COMP B

A nurse is preparing to administer lactated Ringer's 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

13 gtt/min.

A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lb. What is the amount in grams the nurse should administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

18 g.

A nurse is caring for a client who is postpartum and expresses concern about how her preschoolage son will react to having a baby sister. Which of the following strategies should the nurse suggest? A. "Give your son a little gift from his new sister." B. "Give your son plenty of 'alone time' with his sister." C. "Plan for your son to meet his sister for the first time at home." D. "Hold your daughter when your son first meets her."

A. "Give your son a little gift from his new sister."

A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching? A. "I can designate my partner as my health care surrogate." B. "I am only 40 years old, so I don't need to worry about this yet." C. "I will need a lawyer's help to draw up the documents." D. "I understand that my family can alter my advance directives if I become incapacitated."

A. "I can designate my partner as my health care surrogate."

A nurse at an acute care facility is teaching a client about fall risk prevention strategies for use during their stay at the facility. Which of the following statements by the client indicates an understanding of the teaching? A. "I should store my personal items all together on the shelf in my bathroom." B. "I will have to wear a restraint around my waist when I am sitting up in a chair." C. "I should keep the overhead lights on at all times while I am here." D. "I will wear a yellow wristband so everyone knows I am at risk of falling."

A. "I should store my personal items all together on the shelf in my bathroom."

A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching? A. "I will not allow anyone to smoke near my baby." B. "I will place bumper pads in my baby's crib." C. "My baby's head should be placed on a pillow for sleeping." D. "My baby should sleep in a side-lying position."

A. "I will not allow anyone to smoke near my baby."

A nurse is teaching a client who has a new prescription for metformin extended-release tablets. Which of the following statements by the client indicates an understanding of the teaching? A. "I will take the medication in the morning." B. "I will expect to gain weight." C. "I will take the medication on an empty stomach." D. "I will avoid crushing this medication."

A. "I will take the medication in the morning."

A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict? A. "I would like to talk to you about the unit policies regarding break time." B. "If you continue to take a long lunch break, I will have to report this to the nurse manager." C. "Have you thought about how your extended lunch breaks affect the other members of our team?" D. "Did you inform the other members of your team about when you left and returned from break?"

A. "I would like to talk to you about the unit policies regarding break time."

A nurse is planning educational materials for a client who has a new pacemaker. Which of the following information should the nurse include? A. "Keep mobile phones 4 inches from the pacemaker generator." B. "Limit strenuous physical activity for 8 weeks." C. "Check your pulse rate for 30 seconds at different times throughout the day." D. "Expect to have intermittent, prolonged hiccups."

A. "Keep mobile phones 4 inches from the pacemaker generator."

A nurse is teaching a client who is at 20 weeks of gestation about how to manage heartburn. Which of the following instructions should the nurse include? A. "Lie down for 30 min after meals." B. "Eat a high-fat snack at bedtime." C. "Sip carbonated beverages throughout the day." D. "Drink hot herbal tea to relieve symptoms."

A. "Lie down for 30 min after meals."

A community health nurse is planning an educational program on Lyme disease for the general public. Which of the following statements should the nurse include in the program? A. "Use a product with DEET on your skin and clothes when you are walking in a wooded area." B. "Symptoms of Lyme disease appear 2 days after being bitten by an infected tick." C. "Remove embedded ticks by squeezing the body with tweezers." D. "If bitten by a tick, testing for Lyme disease should occur within 2 weeks."

A. "Use a product with DEET on your skin and clothes when you are walking in a wooded area."

A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care? A. "We can expect the hospice nurse to provide support for us after our mother's death." B. "A hospice nurse will come to the house each time our mother needs pain medication." C. "Now that my mother is receiving hospice services, we will not be able to get respite care." D. "Hospice care focuses on arranging treatment that will prolong our mother's life."

A. "We can expect the hospice nurse to provide support for us after our mother's death."

A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first? A. A 6-month-old infant who has croup and an O2 saturation of 92% on room air B. A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication C. A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel movements over the past 24 hr D. A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain

A. A 6-month-old infant who has croup and an O2 saturation of 92% on room air

A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge? A. A client who has cellulitis and is receiving oral antibiotics every 8 hr B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex C. A mother and their newborn 12 hr postdelivery D. A client who has lower extremity weakness and is newly admitted for observation

A. A client who has cellulitis and is receiving oral antibiotics every 8 hr

An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions? A. A client who is at 33 weeks of gestation and has severe gestational hypertension B. A client who is at 16 weeks of gestation and has a hydatidiform mole C. A client who is at 28 weeks of gestation and is experiencing vaginal bleeding D. A client who is at 36 weeks of gestation and has a positive group B streptococcal culture

A. A client who is at 33 weeks of gestation and has severe gestational hypertension

A charge nurse observes smoke coming from a trash receptacle in the unit's waiting room. Which of the following actions should the nurse take first? A. Activate the fire alarm system. B. Obtain and use a fire extinguisher. C. Evacuate clients from the area. D. Close the doors and windows on the unit.

A. Activate the fire alarm system.

A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should include which of the following information in the teaching? A. Advocacy is a leadership role that helps others to self-actualize B. Subordinates are advocates for the nurse manager C. Advocacy encourages clients to rely on health care staff for decision-making D. Nurse managers should distrust people who expose inappropriate professional practices

A. Advocacy is a leadership role that helps others to self-actualize

A nurse is caring for a client who is pregnant. Nurses' Notes 1000: The client reports repeated episodes of vomiting and two episodes of diarrhea in past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks. 1015: IV fluids initiated. Prochlorperazine administered via intermittent IV bolus. 1100: Client reports improvement in nausea. Ice chips provided. Client voided 50 mL of dark yellow urine. The nurse is providing discharge teaching to the client. For each discharge instruction, specify if each action is recommended or contraindicated for the client. A. Alternate eating solid foods and liquids B. Eat every 2 to 3 hr C. Drink warm ginger ale when nauseated D. Increase intake of high-fat foods E. Recommended actions

A. Alternate eating solid foods and liquids B. Eat every 2 to 3 hr C. Drink warm ginger ale when nauseated E. Recommended actions

A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first? A. An older adult client who is anxious and attempting to pull out an IV line B. A middle adult client who is reporting nausea after receiving pain medication C. An older adult client who has kidney failure and returned from dialysis 4 hr ago D. A middle adult client who has a terminal illness and is requesting a visit from the chaplain

A. An older adult client who is anxious and attempting to pull out an IV line

A nurse is caring for a client during a follow up visit at a gastrointestinal clinic. Nurses' Notes 0600: Client admitted to the ED with fatigue, shortness of breath, and weakness for the last 2 days. Client states that they have a history of sickle cell disease (SCD). Client is alert and orientated to person, place, and time. Restless. Client rates generalized pain as a 9 on a scale of 0 to 10. Vital signs taken and blood drawn for laboratory tests. Oxygen 2 L via nasal cannula applied. Awaiting prescription for pain management. 0615: Client still rates pain as a 9 on a scale of 0 to 10. Hydromorphone 4 mg IV administered. Which of the following interventions should the nurse implement? Select all that apply. A. Assess peripheral circulation hourly. B. Assess the client's mouth every 8 hr. C. Use humidification with oxygen therapy. Administer IV fluids. D. Raise the knee position on the client's bed. E. Use an

A. Assess peripheral circulation hourly. B. Assess the client's mouth every 8 hr. C. Use humidification with oxygen therapy. Administer IV fluids.

