16-30 RN Qbank
A nurse is teaching a client about digoxin toxicity. Which statement made by the client is incorrect and indicates more teaching is needed? "I must immediately report a strong pulse of 62 bpm." "I should report nausea and vomiting lasting more than a few days." "High levels of digoxin can cause vision changes." "I'll let you know if my pulse feels uneven and misses beats."
"I must immediately report a strong pulse of 62 bpm."
At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. The client asks about preconception diet changes. Which of these statements made by the nurse is the best approach in this situation? "Drink a glass of milk with each meal." "Eat at least one serving of fish weekly." "Include fiber in your daily diet." "Increase your intake of green leafy vegetables."
"Increase your intake of green leafy vegetables."
During the well-baby checkup, the parents respond to questions about their newborn. Which of these parents' comments would reveal an initial finding that's associated with pyloric stenosis? "We notice the baby is fussy and spits up immediately after eating." "I noticed a little lump above the belly button." "The baby seems hungry all the time." "There was some spitting up at first, but now when the baby spits up, it shoots across the room."
"There was some spitting up at first, but now when the baby spits up, it shoots across the room."
A nurse is assigned to a client diagnosed with multiple trauma and head injury with a blood pressure on admission of 140/70 mm Hg. Four hours later the blood pressure is 179/68 mm Hg.
41 The first pulse width is (140 - 70) = 70. The second pulse width is (179 - 68) = 111. The difference between them is 41, which is an increase that is called a widened pulse pressure.
The client is diagnosed with depression. Which therapeutic communication skill is most likely to encourage the client to express feelings? Reality orientation Projective identification Direct confrontation Active listening
Active listening
The client with lymphoma is admitted for treatment of tumor lysis syndrome. Which medication will protect the kidneys by minimizing uric acid deposits? Furosemide (Lasix) Allopurinol (Aloprim, Zyloprim) Hydralazine Mannitol (Osmitrol)
Allopurinol (Aloprim, Zyloprim)
The client is being treated for tuberculosis (TB). Which assessment would indicate that the client is having a possible adverse response to isoniazid? Severe headache Tachycardia Appearance of jaundice Decreased hearing
Appearance of jaundice
A respiratory therapist (RT) is collecting an arterial blood gas (ABG) sample. The RT must respond to an emergency and asks the nurse to manage the puncture site. Which actions should be completed? (Select all that apply.) Apply snug gauze and secure with tape Check for distal capillary refill Thoroughly wash the site with saline, then apply an antibacterial solution Remove dressing in one hour Apply pressure for 5 to 10 minutes
Apply snug gauze and secure with tape Check for distal capillary refill Apply pressure for 5 to 10 minutes
A nurse is caring for a client with end-stage heart failure. The family members are distressed about the client's impending death. Which intervention should the nurse take first? Assess the family's patterns for dealing with death Explain the stages of death and dying to the family Ask about their present religious affiliations Recommend an easy-to-read book on grief
Assess the family's patterns for dealing with death
The nurse is instructing a client with moderate persistent asthma on the proper method for using metered-dose inhalers (MDIs) and various types of medications. Which medication should the nurse advise the client to administer first? Steroid Mast cell stabilizer Beta agonist Anticholinergic
Beta agonist
A staff nurse informs the charge nurse about an issue between two of the unlicensed assistive personnel (UAP) on the unit. What is the most important guideline for the nurses to remember when resolving this conflict between the UAPs? Explain the consequences of not resolving their differences Require the UAPs to reach a compromise Deal with the issues, not personalities Encourage the UAPs to ventilate their anger and use humor to minimize the conflict
Deal with the issues, not personalities
The 17 year-old female is diagnosed with bulimia nervosa. Which lab result does the nurse anticipate? Decreased serum potassium Increased serum glucose Increased sodium retention Decreased blood urea nitrogen (BUN)
Decreased serum potassium
A nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy when the parents express anxiety and concern about the child's reaction to impending surgery. Which nursing intervention should best prepare the child? Arrange a tour of the operating and recovery rooms Encourage the child to bring a favorite toy to the hospital Introduce the child to all staff the day before surgery Explain the surgery one week prior to the procedure
Explain the surgery one week prior to the procedure
A nurse is teaching a client with atrial fibrillation about the use of warfarin at home. The nurse should reinforce the need to avoid which of the following? Large indoor gatherings Active physical exercise Foods rich in vitamin K Exposure to sunlight
Foods rich in vitamin K
The nurse is caring for a client who received tenecteplase to open an occluded coronary artery following an acute myocardial infarction. Which finding should cause the greatest concern for the nurse? Red-colored tint of the urine Pink frothy sputum Serosanguineous drainage from gums Hematemesis
Hematemesis
The nurse is planning care for a client who is taking cyclosporine modified. What is an appropriate nursing diagnosis for this client? High risk for infection Altered growth and development Impaired physical mobility Alteration in body image
High risk for infection
A nurse is interviewing the parents of a child diagnosed with asthma. During data collection, the nurse should have as a priority to assess the child's environment for what factor? Plants such as cactus Lead-based paint Household pets New furniture
Household pets
A client tells the nurse that the client is fearful of the planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse? Deny the feelings Call a chaplain Listen to the client Cite recovery statistics
Listen to the client
The nurse is caring for a newly admitted 6 month-old infant diagnosed with nonorganic failure-to-thrive (NOFTT). What findings would the nurse expect to observe during the initial assessment? Pale skin, thin arms and legs, and uninterested in surroundings Irritable and "colicky," making no attempts to turn or sit up Dusky in color with poor skin turgor over abdomen Alert, laughing, playing with a rattle, and sitting with support
