blah

An Appalachian family has brought a toddler to the emergency department with a fractured arm. The nurse knows that nonverbal communication is important to evaluate with assessing the family. Which factors are involved in nonverbal communication? Select all that apply.

touch, Body posture Use of space Eye behavior Facial expressions

A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement?

3."Tell me what you know about complementary therapies."

When checking a client's skin, the nurse notes the presence of multiple straight and wavy threadlike lines beneath the skin and suspects the presence of scabies. Which precaution should the nurse institute before making contact with the client?

3.Put on a gown and gloves.

The nurse is caring for a client at risk for postpartum endometritis. Which nursing intervention would minimize this risk following delivery?

3.Reviewing hand-washing techniques and pericare with the client

A client with chronic pain has been taught how to operate a transcutaneous electrical nerve stimulation (TENS) unit. Which client action shows understanding of the appropriate use of the device when the level of stimulation is uncomfortable?

3.The client adjusts the setting downward slightly.

An adult female client has a hemoglobin level of 10.8 g/dL (108 g/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?

Iron deficiency anemia

The nurse employed in a well-baby clinic is reinforcing nutrition instructions to the mother of a 1-month-old infant. Which instruction should the nurse provide the mother?

Offer breast milk or formula as the main food.

The medication prescribed is haloperidol, 4 mg intramuscularly, immediately. The medication label states 5 mg/1 mL. The nurse prepares how much medication to administer the dose? Fill in the blank and round the answer to one decimal place.

0.8

The nurse is assisting in preparing a client for discharge to home. Daily cold therapy has been prescribed for the client, and the nurse reinforces instructions about this treatment. Which client statements indicate adequate understanding of cold therapy treatment? Select all that apply.

"I will remove the ice pack if I start to feel numbness." I should wrap the frozen ice pack in a warm towel to help adjust to the cold.

A pulmonary angiography is scheduled for a client suspected of having a pulmonary embolism. The nurse understands that which actions are an appropriate preprocedure care intervention? Select all that apply.

1.Obtain a signed informed consent form. 2.Prepare the anticipated entry site for local anesthesia. 3.Inquire whether the client has any allergies to shellfish. 5.Ask whether client has ever experienced an allergy to any contrast media.

The nurse has conducted dietary teaching with the client diagnosed with iron deficiency anemia. The nurse determines that the client understands the information if the client states the intention to increase intake of which foods? Select all that apply.

1.Oysters 2.Spinach 5.Kidney beans

The nurse is caring for a client following a total abdominal hysterectomy. The nurse anticipates that which postoperative outcome will be the priority in the first 24 hours following surgery?

1.Pain

The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply.

1.Pedal pulses 2.Capillary refill 3.Color of the extremity 4.Temperature of the skin 6.Presence of numbness

The nurse is assisting in the care of a client with a new ileostomy on the clinical nursing unit. Which observations indicate to the nurse that the client is at risk for fluid volume deficit? Select all that apply.

Ileostomy output of 650 mL in 4 hours BP 104/66, temp 98.4 F, pulse 106 beats per min, respirations 20 breaths a min

The nurse considers the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. Which are correct about this protocol? Select all that apply.

1.The surgeon is the person that marks the area of the operative procedure. 4.The site marking is done before the client is brought to the surgical suite in the operating room.

The nurse is preparing a small dose of a medication for administration to an infant. The nurse selects which syringe for preparing the medication? Refer to figure.

2

The nurse is admitting a client to the hospital who has been scheduled for gastrointestinal (GI) surgery later in the day. When asking the client whether the client has taken any scheduled or over-the-counter medications in the past 24 hours, which statements should concern the nurse? Select all that apply.

1.Yes, I take a full-strength aspirin every day." 4."I have taken my medication for my blood pressure this morning."

A primary health care provider has prescribed a liquid oral suspension of amoxicillin. The prescription reads 0.25 gram (g) orally 3 times daily. How many milliliters (mL) should the nurse administer to the client per dose? Refer to the figure. Fill in the blank.

10

Penicillin V potassium 250 mg orally every 8 hours is prescribed for a child with a respiratory infection. The medication label reads: Penicillin, 125 mg per 5 mL. The nurse has determined that the dosage prescribed is a safe dose for the child. How many milliliters (mL) will the nurse administer to the child per dose? Fill in the blank.

10

The nurse is preparing to administer 30 mEq of liquid potassium chloride (KCl) to an adult client. The label on the medication bottle reads 40 mEq/15 mL. The nurse prepares how many milliliters of KCl to administer the correct dose of medication? Fill in the blank. Round your answer to the nearest whole number.

11mL

A primary health care provider prescribes 3000 mL of 5% dextrose to be administered over a 24-hour period. The nurse prepares to set the infusion rate knowing that how many milliliters per hour are to be administered? Fill in the blank.

125

A client is prescribed oral lorazepam 4 mg daily. The medication label reads 2 mg/mL. To ensure the correct dose, the nurse administers how many milliliters per dose? Fill in the blank.

2

A primary health care provider's prescription reads "ketorolac 30 mg intramuscular every 6 hours as needed." The medication label reads "ketorolac 15 mg/mL." The nurse prepares to administer how many milliliters to the client? Fill in the blank.

2

A primary health care provider's prescription reads theophylline 100 mg orally every 6 hours. The medication label reads 50-mg capsules. How many capsules will the nurse give to administer one dose? Fill in the blank.

2

A primary health care provider's prescription zolpidem tartrate 10 mg orally at bedtime daily. The medication bottle is labeled zolpidem tartrate 5-mg tablets. The nurse prepares how many tablet(s) to administer 1 dose? Fill in the blank.

2

The medication prescribed is levodopa 1 g orally, daily. The medication label states levodopa, 500-mg tablets. The nurse prepares to administer how many tablets at the evening dose? Fill in the blank.

2

The medication prescribed is metoclopramide hydrochloride 10 mg intramuscularly times one dose. The medication label reads metoclopramide hydrochloride 5 mg/mL. The nurse prepares how much medication to administer the dose? Fill in the blank.

2

The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding preventing the transmission of the infection to the other children in the family and the other household members. Which instructions should the nurse reinforce to the mother?

3.Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through the saliva.

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse trying to enhance the client's respiratory status should avoid performing which actions? Select all that apply.

3.Increase the liter flow to 5 L per nasal cannula 5.Encouraging the client to breathe slowly and shallowly

An adult client has had serum electrolytes drawn. The nurse receiving the results by telephone from the laboratory should be most concerned with which result?

3.Potassium 5.4 mEq/L

A client with diabetes mellitus has a glycosylated hemoglobin A (HbA1c) level of 8%. Which instruction does the nurse plan to reinforce to the client based on this test result?

3.Prevent hyperglycemia.

The nurse is assigned to reinforce instructions to a client and the family about the management of home intravenous (IV) infusion therapy. The nurse begins the process by teaching the client and family principles related to what actions first?

3.Proper hand-washing technique

A primary health care provider prescribes 3000 mL of 0.9% NaCl to run over 24 hours. The drop (gtt) factor is 15 gtt/mL. The nurse plans to adjust the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

31

The nurse is checking the remaining volume in a 1000-mL intravenous (IV) bag that is scheduled to infuse over 8 hours on an electronic infusion pump. The nurse has just noted at 11:00 am that the remaining IV fluid is at the 500-mL level. At 12:00 noon at which numerical level (mL) should the IV fluid be? Fill in the blank.

375

The primary health care provider's prescription reads "phenytoin 0.2 g orally, twice daily." The medication label states 100-mg capsules. How many capsule(s) should the nurse plan to administer over a 24-hour period? Fill in the blank.

4

A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, "I don't feel any better than I did before surgery." Which response by the nurse is most appropriate?

4. "You are concerned that you don't feel any better after surgery?"

The nurse informs a client that a Papanicolaou smear will be done at the next scheduled clinic visit, and the nurse provides instructions to the client regarding preparation for this test. Which statement by the client indicates an understanding of the procedure?

4."If I have my period at the time of my next scheduled visit, I will not be able to have the test done."

The nursing instructor is providing a session on cultural beliefs related to health and illness and gives some examples. A client of African-Caribbean descent tells the nurse that the present illness may have resulted from a curse from a competitor. Which statement describes the belief of this client?

4."Illness is a disharmonious state that may be caused by demons and spirits."

The nurse should plan to reinforce instructions to which clients about the risk for transmission of disease through blood and sexual contact? Select all that apply.