A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles? A. Autonomy B. Nonmaleficence C. Justice D. Fidelity

A. Autonomy

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan? A. Avoid including raw fruits in the client's diet. B. Restrict visits from young children to 2 hr per day. C. Measure the client's temperature once per shift. D. Use disposable gloves from a box outside the client's room.

A. Avoid including raw fruits in the client's diet.

A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial selfinflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders? A. Borderline B. Antisocial C. Histrionic D. Paranoid

A. Borderline

A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? (Select all that apply.) A. Broccoli B. Yogurt C. Pepperoni pizza D. Cream cheese E. Bologna sandwich

A. Broccoli B. Yogurt

A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including in the preschooler's diet? A. Corn tortilla with black beans. B. Whole wheat pasta with shrimp. C. Low sodium vegetable soup with barley. D. A bologna sandwich on rye bread.

A. Corn tortilla with black beans.

A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching? A. Delegate non-nursing tasks to ancillary staff. B. Stock client rooms with extra supplies. C. Assign dedicated equipment to each client's room. D. Change continuous IV infusion tubing every 24 hr.

A. Delegate non-nursing tasks to ancillary staff.

A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy? A. Difficulty performing ADLs B. Inability to swallow clear liquids C. Elevated blood glucose levels D. Unsteady gait when ambulating

A. Difficulty performing ADLs

A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take? A. Discuss the suspicion of physical abuse with the provider. B. Confront the parents with the suspicion of physical abuse. C. Ask the hospital security to detain and question the parents. D. Contact Child Protective Services

A. Discuss the suspicion of physical abuse with the provider.

A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client? A. Droplet B. Airborne C. Contact D. Protective environment

A. Droplet

A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia. Which of the following actions should the nurse plan to take? A. Ensure that the side rails are up on the client's bed. B. Ambulate the client every 4 hr. C. Check the fetal heart rate twice daily. D. Provide the client with a low-protein diet.

A. Ensure that the side rails are up on the client's bed.

A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client's family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take? A. Facilitate an interdisciplinary conference at the new facility for the family B. Refer the client and family to a social worker for assistance and a follow-up meeting C. Reassure the client's family that the same provider will provide care at the new facility D. Tell the family that the rehabilitation facility has an excellent client care record

A. Facilitate an interdisciplinary conference at the new facility for the family

A nurse is caring for a client who is 1 hr postpartum. Nurses' Notes 1200: Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion. 1215: Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified. Select the 6 actions the nurse should take. A. Firmly massage the uterine fundus B. Provide emotional support C. Administer oxygen D. Weigh the perineal pads E. Insert indwelling urinary catheter

A. Firmly massage the uterine fundus B. Provide emotional support C. Administer oxygen D. Weigh the perineal pads E. Insert indwelling urinary catheter

A nurse is caring for a client who is 1 hr postpartum. Nurses' Notes 1200: Large amount of lochia rubra noted on perineal pad. Fundus boggy at two fingerbreadths above the umbilicus. Oxytocin 20 units being administered via continuous JV infusion. 1215: Large amount of lochia rubra with several large clots noted. Client reports feeling anxious. Skin cool and clammy. Provider notified. Select the 6 actions the nurse should take. A. Firmly massage the uterine fundus. B. Provide emotional support. C. Administer oxygen and Weigh the perineal pads. D. Insert indwelling urinary catheter and Administer methylergonovine. E. Administer terbutaline.

A. Firmly massage the uterine fundus. B. Provide emotional support. C. Administer oxygen and Weigh the perineal pads. D. Insert indwelling urinary catheter and Administer methylergonovine.

A nurse is assessing a client who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective? A. Hemoglobin 14.9 g/dL B. WBC count 12.000/mm C. Potassium 48 mEq D. BUN 18 mg/dL

A. Hemoglobin 14.9 g/dL

A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take? A. Implement fall precautions for the client B. Monitor the client's thyroid function C. Place the client on a fluid restriction D. Discontinue the medication if hallucinations occur

A. Implement fall precautions for the client

A nurse is reinforcing teaching with a client who has a new diagnosis of myasthenia gravis (MG) and a prescription for neostigmine. Which of the following information should the nurse include about the action of the medication? A. Improves muscle strength. B. Destroys the antibodies that cause MG C. Enhances immune system function D. Prevents excessive coughing

A. Improves muscle strength.

A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take? A. Initiate continuous cardiac monitoring. B. Administer 40 mEq/L potassium chloride PO with orange juice. C. Provide a diet rich in legumes, nuts, and green vegetables. D. Monitor the client for tetany.

A. Initiate continuous cardiac monitoring.

A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take? A. Instruct the client to void. B. Position the client on their left side. C. Insert an IV catheter. D. Prepare the client for moderate (conscious) sedation.

A. Instruct the client to void.

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? A. Irritability B. Increased urination C. Vomiting D. Facial flushing

A. Irritability

A nurse is performing a physical assessment of a newborn whose mother used cocaine throughout the pregnancy. Which of the following findings should the nurse expect? A. Irritability. B. Hypotonicity. C. Decreased auditory startle response. D. Increased head circumference.