Pale skin, thin arms and legs, and uninterested in surroundings
A nurse arranges for an interpreter to facilitate communication between a health care team and a non-English speaking client. To promote clearer communication, which of these would be an appropriate action for the nurse to use when working with an interpreter? Plan that the encounter will take more time than if the client spoke English Speak only a few sentences at a time and then pause for a few moments Promote verbal and nonverbal communication with both the client and the family Ask the client to speak slowly and to look at the person spoken to
Promote verbal and nonverbal communication with both the client and the family
The nurse is performing the initial assessment of a client with asthma at the beginning of the shift. The client has oxygen running at 2 liters per minute per nasal cannula. Which assessment finding would the nurse be most concerned about? Excessive thirst with a dry cracked tongue Pulse oximetry reading of 89% Rapid shallow respirations with intermittent wheezes Crackles at the base of the lungs on auscultation
Rapid shallow respirations with intermittent wheezes
What would a nurse expect to see in a client who reports symptoms associated with tardive dyskinesia? Rapid tongue movements Uncontrolled hand tremors during meals Behavioral changes Repetitive slapping movements
Rapid tongue movements
A 71 year-old client is admitted for mitral valve replacement surgery. The client has a history of mitral valve regurgitation and mitral stenosis since he was a teenager. During the admission assessment, the nurse should ask if the client experienced which health issue as a child? Encephalitis Hay fever Rheumatic fever Measles
Rheumatic fever
The nurse is reviewing the list of medications for a client who is scheduled for electroconvulsive therapy (ECT). Which medication does the nurse recognize as the one that will promote skeletal muscle relaxation? Propofol (Diprivan) Atropine Succinylcholine (Anectine) Methohexital (Brevital)
Succinylcholine (Anectine)
The nurse is caring for a 2 month-old infant with a congenital heart defect pre-operatively. How does the nurse best promote adequate nutrition while meeting the child's health needs? Supplement bottle feedings with water Support the mother who breastfeeds Mix medications with formula or breastmilk in a bottle Provide bottle feedings every 2 hours
Support the mother who breastfeeds
The health care team is meeting to discuss discharge planning for a client following total hip replacement surgery. Which assessment finding is most important for the nurse to share? The partner expresses some discomfort with the dressing change The home is a two-story and all bedrooms and bathroom are located upstairs The adult daughter will be responsible for shopping and driving the client after discharge The client does not like the taste of the oral potassium supplement medication
The home is a two-story and all bedrooms and bathroom are located upstairs
Which management style best demonstrates the end of the continuum of management behaviors referred to by Douglas McGregor as Theory Y? The manager is responsible for motivation of employees toward the organizational goals The manager organizes teams of staff and gives compensation to the team rather than individual success The manager takes a hands-off attitude and makes no decisions for employees The manager assumes employees are self-motivated and want to work toward organizational and personal goals
The manager assumes employees are self-motivated and want to work toward organizational and personal goals
A client reports taking lithium as prescribed. Which of these findings indicate early signs of lithium toxicity? Ataxia, agnosia and course hand tremors Electrolyte imbalance, tinnitus and cardiac arrhythmias Vomiting, diarrhea and lethargy Pruritus, rash and photosensitivity
Vomiting, diarrhea and lethargy
The client is admitted to the emergency department with hypertensive crisis. Which finding requires immediate action by a nurse? Crackles at the lung bases Lower extremity pitting edema Weakness in left arm Jugular vein distension
Weakness in left arm
A nurse is observing a client during an excretory urogram. Which of these observations indicate there is a complication? Five minutes into the procedure the client gags and states, "I am getting sick." Within one minute after the dye is injected the client's entire body turns a bright red color A client complains of a salty taste in the mouth when the dye is injected Within two minutes of the dye injection the client states, "I have a feeling of getting warm."
Within one minute after the dye is injected the client's entire body turns a bright red color
A nurse and a client are talking about the client's progress towards understanding the client's behaviors during stressful situations. This is typical of which phase in a therapeutic relationship? Termination Orientation Working Pre-interaction
Working
A nurse notes sudden onset confusion in an 83 year-old client. Which recently ordered medication would have most likely contributed to this change? Anticoagulant Antihistamine Liquid antacid Cardiac glycoside
Antihistamine
The nurse is caring for a child diagnosed with seizures. While teaching the family and the child about the medication phenytoin, what information should the nurse emphasize? Maintain good oral hygiene and dental care Omit the medication if the child is seizure-free Serve a diet that is high in iron Administer acetaminophen to promote sleep
Maintain good oral hygiene and dental care
The nurse assesses a newborn one day after birth, noting a high-pitched cry, irritability and lack of interest in feeding. The mother has left the hospital against medical advice. What intervention is appropriate nursing care at this time for the newborn? Rock the baby frequently Offer formula every two hours Reduce the environmental stimuli Talk to the newborn while feeding
Reduce the environmental stimuli
A client on warfarin therapy after coronary artery stent placement calls the clinic to ask: "Can I take Alka-Seltzer for an upset stomach?" What is the best response by the nurse? "Take Alka-Seltzer at a different time of day than you take the warfarin (Coumadin)." "Select another antacid that does not inactivate warfarin (Coumadin)." "Avoid Alka-Seltzer because it contains aspirin." "Use about half the recommended dose of Alka-Seltzer."
"Avoid Alka-Seltzer because it contains aspirin."