A client diagnosed with hepatitis B virus A client diagnosed with hepatitis C virus A client diagnosed with human immunodeficiency virus (HIV)

Which client is the safest one for a licensed practical nurse (LPN) to care for?

A client recovering from a scheduled cesarean delivery

The nurse is providing directions to the unlicensed assistive personnel (UAP) regarding clients' hygiene needs. Based on the client needs, the nurse instructs the UAP to bathe which client first?

A confused client who is incontinent of stool and urine

The nurse is caring for the client who is going to have an arthrogram using a contrast medium. Which data collected by the nurse should be of highest priority?

Allergy to iodine or shellfish

The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief?

Alternating air pad

A client has just undergone a gastroscopy. Which action should be taken by the nurse as the essential postprocedure nursing intervention?

Monitoring for the gag reflex

The nurse is reinforcing instructions to a client and family regarding home care following cataract removal with lens implantation in the left eye. The nurse should provide the client with instructions to contact the surgeon promptly for which signs or symptoms? Select all that apply.

New floaters Increasing redness in the eye

The nurse knows that spatial behavior is related to territoriality in many Latino cultures. Which client needs are associated with territoriality? Select all that apply.

Privacy Security Autonomy self-identity

Arterial blood gases (ABGs) are obtained on a client with pneumonia. The ABG results are pH, 7.50; Pco2, 30 mm Hg; HCO3-, 20 mEq/L; and Po2, 75 mm Hg. The nurse interprets these results and determines that which acid-base condition exists?

Respiratory alkalosis

In developing a plan of care for a client hospitalized with tuberculosis (TB), the nurse should place emphasis on which intervention?

The strict adherence to following airborne precautions

A child with leukemia is hospitalized and is receiving chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. Which response by the nurse is appropriate?

"The flowers from your garden are beautiful, but they should not be placed in the child's room at this time."

A client with sickle cell anemia is being treated for sickle cell crisis. The primary health care provider prescribes morphine sulfate 2 mg. The concentration of the vial is 10 mg/mL of solution. How many milliliters of solution should the nurse administer? Fill in the blank. Record the answer to one decimal place.

0.2

The medication prescribed is morphine sulfate 6 mg subcutaneously. The medication label states morphine sulfate 10 mg/1 mL. The nurse plans to prepare how much medication to administer the dose? Fill in the blank.

0.6

The nurse is preparing to administer 35 mg of a prescribed intramuscular (IM) dose of medication to a client. The medication label reads 50 mg/mL. How many milliliters should the nurse administer to the client? Fill in the blank.

0.7

A primary health care provider prescribes atenolol 0.05 g orally daily. The label on the medication bottle states, atenolol 50-mg tablets. How many tablet(s) will the nurse administer to the client? Fill in the blank.

1

A primary health care provider prescribes digoxin, 0.125 mg by mouth (PO) daily, for a client with heart failure. The medication label states 0.125 mg per tablet. How many tablet(s) will the nurse administer to the client? Fill in the blank.

1

A primary health care provider prescribes phenytoin 0.1 g orally twice daily. The medication label states, 100-mg capsules. How many capsule(s) will the nurse prepare to administer the dose? Fill in the blank.

1

The nurse is encouraging a client to participate in recreational therapy. The client states that it is best to stay alone and not bother others. Which statement is an appropriate response from the nurse?

1."Can you tell me more about your feelings?"

A pregnant woman has tested positive for human immunodeficiency virus (HIV). The nurse reinforces information to the client about HIV and determines that the need for further teaching is necessary when the client makes which statement?

1."I need to breastfeed my baby."

The client has just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of postprocedure care?

1."I should drink extra fluids for the remainder of the day."

The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which questions should the nurse ask the client? Select all that apply. Refer to video. Click on the Question Video button to view a video showing preparation procedures.

1."What does the pain feel like?" 2."Where is the pain located?" 4."How does the pain affect you?" 6."What makes your pain better or worse?"

The nurse is reading a primary health care provider's prescription and notes that a client is to receive a medication at 1:00 pm. Using the military time clock, the nurse administers the medication at which time? Refer to figure.

1.1

The medication is an intramuscular dose of 400,000 units of penicillin G benzathine. The medication label reads penicillin G benzathine 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Fill in the blank and record the answer using one decimal place.

1.3

The insulin drip (continuous insulin infusion) is infusing at 1.5 mL per hour. There are 100 units of regular insulin in 100 mL of 0.9% NaCl. How many units of insulin will the client receive per hour? Fill in the blank. Record the answer to one decimal place.

1.5

The nurse is caring for a group of clients on a clinical nursing unit. The nurse checks for signs of deficient fluid volume. Which clients are at risk for this fluid imbalance? Select all that apply.

1.A client with pneumonia 2.A client with an ileostomy 5.A client with a temperature of 102.5° F (39.2° C)

During a fire drill, the nurse enters a laundry room and a waste basket is marked as on "fire." The nurse activates the alarm, closes the laundry room door, and obtains a fire extinguisher and returns to the laundry room. Which action by the nurse shows that additional training is needed?

1.Aiming at flames of the fire

A postoperative client has been placed on a clear liquid diet. Which items is the client allowed to consume? Select all that apply.

1.Broth 2.Coffee 3.Gelatin

The client has a three-way closed continuous bladder irrigation system. Which information should be included in the documentation for this client? Select all that apply.

1.Character of drainage 2.Presence of blood clots 3.Amount of drainage emptied 4.Client complaint of pain/spasms 5.Type and amount of irrigation fluid used

A client is admitted to the hospital with a diagnosis of neutropenia. Which interventions should the nurse include in planning care for this client? Select all that apply.

1.Check temperature at least every 4 hours. 2.Monitor white blood cell count daily as prescribed. 4.Remove fresh flowers or plants from the client's room.

The primary health care provider prescribes ibuprofen 5 mg per kg for a child who weighs 13 pounds. How many milligrams (mg) should the nurse administer to the child? Fill in the blank. Record your answer using one decimal place.

29.5

A licensed practical nurse (LPN) is providing follow-up teaching after a client underwent an upper gastrointestinal (GI) series with diatrizoate used for contrast. The nurse instructs the client that which may occur from the diatrizoate?

1.Diarrhea

While caring for a client admitted to the hospital with suspected seizure activity, the client acknowledges the use of the herbal supplement ginkgo, to the nurse. Which follow-up questions by the nurse would be most appropriate? Select all that apply.

1.Do you have a history of seizures? 2.Do you have a history of a clotting disorder? 3.How long and why have you been using ginkgo? 4.Have you been diagnosed with diabetes mellitus?

The nurse performs an audit in the hospital intensive care unit of clients who have indwelling urinary catheters. Which observations, found in the audit, pose a risk for a health care-associated infection? Select all that apply.

1.Drainage bag port touching the floor 2.Dependent loop in the catheter tubing 5.Use of one measuring container between two clients with the same pathogen in the urine

A client diagnosed with schizophrenia who is being prepared for discharge has been prescribed oral risperidone 6 mg daily. The medication label reads 2 mg/tablet. To ensure the correct dose, the nurse instructs the client to take how many tablets once daily? Fill in the blank.

3

The nurse working the 3:00 to 11:00 pm shift notes that a client with coronary artery disease (CAD) has a prescription for serum lipid levels to be drawn in the morning. The nurse places the client on which dietary preparation to ensure accurate test results?

1.Fasting for 12 hours

A client with hypertension has been prescribed a low-sodium diet. The nurse reinforcing instructions about foods that are allowed should include which foods in a list provided to the client? Select all that apply.

1.Fresh tomato 5.Summer squash

The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activities in the nursing care plan for the client on the day of surgery? Select all that apply.

1.Have the client void before surgery 4.Determine that the client has signed the informed consent for the surgical procedure.

The nurse is caring for an adult client with respiratory distress syndrome. A review of the arterial blood gas results indicates that the client is experiencing respiratory alkalosis. The nurse should then examine the results of serum electrolytes to see whether which electrolyte imbalance is present?

1.Hypokalemia

A client has a nasogastric tube in place that is attached to suction. The client is at risk for developing which electrolyte imbalances with prolonged suction? Select all that apply.

1.Hypokalemia 3.Hyponatremia 5.Hypomagnesemia

The nurse monitors a postoperative client who had abdominal surgery for signs of complications. Which signs/symptoms should the nurse determine to be indicative of a potential complication? Select all that apply.

