily, irritability or flexes, cough, sneeze or vigorous cry,

585. Scoring for deep tendon reflex activity is

0= no response 1+= sluggish or diminished 2+= active or expected response 3+= slightly hyperactive, more brisk than normal, not necessarily pathologic 4+= brisk, hyperactive with intermittent clonus associated with disease

186. Cytarabine (Cytosar-U) has been prescribed for a client with acute lymphocytic leukemia. The nurse understands that this medication can cause which adverse effect? Select all that apply

Alopecia= patchy hair loss Stomatitis= oral mucositis (painful swelling and sores inside the mouth) Hyperuricemia= excess of uric acid in the blood Hepatotoxicity= liver damage due to exposure of drugs

17. The nurse who is caring for a client with kidney failure notes that the client is dyspneic and crackles are heard when listening to breath sounds in the lungs. Which additional S/S should the nurse expect to note in this client?

An increased in B/P Rationale: impaired cardiac or kidney function can result in fluid volume excess

660. Which characteristics accurately describes anorexia nervosa? Select all that apply

An intense fear of obesity Disturbed body image and disturbed self concept Onset is often associated with a stressful life event The client is often preoccupied with foods that cause weight loss

384. The nursing instructor is conducting a teaching session on Lawrence Kohlberg's theory of moral development. The nursing instructor describes stage 4 as the child having more concern with society as a whole. Which stage is being described?

Law and order orientation

304. Which interventions will LEAST LIKELY assist in promoting mother infant interaction and bonding in a new mother who is fearful and reluctant to handle her newborn? Select all that apply

Leaving the infant with the mother so that she will be required to provide the care Informing the mother that this behavior is not normal and that she may have postpartum depression

636. The nurse understands that which areas need to be explored to conduct a culturally sensitive assessment related to end of life care? Select all that apply

Communication about death The decision making process The significance of pain and suffering The nurse's beliefs on death and dying Amount and type of accepted interventions

404. The nurse caring for the child with strabismus expects to note which finding?

Complains of a headache

153. When caring for a group of clients, the nurse considers which PRIORITY factors to determine which client to care for FIRST? Select all that apply

Complexity of illness Stability of condition Basic needs of the client

22. A client is receiving a continuous IV infusion of heparin sodium to treat DVT. The client activated aPTT time is 65 seconds. The LVN reviews the lab results with the RN, anticipating that which action is needed?

Leaving the rate of the heparin infusion as is

61. The nurse understands that personal health information can be disclosed in which situations? Select all that apply

Compliance with legal proceedings For research purposes in limited circumstances To a family member or significant other in an emergency To appropriate military authorities is a client is a member of the armed forces

439. The nurse in the newborn nursery is preparing to assist to collect data on a newborn. The nurse places the newborn under a warmer before the assessment to prevent heat loss caused by which method?

Conduction

553. The nurse is reviewing the lab results of a client undergoing a glucose tolerance test. The nurse notes that the 2 hour postload glucose level of 220 mg/dl. The nurse interprets this result as indicative of which condition?

Confirmation of DM

235. The nurse is caring for a client who is taking procainamide. The nurse monitors for which S/S that could indicate potential medication toxicity? Select all that apply

Confusion Drowsiness Dizziness Decreased urination

70. The nurse is caring for an older client who has been prescribed buspirone hydrochloride (BuSpar). Which nursing intervention included in the plan of care should be a PRIORITY to ensure safety?

Maintain bed in lowest position Rationale: client is at risk for falls on this medication

483. The nurse is caring for a client who is receiving peritoneal dialysis (PD). Which intervention should be included in the nursing plan of care to prevent the major complication associated with PD?

Maintain strict aseptic techniques

236. The nurse is administering diphenoxylate/atropine (Lomotil) to an assigned client. The nurse monitors for adverse effects of this medication. Which findings indicate that an adverse effect maybe occurring? Select all that apply

Confusion Tachypnea - fast breathing Palpitations - notably rapid, strong or irregular heartbeat due to agitation, exertion or illness Tachycardia- fast heart rate above 100

163. The HCP has prescribed codeine sulfate for a client with a nonproductive cough to suppress the cough reflex. The nurse tells the client to take measures to prevent which frequent side effect of this medication?

Constipation

29. The nurse is caring for an 18m/o child who has been DX with scabies. The health care provider has prescribed Lindane to be applied to the skin to treat the infection. The nurse should take which MOST APPROPRIATE action at this time?

Contact the HCP for clarification Rationale: Lindane should not be administered to children younger than 2 because of the risk of neurotoxicity

586. The nurse is caring for a client in the postoperative period who has just undergone renal angiography. Which nursing action is contraindicated in this care?

Maintaining a supine position with the head elevated 45 degrees

7. The nurse is educating a new nurse about mass casualty events. (Disasters) which statement by the new nurse needs FURTHER TEACHING? Select all that apply

Mass casualty (M/C) events do not require an increase in the number of staff that are needed M/C event occurs only within the health care facility and could endanger staff M/C events occurs if a fight between visitors occurs in the ED

346. In planning care for a postpartum client who intends to breastfeed her infant, the nurse realizes the importance of including what information in the teaching plan to prevent the development of mastitis?

Massage distended areas as the infant nurse

353. The nurse is caring for a postpartum client who is showing signs of bleeding and shock. Which interventions are contraindicated in the care of this client? Select all that apply

Massaging the fundus vigorously Leaving the client's room to notify the HCP

Hydrocolloidal dressing

Material provides absorption, protection and debridement. Waterproof and painless on removal

543. The nurse is caring for a client who has been DX with secondary cataracts. The nurse understands that which disease can cause secondary cataracts? Select all that apply

Maternal rubella DM Servere myopia Ultraviolet light exposure

669. Which descriptions are characteristics of a victim of elder abuse? Select all that apply

May dismiss the injury as accidental Are often socially isolated by abusers Allow abusers to be dependent on them financially

210. Which data is MOST IMPORTANT for a client with hypothyroidism who was recently started on levothyroxine (Synthroid)?

Measure the heart rate

560. A client requires frequent wound dressing changes. The HCP prescribes wet to moist dressing changes with saline moistened gauze. The nurse understands that this type of dressing brings about which action?