The charge nurse on a cardiac step-down unit makes assignments for the team that consists of a registered nurse (RN), a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP). Which client should be assigned to the LPN? A 35 year-old who is 12 hours post cardiac catheterization A 58 year-old with hypertension, diagnosed with suspected angina A 65 year-old scheduled for discharge after angioplasty and a stent placement A 49 year-old diagnosed with a new onset atrial fibrillation with a rapid ventricular response
A 58 year-old with hypertension, diagnosed with suspected angina
The nurse is providing care to a nullipara client who, at 12-weeks gestation, has just begun prenatal care. Her lab results indicate she is positive for human immunodeficiency virus (HIV). Which of the following statements is most important for the client to understand about caring for herself and her baby? Breast-feeding is recommended because the health benefits of breast-feeding outweigh the risks of HIV transmission A cesarean section will be scheduled before the woman's membranes rupture or she goes into labor Pregnancy is known to accelerate the course of HIV disease in the mother Medication for HIV infection should be started immediately after birth for both mother and baby
A cesarean section will be scheduled before the woman's membranes rupture or she goes into labor
An external disaster has occurred in the town. The triage nurse from the emergency department is transported to the site and assigned to triage the injured. Which of these clients would the nurse tag as "to be seen last" by the providers at the scene? A middle-aged person with deep abrasions that are over 90% of the body A teenager with small amount of bright red blood dripping out of the nose An older adult person with a open fracture of the left arm An infant with bilateral fractured lower legs with no active bleeding
A middle-aged person with deep abrasions that are over 90% of the body
There has been a disaster at a child day care center. Which of these children at the site would the triage nurse put in the "treat last" category? A school-age child with singed eyebrows and hair near the forehead An infant with intermittent bulging anterior fontanelle during crying episodes A preschooler with a lower leg fracture on one side and an upper leg fracture on the other A toddler with severe and deep abrasions over 98% of the body
A toddler with severe and deep abrasions over 98% of the body
The nurse is caring for an 81 year-old client with colorectal cancer. Until now, the client's pain has been managed using acetaminophen with codeine. Because of increased pain, intravenous morphine has now been ordered. What should the nurse recognize about the validity of this order? Appropriate despite the expected effect of mental confusion Inappropriate and demonstrates poor knowledge of pain control Inappropriate because of potential respiratory depression Appropriate pain management around-the-clock
Appropriate pain management around-the-clock
A nurse is caring for a trauma victim who has experienced a significant blood loss. Immediately following multiple transfusions, what is the most accurate indicator of oxygenation? Hemoglobin and hematocrit (H and H) Arterial blood gases (ABGs) Pulse oximetry Complete blood count (CBC)
Arterial blood gases (ABGs)
Which finding should the nurse identify as the most characteristic of an acute episode of reactive airway disease? Inspiratory laryngeal stridor Frequent dry coughing Auditory gurgling Audible expiratory wheezing
Audible expiratory wheezing
A nurse is working with a client in an extended care facility. Which bed position is preferred for a client, who is at risk for falls, as part of a prevention protocol? Bed in lowest position, wheels locked, bed placed against the wall Knees bent, head slightly elevated, bed in lowest position Four side rails up, wheels locked, bed closest to door Lower side rails up, upper wheels locked, bed facing doorway
Bed in lowest position, wheels locked, bed placed against the wall
The nurse is teaching a group of women in a community clinic about prevention of osteoporosis. Which over-the-counter medication should the nurse recognize as having the most elemental calcium per tablet? Calcium carbonate Calcium citrate Calcium chloride Calcium gluconate
Calcium carbonate
A mother wants to switch her 9 month-old infant from an iron-fortified formula to whole milk. Upon further assessment, a nurse finds that the baby eats table foods well, but drinks less milk than before. What information is the priority for the nurse discuss with the mother? Change the baby to whole milk Continue with the present infant formula Offer fruit juice in a sippy cup occasionally Continue introducing new food
Continue with the present infant formula
The nurse reviews an order to administer Rh (D) immune globulin to an Rh negative woman after the birth of her Rh positive newborn. Which assessment is a priority before the nurse gives the injection? Coombs test results Previous RhoGAM history Gravida and parity Newborn's blood type
Coombs test results
During a routine checkup, a client with a history of type 1 diabetes mellitus has the glycosolated hemoglobin (HbA1c) checked. The results indicate a level of 11%. Based on this result, what should the nurse emphasize during teaching? Insulin mixing and preparation Daily peripheral glucose monitoring Review of diet and exercise recommendations Rotation of injection sites
Daily peripheral glucose monitoring
The nurse is performing a physical assessment on a client with type 1 diabetes. Which finding calls for immediate nursing action? Painful hematoma on thigh Intense thirst and hunger Diaphoresis and shakiness Reduced lower leg sensation
Diaphoresis and shakiness
A nurse is performing a developmental assessment on an 8 month-old infant. Which finding should be reported to the health care provider? Rolls from abdomen to back Responds to parents' voices Falls forward when sitting Lifts head from the prone position
Falls forward when sitting
The nurse is caring for a client in a home setting. Which approach is the most effective way to prevent infections when providing care to clients in the home? Wearing a mask with a shield during any eye/mouth/nose examination Wearing non-powdered latex-free gloves to examine the client Handwashing before and after examination of clients Using a barrier between the client's furniture and the nurse's bag
Handwashing before and after examination of clients
A nurse is assessing a hospitalized newborn who was delivered in the home several days ago. The infant's mother has a known history of heroin addiction. Which finding should the nurse expect to find in the infant? Irritability Large for gestational age Central nervous system depression Lethargy with excessive sleepiness
Irritability
The nurse is caring for a client who had a laparoscopy with excision of endometriosis. Where would the nurse expect to find the incision?
Laparoscopy is the most common procedure used to diagnose and treat endometriosis. A small incision is made near the belly button and the abdomen is filled with CO2 gas; the lighted laparoscope is then inserted into the abdomen. (Two other small incisions are also typically made in the abdomen.)