A. Irritability.

A nurse is reviewing the results of laboratory screenings for a 9-month-old infant. Which of the following results should the nurse report to the provider? A. Lead 18 mcg/dL. B. Hemoglobin 12 g/dL. C. Iron 74 mcg/dL. D. Hematocrit 35%

A. Lead 18 mcg/dL.

A nurse is assisting in the care of an older adult client who was admitted from a long-term care facility. Admission Assessment 1400: Client's history includes cigarette smoking for 50 years but quit 3 years ago, Parkinson's disease, and anxiety. Yesterday, client reported "feeling bad." Client is alert and oriented to self, reports upper chest discomfort, and is coughing up thick clear sputum. Select the 3 findings that require immediate follow-up. A. Oxygen saturation level B. Tremors C. Respiratory rate D. Heart rate E. Current level of consciousness F. Chronic health condition

A. Oxygen saturation level C. Respiratory rate E. Current level of consciousness

A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect? A. Pink, frothy sputum B. Bradycardia C. Flushed, dry skin D. Wheezing

A. Pink, frothy sputum

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client? A. Radial vein of the inner arm B. Great saphenous vein of the leg C. Dorsal plexus vein of the foot D. Basilic vein of the hand

A. Radial vein of the inner arm

A nurse is caring for an adolescent. Admission Assessment 1400: Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in . their right leg as 10 on a scale of 0 to 10 and is unable to bear weight. Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds. Which of the following actions should the nurse take after the adolescent returns from surgery? Select all that apply. A. Remove indwelling urinary catheter when no longer indicated B. Elevate affected limb at chest level C. Assist the adolescent with ambulation from bed to chair D. Perform neurovascular

A. Remove indwelling urinary catheter when no longer indicated C. Assist the adolescent with ambulation from bed to chair D. Perform neurovascular assessments every hour

A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect? A. Strict adherence to routines B. Difficulty paying attention to tasks C. Disobedience to authority figures D. Excessive anxiety when separated from parents

A. Strict adherence to routines

A nurse is preparing to administer medication to a client. Which of the following identifiers should the nurse use to identify the client? A. Telephone number. B. Place of birth. C. Driver license number. D. Room number.

A. Telephone number.

A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse? A. The child exhibits discomfort while walking B. The child has thin extremities C. The child has bruises on the upper back D. The child is wearing a stained shirt

A. The child exhibits discomfort while walking

A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings indicates the client's use of ginger tea is effective? A. The client reports a decrease in episodes of nausea. B. The client reports a decrease in breast tenderness. C. The client reports a decrease in headaches. D. The client reports a decrease in urinary frequency

A. The client reports a decrease in episodes of nausea.

A charge nurse is evaluating a newly licensed nurse who is caring for a client who has measles. For which of the following actions by the newly licensed nurse should the charge nurse intervene? A. The nurse places the client on airborne precautions. B. The nurse has the client wear a mask for transport to radiology. C. The nurse wears an N95 respirator when performing client care. D. The nurse ensures the client's room maintains a positive airflow.

A. The nurse places the client on airborne precautions.

A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take? A. Turn off the CPM machine during mealtime. B. Maintain the client's affected hip in an externally rotated position. C. Instruct the client how to adjust the CPM settings for comfort. D. Store the CPM machine under the client's bed when not in use

A. Turn off the CPM machine during mealtime.

A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following laboratory tests should the nurse review prior to adjusting the client's heparin? A. aPTT B. PT C. INR D. WBC count

A. aPTT

A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication? A. "Have you experienced muscle stiffness?" B. "Have you had any stomach pain or bloody stools?" C. "Have you experienced a dry cough?" D. "Have you noticed an increase in urine output?"

B. "Have you had any stomach pain or bloody stools?"

A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make? A. "Perhaps you think the ECT is dangerous, but I've seen it have good results." B. "You have the right to change your mind about this procedure at any time." C. "Everyone gets a little nervous about this procedure as the time for it approaches." D. "Your doctor wouldn't have suggested ECT if they didn't think it would help you."

B. "You have the right to change your mind about this procedure at any time."

A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle feeding her newborn. Which of the following instructions should the nurse include in the teaching? A. "You should apply moist heat to your breasts four times per day." B. "You should manually express milk when engorgement occurs." C. "You should wear a snug-fitting bra continuously for 72 hours." D. "You should limit your fluid intake to 1 liter per day."

B. "You should manually express milk when engorgement occurs."

A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism? A. A client forgets to buy their partner a birthday gift after a disagreement. B. A client who was abused as a child describes the abuse as if it happened to someone else. C. A client who is shorter than average is verbally assertive with coworkers. D. A client states that they did not get a job promotion because the boss did not like them

B. A client who was abused as a child describes the abuse as if it happened to someone else.

A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take? A. Perform ADLs for the client to promote rest B. Allow for frequent rest periods throughout the day C. Use heat to reduce joint inflammation D. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain

B. Allow for frequent rest periods throughout the day

A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take? A. Withhold pain medications for 24 hr after the old patch is removed B. Ask another nurse to witness the disposal of the new patch C. Seal the patches in a plastic bag and place in the client's trash basket D. Stick the two patches to each other and place them in the sharps bin

B. Ask another nurse to witness the disposal of the new patch

A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take? A. Insert air in the tube and listen for gurgling sounds in the epigastric area B. Aspirate contents from the tube and verify the pH level C. Review the medical record for previous x-ray verification of placement D. Auscultate the lungs for adventitious breath sounds

B. Aspirate contents from the tube and verify the pH level

A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer? A. Measuring the group's work against the assigned objectives B. Noting the progress of the group toward assigned goals C. Sharing experiences as an authority figure D. Offering new and fresh ideas on an issue

B. Noting the progress of the group toward assigned goals

A nurse is performing an admission assessment of a school-age child who has spina bifida. The parent states that the child is allergic to latex. The nurse should assess further for crosssensitivity to which of the following foods? A. Almonds. B. Bananas. C. Hazelnuts. D. Strawberries

B. Bananas.

A nurse is caring for an adolescent. Admission Assessment 1400: Adolescent brought to emergency department by parents following a fall while skateboarding. Adolescent reports pain in their right leg as 10 on a scale of 0 to 10 and is unable to bear weight. Adolescent is awake, alert, and oriented x 3. Lungs clear, respirations even and regular. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with active bowel sounds in all four quadrants. Right lower extremity with open wound and displaced bone. Right lower extremity pulse +1, extremity cool to touch, edema present, capillary refill 4 seconds. Select the 4 findings that require follow-up. A. Blood pressure B. Capillary refill C. Pedal pulse D. Heart rate E. Skin temperature F. Pain

B. Capillary refill C. Pedal pulse E. Skin temperature F. Pain

A nurse is documenting admission data for a client on an acute care facility. Which of the following actions should the nurse take? A. Document the client's vital signs obtained by an assistive personnel. B. Chart a summary of the data at the change of the shift. C. Note whether the client has a living will. D. Begin charting with an evaluation of the data.