Mechanically removes necrotic debris

577. The primary care nurse is reinforcing teaching to a client about risk factors for eye disorders. The nurse MOST APPROPRIATELY provides what information to the client? Select all that apply

Medications Aging process DM Congenital factors

468. The nurse educator is preparing a teaching session on factors that effect malnutrition in the older adult population. Which physiologic risk factors should be included in the presentation? Select all that apply

Medications Sensory changes Chronic health factors Problems swallowing

Performing stage means

Members direct group energy toward completion of task

Norming stage means

Members express intimate personal opinions and feelings around personal task

Forming stage means (initial stage)

Members identify tasks and boundaries

90. A 3y/o child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which MOST LIKELY condition?

Metabolic alkalosis

If contrast dye is used for diagnostic procedures, the nurse should assess the need for discontinuation of

Metformin (Glucophage) because of the risk for metformin induced lactic acidosis associated with the dye

423. A child is brought to the clinic complaining of severe abdominal pain. The child is lying on the examination table with his knees pulled up toward the chest. The nurse assists with further assessment of the progression of the child's pain, knowing that the HCP will palpate the abdomen at which location?

Midway between the right anterior superior iliac crest and the umbilicus

206. The nurse is caring for a client who is taking dantrolene sodium (Dantrium) for the treatment of muscle spasms. The nurse explains to the client that which frequent side effect may occur while taking this medication?

Mild diarrhea Drowsiness Dizziness Weakness General malaise= general discomfort

376. The nurse plans to use which product to clean meconium from the newborns buttock area?

Mild soap solution

410. Which intervention is of LOWEST PRIORITY in the care of a child immediately following surgery to correct cryptorchidism?

Monitoring intake and output

568. A client has been DX with Cushing's syndrome. The nurse should monitor this client for which expected manifestation of this disorder?

Moon face and truncal obesity

63. The nurse reinforces teaching about post procedure instructions to a client who underwent a colonoscopy. Evaluation of patient understanding would be evident if the client makes which statements? Select all that apply

My abdominal muscles may be tender because of the procedure My diet should be light at first and then I can progress to a regular diet It's normal to feel gassy or bloated for a short while after the procedure If I develop a fever following the procedure, I should call the HCP immediately

420. The clinic nurse is reinforcing information to the mother of a toddler regarding toilet training. Which statements would indicate that the mother understands this process? Select all that apply

My child shouldn't be forced to sit on the potty for a long periods The ability of my child to remove clothing is a sign of physical readiness My child will not be ready to toilet train until the age of about 18-24 months Because we are moving to a new town, i will wait to begin toilet training until we are settled

347. The nurses is caring for a pregnant client who has been DX with gonorrhea. Which statement by the client indicates further TEACHING?

My partner does not need to be treated even if the infection is present

229. Epidural catheter in place and the nurse checks for the antidote

Naloxone (Narcan)

1.The nurse reviews a clients electrolyte results and notes that the potassium level is 5.4 mEq. What should the nurse look for on the cardiac monitors as a result of this lab value?

Narrow, peaked T waves Rationale: a serum potassium level of 5.4 is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave; prolonged PR interval; a widened QRS complex; and narrow, peaked T waves

101. The nurse is caring for an involuntary committed client who has been premeditated for a ECT. When reviewing the chart, the nurse fails to find an informed consent for the procedure. Based on this information, the nurse should give which intervention PRIORITY?

Notify the client's HCP

486. Modifiable risk factors for cardiovascular disease

Obesity HTN Hyperlipidemia Glucose intolerance

513. The nurse working in a women's health facility is reinforcing instructions to a client on the risk factors of endometrial (uterine) cancer. The nurse includes which information in the teaching plan?

Obesity Use of estrogen therapy Polycystic ovarian disease

506. The nurse is initiating one rescue CPR on a adult client. The nurse should place his/her hands in which position to begin chest compressions?

On the lower half of the sternum

368. The nurse is providing CPR to the child with an advanced airway. The nurse MOST APPROPRIATE delivers how many rescue breaths to the child?

One breath every 6-8 seconds

440. The nurse is preparing to administer the rotavirus vaccination (Rota Teq) to an infant. By which route should this vaccine be administered?

Oral

263. The nurse understands that which conditions are contraindications for the use of fertility medications? Select all that apply

Ovarian cysts Thyroid dysfunction Adrenal dysfunction Ovarian dysfunction

287. The nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the HCP's prescriptions and would expect to note which prescribed treatment for this condition?

Oxytocin (Pitocin) infusion Rationale: therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows.

428. Which findings should the nurse expect to note in a child suspected of having juvenile idiopathic arthritis (JIA)? Select all that apply

Painful,stiff,swollen joints Limited ROM of the joints History of late evening temperature spikes

Abdominal aortic aneurysms nurse should check

Palpate peripheral pulse strength

538. The nurse is reviewing lab test results for the client with liver disease and notes that the client's albumin level is low. Which data collection technique is focused on the consequence of low albumin levels?

Palpating for peripheral edema

176. Tacrolimus (Prograf) is prescribed for a client. Which disorder, if noted in the client's record, indicates that the medication needs to be administered with caution?

Pancreatitis= inflammation of the pancreas Rationale: caution with immunosuppressive clients with renal, hepatic, or pancreatic function impairment

482. A client's serum calcium level is elevated. The nurse understands that which hormone is directly responsible for maintaining the free or unbound portion of the serum calcium w/i normal limits?

Parathyroid hormone

646. The nurse should schedule which activity for a newly admitted client?

Participating in a scheduled staff/client basketball game

600. The nurse is preparing a client for an arterial blood gas (ABG) draw. The nurse ensures which action is taken before this procedure?

Performing an Allen's test

82. A client is experiencing blockage of the Eustachian tubes. The nurse reinforces teaching to the client that which activity may forcibly open the Eustachian tubes?

Performing the Valsalva maneuver

232. Theophylline (Theo-24) tablets are prescribed for a client with chronic airflow limitation. When teaching about this medication, the nurse should provide the client with which pieces of information? Select all that apply

Periodic blood levels will need to be obtained Limit intake of caffeine containing foods and beverages Continue taking the medication even when your feeling better Report any signs of respiratory infections to the HCP

542. The nurse is caring for a client in the post procedure period following cardiac catheterization. The nurse should monitor which PRIORITY measures on a routine basis?

Peripheral pulse

479. The nurse is performing a voice test to check hearing. Which statements describe the accurate procedure for performing this test? Select all that apply

Quietly whisper a statement and ask the client to repeat Ask the client to occlude on external ear canal so that each ear can be tested separately

481. A client with DM is being tested to measure long term diabetic control. This test is based on the fact that chronic high blood glucose levels lead to irreversible glucose binding onto which item?