A nurse is planning care for a client with increased intracranial pressure. What is the best position for this client? Side-lying with head flat Trendelenburg Low Fowler's Supine
Low Fowler's
The nurse is providing care for a client diagnosed with sickle cell crisis. Which medication ordered for pain control should be questioned by the nurse? Codeine Fentanyl (Sublimaze) Meperidine (Demerol) Morphine sulfate
Meperidine (Demerol)
A client has undergone electroconvulsive therapy (ECT). What is an appropriate postprocedure nursing intervention? Expect long-term memory loss for a few hours Permit the client to sleep for four to six hours Remain with client until oriented to time, place and person Offer frequent sips of clear liquids
Remain with client until oriented to time, place and person
The nurse is planning care for a client with a cerebral vascular accident (CVA). Which approach would be most effective in the prevention of skin breakdown? Place client in the wheelchair for four hours daily Pad the bony prominences Reposition every two hours if in bed Massage reddened bony prominence
Reposition every two hours if in bed
The nurse is caring for a client on peritoneal dialysis. While performing a dialysate exchange which finding(s) would alert the nurse that the client has developed an acute complication? Catheter dressing saturated with clear fluid Pulse 86 and blood pressure 112/74 Client sleeps throughout fluid exchange Respiration rate of 30 with crackles throughout the lung fields
Respiration rate of 30 with crackles throughout the lung fields
The nurse cares for a newborn with tracheoesophageal fistula (TEF) and esophageal atresia (EA.) Which nursing diagnosis is the highest priority? Activity intolerance Imbalanced nutrition: less than body requirements Risk for infection Risk for aspiration
Risk for aspiration
A client has expressed to the nurse feelings of hopelessness. Which of the following nursing diagnoses becomes a priority when a client expresses a sense of hopelessness? Ineffective individual coping Risk for self-directed violence Powerlessness Fatigue
Risk for self-directed violence
A child has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse? A report of 10 pounds weight loss in the last month A report of the sudden onset of irritability in the past two weeks A comment by the client: "I just can't sit still." The appearance of eyeballs that appear to "pop" out of the client's eye sockets
The appearance of eyeballs that appear to "pop" out of the client's eye sockets
During teaching to use the metered-dose inhaler (MDI) to a client newly diagnosed with asthma, the client asks: "When will I know the canister is empty?" The nurse's response should include which information? Estimate how many doses are usually in the canister The number of doses that remain will be on the inhaler Shake the canister to detect any fluid movement Drop the canister in water to observe floating
The number of doses that remain will be on the inhaler
A 14 month-old infant is brought to the emergency department with irritability, lethargy over two days, dry skin, and increased pulse. What additional question would be most important for the nurse to ask in assisting the provider with determination of the diagnosis? Reverse of sleep-wake cycles Use of daycare Change in eating habits The number of wet diapers in the past two days
The number of wet diapers in the past two days
The nurse attends an interdisciplinary meeting on the topic of fall prevention. What specific tactics can be used to reduce falls in health care settings? (Select all that apply.) Use "low beds" for at-risk clients Regularly reorient clients Identify vulnerable clients Install and use bed alarms Raise side rails Use a "two to transfer" policy
Use "low beds" for at-risk clients Identify vulnerable clients Install and use bed alarms Use a "two to transfer" policy
Which nursing practice best reduces the chance of communication errors that might otherwise lead to negative client outcomes? Maintain respectful working relationships with all staff Document nursing care at the end of the shift Use standardized forms for client handoffs Speak using a professional tone on the telephone
Use standardized forms for client handoffs
The nurse is caring for a client with a colostomy pouch. During a teaching session, when should the nurse teach that the pouch should be emptied? Prior to meals After each fecal elimination When it is one-third to one-half full At the same time each day
When it is one-third to one-half full
In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize which approach? Avoiding passive smoke Limiting alcohol use Learning relaxation techniques Eat smaller meals
Learning relaxation techniques
At a well-child checkup, the nurse is assessing a 1 year-old who was born prematurely and is being evaluated for cerebral palsy (CP). Which information provided by the parents would support this diagnosis? "He crawls by pushing off with one hand and leg while dragging the opposite hand and leg." "Our child isn't talking yet." "Mealtime is so messy when he tries to feed himself." "We think our child seems smaller than other babies this age."
"He crawls by pushing off with one hand and leg while dragging the opposite hand and leg."
A nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. What should be the nurse's first action? Assess airway, breathing and circulation Begin cardiopulmonary resuscitation Prepare for immediate defibrillation Notify the rapid response team and the health care provider
Assess airway, breathing and circulation
A client is admitted to the emergency department during an acute asthma attack. Which assessment finding would support this diagnosis? Diffuse auditory expiratory wheezing Fever and chills Forced expiratory volume (FEV1) 60% of the predicted value Loose, productive cough
Diffuse auditory expiratory wheezing
The nurse receives report on the following client assignments. Which client should the nurse assess first? A client who underwent a partial gastrectomy and reports feeling lightheaded A client reporting severe gastric distress after taking ibuprofen A client diagnosed with gastroesophageal reflux disease (GERD) reporting difficulty swallowing A client diagnosed with peptic ulcer disease (PUD) who reports feeling dizzy
A client diagnosed with peptic ulcer disease (PUD) who reports feeling dizzy
A client diagnosed with testicular cancer is scheduled for a right orchiectomy. The nurse is able to answer the client's questions about this procedure with the understanding that a unilateral orchiectomy involves which of the following approaches? A dissection of related lymph nodes by the testes A partial surgical removal of the perineal area A surgical removal of one testicle A surgical removal of the entire scrotum
A surgical removal of one testicle
A nurse consistently ignores the call lights of clients who practice alternative lifestyles. The nurse's behavior is an example of what approach? Discrimination Stereotyping Cultural insensitivity Prejudice
Discrimination
A client is admitted to the hospital with a diagnosis of deep vein thrombosis (DVT). During the initial assessment, the client reports sudden shortness of breath. The oxygen saturation reading is 87%. At this time what is the highest priority nursing intervention? Begin continuous cardiac monitoring Administer the PRN albuterol nebulizer Call the health care provider (HCP) Administer oxygen to maintain a saturation of 92%
Administer oxygen to maintain a saturation of 92%
The clinic nurse is counseling a postpartum client who has a substance-abuse problem and is at risk for continued cocaine use. In order to provide continuity of care, which nursing diagnosis should be a priority? Social isolation Sexual dysfunction Ineffective coping Altered parenting