1.Increasing restlessness 3.Unrelieved pain despite receiving analgesics

The nurse is reinforcing teaching to a client about an upcoming colonoscopy procedure. The nurse should include in the instructions that the client will be placed in which position for the procedure?

1.Left Sims' position

Which factors contribute to the problem of stress incontinence? Select all that apply.

1.Obesity 2.Sneezing

The nurse is preparing to suction a client through a tracheostomy tube. The nurse should perform which actions when performing this procedure? Select all that apply.

1.Preoxygenating the client before suctioning 3.Moistening the catheter tip in sterile saline solution before suctioning 4.Introducing the catheter into the tracheostomy tube using a sterile gloved hand

The nurse is preparing a client for a magnetic resonance imaging (MRI) examination. Which action by the nurse is important?

1.Remove metallic objects from the client.

The nurse consults with a dietitian regarding the dietary preferences of an Asian-American client. Which food should the nurse suggest to include in the diet plan?

1.Rice

A client is being advanced to a full liquid diet on the second postoperative day. Which foods are allowed for this client? Select all that apply

1.Tea 3.Ice cream 5.Cream of tomato soup 6.Cream of wheat cereal

A CD4+ count has been prescribed for a child with human immunodeficiency virus (HIV) infection. The mother asks the nurse about the purpose of the test and why the test needs to be done if it is already known that the child has HIV. The nurse should reinforce which information to the mother? Select all that apply.

1.The CD4+ count is used to determine the child's immune status. 3.The CD4+ count is used to identify the risk for disease progression. 4.The CD4+ count identifies the need for Pneumocystis jiroveci pneumonia prophylaxis after 1 year of age. 5.The CD4+ count is measured at ages 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. 6.More frequent monitoring of CD4+ counts is indicated when pneumonia prophylaxis and antiretroviral therapy are administered.

The nurse is caring for a Jewish client who follows a kosher diet. Which foods should the nurse use in planning meals for the client? Select all that apply.

1.Tuna 3.Chicken 4.Potatoes 5.Apples

A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing Allen's test before drawing the blood to determine the adequacy of which?

1.Ulnar circulation

A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, the nurse observed the client has a patent airway. Which is the next nursing assessment?

1.Vital signs

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to consult with the registered nurse if the client is also taking which medications? Select all that apply

1.Warfarin 2.Glimepiride 3.Amlodipine

The nurse is assisting in the care of a client diagnosed with acquired immunodeficiency syndrome (AIDS) who requires an injection. The nurse should include which actions to safely administer the medication? Select all that apply.

1.Wear gloves while administering the injected medication. 3.Dispose of the needle and syringe in a puncture-resistant container.

The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement?

2."Fresh foods such as fruits and vegetables are high in sodium."

The nurse reinforces instructions to a client diagnosed with impetigo. Which statements by the client indicate a need for further teaching? Select all that apply.

2."I can wash my laundry with other household members' items." 4."I should not wash the lesions of the infection once the skin lesions have scabbed over".

A client has been admitted for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?

2.15 mg/dL

The nurse on a medical unit is instructing the unlicensed assistive personnel (UAP) regarding toileting needs of the assigned clients. The nurse should instruct the UAP to prepare to assist which client first?

2.A client who was admitted 2 days ago with a pelvic fracture

The nurse is caring for a client with respiratory insufficiency. The arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 30 mm Hg (30 mm Hg), and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note?

2.A potassium level of 3.0 mEq/L (3.0 mmol/L)

A client's arterial blood gases reveal a pH of 7.51 and a bicarbonate level of 31 mEq/L. The nurse prepares for the administration of which medication that should be prescribed to treat this acid-base disorder?

2.Acetazolamide

The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which actions should the nurse take? Select all that apply.

2.Ask how the client feels and inquire about any feelings of dizziness. 3.Review the client record to determine time and type of analgesia last received. 6.Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU).

A licensed practical nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 36.2° C (97.2° F) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take first?

2.Attempt to arouse the client.

A client is being discharged to home following spinal laminectomy and fusion with insertion of a metal implant. The nurse includes which instructions about activity after discharge? Select all that apply.

2.Avoid activities that involve pulling or pushing. 3.Do not lift objects weighing more than 5 pounds. 5.Do not climb stairs until after the follow-up appointment with the surgeon.

A client has arrived back to the nursing unit from special procedures with an epidural catheter in place for pain control. The nurse is revising the plan of care to reflect the epidural catheter and the interventions needed to prevent infection at the site. Which interventions should the nurse include in the plan of care? Select all that apply.

2.Change dressing as needed. 3.Change infusion tubing every 24 hours. 4.Use strict aseptic technique when caring for the catheter.

The nurse determines that which clients are at high risk for metabolic acidosis? Select all that apply.

2.Clients with diabetes 4.Clients with kidney failure 6.Clients with malnourishment

A client who has calcium phosphate kidney stones tells the nurse, "Tell me what I can do, so that I never have this pain again." Which instructions should the nurse plan to include in the reinforcement of dietary instructions? Select all that apply.

2.Decrease sodium intake. 4.Limit the intake of whole grains. 5.Limit protein to 5 to 7 servings per week.

A 3-year-old child is hospitalized because of persistent vomiting. Which conditions should the nurse expect this child to be high risk for? Select all that apply.

2.Dehydration 4.Metabolic alkalosis

A client on the medical unit tells the nurse of back discomfort but does not want any pain medication. Which nonpharmacological interventions should the nurse offer the client to help reduce the pain? Select all that apply.

2.Distraction 4.Back massage 5.Relaxation breathing

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do? Select all that apply.

2.Document the amount of residual. 4.Reinstill the residual and administer the feeding.

The nurse reinforces what information to a client who is scheduled for an electromyogram (EMG)?

2.Electrodes will be inserted into the skeletal muscles.

A client is scheduled for an oral cholecystography. The nurse should plan to obtain what type of diet for the evening meal before the test?

2.Fat-free

A client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client and determines which symptoms correlate with this client's fluid imbalance? Select all that apply.

2.Flat neck veins 3.Weakly palpable peripheral pulses 4.Heart rate of 104 beats per minute

The nurse is assigned to collect data from a Hispanic-American client during the hospital admission. On initial meeting of the client, the nurse should plan to do which?

2.Greet the client with a handshake.

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed and the serum calcium level is 12.0 mg/dL (3.0 mmol/L). Based on this laboratory value, the nurse should take which action?

2.Inform the registered nurse of the laboratory value.

The nurse is collecting data from a client with a suspected diagnosis of gastric ulcer. The client tells the nurse that oral antacids are taken frequently throughout the day. The nurse continues to collect data from the client, understanding that the client is at risk for which acid-base disturbance?

2.Metabolic alkalosis

The nurse is changing a dressing on the wound of a postsurgical client who is receiving contact precautions because of a history of methicillin-resistant Staphylococcus aureus (MRSA) from a previous surgery. Which interventions should the nurse follow? Select all that apply.

2.Observe the incision line for redness and drainage. 5.Change gloves between removal of the old dressing and applying the new.

The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client. Which instructions should be included in the list? Select all that apply.

2.Obtain a Medic-Alert bracelet. 4.Prevent debris from entering the stoma. 5.Avoid exposure to people with infections. 6.Avoid swimming and use care when showering.

The nurse is instructing a group of unlicensed assistive personnel (UAP) in the principles of body mechanics. The nurse determines that a student is using the principles appropriately if the nurse observes the UAP doing which action?

2.Positioning a box that is to be lifted between the knees

The nurse is reading a client's urinalysis report. The nurse interprets which item found on the report to be considered abnormal? Select all that apply.

2.Positive protein 5.Leukocyte esterase positive 6.White blood cells, 10 per high power screen

The nurse is assigned to the care of a client who is being admitted to a facility. The nurse notes which observations as indications the client likely has a hearing deficit? Select all that apply.

2.The client answers questions incorrectly. 3.The client states she quit attending social events. The client does not respond to a person unless facing the speaker.

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

2.The client with a ileostomy

A 9-year-old child with leukemia is in remission and has returned to school. The school secretary calls the mother of the child and tells the mother that a classmate has just been diagnosed with varicella (chickenpox). The mother immediately calls the nurse at the primary health care provider's office because the leukemic child has never had chickenpox. The nurse should make which response to the mother?

3."Bring the child to the office for an injection called immune globulin."