RBC's

69. A client passes a urinary stone, and lab analysis of the stone indicates that it is composed of calcium oxalate. On the basis of this analysis, which directions should the nurse reinforce in the dietary instructions? Select all that apply

Eat and drink citrus fruits and citrus juices Eat plenty of leafy vegetables, but avoid spinach and beets Increase intake of foods such as meat, fish, plums and cranberries

320. The client who is 8 weeks pregnant calls the health care clinic and tells the nurse she is experiencing N/V every morning. The nurse should suggest which measures to BEST promote relief of the symptoms? Select all that apply

Eat dry crackers before getting out of bed Increase fluids between meals rather that with meals Eat small frequent meals rather that three large ones

515. The nurse caring for a client withICP understands that which condition can cause this problem? Select all that apply

Edema Trauma Tumors Hemorrhage Hydrocephalus-

92. The nurse caring for a client with cirrhosis of the liver understands that which intervention should be included in this client's plan of care?

Elevate the head of the bed Rationale: elevation of the head helps SOB due to fluid overload

397. The mother of a 6y/o child who has T!DM calls the clinic nurse and reports that the child has been sick. The mother reports that she checked the child's urine and it showed positive ketones. The nurse should tell the mother to perform which action? Select all that apply

Encourage the child to drink liquids frequently Continue to check the urine for ketones at each voiding

408. The mother of an 8y/o child who is being treated for right lower lobe pneumonia tells the nurse that the child is complaining of discomfort on the right side and that acetaminophen (Tylenol) has not been very effective. The nurse should tell the mother to implement which measures?

Encourage the child to lie on the right side

399. A 4y/o child hospitalized for chemotherapy is fearful. Which intervention is MOST APPROPRIATE to alleviate the child's fears?

Encourage the child's parents to stay with the child

19. A client has the following lab values: a ph of 7.55, an HCO3 level of 22 mEq/L and a PCO2 of 30 mm Hg. Which action should the nurse plan to take?

Encourage the client to slow down breathing

357. The nurse is reviewing a plan of care for a hospitalized adolescent and should include which interventions that will facilitate normal growth and development? Select all that apply

Encourage visit from friends Encourage the adolescent to communicate with others via the internet

667. When planning activities for the hospitalized, depressed client, the nurse should recognize which approach as MOST therapeutic?

Encouraging the client to participate scheduled 30 min game of bingo after lunch in the day room

310. The nurse is caring for the postpartum client who is continually experiencing afterpains. The nurse understands that this could be related to which condition?

Endometriosis

529. The secretions of ovarian hormones results in changes in which reproductive structure?

Endometrium

169. The nurse is caring for a client who has been prescribed albuterol (proventil HFA). The nurse understands that this medication is used with caution in which condition? Select all that apply

HTN= high b/p Hyperthyroidism= overactive thyroid DM= too much sugar in the blood cardiovascular disease=diseased vessels, structural problems and blood clots

473. The nurse understands that collecting data about which body structure can provide information about fluid status in the older adult client? Select all that apply

Hair Skin Nails Mucus membranes

620. The nurse is caring for a client with renal calculi who has been placed on an alkaline ash diet. The nurse should tell the client to include which foods in the diet? Select all that apply

Halibut Broccoli Rhubarb

534. The nurse is caring for a client with dark colored skin who is DX of acute viral hepatitis. Which specific body areas should the nurse monitor for jaundice in this client? Select all that apply

Hard palate of the mouth Sclera closest to the cornea

655. The nurse understands that which descriptions are characteristics of a client with anorexia nervosa? Select all that apply

Has desire to please others Observes rigid rules and regulations Has the need to be correct or perfect

228. A client has been taking omeprazole (Prilosec) for 4 weeks. The nurse concludes that the client is receiving the optimal intended effect of the medication if the client reports absence of which symptom?

Heartburn

167. Tetracycline hydrochloride has been prescribed for a child. The nurse should reinforce to the mother which medication administration instructions?

Help the child rinse their mouth after taking the medication

38. The nurse is reviewing lab values that were prescribed to determine nutritional status for the older client. Which lab values would be of concern to the nurse? Select all that apply

Hematocrit 30% Albumin 3.0 g/dl Hemoglobin 8 g/dl NORAML RANGE FOR ADULTS Hematocrit 38-44% Albumin 3.5-5.0 g/dl Hemoglobin 12-16 g/dl

603. The public health nurse is conducting an informal session on risk factors for renal disorders. Which risk factor, if noted by a client, indicates a NEED for further instruction?

Hepatic disease

162. A client is scheduled to receive chemotherapy with asparaginase (Elspar). The nurse anticipates that this medication will be discontinued from the regimen after noting which disorder in the client's medical record?

Hypersensitivity Pancreatitis

Signs of fluid volume overload

Hypertension and bounding pulse JVD Peripheral edema Polyuria Weight gain Tachypnea Dyspnea Crackles Pulmonary edema

550. The nurse is reviewing the results of a radioactive iodine uptake test 4 hours following administration of the radioactive iodine. The results indicate a 15% level of radioactivity. The nurse understands that this result could be indicative of which condition?

Hyperthyroidism

531. The nurse notes that a client is exhibiting U waves on the ECG. The nurse reviews the client's lab results, recalling that which electrolyte imbalance could be responsible for this development?

Hypokalemia

239. An older client takes cascara sagrada for ongoing management of chronic constipation. The nurse monitors the clients lab results for which PRIMARY electrolyte imbalance related to long term use of this medication?

Hypokalemia- low potassium levels

625. When collecting data on admission, the nurse is obtaining subjective data about a client's sexual and reproductive status. The client states " I don't want to discuss this; its private and personal" Which response by the nurse is MOST therapeutic?

I know that some of theses questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality

447. A lab test is performed on an adolescent with chronic fatigue, and the results indicate the presence of Epstein Barr virus (mononucleosis). The nurse reinforces instructions to the mother regarding care of the adolescent. Which statement by the mother indicates an understanding of the care measures?

I need to call the HCP if my child complains of abdominal pain

366. A child hospitalized with a pertussis is in the convalescent stage, and the nurse is preparing the child for discharge. The nurse reinforces instructions to the parents for home care. Which statement by the parents indicate a need for further TEACHING?

I need to make sure that my child is isolated from other children for at least 2 weeks to prevent spreading the virus to them

245. The nurse has reinforced instructions to a client receiving enalapril maleate (Vasotec). Which statement by the client indicates further teaching?

I need to notify the HCP if nausea occurs

475. A client is resuming a diet after hemigastrectomy, and the nurse is reinforcing instructions in measures to prevent dumping syndrome. The nurse determines that the client needs additional INSTRUCTIONS if the client makes which statement? Select all that apply

I need to sit upright for at least an hour after eating I need to be sure to drink plenty of water or other fluids when I eat

270. The nurse is reinforcing instructions to a postpartum client regarding postpartum exercises. Which statement by the client indicates an understanding of the exercise?