Altered parenting
A client is transported by a family member to the emergency department following a boating accident. The client is conscious, shivering, and confused. The client is still wearing wet clothes. Which interventions does the nurse implement? (Select all that apply.) Apply warm blankets Monitor vital signs Infuse warm IV solutions as ordered Massage cold extremities Remove wet clothes Give sips of warm fluids
Apply warm blankets Monitor vital signs Infuse warm IV solutions as ordered Remove wet clothes
A client with chronic kidney disease (CKD) is scheduled for hemodialysis at 9 am. It is now 6:30 am and the client is eating breakfast. How should the nurse help the client to prepare for hemodialysis? (Select all that apply.) Hold all oral medications Administer prescribed phosphate binder This is a part of the correct response Administer prescribed vitamin D This is a part of the correct response Assess patency of the access site
Assess patency of the access site
A nurse is teaching a mother who will breast-feed for the first time. Which of these approaches is a priority? Give the mother privacy for the initial feeding Assist the mother to position the newborn at the breast Give the mother several illustrated pamphlets Show the mother films on the physiology of lactation
Assist the mother to position the newborn at the breast
A pregnant woman is advised to increase the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet best satisfies the client's requirements? Beef, 1/2 cup lima beans, 8-ounce glass of skim milk, 3/4 cup strawberries 3 ounces chicken, 1/2 cup corn, lettuce salad, small banana 1 cup macaroni, 3/4 cup peas, glass whole milk, medium pear Scrambled egg, hash browned potatoes, large nectarine
Beef, 1/2 cup lima beans, 8-ounce glass of skim milk, 3/4 cup strawberries
The pregnant woman asks how a health care provider (HCP) can tell she is pregnant "just by looking inside." What is the best explanation for this? Slight rotation of the uterus to the right Pronounced softening of the cervix Bluish coloration of the cervix and vaginal walls Plug of very thick mucus
Bluish coloration of the cervix and vaginal walls
A child is sent to the school nurse by a teacher who has a written note that fifth disease is suspected. Which of the following should the nurse expect to find if the child has this condition? Koplik spots appear first followed by a rash that appears first on the face and spreads downward Discrete rose pink macules will appear first on the trunk and fade when pressure is applied Bright red cheeks, with a "slapped face" appearance Macule that rapidly progresses to papule and then vesicles
Bright red cheeks, with a "slapped face" appearance
The nurse is having difficulty reading the health care provider's written order that was written just before the shift change. What action should the nurse take? Leave the order for the oncoming staff to follow up on Contact the charge nurse for an interpretation Ask the pharmacy for assistance in the interpretation Call the provider for clarification of the order
Call the provider for clarification of the order
An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight change at six months of age? Gain six ounces each week Triple the birth weight Add two pounds each month Double the birth weight
Double the birth weight
A nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness would the nurse recognize as increasing the risk of developing Reye's syndrome? Hepatitis Rubeola Meningitis Influenza
Influenza
The client is prescribed warfarin (Coumadin, Jantoven). Which lab test would the nurse monitor to determine a therapeutic response to the drug? International Normalized Ratio (INR) Bleeding time Coagulation time Partial thromboplastin time (PTT)
International Normalized Ratio (INR)
A nurse is caring for a client with renal calculi. Which focus of the health care provider's orders would be a priority? Push oral fluids and keep open IV rate Start intravenous antibiotics after blood draw for culture and sensitivity Apply continuous warm compresses to the flank area Morphine sulfate using patient-controlled analgesia
Morphine sulfate using patient-controlled analgesia
The nurse is performing an assessment on an infant with severe airway obstruction. Which assessment finding would the nurse anticipate? Nasal flaring Chest pain aggravated by respiratory movement Cyanosis and mottling of the skin Rapid, shallow respirations
Nasal flaring
The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted with a connection to a ventilator. Which finding should prompt the nurse to take immediate action to resolve the issue? Pulse oximetry of 86% saturation Client is unable to speak Breath sounds are heard bilaterally Mist is visible in the T-Piece of the ventilator circuit
Pulse oximetry of 86% saturation
A diabetic client asks the nurse: "Why did the health care provider order a glycosylated hemoglobin (HbA1c) measurement? My blood glucose reading was just done this morning." Which explanation would be best to help explain the purpose of the HbA1c? Is performed to detect any complications of diabetes Reflects an average blood glucose for the prior several months Measures the circulating levels of insulin Provides a more precise blood glucose value than self-monitoring
Reflects an average blood glucose for the prior several months
A client who is a victim of domestic violence states, "If I were better, I would not have been beaten." Which feeling best describes what the client may be experiencing at this time? Self-blame Rejection Helplessness Fear
Self-blame
A client with a panic disorder has a new prescription for alprazaolam. In teaching the client about the drug's actions and side effects, which point should the nurse emphasize? The medication acts as a stimulant Initial side effects often continue unchanged Dosage will be increased as tolerated Short-term relief can be expected
Short-term relief can be expected
A client diagnosed with hypertension is started on atenolol. The nurse should instruct the client to immediately report which of these findings? Feeling tired Slow, irregular pulse Decreased sex drive Insomnia
Slow, irregular pulse
A nurse is teaching the parent of a 9 month-old infant about diaper dermatitis. Which of these actions would be appropriate for the nurse to include during the teaching? Use only cloth diapers that are rinsed in bleach Do not use occlusive ointments on the rash Stop any new food that was added to the infant's diet prior to the rash Use commercial baby wipes with each diaper change
Stop any new food that was added to the infant's diet prior to the rash
A client who is a former actress enters the day room wearing a sheer nightgown, high heels, numerous bracelets, bright red lipstick and heavily rouged cheeks. Which nursing action is the most therapeutic in response to the client's attire? Quietly point out to her how the other clients are dressed on the unit Gently remind her that she is no longer on stage Tactfully explain appropriate clothing for the unit meetings Straightforwardly assist the client to her room for appropriate apparel
Straightforwardly assist the client to her room for appropriate apparel
A 55 year-old woman is taking prednisone and aspirin (ASA) as part of the treatment for rheumatoid arthritis. Which approach would be an appropriate intervention for the nurse? Test stools for occult blood Discuss fiber in the diet to prevent constipation Assess the pulse rate every four hours Monitor the level of consciousness every shift
Test stools for occult blood