B. Chart a summary of the data at the change of the shift.

A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider? A. Tinnitus B. Cough C. Polyuria D. Blurred vision

B. Cough

A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective? A. Decreased blood pressure B. Decreased hallucinations C. Decreased cholesterol D. Decreased esophageal reflux

B. Decreased hallucinations

A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP? A. Perform gastrostomy feedings through a client's established gastrostomy tube B. Determine if the PRN pain medication administered 30 min ago has helped C. Provide instructions about client care to a family member over the telephone D. Teach a client how to measure their own blood pressure

B. Determine if the PRN pain medication administered 30 min ago has helped

A nurse is admitting a client to the medical-surgical unit. The Patient Self-Determination Act requires the nurse to perform which of the following actions during the admission process? A. Provide end-of-life education if the client has a terminal illness. B. Document in the client's medical record if the client has advance directives. C. Provide the client with a list of eligible individuals who can serve as a health care proxy. D. Ensure the client has an attorney to contact for assistance with end-of-life documents.

B. Document in the client's medical record if the client has advance directives.

A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication? A. Diarrhea B. Dry mouth C. Photophobia D. Bruising

B. Dry mouth

A nurse is assessing a client for allergies prior to administering the influenza vaccine. The nurse should identify that an allergy to which of the following foods is a contraindication to receiving this vaccine? A. Shellfish. B. Egg. C. Gelatin. D. Milk.

B. Egg.

A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report? A. Weight loss B. Jaundice C. Bradycardia D. Polyuria

B. Jaundice

A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider? A. Heart rate 136/min B. Nasal flaring C. Transient strabismus D. Overlapping of sutures

B. Nasal flaring

A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up. A. Weight B. Neuro status C. Auditory hallucinations D. Speech E. Restlessness

B. Neuro status C. Auditory hallucinations E. Restlessness

A nurse is caring for a client who is postoperative following an appendectomy. Vital Signs 1800: Temperature 98.4° F (36.8° C) Heart rate 104/min Respiratory rate 22/min Blood pressure 142/80 mm Hg O2 saturation 97% on room air 1800: Client alert and oriented x 4 Skin warm and dry Lungs clear on auscultation Bowel sounds hypoactive in all four quadrants Urine clear yellow Incisional dressing clean and dry Client reports pain as 6 on a scale of 0 to 10 1815: Morphine administered as prescribed 2000: Temperature 98.4° F (36.8° C) Heart rate 110/min Respiratory rate 24/min Blood pressure 158/88 mm Hg O2 saturation 93% on room air. Which of the following 4 client findings should the nurse report to the provider? A. Bowel sounds B. Oxygen saturation C. Nausea D. Vomiting E. Pain level F. Heart rate G. Incision characteristics H. Lungs sounds

B. Oxygen saturation F. Heart rate G. Incision characteristics H. Lungs sounds

A nurse is assessing a client who is at 37 weeks of gestation and reports sudden, severe abdominal pain with moderate vaginal bleeding and persistent uterine contractions. The client's blood pressure is 88/50 mm Hg, and her abdomen is rigid. The nurse should identify these findings as indicating which of the following complications? A. Uterine rupture. B. Placental abruption. C. Placenta previa. D. Amniotic fluid embolus.

B. Placental abruption.

A case manager is performing a home visit for a client following a stroke. The client's partner is providing care in the home. The client's partner states that she sometimes feels exhausted. Which of the following referrals should the case manager recommend for the caregiver? A. Assisted living. B. Respite care. C. Rehabilitation services. D. Skilled nursing facility.

B. Respite care.

A nurse is caring for a school-age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests? A. Chest x-ray B. Serum liver enzyme levels C. ABGS D. Urine culture and sensitivity

B. Serum liver enzyme levels

A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following actions by the newly licensed nurse requires intervention by the preceptor? A. Documents client tasks upon completion B. Starts a task then determines what supplies are needed C. Completes a client assessment while infusing an IV antibiotic over 30 min D. Returns to the nurses' station after completing several tasks in the same location

B. Starts a task then determines what supplies are needed

A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan? A. Massage bony prominences on the client's left side. B. Support the client's left arm on a pillow while sitting. C. Position the bedside table on the client's left side. D. Place the client's cane on their left side while ambulating.

B. Support the client's left arm on a pillow while sitting.

A nurse is caring for a female client who requires bed rest and reports difficulty urinating into a bedpan. Which of the following actions should the nurse take? A. Turn on the faucets in the client's sink. B. Tell the client to gently stroke her lower abdomen. C. Instruct the client to lean slightly backward. D. Pour cool water over the client's perineum.

B. Tell the client to gently stroke her lower abdomen.

A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP? A. Hypoxemia B. Tension pneumothorax. C. Malignant hypertension D. Atelectasis

B. Tension pneumothorax.

A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report? A. The last time the provider evaluated the client B. The client's most recent ventilator settings C. The time of the client's last dose of pain medication D. The frequency in which the client presses the call button

B. The client's most recent ventilator settings

A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record? A. Completion of the incident report B. Time the medication was given C. Reason for the medication error D. Notification of the pharmacist

B. Time the medication was given

A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of labor. Which of the following findings is a contraindication for administration of this medication? A. Preeclampsia. B. Transverse fetal lie. C. Intrauterine growth restriction. D. Postterm pregnancy.

B. Transverse fetal lie.

A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include? A. Maintain a flexible daily schedule for the child B. Use a reward system to modify the child's behavior C. Provide a variety of family members to care for the child D. Administer alprazolam as needed to reduce the child's anxiety

B. Use a reward system to modify the child's behavior

A nurse is providing teaching for a client who has a fracture of the right fibula with a shortleg cast in place and a new prescription for crutches. The client is nonweight-bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching? A. Adjust the crutches for comfort as needed. B. Use a three-point gait. . Wear leather-soled shoes. D. Advance the affected leg first when walking upstairs.

B. Use a three-point gait.

A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching? A. Check the functioning of oxygen equipment once each week. B. Wear clothing made with cotton fabrics while oxygen is in use. C. Apply petroleum-based lubricant to the nares as needed. D. Store full oxygen tanks on their side.

B. Wear clothing made with cotton fabrics while oxygen is in use.

A nurse is caring for a client who has bulimia nervosa. Admission Assessment Day 1, 0630: Client admitted to inpatient unit for evaluation and treatment following report of binge eating and vomiting for over 1 year. Client reports feeling excessively tired and light-headed. Neuro: Client alert and oriented x 3. Respiratory: Lungs clear and equal bilaterally Gl: Diminished bowel sounds noted x 4. Client reports vomiting three to four times per day. Integumentary: Small superficial lacerations and calluses noted on fingers bilaterally. Breakdown noted around edges of lips. Select words from the choices below to fill in each blank in the following sentence. The client is at risk for developing ______________ and __________________ A. cardiovascular abnormalities B. metabolic alkalosis C. hyponatremia D. hypoglycemia

B. metabolic alkalosis

A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make? A. "I'm sure your family does not want you to die." B. "Why would you believe such things?" C. "How does this make you feel?" D. "You should talk to your family about your feelings."