I should alternately contract and relax the muscle of the perineal area Rationale: kegel exercises strengthens the pelvic muscles

337. The nurse is reinforcing instructions to the pregnant client regarding measures that will assist in alleviating heartburn. Which statement by the client indicates an understanding of these measures?

I should avoid eating gas producing foods and fatty foods

360. a child with HIV infection is being discharged from the hospital, and the nurse is reinforcing instructions to the mother regarding home care and infection control measures. Which statements by the mother indicate further INSTRUCTIONS? Select all that apply

I should discard any unused food immediately I need to completely isolate my child from siblings

518. The nurse is reinforcing instructions to a client with DM in measures to prevent the chronic complications of diabetic Nephropathy. Which statement by the client indicates a NEED for further instructions?

I should increase my dietary protein, sodium, and potassium

251. The nurse determines a NEED FOR FURTHER TEACHING related to formoterol (Foradil) inhaler use if which statement is made by the client?

I should inspire slowly when using the inhaler

191. The nurse is reinforcing discharge instructions to a client who has been prescribed desipramine (Norpramin). Which statement, if made by the client, indicates further TEACHING?

I should limit my alcohol intake while taking this medication Rationale: AVOID alcohol with this medication

332. A nursing instructor asks a nursing student to describe the procedure for safely performing the abdominal thrust maneuver on an unconscious pregnant client at 8 months gestation who is experiencing airway obstruction. Which statement by the student indicates an understanding of this procedure?

I should place a rolled up blanket under the right abdominal flank and hip area before performing chest thrust

413. The nurse is reinforcing instructions to the parent on administering of liquid oral iron supplement to an infant with iron deficiency anemia. Which statement by the parent indicates an understanding of the administering of this medication?

I should use a medicine dropper and place the iron near the back of the throat

570. The nurse is reinforcing instructions to a client who has undergone myringotomy. Which statement, if made by the client, indicates a need for FURTHER instruction?

I will avoid blowing my nose with my mouth open

339. The nurse reinforces instructions to a new mother with HEP B regarding breastfeeding her newborn. The nurse determines that the mother understands the instructions if she makes which statement?

I will be able to breast feed once my baby is vaccinated

556. The nurse is reinforcing preprocedure instructions to a client who has been prescribed a glucose tolerance test. Which statement, if made by the client, indicates a need for FURTHER INSTRUCTION?

I will be sure to take my morning insulin on the day of the test

477. The nurse has given a client with polycystic kidney disease information about management of the disorder and prevention and recognition of complications. The nurse determines that the client understands the instructions if the client makes which statement? Select all that apply

I will report episodes of SOB I will take my temperature if i suspect a fever I will call my HCP if I have burning with urination I will call my HCP if I experience a headache that does not subside

496. A client with diplopia has been taught to use an eye patch to promote better vision and prevent injury. Evaluation of learning would be evident if the client makes which statement?

I will wear the patch continuously, alternating eyes each day

156. The nurse determines that learning about levodopa/carbidopa (Sinemet) is evident if the client makes which statement? Select all that apply

I'll change my position slowly My urine and sweat may darken, but I shouldn't be alarmed Hard candy or gum may help lessen the side effects of dry mouth

110. The nurse employed in a mental health clinic is greeted by a neighbor who says "How is Michelle doing?" She is my best friend and is seen at your clinic every week. Which is the MOST APPROPRIATE nursing response?

I'm sorry and I'm sure you will understand, but as a nurse, I'm obligated to protect the privacy of all the clients I encounter. I cannot disclose any client information

628. The nurse is working with an anxious client who has sought counseling after an unsuccessful attempt to rescue a neighbor who was trapped in a house fire. Which goal should be addressed during the working phase of the nurse client relationship?

ID any feelings about he client's actions that may affect his normal adaptive coping

80. A client is admitted to the hospital with cellulitis of the lower leg. The nurse checks the HCP prescriptions sheet expecting to note which prescriptions?

IV antibiotics Warm compresses to the effected area Culture and sensitivity of the leg drainage

535. The nurse is caring for an older client who is complaining of chronic pain. Which action should the nurse take FIRST in the care of this client?

Identify the pattern of pain

375. The nurse is reinforcing instructions to the parents of a child with hemophilia. Which statement, if made by the parents, indicates a need for further TEACHING?

If my child has a nosebleed, I will apply pressure to the bridge of the nose and hold the child's head back

247. The nurse is reinforcing instructions to an adolescent who is taking phenytoin (Dilantin) for the control of seizures. Which statement by the adolescent indicates a need for further teaching?

If my gums become sore, i need to stop the medication

401. The mother of a 5y/o child expresses concern because her hospitalized child began bed wetting 2 days after hospital admission. The nurse should reinforce which information to the mother? Select all that apply

Ignore the behavior This behavior occurs due to the stress of hospitalization Continue to praise existing patterns of appropriate behavior

639. The nurse notes that the client's DX is documented as schizophrenia. The nurse plans care, knowing that the client is MOST LIKELY to experience which manifestation of the disorder?

Illusions

59. The nurse educator is conducting a teaching session regarding the risk factors for the development of pressure ulcers. The nurse plans to include which factors in the teaching sessions? Select all that apply

Immobility Moisture on the skin Skin pressure and shearing Urinary and bowel incontinence

412. The nurse caring for a child with glomerulonephritis understands that this disorder is PRIMARILY caused by which type of reaction?

Immunologic

633. The nurse is conducting a group therapy session when a client DX with a manic disorder begins monopolizing the group. The nurse should take which actions? Select all that apply

Inform the client that this is not appropriate behavior Suggest that the client stop talking and try listening to others in the group

381. The nurse is caring for a 5y/o child and notes that the child is able to initiate his own activities . To which stage of psychosocial development has the child progressed?

Initiative versus guilt

212. What are the appropriate steps for preparing and administering a dose of Humalog insulin using an insulin syringe? Number the actions in the options in order of PRIORITY with regard to how the nurse should perform them.

Insert the needle into the cleansed rubber top of the vial Insert air into vial W/d the insulin to the correct mark for the needed number of units Cleanse the injection site with alcohol Administer medication

225. Before administering an MMR, vaccine to a 15 m/o child, which questions should the nurse asl the child's mother?

Is your child allergic to any antibiotics

218. A client has been started on medication therapy with alprazolam. When the nurse explains to the client that the medication should not be discontinued abruptly, the client asks why. The nurse should incorporate which information when replying?