The nurse is preparing to hang an intravenous (IV) solution of 1000 mL 5% dextrose in lactated Ringer's to flow at 80 mL/hour. The nurse time-tapes the bag with a start time of 07.00. After making hourly marks on the time-tape, the nurse notes that the completion time for the bag would be what?

3.19.30

A primary health care provider prescribes phenobarbital, 10 mg by mouth daily. The medication bottle is labeled 15 mg/5 mL. How many milliliters (mL) will the nurse administer? Fill in the blank. Record your answer using one decimal place.

3.3

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

3.A 10-year-old female client with a urinary tract infection

The nurse checks the food on a tray delivered for an Orthodox Jewish client and notes that the client has received a cheeseburger and potato fries with whole milk as a beverage. Which action should the nurse take?

3.Call the dietary department and ask for a different meal.

Which laboratory result would verify the diagnosis of bacterial meningitis?

3.Cloudy cerebrospinal fluid with high protein and low glucose levels

A client's preoperative vital signs are temperature 98.6° F (37° C) orally, apical pulse 80 beats per minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which action should the nurse take first?

3.Compare these values to those recorded previously.

A 24-year-old Chinese-American who delivered her baby yesterday is breastfeeding her infant girl. The client's mother asked the nurse not to include cold foods on her daughter's tray because they are not good for the baby. The nurse responds by telling the client that she can have what she wants; it is not up to her mother. This response of the nurse demonstrates which cultural characteristic?

3.Ethnocentrism

The nurse is reading the primary health care provider's (PHCP's) progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?

3.The client with a fast respiratory rate

Cloxacillin sodium 100 mg orally every 8 hours is prescribed for a child with an elevated temperature who is suspected of having a respiratory tract infection. The child weighs 17 pounds. The safe pediatric dosage is 50 mg/kg/day. Which statement accurately describes the prescribed dosage for this child?

3.The dosage is within the safe dosage range.

The nurse is preparing a client scheduled for a bone marrow aspiration, and the client asks the nurse whether the procedure will be painful. The nurse should make which response to the client?

4."A local anesthetic will be given and will decrease the discomfort."

A child is diagnosed with bacterial conjunctivitis and antibiotic eye drops are prescribed for the child. The parent asks the nurse when the child can return to school. The nurse should make which response to the parent?

4."The child should be kept home until the antibiotic eye drops have been administered for 24 hours."

Abdominal ultrasonography is prescribed for a client who is pregnant. The nurse provides information to the client regarding the procedure and makes which statement?

4."You will be positioned on your back and turned slightly to one side with your head elevated."

A licensed practical nurse (LPN) is asked to prepare an intravenous (IV) infusion of 1000 mL 5% dextrose in lactated Ringer's at 80 mL/hr to be administered to an assigned client. The LPN time-tapes the bag with a start time of 09:00. After making hourly marks on the time-tape, the LPN notes that which time would mark the completion time for the bag?

4.21:30

The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside?

4.A pair of scissors

A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The primary health care provider inserts a nasogastric tube and prescribes a tube feeding of a standard formula feeding to run at 50 mL/hr. The nurse plans care, knowing that which is true regarding enteral feedings?

4.Enteral feedings require the normal digestive capabilities of the gastrointestinal (GI) tract.

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance?

4.Generalized muscle weakness

The nurse is observing a client who is independently performing the application of an ostomy appliance for the first time. Which actions observed demonstrate the need for further teaching? Select all that apply.

4.Lightly scrub the stoma with soap and water. 6.Cut the opening on the appliance ½ inch larger than stoma.

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional sign/symptom should the nurse expect to note in this client if hyponatremia is present?

4.Postural blood pressure changes

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to reinforce teaching the client about the need for which measure?

4.Preventing and recognizing hyperglycemia

The nurse is assisting in preparing a plan of care for a client who is a Jehovah's Witness. The client has been told that surgery is necessary. Considering the client's religious preferences, the nurse should first verify with the client and then document which information?

4.The administration of blood and blood products is forbidden.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

4.The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

The nurse educator is describing the yin and yang theory of the ancient Chinese philosophy of Tao to a group of nursing students. The nurse educator explains that in this theory, foods are classified as hot and cold and are transformed into yin and yang energy when metabolized by the body. The nursing student understands this theory when the student makes which statement?

4.The client consumes cold foods when a "hot" illness is present.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing?

4.The client with diabetes mellitus

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

4.The client with the syndrome of inappropriate secretion of antidiuretic hormone

The nurse is reviewing the laboratory studies of a client receiving epoetin alfa. When should the nurse expect to note a therapeutic effect of this medication on the hemoglobin and hematocrit?

4.Two months after therapy

The primary health care provider's (PHCP's) prescription reads acetaminophen 240 mg orally every 6 hours as needed for relief of pain, for a 5-year-old child. The medication label reads "acetaminophen 160 mg per 5 mL." How many mL per dose should the nurse administer to the child? Fill in the blank.

7.5

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action?

Activate the fire alarm.

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?

Advance the catheter to the bifurcation and inflate the balloon.

A client will undergo a barium swallow to confirm a diagnosis of a hiatal hernia. In preparation for the test, which instruction should the nurse provide the client?

Avoid eating or drinking after midnight before the test.

The nurse is preparing to clean up a blood spill on the client's bedside table. The spill occurred when a blood tube containing the client's blood specimen broke. The nurse avoids doing which action when cleaning up the blood spill?

Blotting up the spill with a face cloth or cloth towel

A postoperative client has been receiving morphine sulfate every 3 to 4 hours for pain. The nurse should be sure to implement which measures to reduce the risk of adverse effects from this medication? Select all that apply.

Encourage fluids when not NPO. Encourage coughing and deep breathing. Monitor the number of bowel movements.

An abdominal postoperative client has been tolerating a full liquid diet, and the nurse plans to advance the diet to solid food as prescribed. The nurse collects data regarding which important item before advancing the diet to solids?

Dentition and ability to chew

A licensed practical nurse (LPN) is assisting in the care of a client receiving a continuous intravenous (IV) infusion of heparin sodium for deep vein thrombosis (DVT). The LPN notes that the result of a newly drawn activated partial thromboplastin time (aPTT) level is 90 seconds. The client's baseline before the initiation of therapy was 30 seconds. The LPN should take which action?

Notify the RN about the value immediately.

The nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which action should the nurse plan to take first?

Recheck the vital signs in 15 minutes.

The nurse enters the room to find that the client's trash can is in flames. The client is in bed and the edge of the gown is smoking. The nurse should take which action first?

Remove the gown from the client and remove the client from the room.

Etidronate, an antihypercalcemic medication, is prescribed for a client. Which information should the nurse reinforce when instructing the client about taking this medication?

Take 2 hours before meals.

The nurse admits a client who has seizure precautions prescribed. The client has a seizure just after the nurse has implemented the precautions. Which actions should the nurse take? Select all that apply.

1.Time the start and stop of the seizure. 2.Apply oxygen at 2L with nasal cannula. 3.Turn the client to the side and do not restrain. 4.Note the distinguishing characteristics of the seizure. 6.Turn on the suction machine with oral catheter.

The nurse is preparing to initiate a tube feeding for a client and the primary health care provider has prescribed that the feeding be infused at 50 mL per hour. The nurse brings an electronic feeding pump to the bedside and discovers that there is no available outlet in the wall socket to plug the pump into. Which action should the nurse implement?

2.Contact the electrical maintenance department for assistance.

The nurse has just confirmed that a client has been scheduled for a mammogram for the following week. The nurse reinforces that the client should take which actions? Select all that apply.

Avoid applying skin lotion on the day of the test. Remove any necklaces before presenting for the procedure.

A client has the following laboratory values: pH of 7.55, HCO3- of 22 mm Hg, and a Pco2 of 30 mm Hg. Which action should the nurse take?

Encourage the client to slow down breathing

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis (TB). The nurse should plan to wear which items when performing this care?

Particulate respirator, gown, and gloves

A primary health care provider's prescription reads atenolol 0.025 grams orally daily. The medication bottle reads atenolol 50-mg tablets. The nurse prepares how many tablet(s) to administer the dose? Fill in the blank. Record the answer to one decimal place.

0.5

The medication prescribed is heparin 5000 units subcutaneously, every 12 hours. The medication vial reads heparin 10,000 units/mL. The nurse prepares how many milliliters to administer one dose? Fill in the blank.

0.5

Which laboratory results indicate a therapeutic drug level? Refer to chart. Select all that apply.