There is an order to insert a urinary catheter. The client is an adult female. The nurse slips the catheter approximately 4-5 inches (10-12 cm) into an opening, but no urine is obtained. What is the most probable reason for this outcome? The catheter is located in the vaginal canal No urine is present in the bladder The bladder is overdistended without the ability to empty The catheter is not inserted far enough into the canal
The catheter is located in the vaginal canal
The nurse works with children who have chronic conditions requiring frequent hospitalization and activity limitations. Which statement best describes the effects of immobility in children? Children are more susceptible than adults to the multisystem effects of immobility The physical effects of immobility are similar in both children and adults Immobility promotes independence and self-reliance in children Immobilized children quickly develop confusion and mental status changes
The physical effects of immobility are similar in both children and adults
The nurse who travels with an agency is uncertain about what tasks can be performed when working in a different state. It would be best for the nurse to check which resource? The American Nurses Association's Social Policy Statement The state nurse practice act in which the assignment is made With a nurse colleague who has worked in that state two years ago The policies and procedures of the assigned agency in that state
The state nurse practice act in which the assignment is made
The nurse is talking with the parents of a child who has recently been diagnosed with Hemophilia A. What should the nurse understand about the offspring of an unaffected father and a carrier mother? It is likely that all sons will be affected There is a 25% chance a daughter will be a carrier There is a 50% probability that sons will have the disease Every daughter is likely to be a carrier
There is a 25% chance a daughter will be a carrier
A novice charge nurse is delegating duties. Which tasks, if delegated to an unlicensed assistive personnel (UAP), would require intervention by the nurse manager? To help an older adult client to the bathroom To empty a urethral collection bag To feed a 2 year-old with a broken arm To bathe a woman with internal radon seeds and device
To bathe a woman with internal radon seeds and device
A mother of a burned child asks the nurse to clarify what is meant by a third-degree burn. The best response by the nurse should include which point? "The skin layers are swollen and reddened." "All layers of the skin were destroyed in the burn." "The top layer of the skin is destroyed." "Muscle, tissue and bone have been injured."
"All layers of the skin were destroyed in the burn."
A clinic nurse is discussing health promotion with a group of parents when a mother expresses concern about Reye's syndrome and asks about prevention. Which comment demonstrates appropriate teaching by the nurse? "Avoid use of aspirin for viral infections in children." "Report exposure to this illness as soon as possible." "Immunize your child against this disease." "Seek medical attention for serious injuries."
"Avoid use of aspirin for viral infections in children."
A client was admitted to the psychiatric unit for severe depression. After several days, the client continues to withdraw from the other clients. Which of these statements by the nurse would be the most appropriate to promote interaction with other clients? "Come with me so you can paint a picture to help you feel better." "Your team here thinks it's good for you to spend time with others." "It is important for you to participate in group activities." "Come play a few games of Chinese Checkers with Gloria and me."
"Come play a few games of Chinese Checkers with Gloria and me."
The nurse directs an unlicensed assistive personnel (UAP) to assist the elderly surgical client to ambulate in the hallway. Which instruction by the nurse is best? "If the client is dizzy on standing, ask the client to take a few deep breaths before taking a step." "Don't forget to ask the client to put on his slippers before going for a walk." "After you assist the client back into bed, let me know how the client feels." "Have the client sit on the side of the bed for at least two minutes before helping the client to stand."
"Have the client sit on the side of the bed for at least two minutes before helping the client to stand."
A client with possible hepatitis C discusses his health history with an admission nurse. The nurse should recognize which statement by the client as the most important in supporting this diagnosis? "I had a blood transfusion in 1990." "I got back from Africa a few weeks ago." "I have had unprotected sexual contact with at least one person." "I ate the best raw oysters last week."
"I had a blood transfusion in 1990."
A nurse is teaching a client with asthma about the correct use of the fluticasone inhaler. Which statement, if made by the client, would indicate that the teaching was effective? "I should not use a spacer with my inhaler." "If I forget a dose, I can double up on the next dose." "The inhaler can be used whenever I feel short of breath." "I should rinse my mouth after using the inhaler."
"I should rinse my mouth after using the inhaler."
A nurse is providing information to a young adult client recently diagnosed with testicular cancer and asks the client to state his understanding of the disease. Which of the statements made by the client indicates a need for additional correct information? "I may want to have my sperm frozen and preserved before starting chemotherapy." "After surgery, I can have a prosthesis placed inside my scrotum that will look and feel like the real thing." "The surgeon will remove one or both of my testicles and maybe the lymph nodes in my lower belly, too." "If I have cancer at stage III it means I have a better chance of recovery than if it were stage I or II."
"If I have cancer at stage III it means I have a better chance of recovery than if it were stage I or II."
A pregnant client asks a nurse about the purpose of a blood test for alpha-fetoprotein (AFP). What would be the nurse's best response? "The results help determine if the baby is growing normally." "Placental well-being is being evaluated." "Possible neurological defects may be identified." "It tells us how far along your pregnancy is."
"Possible neurological defects may be identified."
The home health aide calls the nurse to report information about a client. Which of these findings should the nurse act on? "The family wants to discontinue the home meal service called Meals on Wheels." "The urine in the urinary catheter bag is of a deeper amber, almost brown color." "The client reports not sleeping well for the past week." "The partner says the client has gotten slower when doing things every other day."
"The urine in the urinary catheter bag is of a deeper amber, almost brown color."
The parents of a 4 year-old hospitalized child tell the nurse, "We are leaving now and will be back at 6:00 pm." A few hours later the child asks a nurse when the parents will come again. What is the best response by the nurse? "In about two hours, you will see them." "When the clock hands are on the numbers 6 and 12." "They will be back right after you eat supper." "After you play awhile, they will be here."
"They will be back right after you eat supper."
A nurse administered intravenous immune globulin to an 18 month-old child with immune deficiency disorder. The parents asks why this medication is being given. How should the nurse respond? "It will slow down the replication of the virus." "It will increase the effectiveness of the other medications your child receives." "This medication is used to prevent bacterial infections." "This medication will improve your child's overall health status."
