75 u world
A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says to the nurse, "The voices are bad today...they are so angry with me." Which of the following is the best response by the nurse?
"what are the voices saying to you?"
The nurse is reviewing anticipatory guidance with the parents of a 6-month-old infant with phenylketonuria. Which statements by the nurse are appropriate? Select all that apply.
1. "A low-phenylalanine diet is required." 2. "Meat and dairy products should not be introduced into the diet." 4. "Special infant formula is required."
The nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations. The client says in a trembling voice, "There's a bad man standing over there in the corner of my room." What is the best response by the nurse?
1. "I know you are frightened, but I do not see a man in your room." [87%]
The office nurse instructs a client newly diagnosed with asthma about the use of the peak flow meter to evaluate airflow. Which statement made by the client indicates an understanding of the nurse's teaching?
1. "I will exhale as quickly and forcibly as possible through the mouthpiece of the device to obtain a peak flow reading." [42%]
An older client comes to the outpatient clinic for a routine physical examination and health screening. Which findings does the nurse recognize as possible indications of colorectal cancer? Select all that apply.
1. Abdominal pain 2. Blood in the stools 3. Change in bowel habits 5. Unexplained weight loss
The client is brought to the emergency department after falling off a roof and landing on his back. A T1 spinal fracture is diagnosed. The client's blood pressure is 74/40 mm Hg, pulse is 50/min, and skin is pink and dry. What nursing action is a priority?
1. Administer IV normal saline [50%]
The health care provider (HCP) prescribes an oral iron suspension for 3 months for a 2-year-old with iron deficiency anemia. Which instructions should be given to the parent? Select all that apply.
1. Administer doses between meals 2. Administer doses with citrus juice 4. Place medicine at the back of the mouth
The nurse reviews an elderly client's medication administration record and identifies which prescriptions as having the potential for injury in the elderly? Select all that apply.
1. Amitriptyline 2. Chlorpheniramine 5. Lorazepam
Exhibit A client with dilated cardiomyopathy has the rhythm shown in the exhibit. Which action should the nurse take first?
1. Assess the client for a pulse [45%]
The nurse caring for a client with pulmonary edema responds to the mechanical ventilator high-pressure alarm. The nurse would assess for which conditions that can trigger the high-pressure alarm? Select all that apply.
1. Biting endotracheal tube 4. Excessive airway secretions 5. Kinked ventilator tubing
The nurse admits a client to the unit who reports taking high doses of aspirin to ease the pain of chronic headaches. The nurse should monitor for which adverse effects? Select all that apply.
1. Black tarry stools 3. Bruising 5. Ringing in the ears
A 3-month-old who weighs 8.8 lb (4 kg) has just returned to the intensive care unit after surgical repair of a congenital heart defect. Which finding by the nurse should be reported immediately to the health care provider?
1. Chest tube output of 50 mL in the past hour [42%]
The nurse is providing discharge instructions to a 70-year-old client newly diagnosed with heart failure who has a low literacy level. What are some teaching strategies that the nurse can use for this client? Select all that apply.
1. Conduct teaching sessions while a family member is present 3. Have client watch a DVD about heart failure management 4. Print out pictures of a food label and review where to look for sodium content
The nurse reviews the serum laboratory results of a client who was seen in the clinic 2 days ago for worsening joint pain from a flare of systemic lupus erythematosus. Which result is of greatest concern and prompts the nurse to notify the health care provider?
1. Creatinine of 1.8 mg/dL (159 µmol/L) [24%]
The nurse is preparing to administer medications to the clients. Which client attributes are acceptable for use as client identifiers? Select all that apply.
1. Day, month, and year of birth 3. Medical record number
A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT). The CBT includes which interventions and strategies? Select all that apply.
1. Desensitization to a specific stimulus or situation 4. Relaxation techniques 5. Self-observation and monitoring 6. Teaching new coping skills and techniques to reframe thinking
The mental health nurse is planning care for a client newly admitted with dissociative identity disorder. Which interventions will the nurse include? Select all that apply.
1. Develop a trusting relationship with each of the alternate identities 2. Encourage the client to journal about feelings and dissociation triggers 4. Listen for expressions of self-harm from the alternate identities 5. Teach grounding techniques such as deep breathing to hinder dissociation
A new nurse attends a risk management class on the indications and legal implications of using chemical restraints to maintain client safety. Which prescription should the nurse question before administering?