1.1 3.3 5.5

The nurse is reinforcing postprocedure teaching after a client underwent an upper gastrointestinal (GI) series. The nurse reminds the client that the stools will remain white for approximately how long?

1.1 to 2 days

A primary health care provider's prescription reads "meperidine hydrochloride 125 mg by the intramuscular route stat." The medication vial reads 100 mg/mL. How many milliliters of the medication should the nurse draw into the syringe for injection? Fill in the blank. Record answer to two decimal places.

1.25

The nurse is planning to get a client out of bed for the first time after having a total hip arthroplasty (THA). What specific actions would the nurse take? Select all that apply.

1.Place a gait belt on the client. 2.If stretch bands are used, reinforce the correct use. 4.Observe for any signs/symptoms of dizziness the first time the client gets out of bed. 6.After the client sits on the side of the bed, remind the client to stand on the unaffected leg.

Ampicillin sodium 250 mg in 50 mL of 0,9% NaCl is being administered over a period of 30 minutes. The drop (gtt) factor is 10 drops (gtt) per mL. The nurse is asked to check the flow rate of the infusion. The nurse determines that the infusion is running at the prescribed rate if the infusion is delivering how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

17

The primary health care provider (PHCP) has prescribed an antibiotic for a child. The average adult dose is 500 mg. The child has a body surface area (BSA) of 0.63 m2. What is the dose for the child? Fill in the blank.

182

The nurse is caring for a client following an abdominal surgery performed 1 day ago. An intravenous (IV) line is infusing and a nasogastric (NG) tube is in place and attached to low intermittent suction. The nurse monitors the client and notes that the bowel sounds are absent. The nurse should perform which actions? Select all that apply.

2.Ask the client whether he has passed any flatus. 4.Document the finding and continue to check for bowel sounds.

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium?

2.Butter

The nurse is reviewing the health care records of assigned clients. Which clients are at highest risk for excess fluid volume? Select all that apply.

2.The client with renal failur 5.The client with chronic congestive heart failure (CHF)

The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the primary health care provider?

2.Valerian

A client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level. When reviewing the client's results, the nurse determines that which requires a call to the primary health care provider for intervention?

240 mg/dL (13.7 mmol/L)

A primary health care provider prescribes gabapentin 0.9 g three times by mouth daily. The label on the medication bottle states gabapentin 300-mg tablets. How many tablets will the nurse administer to the client for one dose? Fill in the blank.

3

The nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further teaching?

3."I need to be sure to place my cup of coffee on the counter."

The nurse is planning to reinforce nutrition instructions to an African-American client. When reviewing the plan, the nurse is aware that which food may be a common dietary practice of clients with African-American heritage?

3.Fried foods

The nurse is assigned to care for a group of clients on the clinical nursing unit. Which client is least likely to develop third spacing of fluids?

3.Hypertension

A client receiving enteral feedings develops abdominal distention and diarrhea shortly after initiation of the feedings. Which is the appropriate intervention for the nurse to implement?

4.Notify the primary health care provider (PHCP) of the client's signs and symptoms.

Morphine sulfate, 2.5 mg, is prescribed for a child. The safe pediatric dose is 0.05 mg/kg/dose to 0.1 mg/kg/dose. The child weighs 50 kg. Which statement accurately describes the prescribed dosage for this child?

3.The dose is within the safe dosage range.

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

4.An increase in blood pressure

The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all that apply.

4.Frequent assessment of vital signs 5.Coughing and deep breathing exercises 6.Pain monitoring and medications to relieve pain

The nurse is reinforcing preprocedure instructions to a client scheduled for a barium swallow at 8.00 am. Which statement by the client indicates a need for further teaching?

4.I will limit myself to two cigarettes only on the morning of the test.

The nurse is reinforcing instructions to a client regarding how to decrease the intake of phosphorus in the diet. The nurse should tell the client that which food items are allowed with few restrictions in a phosphorus-restricted diet? Select all that apply.

Apples White bread Egg whites

The nurse is assisting in performing an arterial blood gas (ABG) analysis on a client. The nurse initially implements which intervention after the blood gas is drawn to minimize the risk for uncontrolled bleeding?

Applying direct pressure to the site

The nurse is preparing to discontinue an indwelling urinary catheter. Which pieces of equipment should the nurse obtain to perform this procedure? Select all that apply.

Clean towel Sterile 10- or 12-mL syringe

The nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first?

Lower the head of the bed slowly until the dizziness is relieved.

The nurse is assigned to assist in caring for a client who has had surgery and has pneumatic sequential compression devices (SCDs) in place. The client asks about these devices. The nurse instructs the client that SCDs are used for which purpose?

Promoting venous return to the heart

The nurse is explaining The Joint Commission's (TJC's) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves which action?

The surgeon marking the area of the operative procedure

The registered nurse (RN) reviews the results of the arterial blood gas (ABG) values with the licensed practical nurse (LPN) and tells the LPN that the client is experiencing respiratory acidosis. The LPN should expect to note which on the laboratory result report?

ph 7.25, pco2 50mmhg

A client with methicillin-resistant Staphylococcus aureus (MRSA) needs to be placed on contact precautions, and the licensed practical nurse (LPN) in charge asks a newly licensed LPN to initiate contact precautions. Which action by the new LPN would indicate the need to review the procedure for contact precautions?

3.Wears a gown when caring for the client and removes the gown immediately after leaving the client's room

A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week, yet is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern about not being able to continue the tube feedings at home with family caregivers. Which nursing response would be appropriate at this time?

4."Tell me more about your concerns with your feedings after going home."

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

4.The client receiving nasogastric suction

Which instructions should be included in the teaching plan for a mother whose newborn is human immunodeficiency virus (HIV) positive?

Instruct the mother and family to provide meticulous skin care to the newborn and to change the newborn's diaper after each voiding or stool.

The nurse is assisting a client to ambulate when the client states he is feeling faint and cannot stand. Which action should the nurse take to assist the client now?

The nurse should extend one leg to use to slide the client's body down to the floor.

The metabolic panel of a client reveals a calcium level of 6.5 mg/dL (1.6 mmol/L). Based on this laboratory finding, which additional data specific to this calcium level should the nurse collect? Select all that apply.

1. Presence of Chevstek's sign 4. Presence of electrocardiogram abnormalities 5. Presence of tingling in the fingertips and around the mouth 6. Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes

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

1.Eggs

A 1-year-old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse helps minimize the infant's risk for injury by implementing which interventions? Select all that apply.

2.Removing any toy with bright blinking lights 3.Keeping the sides rails of the child's bed padded 4.Turning the infant on the side during any seizure 6.Having oxygen and suction available at the bedside

A nurse about to give a daily dose of digoxin and notes that a serum digoxin level drawn earlier in the day measured 2.7 ng/mL. The nurse should take which actions? Select all that apply.

2.Report the finding to the registered nurse. 5.Gather data from the client related to signs of toxicity.

The nurse reinforces instructions to the parents of a newborn infant regarding car travel and safety seats. Which information related to the safety of the infant is correct?

2.Restrain in a car seat in the back seat in a semi-reclined, rear-facing position.

The nurse is completing the laboratory requisition that will accompany an arterial blood gas (ABG) specimen sent to the laboratory for analysis. The nurse understands that which data will be needed by the laboratory for adequate evaluation of the specimen? Select all that apply.

2.The client's temperature 3.The date the specimen was drawn 4.The time the specimen was drawn 5.Any supplemental oxygen the client is receiving

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply.

2.The presence of purulent drainage 6.Tender firmness palpable around the incision

A primary health care provider's prescription reads: tobramycin sulfate, 7.5 mg intramuscularly twice daily. The medication label states 10 mg/mL. How many milliliters (mL) will the nurse give to administer 1 dose? Fill in the blank. Record your answer to two decimal places.

0.75

A primary health care provider has prescribed prochlorperazine 4 mg intramuscularly for a client who is vomiting. The label on the medication vial indicates prochlorperazine 5mg per 1 mL. The nurse administers how many milliliters (mL) to the client? Fill in the blank. Record the answer to one decimal place.

0.8

The nurse determines that which herbal therapies can be prescribed for use as an antispasmodic? Select all that apply.

4.Chamomile 5.Peppermint oil

The medication prescription states to administer acetaminophen 650 mg orally for a temperature of more than 38° C. The medication bottle states acetaminophen, 325 mg tablets. The nurse takes the client's temperature and notes that it is 101° F. The nurse plans to take which action?

1.Administer two tablets.

