1015

The community health nurse provides care for a client who is taking multiple medications for constipation. Which medication causes the nurse the least concern? 1.Psyllium hydrophilic mucilloid.2.Docusate sodium.3.Magnesium hydroxide.4.Bisacodyl.

1

The nurse provides care for a client who has undergone the repair of a gynecologic fistula. Which intervention will the nurse include in the client's immediate post-operative nursing care? (Select all that apply.) 1.Maintain urinary catheter.2.Warm sitz baths.3.Perineal hygiene.4.Bladder training.5.Increase oral fluids.

1,2,3,5

After attending a presentation on sexually transmitted infections (STIs), an adolescent participant asks the nurse if the human papillomavirus (HPV) vaccination is necessary if a person is not sexually active. Which response will the nurse make to this adolescent? (Select all that apply.) 1."Immunizations are recommended to provide immunity before exposure."2."The human papillomavirus vaccine reduces the risk of ovarian cancer as you get older."3."This vaccine is recommended for males and females at 11 -12 years of age."4."Use of condoms prevents the transmission of this sexually transmitted infection."5."The human papillomavirus vaccine is recommended after the first sexual experience."6."The human papillomavirus can cause cervical or penile cancer."

1,3,6

An LPN/LVN reports to the nurse that a client admitted with persistent chest pain is experiencing moderate, spastic lower abdominal pain, nausea, and some vomiting. Which action does the nurse take first? 1.Determine what medications the client is receiving.2.Perform a comprehensive abdominal assessment.3.Ask the client about a history of GI problems.4.Notify the admitting health care provider.

2 Abdominal pain is not usually associated with myocardial infarction. The nurse should assess for GI issues. The nurse should assess the abdomen prior to notifying the health care provider.

The school nurse assists with planning activities for a class of 10-year-old students. Which activity is appropriate for the nurse to encourage? 1.Using finger paints to create a painting.2.Playacting a nurse-and-client scenario.3.Solving math problems.4.Writing a memoir.

3

A client with a history of alcoholism and cirrhosis of the liver is admitted to the medical unit for ascites management. Which prescribed substance will the nurse administer first? 1.Albumin.2.Spironolactone.3.Indomethacin.4.Platelets

1

The nurse assesses a client in the emergency department. Which symptoms cause the nurse to suspect that the client is experiencing a panic attack? 1.Decreased perceptual field, diaphoresis, fear of going crazy, and palpitations.2.Decreased blood pressure, chest pain, choking feeling.3.Increased blood pressure, bradycardia, shortness of breath.4.Increased respiratory rate, increased perceptual field, increased concentration ability.

1

The nurse in the outpatient clinic receives a phone call from an adolescent who states, "There is no reason to live. I am going to shoot myself." Which response by the nurse is best? 1."Do you have access to a gun?"2."Why do you want to shoot yourself?"3."Think about how this will affect your family."4."Share with me what happened to you today."

1

The nurse instructs a client on the newly prescribed medication imipramine. Which symptoms will the nurse teach the client to report immediately to the health care provider? 1.Sore throat, fever, increased fatigue, vomiting, diarrhea.2.Dry mouth, nasal stuffiness, weight gain.3.Rapid heartbeat, frequent headaches, yellowing of eyes or skin.4.Weakness, staggering gait, tremor, feelings of drunkenness.

1

The nurse provides care for a client diagnosed with severe acute pancreatitis. Which finding requires immediate action? 1.Heart rate of 104 beats per minute.2.Blood pressure of 100/62 mm Hg.3.Respiratory rate of 34 breaths per minute.4.Serum glucose of 236 mg/dL (13.1 mmol/L).

3

The nurse observes a client with type 1 diabetes mellitus prepare an injection of 32 units of intermediate-acting insulin and 8 units of short-acting insulin. Which client action requires intervention by the nurse? 1.After drawing up 8 units of short-acting insulin, the client adds intermediate-acting insulin to the syringe for a total of 40 units.2.The client draws up 32 units of the intermediate-acting insulin followed by 8 units of short-acting insulin for a total of 40 units.3.Initially, the client injects air into the intermediate-acting insulin vial without drawing up any insulin.4.The client injects air into each bottle of insulin equal to the amount of insulin to be withdrawn.