1. Haloperidol for a client with a fall history who keeps getting out of bed without assistance [70%]
The nurse is assessing for the presence of jugular venous distension (JVD) on a newly admitted client with a history of heart failure. Which is the best position for the nurse to place the client in when observing for JVD?
1. Head of the bed elevated to a 45-degree angle
Which nursing interventions would the nurse implement when caring for a client newly diagnosed with acute, viral hepatitis B? Select all that apply.
1. Offer small, frequent meals to prevent nausea 2. Promote rest periods between periods of activity 4. Teach the client not to share razors or toothbrushes with others 5. Teach the client to abstain from drinking alcohol
A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago. The client is becoming increasingly restless. He has been given intravenous morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas (ABG) results best indicate that the client is in acute respiratory failure (ARF) and needs immediate intervention?
1. PaO2 49 mm Hg (6.5 kPa), PaCO2 60 mm Hg (8.0 kPa) [75%]
A client with asthma was recently prescribed fluticasone/salmeterol. After the client has received instructions about this medication, which statement would require further teaching by the nurse?
2. "At the first sign of an asthma attack, I will take this medication." [73%]
The nurse is caring for a 7-year-old child diagnosed with nephrotic syndrome who will be discharged soon. Which statement by the parent indicates the need for reinforcement of teaching?
2. "I'll organize a lot of playdates to keep my child's spirits up." [39%]
A client tells the nurse of wanting to lose 20 lb (9 kg) in time for the client's daughter's wedding, which is 16 weeks away. How many calories (kcal) will the client have to eliminate from the diet each day to meet this goal?
2. 625 kcal/day [46%]
Which actions are appropriate for the registered nurse to delegate to an experienced licensed practical nurse? Select all that apply.
2. Auscultate bowel sounds 2 days after repair of an inguinal hernia 4. Monitor flow rate and drainage in a client receiving bladder irrigation
A home health nurse is visiting a client who underwent right-sided mastectomy with lymph node removal. The client is concerned about swelling in her arm on the affected side. Which instructions should the nurse discuss with the client? Select all that apply.
2. Avoid receiving vaccinations in the affected arm 3. Elevate the arm above the heart 4. Perform isometric exercises 5. Use an intermittent pneumatic compression sleeve
The nurse is reviewing phone messages from clients in a surgery clinic. Which client would be the priority to call back first?
2. Client 8 days postoperative ileostomy placement who reports nausea, vomiting, and abdominal bloating [39%]
The charge nurse is reviewing events that staff nurses experienced during the shift. Which events require an incident/occurrence report to be completed? Select all that apply.
2. Client with alcohol intoxication physically assaulted a nurse 3. Serum troponin level was prescribed but never obtained 5. Visitor fell and refused care in the emergency department
Which client should the charge nurse assign to the room closest to the nurses' station?
2. Client with gastroenteritis and dementia who wanders [80%]
The nurse caring for a client in the intensive care unit reports a critical laboratory value of 120,000/mm3 (120 x 109/L) platelets, decreased from 300,000/mm3 (300 x 109/L) on admission. The health care provider says this is normal. The client is receiving heparin injections. Which nursing action would be the most appropriate?
2. Document the exchange in the chart [63%]
A client receives intermittent bolus enteral feedings through a nasogastric tube. Which are appropriate nursing actions prior to starting the feeding? Select all that apply.
2. Flush the tube before and after the feeding 3. Place the client in the semi-Fowler position 4. Start the feeding after obtaining a gastric residual volume <100 mL
The nurse is teaching an overweight 54-year-old client about ways to decrease symptoms of obstructive sleep apnea. Which interventions would be most effective? Select all that apply.
2. Limiting alcohol intake 3. Losing weight
The nurse prepares to insert an indwelling urinary catheter in a client who is disoriented to time, place, and person and cannot follow directions or commands. Which intervention is most important when inserting the urinary catheter?
2. Maintain a sterile field and keep the urinary catheter sterile [87%]
All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which tasks are appropriate for the registered nurse (RN) to delegate to the UAP to promote client safety? Select all that apply.
2. Place the bedside commode as close to the bed as possible 3. Remind the client to change position slowly 4. Report observations of changes in client's condition immediately
The nurse is caring for a client with partial hearing loss. Which interventions would be appropriate to promote effective communication? Select all that apply.