The nurse reviews a client's serum sodium level and notes that the level is 150 mEq/L (150 mmol/L). The primary health care provider prescribes dietary instructions for the client based on the sodium level. Which food items should the nurse instruct the client to avoid? Select all that apply.

1.Bacon 2.Salami 5.Processed oat cereals

The licensed practical nurse (LPN) is assisting in the care of a client who overdosed on acetylsalicylic acid 24 hours ago. The LPN should report to the registered nurse (RN) which findings associated with an anticipated acid-base disturbance?

1.Drowsiness, headache, and tachypnea

After having a transurethral resection of the prostate (TURP), a client has a continuous bladder irrigation (CBI) postoperatively. The nurse notes that fluid is entering the bladder, but none appears to be draining. Select the appropriate nursing interventions. Select all that apply.

1.Check the bladder for distention. 2.Review intake and output record. 3.Check to ensure drainage tubing is not kinked. 4.Ask the client about bladder spasms and discomfort

The nurse is providing eye care to an unconscious client. Which interventions are included in the procedure? Select all that apply.

1.Cleanse each eye moving from the inner canthus to the outer canthus. 4.Use a clean wet cotton ball or different area of a clean wash cloth for each eye.

The nurse is reinforcing discharge instructions to a Chinese client regarding prescribed dietary modifications. During the teaching session, the client continually turns away from the nurse. Which nursing action is most appropriate?

1.Continue with the instructions, verifying client understanding.

An outbreak of illness has occurred in a community and is suspected to be related to food ingestion. A community health nurse places priority on which intervention?

1.Determining what common food item was ingested by those affected

A client is diagnosed with Haemophilus influenzae pneumonia. In addition to standard precautions, which other precautions should be instituted immediately by the nurse?

1.Droplet precautions

The nurse has instructed a client diagnosed with tuberculosis (TB) about how to prevent the spread of infection after discharge. The nurse determines that the client needs further teaching if the client makes which statement?

1."I should use disposable plates, forks, and knives."

The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement?

1."We will be sure not to leave hot liquids unattended."

Morphine sulfate, 2.5 mg subcutaneously, is prescribed for a child postoperatively. The medication label reads 2 mg/mL. How many milliliters should the nurse administer? Fill in the blank.

1.25

A client who takes theophylline for chronic obstructive pulmonary disease (COPD) is seen in the urgent care center for respiratory distress. Just before initiating treatment for the respiratory distress, a sample for a theophylline level is drawn. The nurse notes the therapeutic range for the serum theophylline level is 10 to 20 mcg/mL and determines that the client may not be taking the medication as prescribed if which result is obtained?

1.6 mcg/mL

The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation?

1.A urinary output of 20 mL/hour

A client is in respiratory alkalosis induced by gram-negative sepsis. The nurse assists in implementing which measure as the effective means to treat the problem?

1.Administer prescribed antibiotics.

The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?

1.It helps to avoid medication errors.

The nurse hangs a 1000-mL intravenous (IV) bag of 5% dextrose in water (D5W) at 0700. The IV is to infuse at 100 mL/hr, and the nurse places a time tape on the IV bag. At noon the nurse should expect that the infusion line on the IV bag would be at which point? Refer to figure.

2

A primary health care provider is caring for a client who is human immunodeficiency virus (HIV) positive and has delivered a newborn baby. The nurse anticipates which interventions should be employed for the newborn to decrease the risk of HIV. Select all that apply.

2.HIV testing of the newborn within 48 hours 4.Antiretroviral prophylaxis for newborns testing HIV positive. 5.Periodic testing for HIV at set intervals until the age of 6 months.

After attending the same social function 5 days ago, 50 individuals arrive at the hospital over a 4-day period with fever; an itchy, reddish brown papule; and complaints of nausea, vomiting, and severe abdominal pain. Cutaneous anthrax is suspected by the health care team. Which is the nurse's priority for client care?

2.Institute contact precautions.

An anxious client is experiencing respiratory alkalosis from hyperventilation as a result of anxiety. The nurse should do which action to help the client experiencing this acid-base disorder?

2.Provide emotional support and reassurance.

The nurse in the primary health care provider's office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. Which statement is appropriate for the nurse to tell the client?

3."These sensations lessen over several months and usually are gone after 1 year."

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates and is unable to obtain any residual tube feeding. Which action should the nurse take next?

3.Turn the client to the side and attempt to aspirate again.

The nurse should institute which interventions for a client diagnosed with Clostridium difficile? Select all that apply.

3.Wear gloves and gown while in the room caring for the client. 4.Use soap and water, not alcohol-based hand rub, for hand hygiene.

The nurse reinforces teaching a client on how to administer enoxaparin subcutaneously. The nurse determines that the client understands the correct procedure if the client does which on a return demonstration?

4.Bunches the skin before injection

The nurse is changing the abdominal dressing on a client following a suprapubic prostatectomy. A wound drain is in place in the abdominal wound. Which nursing action would be appropriate during the dressing change?

4.Checking the wound site for drainage from the drain

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

4.Client who has been vomiting for 2 days 5.Client receiving oral furosemide 40 mg daily

A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing?

4.Closes the roller clamp on the IV tubing

When positioning for a surgical procedure, the nurse understands that the client's respiratory system is most at risk for dysfunction in which position?

4.Lithotomy

The nurse has assisted with obtaining a blood specimen for arterial blood gas (ABG) analysis. The nurse avoids doing which to properly obtain and send the specimen?

4.Obtain a 3-mL syringe that is used for parenteral medication.

The nurse is reinforcing instructions to a client on how to decrease the intake of potassium in the diet. The nurse determines the need for further teaching if the client selects which foods to include in the diet? Select all that apply.

4.Potatoes 5.Avocados 6.Salt substitute

The nurse is assisting in the care of a client who had an ileostomy created a few days ago. The client has high output of drainage from the ileostomy. Based on this the nurse monitors the client for which acid-base imbalance?

1.Metabolic acidosis

Which nursing action would avoid pressure on the popliteal nerve when applying the safety strap across the client's legs on the operating table?

2.Apply the safety strap 2 inches above the knees.

The nurse admits a client with a diagnosis of dehydration and a positive history of cancer to the nursing unit. The client is extremely weak and has an irregular heart pulse rhythm. There are absent bowel sounds, and the client's last bowel movement was 4 days earlier. The nurse plans to review serum electrolyte levels because the client is at high risk for which electrolyte imbalance?

2.Hypercalcemia

A client has been taking prednisone for 3 years. She is scheduled for abdominal hysterectomy. The nurse plans care realizing that postoperatively the client is at risk for which conditions? Select all that apply.

2.Increased risk for dehiscence 4.Increased likelihood of surgical site infection

The nurse is caring for a client who underwent a spinal fusion with a metal implant. The nurse notes that the back dressing is wet with clear drainage. Which actions should the nurse take? Select all that apply.

2.Place the client flat in bed. 3.Notify the registered nurse of the drainage.

A primary health care provider (PHCP) has written a prescription for a preoperative client to have "enemas until clear." The nurse has administered three enemas and the client is still passing brown liquid stool. Which action should the nurse take next?

1.Notify the primary health care provider.

The primary health care provider prescribes a three-way bladder irrigation of normal saline. Over an 8-hour shift, 250 mL has infused from the normal saline. There is 1850 mL in the collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine output for the shift? Fill in the blank.

250

An Asian-American client is experiencing a fever. The nurse plans care so that the client can self-treat the disorder using which method?

3.Foods considered to be yin

A client has returned to the nursing unit following abdominal hysterectomy. To gather data on the client's postoperative bleeding, the nurse should implement which interventions? Select all that apply.

1.Observing perineal pad drainage 2.Observing the abdominal dressing 3.Rolling the client to one side to view bedding 4.Monitoring output from the Jackson-Pratt drain

The nurse is caring for a homebound older postoperative cardiovascular client. The caregiver's daughter says to the nurse, "My mother has fallen out of bed three times." Which actions should the nurse reinforce to prevent falls? Select all that apply.

1.Provide adequate lighting. 3.Ensure that frequently used items are easily accessible. 4.Have the bedside stand and overbed tray table within reach.

The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions should the nurse use to perform this procedure? Select all that apply.

1.Put on a mask. 2.Don gown and gloves. 4.Wear a pair of protective goggles

The nurse prepares a client for the lumbar puncture procedure by which interventions? Select all that apply.