Rebound CNS excitation could occur and cause feelings of restlessness and irritability

289. The nurse is caring for a client who is experiencing precipitous labor. The HCP has been notified but has not arrived yet. The nurse prepares to institute which interventions if delivery is imminent before the arrival of the HCP? Select all that apply

Support infants body during delivery Use restitution to deliver the posterior shoulder Apply genital pressure to the fetal head upward toward the vagina Deliver the infant between contractions, checking for the cord around the neck

443. A mother arrives at the clinic with her 3y/o child and tells the nurse that the child has had a fever and cough for the past 2 days and that this morning the child began to wheeze. Viral pneumonia is DX. On the basis of the diagnosis, the nurse anticipates that which treatment will be a component of the plan? Select all that apply

Supportive treatment Acetaminophen (Tylenol) for fever

274. The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormone changes that occur in pregnancy and provides the woman with which information about the purpose of estrogen? Select all that apply

Suppresses the secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) Stimulates uterine development to provide an environment for the fetus and to stimulate the breast to prepare for lactation

203. The nurse caring for a client taking rabeprazole understands that this medication is associated with which action?

Suppression of gastric acid secretions

554. The nurse understands that which are risk factors for development of respiratory disorders? Select all that apply

Surgery Allergies Chest injuries Crowded living conditions

632. The nurse is planning activities for a client with bipolar disorder who is exhibiting aggressive social behavior. Which activities are MOST APPROPRIATE for this client? Select all that apply

Taking a walk with staff member Working on a finger painting project Writing about his own future plans in a journal

56. The nurse is preparing to assist in examining a Hispanic child who was brought to the clinic by the mother. While collecting data on the child, the nurse should take which actions? Select all that apply

Taking the child's temp Include the child in the discussion Obtaining an interpreter if necessary Asking the mother questions about the child

43. The nurse understands that which procedures are used to detect the presence of dysrhythmias? Select all that apply

Telemetry Holster monitor ECG

643. The nurse is conducting a group therapy session when a client threatens to act out physically and states that he will punch another member of the group. The nurse should take which INITIAL action?

Tell the client that he can talk about his anger but cannot act on it during the group session

460. A client is receiving parenteral nutrition via a central line. The nurse should monitor which item to detect the development of the MOST common complication of parenteral nutrition?

Temperature Rationale: most common complication is infection

194. A client has been taking hydrochlorothiazide (Microzide) for several weeks. The HCP indicates that the client's glomerular filtration rate (GFR) is 40 ml/min. What would the nurse need to discuss with the HCP?

That the client is on hydrochlorothiazide, which is not effective with low GFR Rationale: normal GFR is 90-120 ml/min

610. The nurse is assisting in performing Trendelenburg's test on a client suspected of having varicose veins. The nurse places the client in a supine position with the legs elevated and then ask the client to sit up. The test is considered positive if which is noted?

Varicosities are present

395. The nurse is caring for a child with Kawasaki disease who has been prescribed aspirin. The nurse is reinforcing instructions to the parents regarding S/S of aspirin toxicity. The parents demonstrate understanding of the instructions if they state that which are indicative of toxicity? Select all that apply

Vertigo- internal or external spinning sensation Tinnitus- ringing of the eardrums Bruising Headache

664. A client has been DX with pedophilia. The nurse understands that which findings are often present concurrently with pedophilia? Select all that apply

Voyeurism - secret viewing others in a sexual context without their knowledge Exhibitionism - intentional display of genitals in a public place Rape commitment

93. The nurse is assisting in responding to a disaster. Which personal items should the nurse ensure are taken to the scene? Select all that apply

Warm clothing Copy nursing license Record keeping material Personal health care equipment

95. The nurse on the postsurgical unit receives a client who was transferred from the post anesthesia care unit (PACU) and is planning care for a client. The nurse understands that staff should begin planning for this client's discharge at which point during the hospitalization?

When the client is admitted to the surgical unit (or hospital)

451. The nurse educator is conducting a teaching session on dry suction chest systems. Which statement, if made by a student, indicates an accurate understanding of this system?

When the orange floater valve is in the window, the correct amount of suction has been applied

661. The nurse is performing a mental status examination on an older adult client and is collecting data on the client's remote memory. The nurse appropriately ask the client which question?

Where did you go on your last vacation

400. Which foods should the nurse tell a breastfeeding mother to avoid because it could cause abdominal distress in the infant? Select all that apply

Whole milk Hard cheeses Cottage cheese

345. A pregnant client with diabetes who is to have a nonstress test done asks the nurse about the procedure. Which information should the nurse provide to the client? Select all that apply

You maybe asked to depress a button every time you feel fetal movement The test is noninvasive procedure and requires that you sit comfortably in a reclining chair If the fetus is not moving, you maybe given a drink of glucose, such as OJ, to stimulate movement An ultrasound transducer that records fetal heart activity is secured over your abdomen where the FHR is heard most clearly

449. The nurse is reviewing the results of the lab test for an infant who has been DX with primary hypothyroidism. The nurse would expect to note which findings?

A thyroid stimulating hormone (TSH) level of 7.2 micro units /ml

343. A pregnant client who has HIV infection is being seen in the antenatal clinic. The nurse tells the client that zidovudine (AZT) therapy will be initiated when the fetus has reached how many weeks gestation?

14 weeks

617. The nurse is reviewing the results of a lab report for a client who has had a glycosylated serum albumin (fructosamine) test. The nurse understands that this provides a measure of average serum glucose levels over which time period?

2-3 weeks

415. The nurse is collecting data on a child with a DX of rheumatic fever (RF). The nurse MOST APPROPRIATELY explains to the child's parents that the disease manifest at which time period following an untreated or partially treated group A-beta hemolytic streptococcal infection?

2-6 weeks

300. Which client would be LEAST LIKELY at risk for the development of thromboembolic disorders in the postpartum period?

A 26y/o woman with a family history of thrombophlebitis

9. The nurse employed in the ED is assigned to assist with triage of clients arriving to the ED. The nurse should assign PRIORITY to which client?

A client with chest pain who states that they just ate a pizza that was made with a very spicy sauce

649. The nurse must choose a roommate for a client who is in a state of starvation due to anorexia nervosa. Which clients are appropriate choices for this clients roommate? Select all that apply

A client with... back surgery, fractured pelvis, had a MI Rationale: Clients who have been starving have compromised immune systems

264. The nurse is caring for a client who is taking alprazolam for the treatment of anxiety. Which finding warrants IMMEDIATE notification of the HCP?

Pronounced restlessness

348. The postpartum nurse is reinforcing instructions to a client after delivery of a healthy newborn infant. The nurse instructs the client that she should expect normal bowel elimination to return at which time postpartum?

3 days postpartum

520. The nurse is reinforcing procedure instructions to the client who is undergo corneal staining to assess for irregularities on the cornea. The nurse MOST APPROPRIATELY informs the client by making which statement?