C. "How does this make you feel?"

A nurse is teaching about safe handling of formula to a client who is postpartum and chooses to bottle feed her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I can keep a can of concentrated formula in the refrigerator for 3 days after I open it." B. "I can dilute the ready-to-feed formula with water when my baby wants more than 4 ounces at a feeding." C. "I should boil tap water for 2 minutes and cool it before I mix it with the powdered formula." D. "I will be sure that all of my bottles contain BPA."

C. "I should boil tap water for 2 minutes and cool it before I mix it with the powdered formula."

A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism? . "I have experienced physical discomfort when intimate with my partner since my diagnosis." B. "I wish other women would stop socializing with my partner." C. "I told my doctor that I would like to start a support group for other women who are sick in my community." D. "I used to mistrust my doctor, but now I know that she is the best one to care for me during my illness."

C. "I told my doctor that I would like to start a support group for other women who are sick in my community."

A home health nurse is evaluating a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements? A. "My child doesn't like to sit still for nebulizer treatments." B. "I think that my child has been running a fever over the last couple of days." C. "My child has only a small amount of mucus after percussion therapy." D. "I am concerned about my child's future participation in team sports."

C. "My child has only a small amount of mucus after percussion therapy."

A nurse is creating an incident report due to an accidental omission of a client's dressing change during the previous shift. Which of the following statements should the nurse document on the incident report form? A. "Unable to complete a prescribed dressing change. However, dressing did not appear to be soiled." B. "A nurse accidentally omitted a prescribed dressing change. C. "Prescribed dressing change was accidentally omitted during the previous shift." D. "Incident report completed.

C. "Prescribed dressing change was accidentally omitted during the previous shift."

A nurse is providing client teaching about the basal body temperature method of birth control. Which of the following information should the nurse include in the teaching? A. "Your body temperature will drop approximately 1 degree 1 week after ovulation." B. "You should take your body temperature each evening prior to going to sleep." C. "Your body temperature might decrease slightly just prior to ovulation." D. "Your body temperature is at its highest during menstruation."

C. "Your body temperature might decrease slightly just prior to ovulation."

A nurse is caring for four children in an emergency department. Which of the following clients should the nurse assess first? A. A child who has mononucleosis and reports severe fatigue. B. A child who has Wilms' tumor and an abdominal mass. C. A child who has acute epiglottitis and is drooling. D. A child who has a urinary tract infection and bright red blood in her urine.

C. A child who has acute epiglottitis and is drooling.

A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients? A. A client who had blood drawn from the right antecubital area 1 hr ago. B. A client who has a right peripherally inserted central catheter. C. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm. D. A client who had a right hemisphere stroke.

C. A client who had dialysis and is using an arteriovenous shunt in the left lower forearm.

A nurse is assessing a client who is receiving enteral feedings via an NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's feedings? A. Reposition the NG tube. B. Increase the rate of formula delivery. C. Add water to the formula. D. Switch to a lactose-free formula.

C. Add water to the formula.

A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider? A. Obtain capillary blood glucose level every 2 hr B. Check the neurovascular status of the client's lower extremities every hour C. Apply a cold pack to the client's ankle for 30 min every hour D. Maintain the affected ankle elevated and immobilized

C. Apply a cold pack to the client's ankle for 30 min every hour

A nurse is caring for a client who is in the latent phase of labor and reports severe back pain. The vaginal examination reveals that the cervix is dilated 2 cm, 25% effaced, and -2 station. Which of the following interventions should the nurse implement? A. Administer a dose of terbutaline to the client. B. Place the client in a warm bath. C. Apply counterpressure during each contraction. D. Request the provider prescribe a pudendal nerve block.

C. Apply counterpressure during each contraction.

A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Evaluate dietary intake for a client who has anorexia. B. Measure the vital signs of a client who just returned from the PACU C. Arrange the lunch tray for a client who has a hip fracture. D. Assess I&O for a client who is receiving dialysis.

C. Arrange the lunch tray for a client who has a hip fracture.

A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority? A. Assess fluid intake every 24 hr. B. Ambulate three times a day. C. Assist with deep breathing and coughing. D. Monitor the incision site for findings of infection.

C. Assist with deep breathing and coughing.

A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer. Which of the following interventions should the nurse include in the client's plan of care? A. Limit each of the client's visitors to 2 hr per day. B. Instruct visitors to stay 1 m (3.3 feet) away from the client. C. Attach a dosimeter to the client's gown. D. Strain the client's urine.

C. Attach a dosimeter to the client's gown.

A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolitic stockings. Which of the following actions should the nurse take? A. Remove the stockings every 24 hr. B. Fold the stockings at the top if they are too long. C. Measure the legs with a tape measure to determine stocking size. D. Massage the legs before applying the stockings.

C. Measure the legs with a tape measure to determine stocking size.

A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? A. Assess the client's IV site every 8 hr. B. Check the client's WBC count every 48 hr. C. Monitor the client's mouth every 8 hr. D. Change the client's IV tubing every 48 hr.

C. Monitor the client's mouth every 8 hr.

A nurse is providing discharge teaching to a client who is 1 day postoperative following a right modified radical mastectomy. Which of the following instructions should the nurse include in the teaching? A. Begin ball squeezing exercises. B. Wear a bra with wire support. C. Avoid using the affected arm for eating. D. Use deodorant under the affected arm.

C. Avoid using the affected arm for eating.

A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth? A. Constipation B. Urinary urgency C. Cervical laceration D. Retained placenta

C. Cervical laceration

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first? A. Attach a prefilled syringe to the catheter inflation hub. B. Position the sterile drape leaving the perineum exposed. C. Cleanse the client's meatus with antiseptic solution. D. Lubricate the catheter with watersoluble gel.