2. Post a hearing impairment sign on the client's door 4. Speak directly facing the client
The nurse is feeding a confused client via a small-bore nasoenteric tube. The nurse observes the client pulling at the tube and then notices an increase in external tube length from the original exit mark. After immediately stopping the feeding, which action is appropriate for the nurse to take next?
3. Contact the health care provider to request an x-ray to verify tube placement [62%]
A Muslim woman is admitted to the inpatient trauma unit after falling and sustaining a head injury. In providing culturally competent care for this client, which consideration is most important?
3. Ensuring that female health care workers are available to provide care to the client [79%]
The nurse is caring for a debilitated client with a percutaneous endoscopic gastrostomy (PEG) tube that was inserted 3 days ago for the long-term administration of enteral feedings and medications. While the nurse is preparing to administer the feeding, the tube becomes dislodged. What is the most appropriate intervention?
3. Notify the health care provider who inserted the PEG tube [55%]
The nurse is providing care for a client with cancer of the left lung who will undergo video-assisted thoracic surgery in the morning. The client is nervous, jumpy, and short of breath. Pulse is 120/min, respirations are 30/min and shallow, and expiratory wheezing is auscultated in the left upper and lower lung posteriorly. Which of the following is the priority nursing action?
3. Place head of the bed in Fowler's or high Fowler's position [44%]
The nurse provides teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug?
3. Risk for infection [50%]
The nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors?
3. Seems uncomfortable around people, lack of close friends, indifferent to praise or criticism [15%]
A client with generalized anxiety disorder has received a new prescription for sertraline. The nurse should teach this client about which possible side effect?
3. Sexual dysfunction [50%]
The nurse has just completed discharge teaching about sublingual nitroglycerin (NTG) tablets to a client with stable angina. Which statement by the client indicates the need for further teaching?
4. "I'll keep one bottle in the house and one in the car." [62%]
A client with chronic heart failure is being discharged home on furosemide and sustained-release potassium chloride tablets. Which instructions related to the potassium supplement should the nurse give to the client?
4. "Take it with a full glass of water and stay sitting upright afterward."
A client with advanced multiple sclerosis (MS) has been a resident in a nursing home for the past 2 years. One day, the client tells the nurse, "I want to get out of here and try living in my own home." What is the best response by the nurse?
4. "Tell me how you think your life would be different if you moved from here." [87%]
The nurse is caring for a pregnant client with a positive urine drug screen. When questioned about substance abuse, the client begins to throw objects at the nurse and yells, "I'm leaving this hospital right now before you call the police on me!" What is the best response by the nurse?
4. "You should stay. You and I both have the same goal: to keep you and your baby safe." [54%]
The triage nurse has one isolation room left in the emergency department. Which priority client should be assigned to this room?
4. Child with suspected pertussis who has paroxysms of coughing [88%]
The nurse receives a report on the assigned clients for the shift. Which client should the nurse assess first?
4. Client who underwent thyroidectomy yesterday and now has positive Trousseau's sign [60%]
The nurse is managing an assigned team. The following clients have family members reporting a concern. Which client should the nurse see first?
4. Client with a Glasgow Coma Scale score of 9 is no longer responding when called [80%]
The nurse in the endocrinology clinic is reviewing phone messages from clients. Which client would be the priority to call first?
4. Client with hyperthyroidism who has a new temperature reading of 101.5 F (38.6 C) [55%]
A client taking morphine sulfate for acute pain has not voided in 6 hours. The nurse suspects the client has developed urinary retention. What is the priority nursing intervention?
4. Palpate the client's suprapubic area [58%]
The nurse assesses a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago. Which assessment technique should the nurse use to check for complications in this client?
4. Place blood pressure (BP) cuff on arm, inflate to pressure > than systolic BP, and hold in place for 3 minutes [66%]
The registered nurse (RN) is caring for an elderly client with chronic obstructive pulmonary disease (COPD) whose pulse oximeter shows 91% on room air. After physical therapy, the client reports feeling "short of breath and exhausted" to the student nurse and says he just wants to sleep. To provide comfort, the student nurse initiates the prn nasal oxygen to maintain a saturation >92%, as prescribed. When the RN conducts end-of-shift rounds 3 hours later, the client is still sleeping soundly and the pulse oximeter shows 91%. Which nursing action is most appropriate at this time?]