A dye will be instilled in the sac below the eyeball

20. A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's lab report, should be reported before administering the dose of furosemide?

3.2 mEq/L

497. Potassium normal range levels

3.5 - 5.0 mEq/L

363. The nurse is caring for the immediate postoperative child who has undergone tonsillectomy. The nurse should remove which item if noted on the bedside table?

A straw Rationale: to reduce further injury to the surgical site

595. The nurse is preparing to send an arterial blood gas (ABG) specimen to the lab. The nurse should be sure to document which item on the lab requisition form before sending the specimen?

Clients temperature

579. The nurse caring for a client in the postoperative period following renal biopsy understands that pressure should be held on the insertion site for at least how many minutes?

30 Rationale: if bleeding is still active after 60 minutes the HCP should be called

480. Tonometry is performed on a client with a suspected DX of glaucoma. The nurse determines that which results would support the suspected DX?

30 mmHg Rationale: glaucoma ranges between 22-32 mm Hg

PaC02 normal range

35 to 45 mmHg A primary respiratory problem is determined if the PaC02 is less than 35mmHg (alkalosis) or greater than 45 mmHg (acidosis)

546. The nurse is working in the cardiac catheterization lab is reinforcing preprocedure instructions to a client. The nurse MOST APPROPRIATELY informs the client to withhold fluids for how long before the procedure?

4 hours Rationale: hold water 4 hrs, hold for 6-8 hrs

192. The nurse is caring for a client taking levothyroxine sodium (synthroid) who has been prescribed aluminum hydroxide tablets. The nurse should schedule the new medication to be taken at what time?

4 hrs after the levothyroxine sodium

135. Evidenced-based practice requires that the nurse base nursing practice on evidence from which resource?

Clinical research studies

635. A client is admitted to the mental health unit with a DX of depression, and the nurse is reviewing a plan of care for the client. Which is MOST APPROPRIATE and safest activity to be included in this plan of care?

A structure daily program of activities, with the nurse encouraging the client to participate

106. For which client situation would consultation with a rapid response team (RRT) be MOST APPROPRIATE?

45y/o 2 yrs post-kidney transplant Second hospital day for treatment of pneumonia No urine O/P for 6 hrs T: 101.4F HR 98 bpm R 20 B/P 88/72 is Restless

340. Following vaginal delivery, the nurse is observing for placental separation and delivery. The nurse expects placental delivery to occur at which time following delivery of the baby?

5-30 minutes

ph normal range

7.35-7.45

469. The nurse is collecting data on a client with herpes zoster. Which characteristics should the nurse expect to note when collecting data on the lesions of this infection? Select all that apply

Clustered skin vesicles Small blue white spots with red base

558. A client has sustained a fractured arm. The nurse notes in the imaging report that the bone is crushed and there are numerous fragments. The nurse understands that this is descriptive of which type of fracture?

Comminuted

504. The nurse is reinforcing teaching on the risk factors for integumentary disorders. The nurse should include which information as part of the presentation as risk factors for these disorders? Select all that apply

Advancing age Radiation exposure Nutritional deficiencies Environmental pollutant exposure

557. The nurse is caring for a client with a duodenal ulcer. The nurse explains to the client that which are risk factors for duodenal ulcers? Select all that apply

Alcohol intake Caffeine intake Use of corticosteroids Helicobacter pylorinfection

268. The nurse is caring for a hospitalized child who is receiving ribavirin (Virazole) for the treatment of respiratory syncytial virus. Which complications should the nurse monitor for? Select all that apply

Apnea- temporary cessation of breathing, especially during sleep Anemia- blood doesn't have enough healthy blood cells (hard to exchange 02) Pneumothorax - collapsed lung or lungs Bacterial pneumonia - bacterial infection of the lungs

621. A client calls the clinic and tells the nurse he was bitten by a brown recluse spider. The nurse tells the client to IMMEDIATELY perform which action?

Apply ice to the affected area

26. An adolescent client with a surgically wired jaw has a prescription for a full liquid diet. The nurse should implement which action to promote the client's compliance with this diet prescription?

Ask about food preferences and blenderize these foods into liquids rationale: Adolescent may dislike a diet that only liquids and may be at risk for compliance

197. The nurse is reviewing lab results for a client taking dantrolene sodium (Dantrium). The nurse should notify the HCP if which findings was noted on the lab report?

Aspartate Aminotransferase (AST) 40 U/L

275. The nurse is caring for a pregnant client in labor who is to undergo general anesthesia. The nurse understands that which are adverse effects of this therapy? Select all that apply

Aspiration Respiratory depression

615. The nurse is caring for a client who is receiving combination chemotherapy for the treatment of leukemia. The medications have overlapping toxicities. The nurse understands that these medications will be given at what times?

At entirely different time intervals

313. The nurse educator reinforcing a teaching session on the process of labor should tell the group of attendees that the relationship of the fetal body parts to one another is known by which term?

Attitude

NGT feeding, remember

Auscultation of bowels prior to feedings Check tube placement Elevate HOB 45 degrees Ensure the formula is room temperature

222. A client who has undergone renal transplant is receiving ongoing therapy with cyclosporine (Sandimmune). The nurse would be sure to IMMEDIATELY respond the results of periodic lab work that indicated which findings?

BUN 27mg/dl Rationale: this medication causes nephrotoxicity. Normal BUN levels are 8-25mg/dl

315. A client in the last trimester of pregnancy has been admitted to the hospital with a DX of severe preeclampsia. The nurse monitors for complications associated with the DX and should monitor the client for which finding?

Bleeding in the gums Petechiae- tiny round brown-purple spots due to bleeding under the skin Purpura- a rash of purple spots due to small blood vessels leaking blood into the skin, joints, intestines or organs

Dabigatran (Pradaxa) and bivalirudin (angiomax) are anticoagulants and are at risk for

Bleeding, hemorrhage

107. Which situations are classified as NATURAL disasters? Select all that apply

Blizzard Volcanic eruptions Communicable diseases Cyclones Droughts Earthquakes Tornadoes Floods Forest fires Hailstorms Hurricanes Landslides Mudslides Tidal waves

193. The nurse is reviewing the lab results for a client who is receiving tacrolimus (Prograf). Which findings indicate to the nurse that the client is experiencing an adverse effect of the medication?

Blood glucose 200mg/dl Nephrotoxicity

190. The nurse caring for a client taking somatropin (Humatrope) prepares to monitor which lab studies specifically related to this medication? Select all that apply

Blood glucose level Liver function studies Thyroid function test

185. Cyclosporine (Sandimmune) is prescribed for a client following an allogenic kidney transplant. The nurse reinforces instructions to the client regarding the medication and gives the client which information?