1.Review the coagulation laboratory studies. 2.Observe the lower lumbar area for skin infections. 4.Check to see the client has a signed consent for the procedure.

The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item?

1.Scallops

A newly pregnant client is asking how to prevent neural-tube birth defects. The nurse reinforces which food choices to include in the diet? Select all that apply.

3.Oranges 4.Broccoli 6.Grapefruit

The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula at 2L. To provide a safe delivery of the oxygen the nurse should avoid which actions? Select all that apply.

1.Securing the oxygen tubing to the client's bottom sheet 5.Positioning the nasal prongs in the nares and adjusting the plastic slide on the cannula so that the cannula fits as tight as possible

The nurse is assisting in the care of a client with a left foot that sustained a crush injury. The nurse determines that the client developed third spacing of body fluid based on which observation?

2.Left foot has 4+ pitting edema.

The nurse is preparing to apply a mitten restraint to the client's hand. The nurse does which to ensure that the restraint is applied correctly? Refer to video. Click on the Question Video button to view a video showing preparation procedures.

2.Makes sure that two fingers can be inserted under the restraint

A client who has been prescribed indomethacin for gout is asked to provide a stool sample for guaiac testing. The nurse explains that the purpose of the test is to make which determination?

2.Occult blood

The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS) who has Pneumocystis jiroveci pneumonia. In planning infection control for this client, which should be the appropriate form of isolation to use to prevent the spread of infection to others?

4.Standard precautions

The nurse is caring for a postoperative client who has been NPO and the primary health care provider (PHCP) has prescribed a clear liquid diet. When planning to initiate this diet, which priority item should the nurse place at the client's bedside?

4.Suction equipment

The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? Select all that apply.

2.Open the distal flap of a sterile package first. 3.Prepare the sterile field just before the planned procedure. 6.Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.

A gastric analysis is prescribed for a client with a suspected diagnosis of tuberculosis (TB). The nurse understands that the test is relevant in confirming this diagnosis because of which related fact?

2.People can frequently swallow small amounts of sputum

A hospitalized client states he has chest pain and the nurse notes a prescription for sublingual nitroglycerin 1 tablet every 5 minutes times 3 to relieve chest pain prn. How should the nurse administer the medication?

2.Place one pill under the tongue and reassess for relief in 5 minutes.

A client who is recovering from a brain attack (stroke) has residual dysphagia and is prescribed nectar thickened liquids. The licensed practical nurse has instructed the unlicensed assistive personnel (UAP) in feeding technique. The nurse should intervene if the UAP attempts to perform which activity?

2.Placing food on the affected side of the mouth

A primary health care provider writes a prescription to apply a heating pad to a client's back. The nurse implements the prescription and avoids which action?

2.Placing the heating pad under the client

The nurse is performing oral care for a newly admitted client who is undergoing chemotherapy for thyroid cancer. The nurse should take which actions while performing oral care? Select all that apply.

2.Provide a soft toothbrush. 3.Check oral mucous membranes.5.Check for missing teeth and cavities.

The nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which information about the client is of lowest priority during the data collection?

2.Psychosocial

The nurse is observing a nursing student preparing to obtain a throat culture on a client suspected of having a beta-hemolytic Streptococcus infection. Which actions indicate the need for further teaching regarding collecting this specimen? Select all that apply.

2.The student asks the client to tilt the head forward and to open the mouth. 4.The student places the collection swab initially at the back of the client's tongue.

The nurse has given dietary instructions to a client to minimize the risk of osteoporosis. The nurse determines that the client understands the recommended changes if the client verbalizes the intention to increase intake of which foods? Select all that apply.

2.Yogurt 6.Cottage cheese

A primary health care provider prescribes a bolus of 500 mL of 0.9% NaCl to run over 4 hours. The drop (gtt) factor is 10 drops (gtt) per 1 mL. The nurse plans to adjust the flow rate at how many gtt per minute? Fill in the blank. Record your answer to the nearest whole number.

21

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

1.Milk

The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child. The results indicate an area of induration measuring 8 mm. Which correct interpretation should the nurse make about these results?

1.Negative

A primary health care provider's prescription reads atenolol, 0.025 g orally daily. The medication bottle reads atenolol, 25-mg tablets. The nurse prepares how many tablet(s) to administer the dose? Fill in the blank.

1

A primary health care provider's prescription reads ciprofloxacin 0.5 g orally twice daily. The medication label reads ciprofloxacin 500-mg tablets. The nurse prepares how many tablet(s) to administer 1 dose? Fill in the blank.

1

The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse should perform?

1.Aim at the base of the fire.

A seriously ill client in the hospital tells the nurse that he thinks he has lost some of his ability to hear over the past few days. The nurse reviews the medications the client is currently receiving. Which medications are known to be ototoxic? Select all that apply.

1.Aspirin 4.Furosemide 5.Gentamycin

The nurse reinforces instructions regarding diet for a client at risk for hypokalemia. The nurse determines there is a need for further teaching when the client selects which foods as sources high in potassium? Select all that apply.

1.Bread and butter 2.Carrots and peas 3.Peppers and onions

The nurse instructs a client at risk for hypokalemia from thiazide diuretic therapy about foods that are high in potassium. The nurse determines that there is a need for further teaching if the client states that which foods are high in potassium and should be included in the diet plan? Select all that apply.

1.Eggs 5.White bread with butter

The nurse is preparing to administer an acetaminophen suppository to a child. The nurse plans which action?

1.Insert the suppository 1 to 2 cm into the rectum.

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and should be reported to the primary health care provider before the surgery? Select all that apply.

1.Is allergic to penicillin 2.Quit smoking 3 months earlier 4.Wonders if the surgery could cause incontinence 6.History of deep venous thrombosis in right leg 10 years earlier

A client presents to the emergency department with lethargy; deep, regular respirations; and a fruity odor to the breath. The client's arterial blood gas (ABG) results are pH of 7.25, Pco2 of 34 mm Hg, Po2 of 86 mm Hg, and HCO3- of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance?

1.Metabolic acidosis

A client with diabetes mellitus has a blood glucose level of 596 mg/dL on admission. The nurse anticipates that this client is at risk for which type of acid-base imbalance?

1.Metabolic acidosis

The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?

1.Metabolic acidosis

The nurse is caring for a client who becomes agitated and begins to pull on a surgically placed abdominal drainage tube. The primary health care provider visits and prescribes restraints if needed. Which actions are appropriate to delegate to the unlicensed assistive personnel (UAP), who has completed the facility's education about care of the restrained client? Select all that apply.

1.Socialize with the restrained client. 4.Remove the restraint and perform range of motion activity. 5.Reapply the restraint after assisting the client to the bathroom.

A client is admitted to the surgical unit postoperatively with a self-suction Jackson-Pratt wound drain in place. The nurse determines the drain is functioning correctly with which observations? Select all that apply.

1.The bulb container is fully compressed. 2.Bright red bloody drainage is present in the bulb container.

The nurse receives the culture test results for a client who developed a bloodstream infection from a central venous device. The culture report indicates that the infection is exogenous. The client asks the nurse how she could have contracted this infection. Which should the nurse include in the explanation of potential sources of infectious organisms? Select all that apply.

1.The health care facility 2.The nurse caring for the client 5.The use of contaminated intravenous fluids

The nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is nonreddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 mm3 (7.5 × 109/L). Which interpretation does the nurse make of these findings?

1.The incision line is slightly edematous but shows no active signs of infection.

The medication prescription reads phenytoin 0.2 g orally, twice daily. The medication label states 100-mg capsules. The nurse prepares how many capsule(s) to administer one dose? Fill in the blank.

2

The intravenous prescription is 3000 mL of 5% dextrose in water (D5W) to run over a 24-hour period. The drop factor is 10 gtts/1 mL. The nurse plans to adjust the flow rate to how many gtts/minute? Fill in the blank and record the answer to the nearest whole number.

21

A mother tells the pediatrician's office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work and they feel isolated and fearful. The nurse should suggest which to the mother?

3."You should seek community after-school programs or activities for your children."

The nurse is caring for a child with human immunodeficiency virus (HIV). It is most important that the nurse use which precautions to protect herself and her other clients from infection with HIV? Select all that apply.

3.Perform hand hygiene before and after contact with the client. 4.Use biohazard bags for items saturated with blood and bodily fluids. 5.Wear personal protective equipment when contact with blood and other bodily fluids are anticipated.

The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How should the nurse determine that the restraints are not too constrictive?

3.Place two fingers under the restraint to determine snugness.