C. Cleanse the client's meatus with antiseptic solution.

A rural community health nurse is developing a plan to improve healthcare delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources? A. Agency for Healthcare Research and Quality B. National Institutes of Health C. Department of Agriculture D. World Health Organization

C. Department of Agriculture

A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload? A. Oliguria B. Bradycardia C. Dyspnea D. Poor skin turgor

C. Dyspnea

A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first? A. Document the client's refusal in the medical record B. Honor the client's decision to refuse the blood transfusion C. Explore the client's reasons for refusing the treatment D. Discuss the client's refusal with the provider

C. Explore the client's reasons for refusing the treatment

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nägele's rule, which of the following dates should the nurse document as the client's estimated date of birth (EDB)? A. February 1 B. February 8 C. February 15 D. February 22

C. February 15

A nurse in a provider's office is monitoring the laboratory results of a client who has type 1 diabetes mellitus. Which of the following results indicates that the client demonstrates acceptable glycemic control? A. Random plasma glucose 176 mg/dL. B. Triglycerides 182 mg/dL. C. HbA1c 6.8%. D. Fasting blood glucose 120 mg/dL.

C. HbA1c 6.8%.

A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take? A. Contact the facility chaplain to visit with the client. B. Explain the process of leaving the facility against medical advice. C. Make a referral for social services. D. Encourage the client to continue with inpatient care.

C. Make a referral for social services.

A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority? A. Organizing the work environment B. Delegating assigned tasks appropriately C. Making a list of activities to complete D. Rewarding yourself for accomplishing goals

C. Making a list of activities to complete

A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Palpate the degree of edema. B. Regulate IV pump fluid rate. C. Measure the client's daily weight. D. Assess the client's vital signs.

C. Measure the client's daily weight.

A nurse is planning care for a client prior to an amniocentesis. Which of the following actions should the nurse include in the plan of care? A. Instruct the client to maintain a full bladder for the procedure. B. Administer a tocolytic 30 min before the procedure. C. Monitor the fetal heart rate throughout the procedure. D. Place the client in Trendelenburg position during the procedure.

C. Monitor the fetal heart rate throughout the procedure.

A school nurse is using the Weber's test to check a child's hearing acuity. Which of the following actions should the nurse take? A. Measure the amount of time the child can hear the sound. B. Obtain a tympanogram reading prior to initiating the test. C. Place a vibrating tuning fork on the top of the child's head. D. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears

C. Place a vibrating tuning fork on the top of the child's head.

A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication? A. Hypotension B. Report of tinnitus C. Report of chest pain D. Ecchymosis

C. Report of chest pain

A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg, and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis

C. Respiratory acidosis

A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first? A. Form a committee of staff members to investigate current staffing issues B. Provide support to staff members who are resistant to staffing changes C. Schedule a staff meeting to present the different options to staff members D. Give the staff members advance written notice of staffing changes

C. Schedule a staff meeting to present the different options to staff members

While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take? A. Tighten the tubing connections. B. Request insertion of a tracheostomy tube. C. Suction the client's airway. . Look for a leak in the tube's cuff.

C. Suction the client's airway.

An RN is observing a licensed practical nurse (LPN) and an assistive personnel (AP) move a client up in bed. For which of the following situations should the nurse intervene? A. The LPN and AP lower the side rails before lifting the client up in bed. B. Prior to lifting the client, the LPN and AP raise the bed to waist level. C. The LPN and the AP grasp the client under his arms to lift him up in bed. D. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift.

C. The LPN and the AP grasp the client under his arms to lift him up in bed.

A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take? A. Select a 1-inch needle B. Use a 45° angle when inserting the needle C. Use the ventrogluteal site D. Pinch the skin up during injection

C. Use the ventrogluteal site

A nurse in an acute mental health facility is teaching a client about the potential adverse effects of transcranial magnetic stimulation. The nurse tells the client that he might feel lightheaded, but that it should not affect his memory. The nurse is demonstrating which of the following ethical principles? A. Fidelity. B. Beneficence. C. Veracity. D. Autonomy

C. Veracity.

A client on an acute mental health unit states to a nurse, "Tie a bow. Row the boat. Now I know. Whoa! I see you, yo." The nurse should document that the client is exhibiting which of the following speech alterations? A. Neologisms. B. Echolalia. C. Word salad. D. Clang associations.

C. Word salad.

A nurse is caring for a client who is preoperative for cataract removal. Which of the following statements by the client indicates an understanding of the procedure? A. "I can expect my eyelids to be bruised after this procedure." B. "I will see dark spots in my vision after this procedure." C. "I will receive general anesthesia for this procedure." D. "I know the provider will replace the lens in my eyes during this procedure."

D. "I know the provider will replace the lens in my eyes during this procedure."

A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make? A. "You will be standing with your feet 1 foot apart." B. "You will place and hold your hands on your hips." C. "I will be standing across the room from you to evaluate your sense of balance." D. "I will be checking you once with your eyes open and once with them closed."

D. "I will be checking you once with your eyes open and once with them closed."

A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will administer aspirin to my child to treat pain or fever." B. "I will record an average of three readings from my child's peak expiratory flow meter." C. I will place carpet in my child's bedroom to control allergens." D. "I will make sure my child receives a yearly influenza immunization."

D. "I will make sure my child receives a yearly influenza immunization."

A nurse is caring for a client following an involuntary admission to an acute mental health facility. The client states, "I'm afraid they will give me drugs that put me to sleep." Which of the following statements should the nurse make? A. "It's not your choice to be here, so you have to accept the treatment we plan for you." B. "You will need to rest so that you can recover from the episode that brought you here." C. "Why do you think your provider will prescribe you medications that will make you sleep?" D. "I will make sure that we respect your right to refuse medications

D. "I will make sure that we respect your right to refuse medications

A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching? A. "I will change your IV tubing once every 48 hours." B. "Abdominal distention is an expected effect of this therapy." C. "I will need to check your gastric residual before administering feedings." D. "I will need to measure your weight daily."

D. "I will need to measure your weight daily."

A nurse is teaching a client how to care for his behindthe-ear hearing aids. Which of the following statements by the client indicates an understanding of the teaching? A. "I'll use isopropyl alcohol to clean my hearing aids." B. "I'll replace the batteries every 2 weeks." C. "I'll clean my ear with cotton swabs before I insert my hearing aids." D. "I'll disconnect the battery when I remove my hearing aids."

D. "I'll disconnect the battery when I remove my hearing aids."

A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "The provider will choose a client's health care surrogate." B. "A health care surrogate must be a family member." C. "The provider can go against the client's wishes regarding advance directives." D. "The client can resume control of health care after a temporary loss of competency."