"This medication is used to prevent bacterial infections."
The nurse is assessing a client with a history of hypertension. Which of these questions is a priority for the nurse to ask? "Describe your usual exercise and activity patterns." "What over-the-counter medications do you take?" "Describe your family's cardiovascular history." "Tell me about your usual diet for one day."
"What over-the-counter medications do you take?"
The nurse is teaching a 10 year-old child prior to heart surgery. Which form of explanation meets the developmental needs of this age child? Provide the child with a booklet to read about the surgery Explain the surgery using a model of the heart Provide a verbal explanation just prior to the surgery Introduce the child to another child who had heart surgery three days ago
Explain the surgery using a model of the heart
A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse should understand that a more frequent cause for suicide in adolescents is which factor? Feelings of anger or hostility with others Progressive failure to adapt socially Reunion wish or fantasy of the supernatural Feelings of alienation or isolation from peers
Feelings of alienation or isolation from peers
Several hours after a gastrectomy, the nasogastric tube (NGT) stops draining. After referring to the standing gastrectomy postoperative orders, what order will the nurse implement first? Reposition the tube until it begins to drain Gently irrigate the tube with sterile normal saline Notify the surgeon Increase the amount of suction
Gently irrigate the tube with sterile normal saline
What is the best way for a nurse to obtain the health history of a 14 year-old client? Allow an opportunity for the teen to express feelings Have the mother present to verify information Focus the discussion of risk factors in the peer group Use the same type of language as the adolescent
Allow an opportunity for the teen to express feelings
Where should the nurse administer the annual purified protein derivative (PPD) to the client with a left arm Permcath™?
Always avoid using the arm with a shunt so as to prevent restriction of blood flow and possible clotting or rupture of the fistula. Using the opposite forearm for the PPD administration also reduces the chance for infection.
A 28 year-old is transferred to the emergency department (ED) via ambulance with a traumatic head injury. The client is awake and reports having a headache and some amnesia. What are the priority nursing interventions for this client? (Select all that apply.) Assess the airway Prepare for CT imaging of the head Position this client in high Fowler's position Assess vital signs and neurological function Assess the wound for presence of drainage or bruising on the head
Assess the airway Prepare for CT imaging of the head Assess vital signs and neurological function Assess the wound for presence of drainage or bruising on the head
The nurse is preparing to administer medications to a client diagnosed with heart failure and atrial fibrillation. Which intervention is most important for the nurse to implement before administering digoxin? Monitor intake and output ratios and daily weight Assess the apical pulse, counting for a full minute Assess for peripheral edema and auscultate the lungs for crackles Monitor oxygen saturation on room air
Assess the apical pulse, counting for a full minute
The charge nurse on the night shift at an urgent care center has to admit clients of a higher acuity than usual because of a large fire in the nearby area. Which style of leadership and decision making would be best in this circumstance? Seek input from staff for tasks Use a nondirective approach Assume a decision-making role Shared decision making with others
Assume a decision-making role
The nurse is using the Glasgow Coma Scale (GCS) to assess a client who experienced a head injury. During the last assessment, the client scored a 14. Now the client opens eyes to verbal command (GCS 3), has purposeful movement to painful stimulus (GCS 5) and is using inappropriate words (GCS 3). Which intervention by the nurse should be implemented first? Continue to monitor level of consciousness Increase the flow of oxygen Call the rapid response team and health care provider Raise the head of the bed
Call the rapid response team and health care provider
When taking the client's blood pressure (BP), a nurse cannot hear the sounds through the stethoscope. The nurse is able to palpate the systolic pressure reading. Which action should the nurse take first? Ask the client what the BP usually is Check to see if the stethoscope was turned to the bell side or is plugged in Take the BP again in two minutes in the same arm Use an electronic BP cuff on the other arm
Check to see if the stethoscope was turned to the bell side or is plugged in
The nurse is reviewing the medical records for a newborn and sees that the first APGAR score was an 8 and the second score was a 9. Which category of the APGAR test is most likely the reason for the improved score? Heart rate Cry Muscle tone Color
Color
A young child is receiving treatment for lead poisoning. Which of the following is the most serious effect of long-term exposure to lead? Impaired kidney function Lead colic and constipation Damage to the central nervous system Anemia and fatigue
Damage to the central nervous system
The nurse is caring for a 15 year-old client with a lengthy confining illness. This client is most at risk for altered psychoemotional growth and development due to what issue? Dependence Lack of trust Insecurity Loss of control
Dependence
The nurse notes that a prescription for captopril was changed to losartan, even though the captopril provided effective blood pressure control. What is the most likely reason for discontinuing the captopril? Dry cough Sexual dysfunction Rash and itching Blurred vision
Dry cough
A nurse is caring for a client with schizophrenia who has been treated with quetiapine for one month. Today the client is increasingly agitated and reports having muscle stiffness. Which of these additional findings should be reported to the health care provider? Elevated temperature and sweating Decreased pulse and blood pressure Mental confusion and general weakness Muscle spasms and seizures
Elevated temperature and sweating
A nurse has administered several blood transfusions over three days to a 12 year-old client with thalassemia. What lab value should the nurse monitor during this therapy? Hemoglobin Platelet count Red blood cell indices Reticulocyte count
Hemoglobin
The nurse is caring for a 4 year-old who will have surgery for tetralogy of Fallot tomorrow. Which laboratory report must receive priority attention by the nurse? Erythrocyte sedimentation rate Hemoglobin and hematocrit White blood cell count Arterial blood gases
Hemoglobin and hematocrit
The nurse is assessing a client who takes a prescribed antipsychotic medication. Which findings require immediate discontinuation of this medication? Involuntary rhythmic stereotypic movements and tongue protrusion Cheek puffing and involuntary movements of extremities and trunk Hyperthermia and severe muscle rigidity Agitation and constant state of motion
Hyperthermia and severe muscle rigidity
The father of an 8 month-old asks the nurse if the child's vocalizations are normal for his this age. Which sound should the nurse expect from a child at this age? Throaty sounds Laughter Imitation of sounds Cooing