The nurse monitors the 3-day postoperative client who underwent abdominal surgery. Vital signs are:temperature: 37.9° C (100.2° F), pulse 104 beats per minute, respirations 22 breaths per minute, blood pressure 128/74 mm Hg. Oxygen saturation is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which postoperative problem?

3.Pneumonia

The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of U waves. The nurse checks the client and then reviews the results of the client's recent electrolyte results. The nurse expects to note which electrolyte value?

3.Potassium 3.0 mEq/L

The nurse is reviewing the laboratory results from the lumbar puncture performed on a client with a diagnosis of meningitis. Which findings are indicative of a bacterial infection? Select all that apply.

3.Protein level of 20 mg/dL 4.Increased white blood cells 5.A cerebrospinal fluid (CSF) pressure of 250 mm H2O

The nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who underwent lumbar puncture. The nurse knows that a reported value of 0 is normal for which substance in CSF?

3.Red blood cells

The nurse is developing a nutritional plan for an assigned client. Which is the most critical piece of data to collect before formulating the plan?

3.The presence of food allergies

The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal?

4.Allowing the client to unwrap the utensils and prepare his own meal for eating

The nurse is reinforcing instructions to a client about the use of an incentive spirometer in the postoperative period. The nurse should include which information in discussions with the client? Select all that apply.

4.Use the incentive spirometer for 5 to 10 breaths every hour while awake. 5.The best results are achieved when sitting at least halfway or fully upright.

The nurse is preparing to administer an intramuscular injection to a 1-year-old child. Which location should the nurse select to administer the medication?

4.Vastus lateralis muscle

The nurse reviews the client's laboratory results. Which abnormal findings should the nurse report? Select all that apply.

Calcium 8.2 mg/dL Potassium 6 mEq/L Magnesium 2.9 mg/dL Phosphorus 5.2 mg/dL

The nurse is assigned to care for a client experiencing episodes of postural hypotension who will be discharged home soon. Which actions should the nurse take to ensure safety while transferring the client from the bed to the chair? Select all that apply.

3.Question the client about feelings of dizziness. 4.Put the client's shoes on to help the client avoid slipping on the floor during the transfer. 5.Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

The nurse is preparing to feed a client who is at risk for aspiration. The nurse assesses the client and uses a penlight and tongue blade to check the mouth and cheeks for pockets of food. Which action does the nurse take next?

Places the client in an upright position

The nurse is preparing to administer a continuous tube feeding to a client with a nasogastric tube. The primary health care provider has prescribed an amount of 100 mL/hr. The tube feeding setup is an open system, a bag that has formula added at intervals. How much formula should the nurse plan to add to fill the feeding bag?

1.400 mL of formula

The medication prescribed is methylprednisolone acetate 60 mg intramuscularly. The medication label states methylprednisolone acetate 40 mg/1 mL. How many milliliters will the nurse prepare to administer to the client? Fill in the blank.

1.5

The nurse, caring for a client with a postoperative abdominal wound, observes that the dressing has Montgomery ties in place. The nurse determines this intervention will decrease the risk of which complication?

4.Skin irritation surrounding the wound

The nurse is reinforcing instructions provided to a client with a continuous passive motion (CPM) machine. The nurse determines that there is a need for further teaching when the client states that he should perform which action?

4.Reset the degrees of flexion or extension according to comfort.

The nurse will perform a sterile dressing change after removing the old dressing with clean gloves. The nurse removes the gloves, uses alcohol-based hand sanitizer to perform hand hygiene, and prepares to perform open sterile gloving. The nurse removes the gloves from the outer package. The nurse is right-handed. The nurse opens the inner wrapper and flattens the wrapper to expose the gloves. Which is the next action the nurse takes when donning sterile gloves?

4.Pick up right glove at cuff with left thumb and forefinger.

The nurse is checking postoperative prescriptions and planning care for a 110-pound child after spinal fusion. Morphine sulfate, 8 mg subcutaneously every 4 hours as needed (PRN) for pain, is prescribed. The pediatric drug reference states that the safe dosage is 0.1 to 0.2 mg/kg/dose every 2 to 4 hours. What should the nurse determine about the medication dosage?

3.The dosage is within the safe range

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a left Sims' position. The nurse explains that this positioning is preferred because of which reason?

3.The enema will flow into the bowel easily.

Following a surgical procedure, the nurse applies sequential compression devices to both lower extremities and turns the machine on. The nurse implements this intervention for which purpose?

3.To prevent thrombosis formation in the veins

The nurse is assigned to care for an Asian-American client. The nurse, when planning care for this client, considers that the client may believe what is the cause of illness if they follow traditional beliefs?

3.Illness is caused by an imbalance between yin and yang.

The nurse is monitoring the fluid balance of a client with advanced human immunodeficiency virus (HIV) infection. Because the client has lost a great deal of weight and muscle mass, the nurse understands that which action will provide a reliable indicator of fluid balance?

3.Monitoring for decreased urine output and hypotension

The nurse is caring for a Hispanic client who reports that she is a practicing Roman Catholic. Which actions by the nurse demonstrate spiritual and cultural sensitivity? Select all that apply.

3.Allow the client to observe communion daily if requested. 4.Facilitate anointing of the client by a priest if requested.

The nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions that which could cause a false-negative result?

3.Ascorbic acid

The nurse is working with an unlicensed assistive personnel (UAP) to care for clients. While observing the UAP's delivery of care, the nurse notes which actions by the UAP that indicates the need for further teaching regarding standard precautions? Select all that apply.

3.Removes gloves and immediately uses computer to document care 5.Uses soap and water to wash hands for 5 seconds and then dries hands 6.Empties collection bag of an indwelling urinary catheter without wearing gloves

The nurse is assisting in monitoring a client who may be started on parenteral nutrition (PN). The nurse reviews the client's laboratory results and determines that the client is at risk of severe malnutrition if the report indicates which critical level?

3.Serum albumin 2.8 g/dL

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. Neutropenic precautions have been implemented. Which activity should the nurse question if observed while caring for this client?

3.The client orders lunch of soup, salad with tomatoes and cucumbers, and an apple.

A client with a history of seizure disorder is receiving phenytoin in the hospital. The client has a seizure and the nurse reviews the laboratory results of the phenytoin level of 18 mcg/mL. The therapeutic level is 10 to 20 mcg/mL. The nurse understands from reviewing the medication level that which is the correct situation?

4.Phenytoin alone is not effectively controlling seizures.

A client has a prescription to have radial arterial blood gases (ABGs) drawn. Before drawing the sample, an Allen's test will be performed. In performing the Allen's test, which blood vessel(s) should the nurse occlude?

4.Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery

The nurse employed in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which is the immediate action of the nurse?

4.Remove the clients from the waiting room.

The nurse is providing care to a Cuban-American client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. Which nursing action is most appropriate?

4.Request permission to move the client to a private room, and allow the family members to visit.

A client who has fallen from a roof and fractured his ribs has arterial blood gas (ABG) results of: pH 7.48, Paco2 32 mm Hg, Pao2 89 mm Hg, and HCO3- 22 mEq/L. How should the nurse interpret the client's blood gas results?

4.Respiratory alkalosis

The nurse is told that the arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 32 mm Hg (32 mm Hg). The nurse determines that these results are indicative of which acid-base disturbance?

4.Respiratory alkalosis

The nurse is assisting in caring for a client in transfer from the postanesthesia care unit following nasal surgery. Nasal packing and a mustache dressing are in place. The nurse places the client in which position to best reduce swelling?

4.Semi-Fowler's

The nurse is reinforcing teaching with a client who is having difficulty sleeping. Which bedtime snacks will help the client achieve a restful night's sleep? Select all that apply.

3.A glass of warm milk 4.A cube of Swiss cheese6.A cup of caffeine-free tea

The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? Select all that apply.

1.Apply disposable gloves. 3.Lubricate the enema tube and insert it approximately 4 inches. 4.Clamp the tubing if the client expresses discomfort during the procedure. 6.Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C).

The nurse is caring for a client recovering from hepatitis. The nurse recognizes the need to report which laboratory test result to the primary health care provider?

3.Alanine aminotransferase (ALT) that is significantly elevated

The medication prescribed is hydromorphone hydrochloride 3 mg intramuscularly, every 4 hours as needed. The medication label reads hydromorphone hydrochloride 4 mg/1 mL. The nurse should prepare to administer how many mL to the client? Fill in the blank.

0.75