D. "The client can resume control of health care after a temporary loss of competency."

A nurse has received change-of-shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction? A. A client who is receiving verapamil and has a continuous infusion of total parenteral nutrition (TPN) B. A client who is taking phenytoin and is requesting a milkshake C. A client who is receiving a diet high in potassium-rich foods and furosemide by mouth D. A client who is receiving an MAOI and is requesting a cheeseburger for dinner

D. A client who is receiving an MAOI and is requesting a cheeseburger for dinner

A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of AllInclusive Care for the Elderly (PACE) for which of the following clients? A. A client whose family requests hospitalbased hospice care B. A client who requires transfer to a skilled care facility C. A client who qualifies for telehealth for pacemaker diagnostics D. A client whose caregiver requests adult day care services

D. A client whose caregiver requests adult day care services

A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? A. An older adult client who reports constipation of 4 days B. A preschooler who has a skin rash C. An adolescent who has a closed fracture D. A middle adult client who has unstable vital signs

D. A middle adult client who has unstable vital signs

A nurse is teaching a class about using niacin to reduce LDL cholesterol. The nurse should include in the teaching that which of the following conditions is a contraindication for receiving this medication? A. Hyperthyroidism. B. Asthma. C. High blood pressure. D. Active liver disease.

D. Active liver disease.

8-year-old male admitted with cystic fibrosis reports the following symptoms: Shortness of breath Wheezing throughout lung fields Productive cough with thick sputum A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan? A. Initiate droplet isolation precautions B. Keep the child on NPO status for 12 hr C. Maintain the child on bed rest for 24 hr D. Administer high-dose antibiotic therapy

D. Administer high-dose antibiotic therapy

A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation? A. Evaluate the changes the partner requests B. Review the client's plan of care C. Analyze other reports of poor care to look for trends D. Ask the partner to list specific concerns

D. Ask the partner to list specific concerns

A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take? A. Wear a surgical mask when providing client care B. Have visitors maintain a distance of 1.8 m (6 feet) from the client C. Restrict fresh flowers from the client's room D. Assign the client to a private room with negative air pressure

D. Assign the client to a private room with negative air pressure

A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take? A. Assess the apical pulse while the newborn is crying B. Palpate the radial pulse for 30 seconds C. Listen to the apical pulse while palpating the radial pulse D. Auscultate the apical pulse at least 1 min

D. Auscultate the apical pulse at least 1 min

A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication? A. Diarrhea B. Frequent urination C. Excessive salivation D. Blurred vision

D. Blurred vision

A nurse is part of a task force planning to audit a facility's nursing units concerning adherence to handhygiene protocols. Which of the following steps should the task force take first? A. Take corrective measures to enforce hand hygiene. B. Establish methods for collecting data within the facility. C. Compare the facility's data with the established criteria for hand hygiene. D. Determine the accepted standards for hand hygiene.

D. Determine the accepted standards for hand hygiene.

A nurse is admitting a school-age child who has bacterial meningitis. Which of the following types of isolation precautions should the nurse initiate? A. Protective environment. . Airborne. C. Contact. D. Droplet.

D. Droplet.

A charge nurse is observing an assistive personnel perform delegated tasks. Which of the following actions by the AP requires the charge nurse to intervene? A. Providing postmortem care for a client who has recently died. B. Performing a simple dressing change on a client's foot. C. Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile. D. Emptying an indwelling urinary catheter bag for a client while wearing clean gloves.

D. Emptying an indwelling urinary catheter bag for a client while wearing clean gloves.

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority? A. Instruct the client about the importance of regular medical appointments. B. Encourage the client to participate in daily exercise. C. Explain proper foot care techniques to the client. D. Ensure that the client understands the medication regimen

D. Ensure that the client understands the medication regimen

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority? A. Instruct the client about the importance of regular medical appointments. B. Encourage the client to participate in daily exercise. C. Explain proper foot care techniques to the client. D. Ensure that the client understands the medication regimen.

D. Ensure that the client understands the medication regimen.

A nurse is teaching a client who has a new prescription for sertraline to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome? A. Insomnia. B. Constipation. C. Dry mouth. D. Excessive sweating.

D. Excessive sweating.

A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet? A. Calories B. Protein C. Potassium D. Fiber

D. Fiber

A nurse is caring for a client who has active tuberculosis (TB). Which of the following actions should the nurse plan to take to prevent the transmission of the disease? A. Initiate contact precautions for the client upon admission B. Restrict visitors from entering the client's room during hospitalization C. Wear a surgical mask while providing care for the client D. Have the client wear a surgical mask while being transported outside the room

D. Have the client wear a surgical mask while being transported outside the room

A nurse is caring for a 3-year-old toddler who has dehydration. Which of the following findings should the nurse report to the provider? A. Sodium 142 mEq/L. B. Respiratory rate 22/min. C. Potassium 3.9 mEq/L. D. Heart rate 148/min.

D. Heart rate 148/min.

A nurse is planning to reinforce teaching with a preschooler who is about to undergo an incision and drainage for cellulitis on the left arm. Which of the following techniques should the nurse use? A. Plan for a 30-min instructional session. B. Schedule the instructional session for 24 to 36 hr before the procedure C. Take the child on a tour of the surgery and recovery areas. D. Help the child put a dressing on a doll

D. Help the child put a dressing on a doll

A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend? A. Human papillomavirus (HPV) B. Rotavirus. C. Diphtheria, tetanus, and acellular pertussis (DTaP) D. Herpes zoster

D. Herpes zoster

A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority? A. Encourage oral fluids. B. Apply topical calamine lotion. C. Administer acetaminophen as an antipyretic D. Initiate transmission-based precautions

D. Initiate transmission-based precautions

A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool? A. Place the client in the lithotomy position. B. Elicit a vagal response by performing gentle rectal stimulation. C. Administer oral bisacodyl 30 min prior to the procedure. D. Insert a lubricated gloved finger and advance along the rectal wall.

D. Insert a lubricated gloved finger and advance along the rectal wall.

A community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area. Which of the following interventions should the nurse include? A. Suggest that the client attend adult day care three times per week. B. Review assisted living accommodations with the client. C. Discuss a long-term care referral for the client with the provider. D. Instruct the client about the use of telehealth services.

D. Instruct the client about the use of telehealth services.

A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical aseptic technique? A. Hold hands folded below the waist after donning sterile gloves B. Pick up and pour solutions with the palm of the hand covering bottle labels C. Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape D. Maintain sterile objects within the line of vision

D. Maintain sterile objects within the line of vision

planning to administer packed RBCs to an older adult client who has a low hemoglobin level. Which of the following actions should the nurse plan to take? A. Hang the transfusion with dextrose 5% in 0.9% sodium chloride. B. Infuse the transfusion over 5 hr. C. Use a 20-gauge IV catheter to transfuse the blood. D. Monitor vital signs every hour throughout the transfusion.