Blood levels of this medication will need to be measured periodically This medication will be taken for life

Hypovolemic shock most common occurs from

Blood loss but can occur in any condition that reduces intravascular volume

548. The nurse is assisting in conducting a teaching session on breast cancer at a community health clinic. The nurse includes information about sites of metastasis for this type of cancer and states that which are common sites? Select all that apply

Bone Lung Brain Liver

605. The client who has been DX with prostate cancer asks the nurse about common sites of metastasis for this type of cancer. The nurse informs the client that this type of cancer MOST commonly spreads to which sites? Select all that apply

Bone Spine Lung Liver Kidneys

532. The assessment findings for a client with Paget's disease include back leg pain, a crouched forward posture, and legs that bow outward. The nurse plans care knowing that these manifestations are due to disturbances with which bodily process?

Bone resorption and regeneration

545. The nurse is reviewing an anti dsDNA antibody test report for a client who is suspected of having systemic lupus erythematosus (SLE). The results show a value of 100 units. The nurse understands that this value indicates which results?

Borderline Rationale: borderline test results 70-200 units, negative lower than 70 units, positive higher than 200 units

21. The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dl. Which prescribed medication should the nurse plan to assist in administering to the client?

Calcitonin

165. A client with metastatic breast cancer is receiving tamoxifen (Nolvadex). The nurse should specifically monitor which lab value the client is taking this medication?

Calcium level

Hernia surgery repair, finds further complications, what should be done?

Call the clients medical power of attorney so that the surgeon can obtain consent for additional procedure

500. The nurse is caring for a client who is asking about transmission of hemophilia. The nurse MOST accurate informs the client that transmission occurs by which method?

Carrier females pass the defect to affected males

64. A vegetarian client asks the nurse about foods to eat that are high in vitamin A. The nurse should include which items in a list of the foods highest in this vitamin? Select all that apply

Carrots Yellow squash

195. The nurse is assigned to care for a client with lymphoma who is receiving bleomycin sulfate. Which intervention would be the PRIORITY for this client?

Checking lung sounds Rationale: pulmonary toxicity

269. A HCP prescribes IV potassium for a child with hypertonic dehydration. The nurse PRIORITIZES data collection on which finding before the prescription is implemented?

Checking the amount of urine output

204. The client has been tentatively diagnosed with gout. The nurse determines that which condition indicates a potential contraindication for therapy with colchicine?

Cirrhosis= chronic liver damage

114. The nurse is reviewing lab values for the assigned clients. Which finding, based on the clients medical history, indicates the need for IMMEDIATE follow up?

Client with HF and a B-type natriuretic peptide (BNP) of 140 pg/ml Rationale: BNP levels shouldn't be above 100

39. The nurse understands that which are characteristics of anthrax? Select all that apply

Cutaneous lesions become black eschar Gastrointestinal anthrax causes bloody diarrhea Flulike symptoms are a sign of pulmonary anthrax Person to person transmission of inhalation disease does not occur A person can become infected through skin contact, ingestion, or inhalation of the bacillus

414. On reviewing the records of a child with a DX of a right to left cardiac shunt, the nurse would expect to note documentation of which MOST common finding?

Cynosis

344. The nurse is monitoring the pregnant client with cardiac disease. Which findings maybe indicative of cardiac decompensation, warranting notification of the HCP? Select all that apply

Cough Dyspnea- difficult or labored breathing Chest pain Tachycardia- fast heart rate above 100 Peripheral edema- swelling of the lower legs or hands

88. The nurse provides the client with heart disease, a list of high-fat foods to avoid. Which food items should the nurse include in this list? Select all that apply

Cream cheese Fish and potato fries Baked macaroni and cheese

217. The nurse is caring for a client who has just been prescribed haloperidol for the treatment of schizophrenia. The nurse should expect to note which findings in this client related to schizophrenia? Select all that apply

Delusions Aggression Hallucinations

301. A client DX with severe preeclampsia is receiving a magnesium sulfate continuous IV infusion. Which finding indicates that the medication should be discontinued?

Depressed deep tendon reflex

48. Which should be included in a change of shift report?

Describing objective measurements or observations about a client's condition

151. The nurse is reinforcing a discharge teaching plan for a client who is going home following a COPD exacerbation. In reinforcing teaching to the client, which step should the nurse take FIRST?

Determine the client's immediate learning needs

121. With regard to advance directives, which situation identify an aspect of the nurse's role? Select all that apply

Determining whether an advance directive exists upon admission Ensuring that all health care workers caring for the client are aware of the code status Ensuring that the HCP is aware of the presence of an advance directive Ensuring that the client has been providing with the necessary information to to make the decision regarding life saving measures

406. The nurse is reinforcing teaching to a mother on how to administer ear drops to an infant. The nurse demonstrates the procedure by pulling the ear and administering the medication by which method?

Down and back, directing the solution toward the wall of the canal

15. A client brought to the ED states that he has accidentally been taking two times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to assist the RN with what action?

Drawing a sample for prothrombin time (PT) and international normalized ratio (INR) PT and INR is for warfarin

309. The nurse reinforces teaching to a pregnant client about the food items that are highest in folic acid. The nurses should tell the client that which item is highest in folic acid?

Dried peas

243. Allopurinol (Zyloprim) is prescribed for a client. The nurse should reinforce which instructions to the client?

Drink an increased amount of fluid daily

172. The nurse is administering enoxaparin (Lovenox) subcut to a client. The nurse is monitoring for adverse effects related to this medication and understands that the adverse effects maybe occurring if which findings is noted?

Thrombocytopenia= a low number of platelets in the blood

103. Which scenarios represent malpractice on the part of the nurse? Select all that apply

Failure to regulate the temperature of a bath resulting in a burn on a client Failure to implement proper safety precautions resulting in client falling and sustaining a fracture to the ankle

541. The nurse caring for an older client is monitoring for nonspecific symptoms that indicate illness or infection. Which symptoms indicate that this maybe occurring? Select all that apply

Falling Apathy Confusion

67. The nurse is preparing to administer a rectal suppository to a client. The nurse explains to the client that which position will prevent immediate expulsion of the suppository?

Flat

277. The nurse in a labor room is assisting with the vaginal birth of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which event occurs?