Imitation of sounds
A client with heart failure has digoxin ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? Increased heart rate with increased respirations Improved respiratory status with increased urinary output Decreased chest pain with decreased blood pressure Diaphoresis with decreased urinary output
Improved respiratory status with increased urinary output
A 48-year old female with metastatic breast cancer is scheduled to receive her first dose of a trastuzumab (Herceptin). Which of the following results would prompt the nurse to hold the prescribed treatment and discuss the assessment with the ordering health care provider? Blood glucose 130 mg/dL Positive human epidermal growth factor receptor 2 (HER2) Positive lymph node involvement Irregular apical pulse
Irregular apical pulse
Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parents remark: "We just don't know how he caught the disease!" The nurse's response should be based on an understanding of which of these points? It is not "caught" but is usually an immune response to a previous strep infection or an autoimmune condition The disease is easily transmissible in schools and camps The illness is usually associated with chronic respiratory infections AGN is a streptococcal infection that involves the kidney tubules
It is not "caught" but is usually an immune response to a previous strep infection or an autoimmune condition
The client with coronary artery disease has a prescription for nitroglycerin transdermal patches. What is the best reason the client should not wear a patch for more than 12 to 14 hours each day? It will cause profound hypotensive effects it will irritate the skin It may no longer work as well It can cause severe headaches
It may no longer work as well
A 38 year-old female client is admitted to the hospital diagnosed with an acute exacerbation of asthma. This is her third admission for asthma in seven months and she admits she doesn't really like having to use her medications all the time. Which explanation by the nurse best describes the long-term consequence of uncontrolled airway inflammation? Chronic bronchoconstriction of the large airways will occur The client will experience frequent bouts of pneumonia The alveoli will degenerate and balloon out Lung remodeling and permanent changes in lung function will result
Lung remodeling and permanent changes in lung function will result
A client is receiving erythromycin 500 mg PO every six hours for the treatment of pneumonia. What is the most common side effect of this anti-infective? Nausea/vomiting Severe headache Blurred vision Muscle aches
Nausea/vomiting
A nurse is completing the initial assessment for a child immediately after a surgical correction of a ventricular septal defect. Which nursing assessment should be a priority during the process? Auscultate for pulmonary congestion Monitor for the equality of peripheral pulses Observe for postoperative arrhythmias Blanch nail beds for color and refill
Observe for postoperative arrhythmias
A nurse is performing physical assessments on adolescents. What finding should the nurse anticipate concerning female growth spurts? Occur about two years earlier than for males Begin about the same time for males Start just prior to the onset of puberty Characterized by an increase in height of 4 inches each year
Occur about two years earlier than for males
The adult client is alert and cooperative. The client has a short leg cast and can only partially bear weight on the casted leg. Which technique can be safely used to transfer the client from the bed into a chair? One caregiver applies a transfer belt and uses the stand-and-pivot technique Two caregivers lift the client from the bed and move the client into the chair One caregiver applies a gait belt and transfers the client toward the weak side Two caregivers use a friction-reducing device and wide base of support when transferring the client
One caregiver applies a transfer belt and uses the stand-and-pivot technique
A client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. This client constantly "bothers" other clients, tries to help the housekeeping staff, demonstrates pressured speech and demands constant attention from the staff. Which activity should the nurse attempt to get the client to do? Checkers Reading Ping-pong Cards
Ping-pong
The client who is diagnosed with autism begins to eat the food on his plate using his hands. Because the client regularly uses utensils to eat his food, which response by the nurse would be best? Jokingly state: "Well I guess fingers sometimes work better than spoons." Make the comment: "I believe you know better than to eat with your hands." Remove the food and state: "You can't have anymore food until you use the spoon." Place the spoon in the client's hand and state, "Use the spoon to eat your food."
Place the spoon in the client's hand and state, "Use the spoon to eat your food."
A 3 year-old child who is diagnosed with celiac disease attends a day care center. Which of the following foods would be an appropriate snack? Cheese crackers Peanut butter sandwich Vanilla cookies Potato chips
Potato chips
A nurse notes that a 2 year-old child recovering from a tonsillectomy has a temperature of 98.2 F (36.7 C) at 11:00 am. At 1:00 pm the child's parent reports that the child "feels very warm" to touch. What should the nurse do first? Reassess the child's temperature Administer the prescribed acetaminophen Reassure the parent that this is normal Offer the child cold oral fluids
Reassess the child's temperature
An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident (CVA) has had a blood pressure of 160/100 to 180/110 over the past two hours. The nurse has also noted increased lethargy since admission. Which of the following new findings should the nurse report immediately to the provider? Muscle weakness Rapid pulse Slurred speech Incontinence
Slurred speech
A 14 month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after discharge. Which lunch is the best example of an appropriate meal at this time? Soup, blenderized soft foods, ice cream, milk Hot dog, carrot sticks, gelatin, milk Baked chicken, applesauce, cookie, milk Peanut butter and jelly sandwich, chips, pudding, milk
Soup, blenderized soft foods, ice cream, milk
A client was admitted to the psychiatric unit after refusal to get out of the bed. Once admitted, the client is observed talking to unseen people and voiding on the floor. The nurse should handle the problem of voiding on the floor by which of these approaches? Restrict the client's fluids throughout the day Require the client to mop the floor after each incident Toilet the client more frequently with supervision Withhold privileges each time the voiding occurs
Toilet the client more frequently with supervision
A client has been taking alprazolam for three days. The nurse should expect to find which intended effect of this drug? Relief of insomnia and phobias Increased coordination and ability to concentrate Sedation and long-term analgesia Tranquilization and calming effects
Tranquilization and calming effects
A client has chronic renal failure and is being treated at home. During weekly home visits, which factor is the most accurate indicator of fluid balance? Trends in daily weights Changes in mucous membrane moistness Skin turgor over at least two areas of the body Difference between intake and output
Trends in daily weights