D. Monitor vital signs every hour throughout the transfusion.

During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take? A. Keep the client's television on with the volume low B. Insert an indwelling urinary catheter to minimize interaction with the client C. Consult the provider regarding administering a mild sedative on a schedule D. Move the client to a room near the nurses' station

D. Move the client to a room near the nurses' station

A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take? A. Obtain the client's vital signs every other day. B. Weigh the client every 48 hr. C. Allow the client to eat meals in his room. D. Observe the client for 1 hr after meals.

D. Observe the client for 1 hr after meals.

A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside? A. Wire cutters. B. Tracheostomy tray. C. Montgomery straps. D. Padded clamp.

D. Padded clamp.

A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure (ICP)? A. Flex the client's neck forward B. Group several nursing activities to be completed at one time C. Limit suctioning the client's airway to 30 seconds at a time D. Place the client in a quiet environment

D. Place the client in a quiet environment

A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take? A. Contact the facility's ethics committee B. Obtain consent from the client's employer C. Limit care to comfort measures D. Proceed with provision of medical care

D. Proceed with provision of medical care

A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan? A. Encourage the client to take a cool sponge bath each morning. B. Administer opioid analgesia. C. Increase the client's dietary iron intake. D. Restrict the client's intake of foods high in purines.

D. Restrict the client's intake of foods high in purines.

A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis? A. Obesity B. Acromegaly C. Estrogen replacement therapy D. Sedentary lifestyle

D. Sedentary lifestyle

A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take? A. Initiate IV access on the palmar side of the client's wrist. B. Insert a larger gauge IV catheter to prevent phlebitis. C. Choose the client's dominant arm for IV access whenever possible. D. Select a site proximal to previous venipuncture sites.

D. Select a site proximal to previous venipuncture sites.

A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first? A. Instruct a staff member to maintain a log of emergency care provided. B. Apply cervical spine collars to children who have suspected neck trauma. C. Notify guardians of the emergency and injuries to their children. D. Survey the scene for potential hazards to staff and children

D. Survey the scene for potential hazards to staff and children

A nurse is providing teaching to a schoolage child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include? A. Clean the mouthpiece with warm water every 2 weeks B. Wait 10 seconds between inhalations C. Take a quick inhalation when pressing the dispenser D. Take the medication 15 min before playing sports

D. Take the medication 15 min before playing sports

The nurse is continuing to care for the adolescent. Provider Prescriptions 1415:X-ray of right leg shows open fracture of the right proximal tibia Surgery consult Morphine 4 mg IV every 2 hr as needed for pain. The nurse is preparing the adolescent for the fasciotomy. Which of the following findings should the nurse report to the provider prior to surgery? A. The adolescent's parents have concerns regarding the surgery B. The adolescent's blood pressure is 131/89 mm Hg C. The adolescent reports severe pain D. The adolescent has not voided in 4 hr

D. The adolescent has not voided in 4 hr

A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence? A. The client is taking numerous deep, measured breaths B. The client is calmly telling their partner that "the staff here is so controlling C. The client is sitting with their head in their hands and appears to be crying D. The client is pacing around the chair in which their partner is sitting

D. The client is pacing around the chair in which their partner is sitting

A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse not include in the change-ofshift report? A. The last time the provider evaluated the client B. The client's most recent ventilator settings C. The time of the client's last dose of pain medication D. The frequency in which the client presses the call button

D. The frequency in which the client presses the call button

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification? A. Check the client's blood type and crossmatch it against the provider's orders B. Ask the client to state their blood type prior to beginning blood administration C. Compare information on the blood product to the informed consent form D. Verify the client and blood product information with another licensed nurse

D. Verify the client and blood product information with another licensed nurse

A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect? A. Weight gain B. Decrease in anteroposterior diameter of the chest C. HCO3 24 mEq/L D. pH 7.31

D. pH 7.31

A nurse is caring for a client who is postoperative following administration of Vital Signs 0830: Temperature 36.9° C (98.5° F) Heart rate 134/min Respiratory rate 28/min Blood pressure 92/52 mm Hg Pulse oximetry 89% on room air Select from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Select: 1. Condition Most Likely Experiencing 2. 2 Actions to Take 3. 2 Parameters to Monitor A. Obtain the latex free cart B. Paralytic ileus C. Nausea and vomiting D. Hypercapnia E. Nasogastric (NG) tube F. Malignant hyperthermia G. Administer ondansetron H. Administer dantrolene I. Latex allergy J. Urticaria K. Muscle rigidity L. Bowel sounds

F. Malignant hyperthermia H. Administer dantrolene K. Muscle rigidity

A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy. Laboratory Results 0700: Sodium 143 mEq/L (136 to 145 mEq/L) Potassium 3.5 mEq/L (3.5 to 5.0 mEq/L) Chloride 104 mEq/L (98 to 106 mEq/L) BUN 15 mg/dl (10 to 20 mg/dl) Magnesium 1.5 mEq/L (1.3 to 2.1 mEq/L) Total calcium 8.0 mg/dL (9.0 to 10.5 mg/dL) Phosphate 4.6 mg/dL (3.0 to 4.5 mg/dL) Glucose 95mL (74 to 106 mg/dL) WBC 9,500/mm3 (5,000 to 10,000/mm3) Complete the following sentence by using the lists of options. The client is at the highest risk for developing hypocalcemia evidenced by the ____

Total calcium 8.0 mg/dL (9.0 to 10.5 mg/dL)

A nurse is providing phone advice for a client who is pregnant. Complete the following sentence by using the lists of options. Nurses' Notes We e k 6 o f ge s tatio n: Spoke with client ove r t h e ph o n e. Clie n t r epo r t s nau s ea and v o miting wit h a w eig h t loss of 0.9 kg (2 lb) from their prepregnancy weight. Client reports no noted change in vomiting pattern and denies dr y m u c u s m e mbran e s. Advis ed clie n t t o eat s mall f r equ e n t m eal s o f n o n-g r e a s y , dr y , s w e e t o r sal t y f o ods , s u c h as d r y t o a s t , c rac k e r s , and pr e t z els. E n c o u raged clie n t t o call bac k if nau s ea and v o mitin g w o r s e n s. We e k 1 0 o f ge s tatio n: Spoke with client ove r t h e ph o n e. Clie n t r epo r t s a 6.8 kg ( 1 5 lb) w eigh t lo s s o v e r t h e pas t m o n t h. Clie n t s tat e s nau s e a c o n tin u e s , making it di f fic ult t o eat. T h e y de s c

Vomiting