4. Remove the nasal oxygen and measure saturation [25%]
A new graduate nurse is preparing to administer the following analgesics to clients with postoperative pain. Which situation would require intervention by the precepting nurse?
4. Selects a 25-gauge ½-inch (1.3-cm) needle to inject ketorolac intramuscularly [53%]
The nurse cares for a group of clients on a medical surgical floor. The client with which condition is at highest risk for developing syndrome of inappropriate antidiuretic hormone (SIADH)?
4. Small cell lung cancer [42%]
A nurse reviews the most current serum laboratory results for assigned clients. Which result is the highest priority to report to the health care provider?
4. Sodium of 120 mEq/L (120 mmol/L) in a client with small cell lung cancer [68%]
The clinic nurse is caring for an elderly client who is overweight and being treated for hypertension. What is most important for the nurse to emphasize to prevent a stroke (acute brain attack)?
4. Take prescribed antihypertensive medications [60%]
A client is scheduled for an elective laparoscopic prostatectomy in the morning. The nurse should notify the health care provider (HCP) about which assessment data as soon as possible before surgery?
4. Temperature 100.4 F (38 C) with cough [71%]
A client with mitral valve disease is experiencing uncontrolled atrial fibrillation (AF) for 3 days that has been unresponsive to drug therapy. The client is scheduled for electrical cardioversion. What other procedure or test does the nurse anticipate that this client will require?
4. Transesophageal echocardiogram (TEE) [56%]
The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which assessment finding does the nurse anticipate?
4. Tremors and brisk deep-tendon reflexes
A client with chronic heart failure developed an intractable cough and an incident of angioedema after starting enalapril. Which prescription does the nurse anticipate for this client?
4. Valsartan [47%]
A category 4 hurricane has disrupted a rural local health care system, creating a significant increase in emergency department admissions. Which client would the nurse assess first?
7 year old with status ashmaticus and an oxygen saturation of 89%
A nurse cares for a client after cardiac catheterization. During assessment of the groin site, the nurse notices that the dressing is saturated with blood and a small trickle leaks down the client's leg. What should the nurse do first?
Apply direct manual pressure at and above the skin puncture site
The nurse is assessing urine dipstick results in a client with right flank area pain for the past 24 hours. According to the dipstick results, what is the nurse's best action? Click on the exhibit button for additional information.
Ask the client about any recent illnesses.
The nurse is monitoring a client who has been on clopidogrel therapy. Which assessments are essential? Select all that apply.
Assess for bruising. Assess for tarry stools. Monitor platelets.
A client has just returned from the cardiac catheterization laboratory for a permanent pacemaker placement. How should the nurse document the rhythm on the client's cardiac monitor? Click on the exhibit button for additional information.
Atrioventricular paced rhythm
A nurse in the emergency department assesses 4 clients. Based on the laboratory results, which client is the highest priority for treatment?
Client with dull headache, pulse oximeter reading 95%, and serum carboxyhemoglobin level 20% [27%]
A fire has started in the respiratory supply cabinet on the medical/surgical floor. Place the nurse's actions in the appropriate order. All options must be used.
Correct Response Rescue/remove any clients in immediate danger Pull the fire alarm Close the door to the supply room, confining the fire Attempt to put out the fire with a fire extinguisher Discourage visitors from using the elevators
The nurse is reviewing new prescriptions from the health care provider. Which prescription would require further clarification?
Cyclobenzaprine for muscle spasms in a client with hepatitis.
The nurse assesses these symptoms in a client with bacterial pneumonia: chills, elevated temperature, tachypnea, productive cough of yellow sputum, shortness of breath, and fatigue. Based on the assessment data, what is the most appropriate nursing diagnosis (ND) for this client?
Impaired gas exchange
The nurse admits a postoperative client following weight loss surgery. Which prescription should the nurse question?
Insert nasogastric tube for uncontrolled nausea [32%]
What is the best activity for a school-aged child hospitalized for vaso-occlusive sickle cell crisis?
Watching a favorite movie.
Which client does the nurse assess first after receiving morning report?
Which client does the nurse assess first after receiving morning report? 1. Client 1 day postoperative with intravenous (IV) patient-controlled analgesia (PCA) who reports burning at the IV site [70%]