Forceps delivery Rationale: excessive fundal pressure, forceps delivery, violent bearing down efforts, tumultuous labor and shoulder dystocia can cause uterine rupture

525. Eosinophils stack and destroy

Foreign particles that have been coated with antibodies of the IgE class

656. A client who is admitted to the nursing unit following a fall from a second story porch has a history of heroin addiction. The nurse should monitor this client carefully for which signs of heroin withdrawal? Select all that apply

Frequent yawning Runny nose (rhinorrhea) Goosebumps (piloerction) Inability to sleep (insomnia)

253. The nurse interprets noncompliance with the new medication clomipramine hydrochloride (Anafranil) when she exhibits which findings during the interaction

Frequently checking her purse for her keys

294. The nurse is monitoring for side effects of a lumbar epidural block on a pregnant client. Which findings indicate that a side effect is occurring? Select all that apply

HTN Bladder distention Prolonged second stage

495. Risk factors for chronic kidney disease (CKD)

HTN Family history Ethnic minority DM Cardiovascular disease

511. The nurse is caring for a client with a dysfunctional thyroid gland and is concerned that the client will exhibit signs of THYROID STORM. To detect this complication, the nurse should monitor for which sign?

HTN Rationale: Thyroid storm S/s temperature high as 106F, tachycardia, HTN, N.V.D. Tremors, irritability, confusion, seizures and coma if left untreated

155. Which finding indicates the presence of systemic toxicity from topical salicylic acid?

Tinnitus

177. Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering this medication, the nurse should contact the HCP who prescribed the medication if which condition is documented in the client's medical history?

Peripheral vascular disease=narrowing blood vessels that reduce the blood flow to the limbs Methylergonovine is an ergot alkaloid for postpartum hemorrhage, ergot alkaloids are to be avoided in clients with significant cardiovascular disease, peripheral disease, HTN, preeclampsia or eclampsia

472. The nurse is performing the confrontational test on a client during physical examination. The client asks the nurse about the purpose of this test. The nurse explains to the client that this examination tests which item?

Peripheral vision

213. The nurse is reinforcing medication information to a client who is beginning therapy with enalapril (Vasotec). The nurse tells the client that which findings is an anticipated although unpleasant side effect of this medication?

Persistent cough Rationale: "pril" ace inhibitors cause coughing

152. When prioritizing the care for a group of clients, the nurse should remain mindful of which item as the HIGHEST PRIORITY?

Physiological needs of the client

607. The nurse is caring for a client with laryngeal cancer. Which number intervention is of HIGHEST PRIORITY in the care of this client?

Place in the Flower's position

326. The nurse in a labor room is checking the vagina for a client in labor and notes the presence of the umbilical cord protruding from the vagina. Number the actions in order of PRIORITY

Place the client in the trendelenburg position Push the call light to summon help Place a sterile gloved hand into the vagina, and hold the presenting part off the umbilical cord Place oxygen at 8 -10 L/min by face mask on the mother Reassure the mothers partner Reassure the mother

73. The nurse has a prescription to collect a 24 hr urine specimen from a client. The nurse should perform which actions while completing this procedure? Select all that apply

Place the specimen on ice Discard a urine collected at the start time Ask the client to save a sample voided at the end of the collection time Label the specimen with the client's name and send to the lab promptly

24. Several lab test are prescribed for a client and the nurse reviews the results of the test. Which lab test results should the nurse report? Select all that apply

Platelet 35,000 mm3 Sodium 150 mEq/L WBC 3,000 mm3 Segmented neutrophils 40%

34. The nurse reviews the most current lab data for the four clients to whom the nurse is assigned. The nurse should FIRST collect data on the client with which lab results?

Platelets 40,000 cells/mm3 Rationale: a client with platelets at 40,000 cells/mm3 or below is at risk for spontaneous bleeding

654. Which behaviors observed by the nurse indicate reason for suspicion that a depressed client maybe suicidal? Select all that apply

Poor appetite and difficulty sleeping Client doesn't attend activities any more Client asks where the cleaning agents are so she can clean her room

12. The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional S/S should the nurse expect to note in this clients if hyponatremia is present?

Postural B/P changes

211. The nurse is caring for a client with a history of heart failure who has been prescribed bemetanide. The nurse determines that an adverse effect maybe occurring if which finding is noted?

Potassium level 3.2 mEq/L Rationale: potassium level of 3.2 indicates hypokalemia

666. A client with a medical DX of major depression began exhibiting psychotic features and expressing suicidal ideation 24 hrs ago and is admitted to the mental health unit. To create a safe environment for the client, the nurse should address which problems in the plan of care? Select all that apply

Potential for injury Thought process disturbance Potential for self inflicted violence

159. A client who is HIV seropositive has been taking stavudine (Zerit). The nurse should monitor which item closely while the client is taking this medication?

Presence of paresthesias

328. The nurse is assisting in conducting a prenatal session with a group of expectant parents. The nurse reinforces instructions to the parents that which primary hormone stimulates the secretion of milk?

Prolactin

286. The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, should alert the nurse that the client is at risk for developing gestational Diabetes during this pregnancy?

The client's history of chronic HTN

57. The nurse is performing closed catheter irrigation on an assigned client. Which outcome, if noted by the nurse, indicates the NEED FOR FOLLOW-UP?

The urine is noted to be cloudy and dark in color

574. A client with glaucoma is concerned about surgery and asks the nurse if complete vision will return once the surgical procedure is done. The nurse should make which response to the client?

The vision loss that you have may not return, but further loss can be prevented by adhering to the treatment plan.

209. The nurse is caring for a client who has been prescribed sucralfate (Carafate). The nurse checks the client's medication history because of absorption of which medication can be affected if taken concurrently? Select all that apply

Theophylline Digoxin (Lanoxin) Phenytoin (Dilantin) Warfarin sodium (Coumadin)

662. The nurse is caring for a client who has been DX with dissociative identity disorder (multiple personalities). Which findings should the nurse expect to note in this client? Select all that apply

There is a host personality and other personalities referred to as alters The alters may be aware of the host but the host usually is not aware of the alters Two or more fully developed, distinct, and unique personalities exist within the client

134. The nurse manager is attending an inservice session on policies, procedures, and protocols of an organization. Which description is accurate regarding the meaning of protocols?

They prescribe a specific course of action for a specific type of client or problem

145. The nurse is attending an inservice on ethical codes. The instructor of the class determines that the nurse understands ethical codes if which statement is made by the nurse?

They provide broad principles for evaluating care

118. Which BEST describes nursing standards of care? Select all that apply

They're guidelines for nursing practices Nursing standards of care are defined in Nurse Practice Acts The law upholds the standards of care that the nurse must follow They're used to measure nursing conduct in malpractice lawsuits They're used to determine whether the nurse acted as any responsibly prudent nurse under the same or similar conditions

230. Coal tar has been prescribed for a client with psoriasis, and the nurse reinforces instructions to the client about this treatment. Which statement by the client indicates an understanding of this therapy?

This medication has an unpleasant odor and may cause irratation