2

The nurse provides care to an adult client who sustained a T3 spinal cord injury 2 days ago. The nurse suspects a developing emergency based on which assessment finding? (Select all that apply.) 1.Respiratory rate of 18 breaths/min. 2.Warm, dry, flushed skin.3.Absence of sensation in lower extremities.4.Blood pressure of 88/42 mm Hg.5.Heart rate of 88 beats/min.

2,4

The nurse evaluates tasks delegated to the staff. Which observation indicates that the care provided to a client who is positive for human immunocompromised virus (HIV) is appropriate? 1.LPN/LVN applies a gown when entering the room.2.Nursing assistive personnel uses sterile linen to make the bed.3.Nursing staff wear gloves when exposed to secretions.4.Family members wear gown, gloves, and mask when entering the room.

3

A client has a prescription for hydrochlorothiazide. Which client statement indicates to the nurse that teaching is successful? 1."I should not operate heavy machinery. "2."I should drink five glasses of liquid per day. "3."This medication will cause orange urine. "4."I should eat dried apricots each day. "

4

The nurse evaluates the basal body temperature record of a client trying to conceive. Which part of the waveform indicates the probable time of ovulation?

slight drop then rise of temp

The nurse obtains a history from a client scheduled to undergo electroconvulsive therapy (ECT). Which finding does the nurse report to the health care provider (HCP)? 1.The client takes alendronate once a day.2.The client reports feelings of lethargy and fatigue.3.The client has received the therapy in the past.4.The client walks for a half hour three times per week.

1

The nurse provides care for clients in the diabetic clinic. Which client does the nurse assess first? 1.The client with sunken eyeballs and a fruity breath odor.2.The client reporting pain in both calves when exercising.3.The client drinking copious water with constant hunger.4.The client with difficulty sleeping and frequent crying.

1

The nurse provides care to a client with an external fixator device to stabilize a fractured femur. Which assessment findings concern the nurse? (Select all that apply.) 1.Pain distal to the injury that is not relieved by opioid analgesics.2.Paresthesia distal to the area of injury.3.Reports of pain at pin insertion sites.4.Toes on affected leg edematous and cool to touch.5.Weak pedal pulse strength in affected leg.

1,2,4,5

The nurse in the day care center observes a toddler squatting and panting after chasing a ball. Which action does the nurse take first? 1.Remove the child from the playground and encourage rest.2.Check for sweating, color, and tachycardia.3.Ask the child about a sore throat or achy joints.4.Restrict the child from playing ball.

2

The nurse on the behavioral health unit negotiates a behavior modification contract with an adolescent client with anorexia nervosa. The nurse determines further teaching is necessary when the client makes which statement? 1."Exercise is not allowed until I reach my target weight."2."The faster I gain weight, the faster I will return to school."3."I will eat at each meal time because it's my only option."4."I know someone will watch me during eating and after I eat."

2

The nurse provides a client diagnosed with type 1 diabetes mellitus an insulin injection of 30 units of isophane insulin (NPH) and 10 units of regular insulin at 0700. At which time will the nurse instruct the client to observe for an insulin reaction? 1.07002.10003.13004.2100

2

The nurse provides discharge teaching to a client recovering from an appendectomy. Which client statement indicates that teaching is effective? 1."I shall eat a diet low in protein, high in carbohydrates, and low in fats. "2."I shall eat a diet high in protein, high in calories, and high in vitamin C. "3."I shall eat a diet high in protein, low in calories, and low in fat. "4."I shall eat a diet low in protein, low in carbohydrates, and high in vitamin D. "

2

Which is the first measure for the charge nurse to implement during a low-census client care shift? 1.Keep all staff to provide care for new admissions.2.Contact the hospital supervisor with staffing information.3.Dismiss excess staff with instructions to stay by the phone.4.Dismiss excess staff and instruct them to use paid time off.

2 excess can be floated

The nurse coordinates care on the medical-surgical unit. Which client indicators, if assigned by the nurse to the LPN/LVN, suggest professional negligence? (Select all that apply.) 1.Client with white blood cell count 7000/mm 3 (7 ×10 9/L).2.Client with hemoglobin 6 g/dL (60 g/L).3.Client with blood urea nitrogen 80 mg/dL (28.56 mmol/L).4.Client with prothrombin time of 10 seconds.5.Client with glucose 130 mg/dL (7.21 mmol/L).6.Client with platelet count 22,000/mm 3 (22 ×10 9/L.)

2,3,4,5

The nurse provides care for a client receiving chemotherapy. The medication is an alkylating agent. Which actions will the nurse implement to minimize adverse effects? (Select all that apply.) 1.Prevent ileus formation by encouraging frequent ambulation.2.Administer anti-emetics prophylactically and as needed.3.Offer frequent high fat meals to prevent weight loss.4.Teach client to use saline mouth rinse before and after meals.5.Encourage client to increase fluid intake for the next 3 days.6.Educate client about the benefits of exercise to manage fatigue.

2,4,5,6

Which action involving the client does the nurse determine to be violations of the EMTALA (Emergency Medical Treatment and Active Labor Act)? (Select all that apply.) 1.Client is not provided with advance directives information.2.Client who reports dental pain is denied a medical screening.3.Client's protected health information is shared with those not participating in client's care.4.Client prepares to sell kidney to the highest bidder.5.Client is transferred to another facility before attempts are made to stabilize client.

2,5

The nurse supervises a team of LPN/LVNs. The nurse intervenes if one of the LPN/LVNs allows clients to take licorice pills when which medications are administered? (Select all that apply.) 1.Promethazine.2.Ibuprofen.3.Potassium chloride.4.Furosemide.5.Prednisone.

3,4,5

The nurse in the pediatric clinic performs a physical assessment on an adolescent male client. Which finding by the nurse requires an immediate intervention? 1.The client reports his scrotum aching after exercise. The nurse palpates a worm-like mass above the testes.2.The nurse notes that the client has unilateral breast enlargement.3.The client's scrotum appears swollen, and a soft mass is palpated. The nurse is unable to insert a finger above the mass.4.The client's scrotum appears enlarged and red. The nurse palpates a thickened and swollen spermatic cord.

4

The nurse manager observes the staff nurse apply a transdermal patch on a client. Which observation causes the nurse manager to determine that care is appropriate? 1.The nurse wears sterile gloves when applying the patch.2.The nurse cleanses the skin with alcohol before applying the patch.3.The nurse places a heat lamp over the patch for 20 minutes.4.The nurse folds the old patch in half with sticky sides together.

4

The nurse observes a family member enter a client's room and stand 4 feet from the client. The nurse determines that the family member is using proper precautions because the client is being treated for which diagnosis? 1.Tuberculosis.2.Localized herpes zoster.3.Lyme disease.4.Influenza.

4

The nurse observes the unlicensed assistive personnel (UAP) prepare to obtain the vital signs of an infant diagnosed with respiratory syncytial virus (RSV). Which observation requires an intervention by the nurse? 1.The UAP wears a gown, gloves, and mask when entering the room.2.The UAP is using the stethoscope found in the infant's room.3.The UAP provided care to a post-operative client after a shunt repair before tending to the client with RSV.4.The UAP removes the gown and gloves and places them in a hamper in the hall.

4

The nurse provides care for a client on bed rest who must maintain immobilization of the right leg. Which nursing action is most important? 1.Install a trapeze on the client's bed.2.Assess bony prominences once per shift.3.Place foam dressings on bony prominences.4.Assist the client to turn safely every 2 hours.

4

The nurse provides care to a client who underwent a bone marrow biopsy. During the post-procedure period, the nurse implements which action? 1.Measure abdominal girth at the level of the umbilicus.2.Assist the client to a right side-lying position.3.Observe for changes in the client's cough and sputum.4.Assess for bleeding and hematoma formation.

4

The nurse reviews nutrition with a client who plans to breastfeed for the next 6 months. Which client statement indicates to the nurse that teaching was successful? 1."I will mix baby cereal in a formula bottle when I am ready to give my baby cereal."2."My breast milk should be discarded if left in the freezer for 3 months."3."I should introduce fortified cereal at 2 months of age."4."My breast milk contains iron that is more easily absorbed than iron-fortified formula."

4

The nurse interviews a college student involved in an auto accident 6 months ago that killed the client's best friend. The student reveals to the nurse an inability to study, trouble sleeping, and feeling of going crazy. Which action by the nurse is most appropriate? 1.Complete a physical and social history.2.Obtain a drug and alcohol history.3.Review significant events from the past year.4.Determine the student's past coping behaviors.

4 Obtaining information about how the client coped in the past will help the nurse determine interventions to assist the client to cope now.